Jugular Vein Intracardiac Echocardiography-Guided Percutaneous Transluminal Septal Myocardial Ablation: A Novel Approach in 4 Cases

Abstract

Objective: This study sought to describe a novel technique for percutaneous transluminal septal myocardial ablation using intracardiac echocardiography (ICE) through the right internal jugular vein (JV) in patients with hypertrophic obstructive cardiomyopathy.

Key steps: Prepare the equipment and establish vascular access, insert the JV ICE catheter using a sterile sleeve, perform initial screening with JV ICE to obtain key cardiac views, identify target septal branch using coronary angiography and JV ICE, monitor contrast injection and ethanol administration in real time with JV ICE, continuously assess for immediate complications, and evaluate postprocedure gradient reduction and ablation efficacy.

Potential pitfalls: Risks include vascular complications, arrhythmias, cardiac tamponade, embolism, and infections. JV ICE requires specific skills, presenting a learning curve. Mitigation strategies involve ultrasound-guided access, careful catheter manipulation, strict asepsis, comprehensive training, optimized settings, and continuous monitoring.

Keywords: cardiomyopathy; echocardiography; treatment.

Graphical abstract

Figure 1

Setup Example ICE = intracardiac echocardiography; ICU = intensive care unit; LV = left ventricular; PM = pacemaker.

Figure 2

Imaging in Case 1 (A to C) Coronary angiography (A) before ablation, (B) during ballooning, and (C) post ablation. (D to G) Intracardiac echocardiography (ICE) (D) in the early phase of contrast injection, (E) in the late phase of contrast injection, (F) in the early phase of ethanol injection, and (G) in the late phase of ethanol injection. (H) A 3-chamber view by myocardial contrast echocardiography using transthoracic echocardiography. The contrast agent initially stains the myocardium in a wedge-shaped pattern from (D) the right ventricular side, eventually reaching (E) the surface of the left ventricle (LV). (F and G) The myocardium is gradually stained in proportion to the amount of alcohol injected. Intracardiac echocardiography provides superior visualization of the ablated myocardium compared with (H) transthoracic echocardiography. AV = aortic valve; PM = pacemaker; RV = right ventricle.

Figure 3

Imaging in Case 2, Second Session (A to D) Coronary angiography (A) before ablation, (B) during wiring to the first branch from the diagonal branch, (C) during wiring to the second branch from the left anterior descending (LAD) artery, and (D) post ablation. (E and F) Jugular vein intracardiac echocardiography showing (E) contrast agent injection to the first branch from the diagonal branch and (F) ethanol injection to the second branch from the left anterior descending artery. High signal intensity is observed up to the membranous septal region. LV = left ventricle.

Figure 4

Imaging in Case 3 (A to C) Coronary angiography (A) before ablation, (B) during ballooning to the second branch from the left anterior descending artery (LAD), and (C) during wiring to the first branch from the diagonal branch. (D and E) Jugular vein intracardiac echocardiography showing (D) contrast agent injection to the second branch from the left anterior descending artery and (E) ethanol injection to the first branch from the diagonal branch. High signal intensity is observed up to the membranous septal region. (F and G) Transthoracic echocardiography. (F) Parasternal long-axis view. (G) A 3-chamber view. Compared with (D and E) the intracardiac echocardiography imaging, (F and G) the transthoracic echocardiography imaging was poor. Ao = aorta; LA, left atrium; LV = left ventricle.

Figure 5

Imaging in Case 4 (A and B) Coronary angiography (A) before ablation and (B) during wiring to the first branch from the left anterior descending artery. (C) Jugular vein intracardiac echocardiography showing an ethanol injection to the first branch from the left anterior descending artery. No high signal intensity is observed in the membranous septal region. LV = left ventricle.

Figure 6

Puncture Site and Intracardiac Echocardiography Setup (A) Intracardiac echocardiography catheter with a sterile sleeve. The use of a sterile sleeve and a transparent seal maintains cleanliness of the puncture site and internal tissues while allowing the echocardiographer to operate in a nonsterile environment. (B) Intracardiac echocardiography device on a table. Placing the intracardiac echocardiography device on a table at the same height as the puncture site enhances stability during the procedure. (C) Echocardiographer operating an intracardiac echocardiography device. Reducing radiation exposure for the echocardiologist is crucial, in addition to maintaining sterile technique. Our institution uses a radiation shield of appropriate size to avoid interference with fluoroscopic equipment.

Figure 7

Multiple Views With Jugular Vein Intracardiac Echocardiography Identifying Complications or Hemodynamics (A) Long-axis ascending view. (B) Atrial septum view. There is small atrial septal defect with left-to-right shunt flow. (C) Long-axis tricuspid view. There is mild to moderate tricuspid regurgitation. (D) Pulse Doppler image of tricuspid regurgitation demonstrating the pressure gradient from the right ventricle (RV) to the right atrium (RA) of 24 mm Hg. (E) Long-axis left ventricular view. (F) Long-axis mitral valve view. (G) Long-axis aortic valve view. AML = anterior mitral leaflet; LA = left atrium; LV = left ventricle; PML = posterior mitral leaflet.

Figure 8

Equipment Setting for Percutaneous Transluminal Septal Myocardial Ablation Using Different Echocardiographic Approaches and ICE Positioning (A) Myocardial contrast echocardiography using a transthoracic echocardiography setup. (B) Comparison of intracardiac echocardiography (ICE) positioning for jugular vein intracardiac echocardiography (JV-ICE) and femoral vein intracardiac echocardiography (FV-ICE). (C) Femoral vein intracardiac echocardiography setup. (D) Jugular vein intracardiac echocardiography or transesophageal echocardiography (TEE) setup. Echo = echocardiography.