Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures

Abstract

Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes.

Keywords: Percutaneous cardiovascular procedures; echocardiographic guidance; vascular access.

Figure 1

Anatomy of internal jugular vein. A. Normal internal jugular vein and artery; B. Internal jugular vein compressed with US transducer

Figure 2

Ultrasound guidance technique of transfemoral artery access. A. Illustration of US transducer with needle guide and artery; B. The right femoral artery bifurcation is seen in the axial plane, identifying the separation of the profunda femoral artery (PFA), superficial femoral artery (SFA), and femoral vein (FV). Note the compressed FV, which can be differentiated from arteries; C. The transducer is moved superiorly until common femoral artery (CFA) is visualized. During needle advancement, the artery is kept under the central target line (green circles), which indicates the path of the needle. Reprinted with permission from Seto et al.

Figure 3

A-B. Patient in supine position. These figures illustrate the three windows often used for needle entry during pericardiocentesis– apical, subcostal, and parasternal access; C-D. These figures show apical entry for performance of pericardiocentesis with transhthoracic echo monitoring; E. Post-procedure illustration of pericardial catheter drainage after trans-apical pericardiocentesis

Figure 4

A. Transthoracic 2-D echo during pericardiocentesis demonstrates a catheter within the pericardial space. The pericardial fluid was hemorrhagic; B. Saline contrast study shows contrast in the pericardial space, confirming that the pericardial catheter is not intracardiac

Figure 5

During echo monitoring of pericardiocentesis, it was noted that the guidewire had entered the left ventricle (arrows). The guidewire was subsequently removed and repeat pericardiocentesis performed

Figure 6

Transthoracic 2-D echo guidance during myocardial biopsy demonstrates the bioptome (arrows) is optimally positioned at the RV apex adjacent to the interventricular septum, facilitating a safe biopsy procedure

Figure 7

Echo can be used to biopsy the right side of the interventricular septum at different sites. In this example, the bioptome (arrow) is positioned at the mid portion of the septum. Asterix indicates RV free wall. RV, right ventricle; LV, left ventricle; RA, right atrium; LA, left atrium

Figure 8

The bioptome (arrow) is directed towards the right ventricular free wall and it was subsequently redirected towards the septum to allow for safe biopsy sampling

Figure 9

2D TEE view off a stented pulmonary artery with severe PR by 2D and 3D color flow doppler. PR, pulmonary regurgitation

Figure 10

A catheter is clearly visualize in the stent graft

Figure 11

A. Pre-deployment echo of PV with catheter; B. Successful implantation of pulmonic valve. PV, pulmonary valve

Figure 12

CoreValve (left, courtesy of Medtronic). SAPIEN 9000 TFX (bottom right) and SAPIEN XT 9300 TFX (top right) valves (courtesy of Edwards Lifesciences Inc.)

Figure 13

X-plane from 3D TEE system demonstrating in left panel cross section of aortic valve in a short axis view at the level of the aortic annulus; right panel, long axis view of left ventricular tract and aorta. Note: Dimension of aortic annulus is different in the short axis and long axis planes. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 14

Assessment of the relationship of the left (panels A and B) and right (panels C and D) coronary artery ostia (arrows) to the implanted stent-valve following TAVI using 3DTEE. (From Siegel et al. Curr J Cardiovasc Imaging Rep 2011, in press, with permission)

Figure 15

Multiplanar assessment of aortic annulus using 3DTEE. A. Short axis assessment of aortic valve; B. Left ventricular outflow tract view with measurement of aortic annulus diameter; C. Orthogonal measurement of the aortic annulus; D. A composite of three panels. The use of 3D TEE facilitates measurements of the aortic annulus from multiple angles. (From Siegel et al. Curr J Cardiovasc Imaging Rep 2011, in press, with permission)

Figure 16

Demonstration of the short axis view of the left ventricular outflow tract by 3DTEE shows the shape of the LVOT to be oval in this patient with severe aortic stenosis undergoing TAVI. A catheter (arrow) is present in the LVOT. (From Siegel et al. Curr J Cardiovasc Imaging Rep 2011, in press, with permission)

Figure 17

RT 3D TEE long axis view through mitral valve, LVOT, and aorta. View of length of catheter (arrows) from aorta traversing stenotic aortic valve and entering the LV. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 18

A. 3D view of balloon inflation during balloon valvuloplasty; B. Full volume 3D color flow showing severe aortic regurgitation after balloon valvuloplasty; (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 19

A. 2D TEE long axis view of 23mm bioprosthetic aortic valve B. 3D TEE long axis view-the stent length is too aortic and needs to be lower (more toward LVOT); C. The valve is now perfectly aligned. From Lerakis S. et al. JACC Vascular Imaging 2010;3:219-221), reprinted with permission

Figure 20

3D imaging during balloon inflation deploying Edwards Sapien bioprosthetic valve. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 21

A. Post deployment of the bioprosthetic valve; B. Full volume color flow demonstrates site and severity of aortic regurgitation. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 22

3D TEE color long axis view of the aortic valve demonstrating moderate peravalvular and transvalvular aortic regurgitation. (From Siegel et al. Curr J Cardiovasc Imaging Rep 2011, in press, with permission)

Figure 23

A. The schematic shows the Carpentier classification of the mitral valve scallops. P=posterior leaflet; A=Anterior leaflet; 1=lateral; 2=middle; 3=medial scallops; B. The measurements of coaptation length; C. flail gap, and D. flail width are shown. These are important for inclusion and exclusion criteria that need to be fulfilled prior to MitraClip placement. (From Siegel et al. Curr J Cardiovasc Imaging Rep 2011, in press, with permission)

Figure 24

A. 5 Chamber 2D TEE view suggests the lateral scallop of the posterior leaflet is flail; B. 3D TEE reveals the middle scallop of the posterior leaflet is flail and that there are 2 ruptured chordae tendineae (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 25

A-B. 2D TEE 4 Chamber views show prolapse and flail of the middle scallop (P2) with associated MR; C. 2D 3 chamber long axis view also shows middle scallop (P2) prolapse and flail; D. 3D RT TEE show flail medial and middle scallops (P2 and P3) (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 26

A. Short axis view at level of aortic valve shows transeptal catheter indenting the intra-atrial septum; B. 4 Chamber view shows transeptal catheter indenting the intra-atrial septum; C. X-plane imaging shows simultaneous views of intra-atrial septum during the transeptal puncture from the aortic short axis (left panel) and the bicaval view (right panel). (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 27

A. 2D TEE 4 Chamber view shows transeptal catheter indenting the intra-atrial septum; B. 3D TEE transeptal catheter indenting the intra-atrial septum from the left side of the septum. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 28

A-D. Serial 3 D images show how the open MitraClip is progressively re-oriented to that the clip is at the mid-portion of the mitral valve (above A2-P2) and perpendicular to the line of MV coaptation. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 29

A. 2D TEE transgastric view shows from the LV that the clip is perpendicular to the MV line of coaptation and near the central portion of the valve; B. 3D view from LV shows clip is at the mid-portion of the mitral valve (below A2 P2) and perpendicular to the line of MV coaptation. (From Siegel et al. Int Cardiovasc Imaging 2011, in press, with permission)

Figure 30

A. 2D TEE long axis view shows the MitraClip grasping the anterior and posterior leaflets; B. 3D TEE shows the MitraClip grasping the anterior and posterior leaflets (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)

Figure 31

3D TEE evaluation of size and the shape of the dual mitral orifices after MitraClip deployment. (From Siegel et al. Int J Cardiovasc Imaging 2011, in press, with permission)