Feasibility, Safety and Accuracy of Echocardiography-Fluoroscopy Imaging Fusion During Percutaneous Atrial Septal Defect Closure in Children

Advancing paediatric cardiac imaging: a comprehensive analysis of the feasibility and accuracy of a novel 3D paediatric transoesophageal probe

Aims

Pediatric transoesophageal echocardiography (TOE) probes have remained two-dimensional (2D) limiting their use compared to adults. While critical in pediatrics for interventions and post-surgery assessments, technological advancements introduced a three-dimensional (3D) pediatric TOE probe. This study assessed the new 3D pediatric TOE probe (GE 9VT-D) for feasibility, handling, and imaging quality.

Methods and results

At Children's Hospital of Toulouse, 2-month prospective study enrolled children undergoing TOE with the new probe. All imaging modalities were rated by 2 operators using a 5-point Likert-type scale from 1 (very poor) to 5 (very good) quality. Forty-five children, median age 3.7 (range: 2 months-14.7 years) median weight 7.8 kg (range: 4.3-48 kg) underwent 60 TOEs: 25% pre-surgery, 45% post-surgery, 28% during percutaneous procedures, and 2% in intensive care. Probe handling was "very easy" in all cases without adverse events. The median score of 2D, 2D colour, pulsed Doppler and 3D were noted 5 out of 5 and continuous Doppler and 3D colour 4 out of 5. The 3D image quality remained consistent irrespective of the patient weighing above or below 7.8 kg (p = 0.72). Postoperative TOEs identified two cases needing further interventions, emphasizing its value in evaluating surgical outcomes and also for guiding percutaneous interventions.

Conclusion

Our comprehensive evaluation demonstrates that the new 3D pediatric TOE probe is feasible and provides high-quality imaging in pediatric patients. The successful integration of this novel probe into clinical practice has the potential to enhance diagnostic accuracy and procedural planning, ultimately optimizing patient outcomes in pediatric cardiac care.

Renaissance of Cardiac Imaging to Assist Percutaneous Interventions in Congenital Heart Diseases:The Role of Three-Dimensional Echocardiography and Multimodality Imaging

Percutaneous interventions have completely refashioned the management of children with congenital heart diseases (CHD) and the use of non-invasive imaging has become the gold standard to plan and guide these procedures in the modern era. We are now facing a dual challenge to improve the standard of care in low-risk patients, and to shift our strategies from the classic open chest surgery to imaging-guided percutaneous interventions in high-risk patients. Such rapid evolution of ultrasound technologies over the last 20 years have permitted the integration of transthoracic, transesophageal and intracardiac echocardiography into the interventional workflow to improve image guidance and reduce radiation burden from fluoroscopy and angiography. Specifically, miniaturization of transesophageal probe and advances in three-dimensional (3D) imaging techniques have enabled real-time 3D image guidance during complex interventional procedure, In addition, multimodality and fusion imaging techniques harness the strengths of different modalities to enhance understanding of anatomical and spatial relationship between different structures, improving communication and coordination between interventionalists and imaging specialists. In this review, we aim to provide an overview of 3D imaging modalities and multimodal fusion in procedural planning and live guidance of percutaneous interventions. At the present times, 3D imaging can no longer be considered a luxury but a routine clinical tool to improve procedural success and patient outcomes.

Real-time echocardiography-fluoroscopy fusion imaging for left atrial appendage closure: prime time for fusion imaging?

BACKGROUND

Real-time echocardiography-fluoroscopy fusion imaging (FI) merges real-time echocardiographic imaging with fluoroscopic images allowing intuitive anatomical spatial orientation during structural heart disease interventions. We aimed to assess the safety and efficacy of FI during percutaneous left atrial appendage closure (LAAC).

METHODS

34 consecutive patients before (-FI) and 121 patients after (+FI) the introduction of FI for LAAC were included in a single-centre study. In-hospital safety parameters were analysed according to adverse event (AE) definition of the Munich consensus document and procedure-related parameters were assessed for efficacy. An ANCOVA was performed to investigate the influence of a learning curve.

RESULTS

Time until successful transseptal puncture was significantly reduced as well as total procedure time and the amount of contrast agent used (+FI/-FI:17 ± 6.35 min vs. 22 ± 8.33 min, p = 0.001; +FI/-FI: 50 min IQR 43 min - 60 min vs. 57 min IQR 45 min -70 min; p = 0.013; +FI/-FI: 70 mL, IQR 55 ml-90 mL vs. 152 mL, IQR 107 mL - 205 mL; p < 0.001). However, fluoroscopy time and dose-area product did not differ between both groups. There was no significant difference in the occurrence of in-hospital adverse events (+FI/-FI: 2.5% vs. 0%; p = 0.596). The ANCOVA revealed that the learning curve does not affect procedural efficacy parameters such as procedure time, time to transseptal puncture, amount of contrast agent and dose-area product.

CONCLUSIONS

FI for LAAC reduces the total procedure time, the time to successful transseptal puncture and periprocedural amount of contrast agent.

Atrial septal defect in adulthood: a new paradigm for congenital heart disease

Atrial septal defects (ASDs) represent the most common congenital heart defect diagnosed in adulthood. Although considered a simple defect, challenges in optimal diagnostic and treatment options still exist due to great heterogeneity in terms of anatomy and time-related complications primarily arrhythmias, thromboembolism, right heart failure and, in a subset of patients, pulmonary arterial hypertension (PAH). Atrial septal defects call for tertiary expertise where all options may be considered, namely catheter vs. surgical closure, consideration of pre-closure ablation for patients with atrial tachycardia and suitability for closure or/and targeted therapy for patients with PAH. This review serves to update the clinician on the latest evidence, the nuances of optimal diagnostics, treatment options, and long-term follow-up care for patients with an ASD.

Sinus Venosus ASDs: Imaging and Percutaneous Closure

PURPOSE OF THE REVIEW

Percutaneous closure of sinus venosus atrial septal defects (ASD) using covered stent implantation is a new and promising minimally invasive technique. New imaging tools are used to ensure preoperative anatomical characterization and preoperative guidance, which are key procedural success factors. Here we will describe and analyze these recent developments.

RECENT FINDINGS

Sinus venosus ASDs present a wide variety of anatomical features which must be described and analyzed using various imaging tools, including 3D technology. Percutaneous closure is challenging, but can hasten clinical recovery compared to the gold-standard conventional open-heart surgery. The feasibility of percutaneous closure relies on precise preoperative anatomical study and on real-time guidance using a multimodal fusion imaging process. Three-dimensional modeling of sinus venosus ASD is essential to understand the large anatomical panel encountered in this pathology. Multimodal fusion imaging guidance is very useful for performing sinus venosus ASD percutaneous closure in selected patients.

Systematic Fluoroscopic-Echocardiographic Fusion Imaging Protocol for Transcatheter Edge-to-Edge Mitral Valve Repair Intraprocedural Monitoring

BACKGROUND

Whether fluoroscopic-echocardiographic fusion imaging (FI) might offer added value for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair is yet unknown, and few data exist regarding the safety and feasibility of this novel technology.

METHODS

The aim of this single-center study was to test and validate a FI protocol for intraprocedural monitoring of transcatheter edge-to-edge mitral valve repair and assess its clinical usefulness. Eighty patients underwent MitraClip implantation using FI guidance (FI+) for either degenerative (35%) or functional (65%) mitral regurgitation and were compared with the last 80 patients before FI introduction, treated using conventional echocardiography and fluoroscopic monitoring (FI-).

RESULTS

The number of patients treated for functional and degenerative mitral regurgitation was similar between the FI+ and FI- groups, as well as the number of devices implanted (1.51 ± 0.5 vs 1.58 ± 0.6, P = .46). The prevalence of complex mitral anatomy for percutaneous repair was high (32.5%, up to 39.2% in the hybrid arm). Fluoroscopy time was significantly lower in FI+ patients (37.3 ± 14.6 vs 48.3 ± 28.3 min, P = .003), but not kerma area product (91.5 ± 74.1 vs 108.8 ± 105.0 Gy · cm², P = .23) or procedural time (92.2 ± 36.1 vs 103.1 ± 42.7 min, P = .086). After adjusting for confounding factors (MitraClip XT device and complex anatomy), FI reduced fluoroscopy time (coefficient = -10.4 min; 95% CI, -18.03 to -2.82; P = .007) and improved procedural success at the end of the procedure (odds ratio, 2.87; 95% CI, 1.00 to 8.24; P = .049) and discharge (odds ratio, 2.24; 95% CI, 1.04 to 4.80; P = .039). Rates of periprocedural complications were similar in both groups (8.9% vs 13.0%, P = .40).

CONCLUSIONS

The authors describe the systematic use of an FI protocol for intraprocedural guidance during transcatheter edge-to-edge mitral valve repair, demonstrating a reduction in fluoroscopy time and an improvement in procedural success in a population with a high prevalence of challenging mitral anatomy for percutaneous repair.