Visualization of elusive structures using intracardiac echocardiography: Insights from electrophysiology

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