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Intracardiac echocardiography to guide transseptal catheterization for radiofrequency catheter ablation of left-sided accessory pathways: two case reports
Rodolfo Citro, Valentino Ducceschi, Alessandro Salustri, Michele Santoro, Michele Salierno, Giovanni Gregorio
Cardiovascular Ultrasound , 2004, DOI: 10.1186/1476-7120-2-20
Abstract: Trans-catheter radiofrequency ablation (TCRFA) has become the treatment of choice for patients suffering from refractory to medical treatment supraventricular tachycardias [1,2]. During percutaneous ablation procedures, catheter location is usually monitored by using fluoroscopy together with the analysis of intracardiac electrograms in order to clarify the mechanisms underlining the arrhythmia and to both locate its origin and record its circuit. This technique may be adequate for several standard ablative procedures, but it has still some limitations concerning the treatment of more complex tachycardia forms.Left-sided accessory pathway (LSAP) may be ablated using two different modalities: conventional approach through the aortic valve, or transseptal puncture of the fossa ovalis. By using the traditional approach, the left atrium is reached by a retrograde way through the left ventricle and crossing the mitral valve [3,4] whereas, with the transseptal puncture, the mitral ring is reached by an anterograde approach. For this reason, this approach has been considered an alternative and complementary technique for the transvenous introduction of catheters into the left cavities of the heart [5-8]. However, transseptal puncture under fluoroscopic guidance alone, might be hampered by some acute and potentially lethal complications that may be challenging even for expert electrophysiologists [9].With the technological and miniaturization advances of low frequency transducers capable of enhanced tissue penetration, intracardiac echocardiography (ICE) has become feasible and potentially useful for guiding transseptal puncture and ablation procedures, especially when location of specific anatomic landmarks appears to be more crucial [10,11].In this manuscript, two cases of ICE-guided catheter ablation of LSAP via transseptal approach have been described.A 24 year-old woman with Wolf-Parkinson-White (WPW) syndrome and recurrent episodes of sustained supraventricular tachyc
Thrombus Development on a Transseptal Sheath in the Right Atrium Before Electrical Pulmonary Vein Isolation  [cached]
Nieves Romero-Rodriguez,Alonso Pedrote,Eduardo Arana-Rueda,Maria Victoria Mogollon-Jimenez
Indian Pacing and Electrophysiology Journal , 2008,
Abstract: We describe the case of a patient who developed a thrombus on the transseptal sheath in the right atrium before transseptal puncture for circumferential pulmonary vein isolation for paroxysmal atrial fibrillation treatment. The use of intracardiac echocardiography allowed to its identification and probably prevented the patient from suffering a serious thromboembolic complication.
The Role of Intracardiac Echocardiography in Atrial Fibrillation Ablation
Elad Anter,Mathew D. Hutchinson,David J. Callans
Journal of Atrial Fibrillation , 2009, DOI: 10.4022/jafib.v1i9.553
Abstract: Radiofrequency catheter ablation of pulmonary veins has emerged as an effective therapy for patients with symptomatic atrial fibrillation. Advances in real-time intracardiac echocardiography with 2D and Doppler color flow imaging have led to its integration in atrial fibrillation ablation procedures. It allows imaging of the left atrium and pulmonary veins, including identification of anatomic variations. It has an important role in guiding transseptal catheterization, imaging the pulmonary vein ostia, assisting in accurate placement of mapping and ablation catheters, monitoring lesion morphology and flow changes in the ablated pulmonary veins, hence allowing titration of energy delivery. Importantly, it allows instant detection of procedural complications.
Intracardiac Echocardiography during Catheter-Based Ablation of Atrial Fibrillation  [PDF]
Jürgen Biermann,Christoph Bode,Stefan Asbach
Cardiology Research and Practice , 2012, DOI: 10.1155/2012/921746
Abstract: Accurate delineation of the variable left atrial anatomy is of utmost importance during anatomically based ablation procedures for atrial fibrillation targeting the pulmonary veins and possibly other structures of the atria. Intracardiac echocardiography allows real-time visualisation of the left atrium and adjacent structures and thus facilitates precise guidance of catheter-based ablation of atrial fibrillation. In patients with abnormal anatomy of the atria and/or the interatrial septum, intracardiac ultrasound might be especially valuable to guide transseptal access. Software algorithms like CARTOSound (Biosense Webster, Diamond Bar, USA) offer the opportunity to reconstruct multiple two-dimensional ultrasound fans generated by intracardiac echocardiography to a three-dimensional object which can be merged to a computed tomography or magnetic resonance imaging reconstruction of the left atrium. Intracardiac ultrasound reduces dwell time of catheters in the left atrium, fluoroscopy, and procedural time and is invaluable concerning early identification of potential adverse events. The application of intracardiac echocardiography has the great capability to improve success rates of catheter-based ablation procedures. 1. Introduction Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia. Catheter-based ablation of AF is usually recommended for patients with symptomatic paroxysmal AF that is resistant to antiarrhythmic drug therapy. This approach is supported by results of randomized and prospective trials comparing antiarrhythmic drug treatment with catheter-based ablation, showing significantly better rhythm control after ablation. In addition, meta-analyses of studies performed mostly in patients with paroxysmal AF, comparing antiarrhythmic drugs and catheter-based ablation, have also clearly supported these findings [1–5]. As catheter-based ablation with electrical isolation of the pulmonary veins (PVs) has become an established therapeutic option for patients with symptomatic AF, accurate recognition of the complex and variable anatomy of the left atrium (LA) is indispensable. Circumferential PV isolation is generally guided by three-dimensional (3D) electroanatomical mapping [6–8], fluoroscopy [9], and/or intracardiac echocardiography (ICE) [10, 11]. However, only ICE offers the unique ability to image the LA in real time during the course of the procedure and to identify all structures which are important for the ablation. Endpoints for a circumferential PV isolation procedure are either amplitude reduction within the ablated
Double Transseptal Puncture for Catheter Ablation of Atrial Fibrillation: Safety of the Technique and Its Use in the Outpatient Setting  [PDF]
Laurent M. Haegeli,Thomas Wolber,Ercüment Ercin,Lukas Altwegg,Nazmi Krasniqi,Paul G. Novak,Laurence D. Sterns,Corinna B. Brunckhorst,Thomas F. Lüscher,Richard A. Leather,Firat Duru
Cardiology Research and Practice , 2010, DOI: 10.4061/2010/295297
Abstract: Introduction. For pulmonary vein isolation in patients with atrial fibrillation (AF), some centers use the double transseptal puncture technique for catheter access in order to facilitate catheter manipulation within the left atrium. However, no safety data has so far been published using this approach. Method. 269 ablation procedures were performed in 243 patients (mean age 5 6 . 6 ± 9 . 3 years, 75% men) using the double transseptal puncture for catheter access in all cases. Patients were considered for ablation of paroxysmal (80%), persistent (19%), and permanent (1%) AF. 230 procedures were performed on an outpatient basis (85.5%), and 26 were repeat procedures (9.7%). Results. The double transseptal puncture catheter access was successfully achieved in all patients. The procedural success with the endpoint of pulmonary vein isolation was reached in 255 procedures (95%). A total of 1048 out of 1062 pulmonary veins (99%) were successfully isolated. Major complications occurred in eight patients (3.0%). Of these, seven patients (2.6%) had pericardial effusion requiring percutaneous drainage, and one patient (0.4%) suffered a minor reversible stroke. One patient (0.4%) had a minor air embolism with transient symptoms. Conclusion. The double transseptal puncture catheterization technique allows easy catheter manipulation within the left atrium to reach the goal of acute procedural success in AF ablation. Procedure-related complications are rare, and the technique can be used safely for AF ablation in the outpatient setting. 1. Introduction Atrial fibrillation (AF) is the most common of all cardiac arrhythmias with an incidence and prevalence on the rise. Radiofrequency catheter ablation is widely performed as an effective treatment for recurrent, drug-resistant AF [1–4]. Pulmonary vein isolation guided by circumferential mapping is the cornerstone in the catheter ablation for AF [5, 6]. The transseptal puncture is the conventional approach to access the left atrium, which was initially developed and described by Ross et al. for the measurement of left atrial pressure and for mitral valve repair [7]. Recently, the technique is routinely used in electrophysiologic laboratories in order to percutaneously map and ablate left atrial arrhythmias, especially AF [8]. When the electrophysiological or the combined electrical and anatomic approach for the ablation of AF aims for isolation of the pulmonary veins, two catheters have to be introduced by the transseptal access into the left atrium for mapping of the pulmonary veins and for radiofrequency ablation,
Intra-atrial endothelial lesion resulting from transseptal puncture for catheter ablation of atrial fibrillation  [cached]
Conrad Genz,Hans D. Esperer,Alexander Schmeisser,Ruediger C. Braun-Dullaeus
Heart International , 2012, DOI: 10.4081/hi.2012.e8
Abstract: Thromboembolic events are known complications of left atrial ablation therapy. We describe a complication which may also lead to systemic thromboembolism that has not been reported so far: the formation of a moving structure attached to the fossa ovalis after an attempted transseptal puncture in a 66-year old patient with symptomatic paroxysmal atrial fibrillation.
Intracardiac Echocardiography Guided Transeptal Catheter Injection of Microspheres for Assessment of Cerebral Microcirculation in Experimental Models  [PDF]
Judith Bellapart,Kimble R. Dunster,Sara Diab,David G. Platts,Christopher Raffel,Levon Gabrielian,Marc O. Maybauer,Adrian Barnett,Robert James Boots,John F. Fraser
Cardiology Research and Practice , 2013, DOI: 10.1155/2013/595838
Abstract: The use of microspheres for the determination of regional microvascular blood flow (RMBF) has previously used different approaches. This study presents for the first time the intracardiac injection of microspheres using transeptal puncture under intracardiac echocardiography guidance. Five Merino sheep were instrumented and cardiovascularly supported according to local guidelines. Two catheter sheaths into the internal jugular vein facilitated the introduction of an intracardiac probe and transeptal catheter, respectively. Five million colour coded microspheres were injected into the left atrium via this catheter. After euthanasia the brain was used as proof of principle and the endpoint for determination of microcirculation at different time points. Homogeneous allocation of microspheres to different regions of the brain was found over time. Alternate slices from both hemispheres showed the following flow ranges: for slice 02; 0.57–1.02?mL/min/g, slice 04; 0.45–1.42?mL/min/g, slice 06; 0.35–1.87?mL/min/g, slice 08; 0.46–1.77?mL/min/g, slice 10; 0.34–1.28?mL/min/g. A mixed effect regression model demonstrated that the confidence interval did include zero suggesting that the apparent variability intra- and intersubject was not statistically significant, supporting the stability and reproducibility of the injection technique. This study demonstrates the feasibility of the transeptal injection of microspheres, showing a homogeneous distribution of blood flow through the brain unchanged over time and has established a new interventional model for the measurement of RMBF in ovine models. 1. Introduction The measurement of microcirculation in specific organs has been the focus of multiple studies since 1967, when 50?μ diameter radionuclide-labelled carbonised spheres were injected in the foetal umbilical vein of sheep [1]. Since then, several studies have introduced modifications to the methods including the description of the reference sample for the calculation of blood flow [2], the injection of microspheres into the left atrium (LA) to minimise peripheral and central shunting [3], transient occlusion of the pulmonary artery also to minimise shunting [4], and the use of two different radioactive spheres and simultaneous LA and right atrium (RA) injections (via a left thoracotomy) to discriminate shunting from pulmonary blood flow [5]. Substantial modifications in this technique also included the use of nonradioactive spheres [6] which added significant environmental and logistical advantages. In addition, the use of smaller size spheres showed to be less
Endomyocardial Biopsy of Right Atrial Angiosarcoma Guided by Intracardiac Echocardiography  [PDF]
Suman S. Kuppahally,Sheldon E. Litwin,Andrew D. Michaels
Cardiology Research and Practice , 2010, DOI: 10.4061/2010/681726
Abstract: We report a case of a 22-year-old female who presented with pericardial effusion and cardiac tamponade. She was diagnosed with a right atrial mass by computed tomography and was referred to our institution for biopsy of this mass. Transcatheter biopsy was performed with intracardiac echocardiography (ICE) guidance, avoiding the need for transesophageal echocardiography or surgery to obtain the biopsy. ICE for transcatheter biopsy of an intracardiac mass is an attractive modality which provides precise localization of the cardiac structures. 1. Case Report A 22-year-old female presented with dyspnea on exertion for 2 months and a syncopal episode. On presentation to an outside hospital, she was found to have a pericardial effusion with evidence of cardiac tamponade. An emergent pericardiocentesis was performed and 50 milliliters of bloody fluid were drained with immediate improvement in her hemodynamics. Cytology of pericardial fluid did not demonstrate malignancy. Transthoracic echocardiogram showed mild thickening of the right atrial wall (Figure 1(a)). Electrocardiographic-gated computed tomography (CT) showed a large mass with a broad-based attachment to the free wall of the right atrium (RA). The mass filled most of the RA appendage with an irregularly shaped border (Figure 1(b)). The right coronary artery was not involved. A 1.5 Tesla cardiac MRI (Avanto, Siemens Medical Solutions, Malvern, PA) with gadolinium contrast showed a similar appearance of the mass without evidence of fat or any delayed enhancement (Figure 1(c)). She was referred to our institution for biopsy of the mass. Figure 1: Right atrial mass imaging by different modalities: (a) Transthoracic echocardiography, apical four-chamber view. Thickening of the right atrial wall (arrow). (b) Chest CT, axial view. Enhancing mass (arrow) with papillary projections in the lateral wall of the right atrium. (c) Cardiac MRI, axial view. A heterogeneous, vascular mass involving the right atrial lateral wall. (d) Intracardiac echocardiography. Irregular mass (arrow) infiltrating the right atrial wall. We performed percutaneous transcatheter biopsy of the RA mass using fluoroscopic and intracardiac echocardiographic (ICE) guidance (10F Sound-Star, Biosense Webster, Diamond Bar, CA). The tumor infiltrated the wall of RA free wall and was 1.5 centimeters in thickness. ICE showed papillary projections as seen on the CT scan (Figure 1(d)). Pathologic analysis showed a malignant angiosarcoma. She underwent 4 cycles of chemotherapy with doxorubicin and ifosfamide, and surveillance cardiac MRI showed
Visualization of elusive structures using intracardiac echocardiography: Insights from electrophysiology
T Szili-Torok, EP McFadden, LJ Jordaens, JRTC Roelandt
Cardiovascular Ultrasound , 2004, DOI: 10.1186/1476-7120-2-6
Abstract: During the last two decades revolutionary diagnostic and therapeutic changes were implemented in the management of patients with arrhythmias. The development of transcatheter ablation provided a curative treatment of most supraventricular tachyarrhythmias including atrioventricular (AV) and AV nodal reentry tachycardias and more recently atrial flutters. Life threatening ventricular arrhythmias are effectively palliated by implantable anti-tachycardia devices and conduction disorders treated by pacemakers, with instantaneous improvement. New challenges are the effective treatment of patients with atrial fibrillation, which is the most frequent and often disabling arrhythmia and the curative treatment of patients with life threatening arrhythmias. The development of novel ablative procedures are currently being investigated but the success rate still remains suboptimal. Since the arrhythmia substrate is frequently associated with certain anatomical structures or morphological variants, improved imaging has increasing role in the improvement of these treatments. Furthermore, novel catheter ablation approaches require catheter placement to sites, which may be associated with increased complication risk. Therefore imaging has a crucial role both in guiding and improving safety of electrophysiology (EP) procedures. Also, thromboembolic risk stratification, fine-tuning of the implanted sophisticated devices require advanced and effective imaging techniques as does their follow-up.Electrophysiological mapping and ablation techniques are increasingly used to diagnose and treat many types of supraventricular and ventricular tachycardias. These procedures require an intimate knowledge of intracardiac anatomy and their use has led to a renewed interest in visualization of specific structures [1-3]. This has required collaborative efforts from imaging as well as electrophysiology experts. Classical imaging techniques may be unable to visualize structures involved in arrhythmia
Aplica??es do ecocardiograma intracardíaco no laboratório de eletrofisiologia
Saad, Eduardo B.;Costa, Ieda Prata;Camanho, Luiz Eduardo M.;
Arquivos Brasileiros de Cardiologia , 2011, DOI: 10.1590/S0066-782X2011000100019
Abstract: the intracardiac echocardiography (ice) offers a detailed visualization of the cardiac structures, in association with hemodynamic information, allowing the precise and real-time positioning of the catheters, decreasing the time of exposure to fluoroscopy and the monitoring of acute complications during the electrophysiological procedure (i.e., formation of thrombi, pericardial effusion, cardiac tamponade), consequently, its use has progressively increased, mainly in the ablation of atrial fibrillation and ventricular arrhythmias. it has shown to be very useful in the ablation of atrial fibrillation by providing anatomic data on the left atrium and pulmonary veins, helping in transseptal punctures, locating the ostium and antrum of the pulmonary veins, monitoring tissue injury during radiofrequency (rf) use, preventing esophageal injury by monitoring the injuries caused by rf on the left atrial posterior wall and assessing the pulmonary vein flow.
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