Table Of ContentPractical Intracardiac
Echocardiography in
Electrophysiology
Thisbookisdedicatedtomywife,Helen,ourdaughter,Kenna,andherchildren,
JonathanandJeremy[Jian-FangRen]
Practical Intracardiac
Echocardiography
in Electrophysiology
Jian-Fang Ren, MD
SeniorResearchInvestigator
ClinicalandExperimentalElectrophysiologyLaboratories
UniversityofPennsylvaniaSchoolofMedicine
Philadelphia,PA,USA
Francis E. Marchlinski, MD
ProfessorofMedicineandDirectorofElectrophysiology
UniversityofPennsylvaniaHealthSystem
Philadelphia,PA,USA
David J. Callans, MD
ProfessorofMedicineand
DirectoroftheCardiacElectrophysiologyLaboratory
HospitaloftheUniversityofPennsylvania
Philadelphia,PA,USA
David Schwartzman, MD
AssociateProfessorofMedicine
UniversityofPittsburgh
Pittsburgh,PA,USA
©2006Jian-FangRen,FrancisE.Marchlinski,DavidJ.Callans,andDavidSchwartzman
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Ren,Jian-Fang.
PracticalintracardiacEchocardiographyinelectrophysiology/authorandco-authors,
Jian-FangRen...[etal.].
p.;cm.
1.Echocardiography.2.Cardiaccatheterization.I.Title.
[DNLM:1.Echocardiography–methods.2.Electrophysiologic
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4.Ultrasonography,Interventional–methods.WG141.5.E2R3932005]
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Contents
Contributors, vii 7 IntracardiacEchocardiographicImagingin
RadiofrequencyCatheterAblationfor
Preface, ix
AtrialFibrillation, 88
1 IntracardiacEchocardiography:Basic Jian-FangRen,MD,&
Concepts, 1 FrancisE.Marchlinski,MD
Jian-FangRen,MD,&
8 LeftHeartTransducerPosition, 117
FrancisE.Marchlinski,MD
DavidSchwartzman,MD
2 ImagingEquipmentandRightHeart
9 IntracardiacEchocardiographicImagingin
CatheterizationTechnique, 5
RadiofrequencyCatheterAblationfor
Jian-FangRen,MD,&JeffreyP.Weiss,MD
VentricularTachycardia, 150
3 ImagingTechniqueandCardiac Jian-FangRen,MD,&
Structures, 18 FrancisE.Marchlinski,MD
Jian-FangRen,MD,&JeffreyP.Weiss,MD
10 IntracardiacEchocardiographicImagingin
4 CardiacAnatomicandFunctional RadiofrequencyCatheterAblationin
AbnormalitiesCommonlyDiagnosedin PatientswithEbstein’sAnomaly, 168
PatientsUndergoingElectrophysiological Jian-FangRen,MD,&DavidJ.Callans,MD
Procedures, 41
11 MonitoringandEarlyDiagnosisof
Jian-FangRen,MD,&DavidJ.Callans,MD
ProceduralComplications, 180
5 UtilityofIntracardiacEchocardiographic Jian-FangRen,MD,&
ImagingforTransseptalCatheterization, FrancisE.Marchlinski,MD
56
12 UtilityforExperimental
Jian-FangRen,MD,&
ElectrophysiologicalProcedures
FrancisE.Marchlinski,MD
inSwine, 208
6 IntracardiacEchocardiographicImagingin Jian-FangRen,MD,DavidJ.Callans,MD,
RadiofrequencyCatheterAblationfor &DavidSchwartzman,MD
InappropriateSinusTachycardiaandAtrial
Tachycardias, 74
Jian-FangRen,MD,&DavidJ.Callans,MD Index, 235
v
Contributors
David J. Callans, MD David Schwartzman, MD
ProfessorofMedicineand AssociateProfessorofMedicine
DirectoroftheCardiacElectrophysiologyLaboratory UniversityofPittsburgh
HospitaloftheUniversityofPennsylvania Pittsburgh,PA,USA
Philadelphia,PA,USA
Jeffrey P. Weiss, MD
Francis E. Marchlinski, MD AssociateProfessorofRadiology
ProfessorofMedicineandDirectorofElectrophysiology TempleUniversity
UniversityofPennsylvaniaHealthSystem Philadelphia,PA,USA
Philadelphia,PA,USA
Jian-Fang Ren, MD
SeniorResearchInvestigator
ClinicalandExperimentalElectrophysiologyLaboratories
UniversityofPennsylvaniaSchoolofMedicine
Philadelphia,PA,USA
vii
Preface
Tremendous advances in intracardiac echocardio- Chapter 4 describes commonly encountered cardiac
graphy (ICE) have coincided with the evolution of anatomicandfunctionalabnormalities.Thenextsix
interventional electrophysiology. The development chapterscovercurrentclinicalapplicationsofICEthat
of the latter has created a pressing need to directly includeguidingandmonitoringof transseptalcath-
imagecardiacanatomyduringcathetermanipulation eterization (Chapter 5) as well as mapping/ablating
and ablative therapy. The lower frequency (12.5– ofinappropriatesinustachycardia/atrialtachycardias,
9 MHz) mechanical ultrasound catheter and, more atrialfibrillation,ventriculartachycardia,andWolff–
recently,theelectronicphased-arraydiagnosticultra- Parkinson–Whitesyndrome(Chapters6–10).Oneof
soundcatheterwithDopplercolorflowimaginghave themorepowerfulapplicationsofICEimagingliesin
facilitated the use of an intravascular approach to itsabilitytoefficientlyidentifyproceduralcomplica-
image cardiac and adjacent non cardiac structures tionsbeforetheybecomelifethreatening.Chapter11
accurately, assess function and monitor closely for providesadetaileddescriptionofthesecomplications
complications.PracticalIntracardiacEchocardiography in addition to those described throughout the text.
inElectrophysiologyisdesignedtoprovidetheelectro- Thefinalchapterdescribesexperimentalapplications
physiologistandechocardiographerwithanin-depth ofICEinswine.
view of the role and value of ICE during electro- This book would not have been possible without
physiologic procedures. A guide to techniques used theeffortanddedicationofitsnumerouscontributors
foroptimalICEimagingincardiacelectrophysiology andforthis,Iowethemmyhighestregard.Iamalso
isprovided.Inaddition,newandlesswell-recognized honoredtohavehadtheprivilegeofworkingwithDrs
uses of ICE in electrophysiological procedures are Francis E. Marchlinski, David J. Callans, and David
described and their clinical applications are presen- Schwartzman,towhomIowethesuccessofmycareer.
ted.Thisbookcanalsobeusedasapracticalatlasasit IamalsogratefulforthesupportofAcuson-Siemens
hasover500illustrations,manyofwhichareincolor. MedicalSolutionsUSA,Inc.especiallyinsponsoring
Readersneednotbeexpertsinthefieldof echocar- theAcuNavpeertrainingcoursesinwhichIhadthe
diographytobenefitfromthispracticalapproachto pleasure to participate. These sessions provided me
intracardiacimaginginelectrophysiology. theopportunitytomeetsomanyenthusiasticecho-
Organized into 12 chapters, this text begins with cardiographersandelectrophysiologistseagertolearn
Chapter 1 describing the basic concepts of ICE about this new technology and imaging application
imaging. Chapter 2 deals with imaging equipment, andsharpenedmyfocusonwhatinformationneeded
ultrasound catheters, technical controls, and right tobeconveyedaboutthisexcitingnewfield.Inaddi-
heartcatheterizationtechniques.Informationregard- tion, this book is a tribute to the magnificent work
ingoptimalimageacquisitionandDopplerrecording ofallthepersonnelatBlackwellPublishingLtd.Last,
is presented and identification of acoustic artifacts I would like to take this opportunity to express my
on ICE image is described. Chapter 3 is devoted to appreciationofallthecardiologists,trainees,andstaff
ICE imaging techniques. Major emphasis has been whohaveworkedtirelesswithmeovertheyearsinthe
placed on optimizing transducer positioning and UniversityofPennsylvaniaHealthSystem.
imagingspecificcardiacstructuresespeciallyasthey
relate to electrophysiological arrhythmia substrate. Jian-FangRen
ix
Practical Intracardiac Echocardiography in Electrophysiology
Jian-Fang Ren, Francis E. Marchlinski, David J. Callans, David Schwartzman
Copyright © 2006 Jian-Fang Ren, Francis E. Marchlinski, David J. Callans, and David Schwartzman
1
CHAPTER 1
Intracardiac Echocardiography:
Basic Concepts
Jian-Fang Ren, , & Francis E. Marchlinski,
MD MD
Introduction ScientificCo.,Watertown,MA)anda10MHz(10Fr,
mechanical system, Cardiovascular Imaging System,
Intracardiac echocardiography (ICE), also termed
Sunnyvale, CA) ultrasound catheter were developed
intracardiacultrasoundcatheterimaging,allowsvisu-
intheearly1990s.Clinicalacceptanceoftheselower
alizationoftheheartfromwithinthecardiacchambers
frequencyultrasoundcathetertransducerswasrapid
orfromwithinthegreatvessels. Catheter-basedICE
inthatdetailedcardiacanatomyandfunctioncouldbe
has advanced from devices bearing single-element
easilydefined[13–15].Theclinicalefficacyandsafety
transducersandM-modetransducers[1,2]tothecur-
of ICE for diagnosis of cardiac structure and func-
rent technology, which allows for higher resolution
tion,forguidanceofradiofrequencycatheterablation,
two-dimensional imaging with pulsed/continuous-
andfortransseptalcatheterizationhavebeenextens-
wave Doppler and color flow evaluation of blood
ively described [13–20]. With further lowering of
vesselsandintracardiacstructures.
ultrasound frequency, ICE with 9 MHz mechan-
icalultrasoundcatheter(9Fr,BostonScientific,Co.,
Historical developments Watertown,MA)showedenhancedimagingcapabil-
itywithgreaterdepthofimagingfieldcomparedwith
Over the past 15 years, transducer miniaturization
the12.5and10MHzcatheters[21,22],buttheystill
andadvancesinmicroelectricandpiezoelectriccrystal
did not allow satisfactory imaging of the left heart
technology have allowed ICE to become an invalu-
fromtherightatriumortherightventricleinadults
abletoolforcardiacassessment.Noothertechnology
or an enlarged heart. Recently, a new 5.5–10 MHz,
allows for such superb temporal and spatial resolu-
10 Fr, electronic phased-array ultrasound catheter
tion through opaque blood [3–7]. In the late 1970s
withpulsed/continuous-waveDopplerandcolorflow
andearly1980s,real-timeM-modeechocardiography
imaginghasbeendeveloped(AcuNav,SiemensMed-
wastestedforintracardiacimaging[8,9].Inthe1990s,
ical Solutions USA,Inc., MountainView, CA). This
modified transesophageal transducers with low fre-
devicecanbeusedforimagingofleftheartstructures,
quency(5or7MHz)wereusedasultrasoundcatheters
for visualization of mapping/ablation catheters, and
for intracardiac imaging research in animal models
forevaluationofpulmonaryveinflow[23–25].This
but were not in clinical use due to the large size
ultrasound catheter has a flexible tip that provides
(24–30Fr) of the transducer [5,6,10,11]. A higher
for higher resolution and deeper penetration of the
frequency (20MHz) intravascular ultrasound cath-
left side of the heart from the right atrium during
eter was available for intracardiac imaging in 1990
interventional cardiac electrophysiologic procedures
[12]butwassuboptimalforimagingofcardiacstruc-
[24,26–27].
tures due to its diminished tissue penetration. One
of the initial limitations of this growing technology
ICE in electrophysiology
was the large size of the lower frequency ICE cath-
eters. Clinical usage of these devices was limited Duringthepast20years,interventionalcardiacelec-
until a 12.5 MHz (6 Fr, mechanical system, Boston trophysiologyprocedureshavebeenperformedalmost
1
2 CHAPTER1
exclusively under fluoroscopic guidance. Although has been further demonstrated not only in guiding
thistwo-dimensional“silhouette”imagingprovidesa transseptalcatheterizationandassistanceincatheter
generalrepresentationofcardiacanatomy,itrequires placementintherightheart,butalsowithassistance
substantial experience to position the intracardiac inplacementofmapping/ablationcathetersintheleft
catheterataspecificintracardiactarget.However,with heart,forinstanceinthepulmonaryveinostiaorat
the increasing complexity of interventional electro- the aortic valve cusps [37–39]. Rapid assessment of
physiologicprocedures,accurateimagingofintracar- the pulmonary vein flow velocity and identification
diacanatomicstructuresandinterventionalcatheter ofhemodynamicallysignificantstenosiscanbemade
deviceshasbeenrequired. Sotransesophagealecho- during pulmonary vein ablation procedures [25].
cardiographyhasbeenusedasamajorcomplement Instantdetectionofproceduralcomplications,suchas
to fluoroscopy for imaging of intracardiac struc- left atrial thrombus formation [40] and pericardial
turesforguidanceofinterventionalprocedures,such effusion,hasallowedforearlymanagementstrategies
as radiofrequency ablation and transseptal cathet- thatlimitadverseoutcome[24]. Morerecently, ICE
erization [28–32], and for assessing/monitoring the hasbeenusedtopreventesophagealdamageduring
placementoftranscatheterdevices[33,34].However, radiofrequencycatheterablationattheposteriorleft
severaldisadvantageshavelimiteditsroutineusedur- atrialwalladjacenttotheesophagusbyonlineassess-
ing interventional procedures, including prolonged ment of lesion development [41,42]. Additionally,
placementof thetransesophagealtransducerrequir- appropriateutilizationofthesepowerfulimagingtools
ingheavysedationand/orgeneralanesthesia[30,35], hasbeenaccompaniedbyareductionoffluoroscopic
the risk of vagal nerve stimulation that can be a exposure time for both the patient and the physi-
potentiallyseriouscomplication, andproblemswith cianwhichhasbeenanotherbenefitofICEguidance
inadequate orientation of transesophageal imaging [16,20,22].
planesforvisualizationof specificcardiacstructures
[10]. The new catheter-based ICE with mechanical
Future directions
radialimaging(9MHz,9Fr)hasdemonstrateditsutil-
ity for the safe and efficient guidance of transseptal
ICE heralds a novel era of catheter-based intrac-
catheterization[22].Foranatomicallybasedablation
ardiac ultrasound imaging technology. Additional
proceduresintherightheart,thisdevicecanprovide
improvementcanbeexpectedinthenearfutureallow-
real-timeguidanceandmonitoringof catheterloca-
ing multiplane and computer-reconstructed three-
tion, its tissue contact and stability, and assessment
dimensionalimaging[43,44],whichwillprovidemore
of the targeted lesion, such as in sinus node abla-
rapid and efficient diagnosis, guidance, and monit-
tion[36].Electronicallyphased-arrayICEcanprovide
oring.Althoughtherearenoreportedcomplications
cardiac structural and functional imaging in more
directlyrelatedtotheuseoftheultrasoundcatheter,
detail, especially for the left heart, which is com-
furtherrefinementandminiaturizationwillexpandits
parable with transesophageal echocardiography, but
clinical applications and ease of use of ICE imaging
withoutmanipulationinalimitedesophagealspace.
in diagnostic and therapeutic interventional elec-
In contrast to the mechanical radial imaging cath-
trophysiologic procedures, especially for ventricular
eterwithafixedultrasoundfrequencyandrigidtip,
tachyarrhythmia ablation directed at the ventricular
theelectronicphased-arrayICEcatheterhasvariable
endo-and/orepicardium.
ultrasonicfrequencyfrom5.5to10MHzandadeflect-
abletip, whichprovidesgreaterdetailandincreased
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