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Review
. 2013 Apr 6;5(6):786.
doi: 10.4022/jafib.786. eCollection 2013 Apr-May.

Role of Intracardiac echocardiography in Atrial Fibrillation Ablation

Antonio Dello Russo  1 , Eleonora Russo  1 , Gaetano Fassini  1 , Michela Casella  1 , Ester Innocenti  1 , Martina Zucchetti  1 , Claudia Cefalu  1 , Francesco Solimene  2 , Gaetano Mottola  2 , Daniele Colombo  1 , Fabrizio Bologna  1 , Benedetta Majocchi  1 , Pasquale Santangeli  3 , Stefania Riva  1 , Luigi Di Biase  3 , Cesare Fiorentini  1 , Claudio Tondo  1
Affiliations
Review

Role of Intracardiac echocardiography in Atrial Fibrillation Ablation

Antonio Dello Russo et al. J Atr Fibrillation. .

Abstract

In the recent years, several new evidences support catheter-based ablation as a treatment modality of atrial fibrillation (AF). Based on a plenty of different applications, intracardiac echocardiography (ICE) is now a well-established technology in complex electrophysiological procedures, in particular in AF ablation. ICE contributes to improve the efficacy and safety of such procedures defining the anatomical structures involved in ablation procedures and monitoring in real time possible complications. In particular ICE allows: a correct identification of the endocardial structures; a guidance of transseptal puncture; an assessment of accurate placement of the circular mapping catheter; an indirect evaluation of evolving lesions during radiofrequency (RF) energy delivery via visualization of micro and macrobubbles tissue heating; assessment of catheter contact with cardiac tissues. Recently, also the feasibility of the integration of electroanatomical mapping (EAM) and intracardiac echocardiography has been demonstrated, combining accurate real time anatomical information with electroanatomical data. As a matter of fact, different techniques and ablation strategies have been developed throughout the years. In the setting of balloon-based ablation systems, recently adopted by an increasing number of centers, ICE might have a role in the choice of appropriate balloon size and to confirm accurate occlusion of pulmonary veins. Furthermore, in the era of minimally fluoroscopic ablation, ICE has successfully provided a contribute in reducing fluoroscopy time. The purpose of this review is to summarize the current applications of ICE in catheter based ablation strategies of atrial fibrillation, focusing-on electronically phased-array ICE.

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Figures

Figure 1.
Figure 1.. Panel A: Intracardiac echocardiography (ICE)-2D image of the left atrium (LA), left atrial appendage (LAA) and fossa ovalis (FO). The green lines represent the endocardial borders tracked in order to build a 3D anatomical shell. Panel B: Co-registration of the LA ICE-3D-anatomical shell and the pre-operative cardiac computed tomography (CT) scan.
Figure 2.
Figure 2.. Panel A: Intracardiac echocardiography (ICE) 2D image of the left atrium (LA), left superior and inferior pulmonary veins (LSPV and LIPV). The green lines represent the endocardial borders. Panel B: Co-registration of the LA ICE-3D-anatomical shell and the pre-operative cardiac CT scan
Figure 3.
Figure 3.. Panel A: Intracardiac echocardiography (ICE)-2D image of the left atrium (LA), right inferior pulmonary vein (RIPV). The green lines represent the endocardial borders. Panel B: Co-registration of the LA ICE-3D-anatomical shell and the pre-operative cardiac CT scan.
Figure 4.
Figure 4.. Panel A: Intracardiac echocardiography (ICE)-derived 2D image of the left atrium (LA), right superior pulmonary vein (RSPV). The green lines represent the endocardial borders. Panel B: Co-registration of the LA ICE 3D-anatomical shell and the pre-operative cardiac CT scan
Figure 5.
Figure 5.. Two-dimensional ICE image derived from a transducer location in right atrium (RA). From this view it is possible to see the fossa ovalis (FO) and left atrium (LA)
Figure 6.
Figure 6.. Two-dimensional ICE image that shows the Brockenbrough-curve needle is advanced from the right atrium (RA) to the fossa ovalis (FO) for transseptal puncture guided by ICE. LA: left atrium.
Figure 7.
Figure 7.. Interatrial septum visualized using ICE transoesophageally, tenting of the interatrial septum towards the left atrium (LA); RA, right atrium.
Figure 8.
Figure 8.. Sequence of ICE imaging of transseptal puncture by radiofrequency delivery, crossing a thickened interatrial septum. Panel A: the tip of the powered needle is positioned in the fossa ovalis of the interatrial septum. Panel B: tenting of the fossa ovalis is demonstrated. Panel C: a single application of radiofrequency energy was delivered. Panel D: the tip of the needle can be seen in the left atrium (LA) immediately after radiofrequency energy delivery and the needle crossed the septum.
Figure 9.
Figure 9.. Screen shot of the CARTO (Biosense Webster, Inc., Diamond Bar, Calif.) electroanatomical mapping system. The ostium of the left superior PV, identified by ICE, is used as single landmark point (red circle on the ICE image right on the top). On the left the endocardial landmark point is marked on the imported 3-D CT image, thus creating a landmark pair, with one landmark point on the real-time electroanatomical map and the other on the 3-D CT image. Landmark registration approximates the electroanatomical map to the 3D CT surface reconstruction by matching the landmark pair.
Figure 10.
Figure 10.. Screen shot of the CARTO (Biosense Webster, Inc., Diamond Bar, Calif.) electroanatomical mapping system. Using more landmark points increases the accuracy of the registration process. On the right, the ICE 2-D image shows landmark points (red circles). The left panel shows landmarks points on the real time electroanatomical map and on the 3-D CT image.
Figure 11.
Figure 11.. Intracardiac echocardiography (ICE)-derived 2D image of the left atrium (LA). A circular mapping catheter can clearly be visualized in the antrum of the LSPV.
Figure 12.
Figure 12.. Intracardiac echocardiography (ICE)-derived 2D image of the left atrium (LA). Activating the function “show mapping catheter tip”, a green colored electronic representation of the catheter tip appears in the ultrasound real time image when the ultrasound fan intersects it.
Figure 13.
Figure 13.. Intracardiac echocardiography (ICE) 2D image showing a large pericardial effusion (PE) surrounding the left ventricular wall.
Figure 14.
Figure 14.. Pulmonary vein occlusion guided by angiography and intracardiac echocardiography (ICE). Panel A: left anterior oblique fluoroscopic view showing the cryoballoon already inflated and placed in front of the left superior pulmonary vein (LSPV). Angiography shows complete occlusion. Panel B: intracardiac echocardiographic view of the LSPV antrum, displaying the whole left atrial antrum and the PV itself, as well as the balloon that has been placed in front of it. Color Doppler shows the absence of reflow to the left atrium.
Figure 15.
Figure 15.. Panel A: pulmonary vein (PV) isolation using the laser balloon technology. The laser balloon is inflated in the left superior pulmonary vein (LSPV). Panel B: endoscopic view shows LSPV antrum. Panel C: intracardiac echocardiography (ICE)-derived 2D image of the left atrium with the Zonare technology. The laser balloon catheter can be visualized in the antrum of LSPV.
Figure 16a.
Figure 16a.. Screen shot of the CARTO (Biosense Webster, Inc., Diamond Bar, Calif.) electroanatomical mapping system. On the right, in the ICE 2-D image, the green colored electronic representation of the catheter tip in left atrial chamber shows no contact to endocardial tissue (also confirmed by low contact force in left panel.
Figure 16b.
Figure 16b.. Screen shot of the CARTO (Biosense Webster, Inc., Diamond Bar, Calif.) electroanatomical mapping system. On the right, in the ICE 2-D image, the green colored electronic representation of the catheter tip in left atrial chamber shows good contact to endocardial tissue. In the left panel high contact force confirmed good catheter tip-tissue contact.
Figure 17.
Figure 17.. Screen shot of the Sensei robotic navigation system (Hansen Medical, Mountain View, Calif.) with CARTO system (Biosense Webster, Inc., Diamond Bar, Calif.) and the novel Smarttouch catheter (Biosense Webster, Inc., Diamond Bar, Calif.). Bottom right panel, in the ICE 2-D image, the ablation catheter and circular mapping catheter can be visualized in the antrum of LIPV. Top right panel, a left anterior oblique fluoroscopic view of the SmartTouch catheter catheter guided by Sensei robotic navigation system in the left atrium. Multipolar circular mapping and coronary sinus catheters are also shown. Left panel, 3-D CT image view showing left pulmonary veins. Radiofrequency applications (small red circles) were deployed at the posterior aspect of the ostium of the left superior pulmonary vein (LSPV). The ablation catheter tip is positioned at the ridge of the left inferior pulmonary vein (LIPV). The intelisense force and smarthouch force in grams are similar.
Figure 18.
Figure 18.. Panel A: screen shot of the CARTO electroanatomical mapping system showing the nMARQ circular catheter (Biosense Webster, Inc., Diamond Bar, Calif.) in the antrum of the left pulmonary veins (LPVs). Panel B: anteroposterior fluoroscopic view with the nMARQ circular catheter in LPVs. Panel C: the intracardiac echocardiography (ICE)-derived 2D image of the left atrium confirms the position of the multielectrode ablation catheter.
Figure 19.
Figure 19.. Panel A: right anterior oblique view shows placement of a percutaneous left atrial appendage (LAA) device closure (Amplatzer Cardiac Plug, AGA Medical, SJM). Panel B: three dimensional transesophageal echocardiography reconstruction of left atrium and LAA orifice after device positioning. Panel C: intracardiac echocardiography 2D image showing the device placed in LAA.
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