Transesophageal echocardiography and intracardiac echocardiography differently predict potential technical challenges or failures of interatrial shunts catheter-based closure

We sought to prospectively assess the role of transesophageal (TEE) and intracardiac echocardiography (ICE) in detecting potential technical difficulties or failures in patients submitted to interatrial shunts percutaneous closure. We prospectively enrolled 46 consecutive patients (mean age 35+/-28, 8 years, 30 female) referred to our center for catheter-based closure of interatrial shunts. All patients were screened with TEE before the intervention. Patients who met the inclusion criteria underwent ICE study before the closure attempt (40 patients). TEE detected potential technical difficulties in 22.5% (9/40) patients, whereas ICE detected technical difficulties in 32.5% (13/40 patients). In patients with positive TEE/ICE the procedural success (92.4% versus 100% and, P = ns) and follow-up failure rate (7.7% versus 0%, P = ns) were similar to patients with negative TEE/ICE, whereas the fluoroscopy time (7 +/- 1.2 versus 5 +/- 0.7 minutes, P < 0.03), the procedural time (41 +/- 4.1 versus 30 +/- 8.2 minutes, P +/- 0.03), and technical difficulties rate (23.1% versus 0%, P = 0.013) were higher. Differences between ICE and TEE in the evaluation of rims, measurement of ASD or fossa ovalis, and detection of venous valve and embryonic septal membrane remnants impacted on technical challenges and on procedural and fluoroscopy times but did not influence the success rate and follow-up failure rate.     

Comparison of intracardiac echocardiography versus transesophageal echocardiography guidance for percutaneous transcatheter closure of atrial septal defect

Transcatheter closure of interatrial septal defects is guided by transesophageal echocardiography (TEE), which requires general anesthesia in most cases. Using a new intracardiac echocardiographic (ICE) catheter may avoid endotracheal and esophageal intubation while using only local anesthesia. Forty-two patients underwent transcatheter interatrial septal defect closure; half of them underwent TEE guidance with general anesthesia and the other half underwent ICE guidance with local anesthesia. Device deployment success rate, adequate 2-dimensional and Doppler visualization of the defect and deployment steps, interatrial communication closure at 24 hours, and at 3 and 6 months, procedure time length, complications, fluoroscopic time, and length of hospitalization were compared between both methods. All interventions were completed successfully with no complications, except for 1 patient in the TEE group who had a minor oral trauma. Echocardiographic visualization of the septal defect and deployment was adequate by both methods. Catheterization laboratory time (92 +/- 18 vs 50 +/- 12 minutes, p <0.001) and interventional procedure length (47 +/- 8 vs 35 +/- 6 minutes, p <0.001) were shortened using ICE. There was no difference in the rate of closure after 6-month follow-up by either method. ICE guidance offers equivalent echocardiographic views compared with TEE and similar rates of closure. ICE is associated with decreased procedure length while eliminating the risks of endotracheal or esophageal intubation and general anesthesia.     

Intracardiac versus transesophageal echocardiography to guide transcatheter closure of interatrial communications: Nationwide trend and comparative analysis

Objectives

This study aimed to assess current temporal trends in utilization of ICE versus TEE guided closure of interatrial communications, and to compare periprocedural complications and resource utilization between the two imaging modalities.

Background

While transesophageal echocardiography (TEE) has historically been used to guide percutaneous structural heart interventions, intracardiac echocardiography (ICE) is being increasingly utilized to guide many of these procedures such as closure of interatrial communications.

Methods

Using the Nationwide Inpatient Sample, all patients aged >18 years, who underwent ASD or PFO closure with either ICE or TEE guidance between 2003 and 2014 were included. Comparative analysis of outcomes and resource utilization was performed using a propensity score‐matching model.

Results

ICE guidance for interatrial communication closure increased from 9.7% in 2003 to 50.6% in 2014. In the matched model, the primary endpoint of major adverse cardiovascular events occurred less frequently in the ICE group versus the TEE group (11.1% vs 14.3%, respectively, P = 0.008), mainly driven by less vascular complications in the ICE group (0.5% vs 1.3%, P = 0.045). Length of stay was shorter in the ICE group (3 ± 4 vs 4 ± 4 days, P < 0.0001). Cost was similar in the two groups 18 454 ± 17 035$ in the TEE group vs 18 278 ± 15 780$ in the ICE group (P = 0.75).

Conclusions

Intracardiac echocardiogram utilization to guide closure of interatrial communications has plateaued after a rapid rise throughout the 2000s. When utilized to guide interatrial communication closure procedure, ICE is as safe as TEE and does not increase cost or prolonged hospitalizations.

     

Intracardiac echocardiography guided device closure of atrial septal defects

OBJECTIVES: This study was designed to determine the feasibility and accuracy of intracardiac echocardiography (ICE) in guiding percutaneous closure of atrial septal defects (ASD). BACKGROUND: Intracardiac echocardiography is a novel imaging technique that might be used to guide interventional procedures. The sensitivity and specificity of ICE, compared to standard imaging techniques, in detecting potentially adverse procedural events and guiding remedial action will be an important consideration in its use. METHODS: In a prospective study, 24 patients underwent device closure of ASD using ICE as the primary echocardiographic imaging modality. Feasibility was expressed as proportion of cases in which complete diagnostic ICE imaging was achieved. Accuracy was expressed as the percent agreement between ICE and simultaneously performed transesophageal echocardiography (TEE). RESULTS: High-quality ICE images were acquired in all patients, though images were limited in two patients with aneurysmal septa. Intracardiac echocardiography successfully guided closure of 24 out of 25 ASDs (96%) in 23 patients. There was close agreement between ICE and TEE in their assessment of device position and the adequacy of septal capture before device release (98%) and in identifying the presence of significant residual shunts. Intracardiac echocardiography detected all potentially adverse events, including four malpositions, and guided appropriate remedial action. CONCLUSIONS: Intracardiac echocardiography guided device closure of secundum ASDs is feasible in the majority of patients and provides diagnostic data comparable to TEE. These data indicate that ICE may be used to guide routine closure of ASDs in adults without the need for TEE and general anesthesia.     

Use of Intracardiac Compared With Transesophageal Echocardiography for Left Atrial Appendage Occlusion in the Amulet Observational Study

ObjectivesThe aim of this study was to compare patient and procedural characteristics, clinical events, and left atrial appendage (LAA) occlusion rates among implantation procedures guided either by intracardiac echocardiography (ICE) or by transesophageal echocardiography (TEE) in the Amulet Observational Study.BackgroundTEE is standard for intraprocedural imaging during LAA occlusion. ICE is an alternative enabling local rather than general anesthesia.MethodsThe Amulet Observational Study is a prospective, multicenter, post-market study of the Amulet device in patients with atrial fibrillation at risk for thromboembolism from the LAA. Procedures were guided by ICE in the left atrium or TEE. A clinical events committee adjudicated serious adverse events. LAA closure was assessed by a core laboratory 1 to 3 months post-implantation.ResultsNine hundred fifty-five procedures were TEE guided and 130 (12%) were ICE guided. Local anesthesia was used in 93% of ICE-guided cases. Implantation success was >99% in both groups (p = 1.00). The procedure was longer (40 ± 31 min vs. 33 ± 21 min; p = 0.01) and contrast use higher (145 ± 157 ml vs. 98 ± 76 ml; p < 0.01) for ICE cases. LAA closure rate was 100% using ICE and 98% using TEE. Vascular access serious adverse events occurred in 0.8% of ICE patients and 1.5% of TEE patients (p = 0.52). Pericardial effusions or tamponade was observed at rates of 2.5% per year and 1.7% per year in ICE and TEE patients, respectively (p = 0.57). Rates of ischemic stroke (4.1% per year vs. 2.6% per year; p = 0.37) and major bleeding (8.2% per year vs. 10.6% per year; p = 0.44) did not differ significantly between ICE and TEE patients.ConclusionsAmulet LAA occlusion procedures guided by ICE and TEE resulted in comparable clinical event and LAA closure rates, without differences in procedural or vascular complications despite longer procedures and more contrast use.     

Initial clinical experience with intracardiac echocardiography in guiding transcatheter closure of perimembranous ventricular septal defects: feasibility and comparison with transesophageal echocardiography.

Over the last several years, intracardiac echocardiography (ICE) has been employed successfully in guiding transcatheter device closure of a secundum atrial septal defect (ASD) or patent foramen ovale (PFO). Nothing is known regarding the use of ICE to guide catheter device closure of a perimembranous ventricular septal defect (PMVSD). Twelve patients (seven female/five male) who had a PMVSD (among them, three patients with associated atrial communications: two with an ASD and one with a PFO) underwent attempts at transcatheter device closure using the Amplatzer membranous VSD device of their defects, using sequential transesophageal echocardiography (TEE) and ICE guidance with general endotracheal anesthesia (five patients) and using ICE alone with conscious sedation (seven patients). The mean age of patients was 16.9 +/- 3.7, and their mean weight was 42.4 +/- 6.6. Their mean left ventricular end-diastolic dimension preclosure was 45.7 +/- 2.5. The Qp/Qs ratio ranged from 1.0 to 1.8:1. During the procedure, the ICE catheter was positioned in the right atrium (RA) in all 12 patients and the ICE catheter was advanced to the left atrium to obtain a view of the ventricular septum in 3. Both TEE and ICE provided similar anatomical views of the position of the PMVSD. Furthermore, the relationship of the defect to the aortic valve and tricuspid valves, the measured size of defect, and the guidance of various stages of device deployment were comparable by TEE and ICE. There were no complications encountered during or after closure. We conclude that ICE provides unique images of the PMVSD and measurements similar to those obtained by TEE. ICE potentially could replace TEE in most patients as a guiding imaging tool for PMVSD device closure, thus eliminating the need for general endotracheal anesthesia.     

Encerramento percutâneo de defeitos do septo interauricular guiado por ecocardiograma intracardíaco − A experiência de um centro

IntroductionDevice closure of interatrial communications has become a well-established technique to treat left-to-right shunt associated with atrial septal defect (ASD) and to prevent paradoxical embolism in patients with patent foramen ovale (PFO). Guidance by transesophageal echocardiography (TEE) is the standard practice but intracardiac echocardiography (ICE) is a feasible and safe alternative for monitoring these procedures.ObjectivesTo report our experience in the percutaneous closure of ASD and PFO guided by ICE.MethodsWe retrospectively reviewed all patients with ASD or PFO who underwent percutaneous closure guided exclusively by ICE between January 2008 and December 2010. All patients were followed clinically with regular echocardiographic evaluation (at discharge, one month, three, six and twelve months) to exclude residual shunt and device malposition.ResultsA total of 127 patients (mean age 46.6±12.2 years; 71% female) underwent transcatheter device closure of ASD or PFO during the study period. Device deployment with ICE monitoring was 100% successful, with a low rate of complications and eliminating the need for additional imaging techniques.ConclusionsICE provides anatomical detail of ASD/PFO and cardiac structures, facilitating congenital cardiac interventional procedures. It eliminates the major drawbacks associated with TEE and enables the interventional cardiologist to control all aspects of the procedure without relying on additional echocardiographic support.     

Transcatheter Intracardiac Echocardiography-Assisted Closure of Interatrial Shunts: Complications and Midterm Follow-Up

Objective: It has been suggested that intracardiac echocardiography (ICE) improves the safety and effectiveness of transcatheter device-based closure of interatrial shunts, but the impact of this technique on midterm follow-up is unknown. We sought to prospectively evaluate midterm follow-up results of ICE-aided transcatheter closure of interatrial shunts in adults. Methods: Over a 48-month period, we prospectively enrolled 140 consecutive patients (mean age 43 ± 15. 5 years, 98 females) who had been referred to our center for catheter-based closure of interatrial shunts. All patients were screened with transesophageal echocardiography (TEE) before the operation. Patients who met the inclusion criteria underwent ICE study and attempted closure. Immediate success rates, predischarge occlusion rates, complication rates, as well as fluoroscopy and procedural times, patients' radiological exposure, midterm complication rates, and midterm occlusion rates were evaluated. Results: One hundred patients out of 140 (71.4%) underwent an attempt at transcatheter closure. After ICE study and measurements, the TEE-planned device type and size was changed in 31 patients with patent foramen ovale whereas the TEE-planned device size was changed in 41 patients with atrial septal defect (globally 72%). Procedural success rate, predischarge occlusion rate, and complication rate were 99, 90.7, and 12%, respectively. On mean follow-up of 36.6 ± 14.8 months the follow-up occlusion rate was 96.5%. No aortic erosion or device thrombosis was observed. Conclusions: ICE-guided interatrial shunt transcatheter closure is safe and effective and appears to have excellent midterm results thus avoiding the complications caused by device oversizing, such as aortic erosion and device thrombosis.     

Effect of atrial septal mobility on transcatheter closure of interatrial communications

BACKGROUND: Transcatheter techniques have evolved as alternatives to surgical closure of interatrial communications due to its less invasive nature and low morbidity. The technique may be limited by the inability to deploy the device and, thus, may be complicated by significant residual shunting. Mobile or redundant septal tissue has been implicated as a possible cause of unsuccessful closure. METHODS: To determine if atrial septal hypermobility precludes successful transcatheter device closure of interatrial communications, 69 patients (mean age 46.4 +/- 17.5 years [male:female ratio 34:35]) with periprocedural transesophageal echocardiograms were reviewed. Septal excursion was defined as the maximal transit of the interatrial septum between either side of the plane connecting the superior and inferior attachment points. Unsuccessful closure was defined as subsequent cardiac surgery to close the defect, inability to deploy the device, recurrent attempts at closure, device malalignment, residual shunting greater than mild in degree on follow-up transthoracic study, and procedural complications. RESULTS: Reasons for closure were the following: embolic events (n = 48); platypnea/orthodeoxia (n = 15); atrial septal defect with right ventricular dilatation and paroxysmal atrial tachycardia (n = 2); atrial septal defect (n = 3); and prophylactic patent foramen ovale closure in a scuba diver (n = 1). Successful closure occurred in 76% of patients (n = 53). Compared with those patients with successful transcatheter closure, the mean septal excursion in patients with failed closure was 0.66 +/- 0.56 cm versus 0.76 +/- 0.47 cm (P = not significant [NS]). CONCLUSION: Our results do not support the concern that exaggerated septal mobility compromises successful device closure of interatrial communications.     

Echocardiographic Guidance of Percutaneous Patent Foramen Ovale Closure: Head‐to‐Head Comparison of Transesophageal versus Rotational Intracardiac Echocardiography

Background: Transesophageal (TEE) and intracardiac (ICE) echocardiography are commonly used to guide percutaneous patent foramen ovale (PFO) closure. The study aim was to perform a head‐to‐head comparison between TEE and rotational ICE echocardiography in the measurement of the fossa ovalis and device selection. Methods: In 45 patients with cryptogenic stroke or peripheral embolism and PFO with large right‐to‐left shunt, fossa ovalis dimensions were assessed preoperatively by TEE and intraoperatively by rotational ICE. The Amplatzer devices, deployed on the basis of ICE, were compared with those that would have been selected by TEE. Results: A good correlation between TEE and rotational ICE was observed for both longitudinal and transverse fossa ovalis dimensions (TEE four‐chamber vs. ICE four‐chamber: r = 0.75; TEE bicaval vs. ICE four‐chamber: r = 0.77; TEE aorta vs. ICE aorta: r = 0.59; P < 0.001 for all). However, no such correlation was found in 13 patients with atrial septal aneurysm (ASA) (TEE four‐chamber vs. ICE four‐chamber: r = 0.33; TEE bicaval vs. ICE four‐chamber: r = 0.49; TEE aorta vs. ICE aorta: r = 0.05; P = NS for all). At Bland‐Altman analysis, slight systematic differences with wide limits of agreement for each comparison were observed, particularly in patients with ASA, suggesting that the two imaging modalities cannot be used interchangeably. As regards device selection, a moderate agreement was found between TEE‐ and ICE‐guided device size (72%, κ= 0.53, P < 0.001), except in patients with ASA (36%, κ= 0.02, P = NS). Conclusions: Our study suggests a significant disagreement between TEE and rotational ICE in measuring fossa ovalis and selecting the device for PFO closure, particularly in patients with ASA.     

Randomized study comparing mechanical with electronic 2-dimensional intracardiac ultrasound monitoring (MEDIUM) during percutaneous closure of patent foramen ovale in adult patients with cryptogenic stroke

BACKGROUND: Previous studies have shown that mechanical and electronic intracardiac echocardiography (ICE) improves ultrasound monitoring during transcatheter patent foramen ovale (PFO) interventional closure. OBJECTIVES: This study sought to compare the procedural data, clinical imaging quality, and effectiveness PFO closure by using two different ICE monitoring modalities. METHODS: Patients referred for PFO closure (n = 82) were randomly assigned to mechanical (group 1) or electronic (group 2) ICE monitoring of Amplatzer device implantation. The digital ICE images were evaluated offline by means of absolute visual grading analysis score (VGAS(abs)), and the residual shunting at follow-up were assessed by means of contrast echocardiographic studies, all blinded regarding the ICE closure monitoring modality. RESULTS: The two groups were comparable with respect to clinical baseline characteristics, intracardiac fossa ovalis measurements, and procedural data (fluoroscopy time, procedure time and measurement of the amount of radiation that the patients absorbed). The total VGAS(abs) ranked the mechanical clinical images in a higher order than the electronic ones (3.78 +/- 0.09 vs 3.58 +/- 0.12, P = 0.005); additionally, three patients (7.3%) of group 2 needed to cross over to mechanical ICE monitoring because a right-convex atrial septal aneurysm configured itself incompletely. No differences in rates of residual shunting were observed at 12 months follow-up between the two groups (97.5% vs 94.7%, P = 0.951). CONCLUSIONS: Electronic monitoring of PFO closure performed a less diagnostic impact than the mechanical one while maintaining comparable procedural data and clinical outcome. These results represent an important step in validating these new intracardiac ultrasound imaging modalities.     

Transcatheter device closure of interatrial septal defects in patients with hypoxia

BACKGROUND: There has been growing interest in transcatheter closure of interatrial septal defects (IASDs) for a variety of indications, but reports are limited in patients with hypoxia from right-to-left shunting. METHODS: Between August 2000 and October 2004, 181 patients were referred to our institution for elective closure of a patent foramen ovale (PFO) or atrial septal defect (ASD). Among these patients, 10 (5.5%) underwent closure for hypoxia due to persistent or intermittent right-to-left shunting. Clinical evaluation, including echocardiography with color Doppler and agitated saline, was performed in all patients to determine the degree of right-to-left shunting. Defects were closed with Amplatzer (n = 4) or Cardioseal (n = 6) devices, under transesophageal (TEE) or intracardiac echocardiography (ICE) guidance. RESULTS: Mean age was 62.7 years (range: 31-88 years) with 70% female. Characteristics for closure included four patients with persistent hypoxia and six with intermittent hypoxia, including two with platypnea-orthodeoxia syndrome. All patients had echocardiography showing moderate (n = 6) or severe (n = 4) shunting. Patients had significant comorbidities, including chronic lung disease requiring supplemental oxygen (n = 5) and congestive heart failure (n = 2). TEE guidance was used in three patients, and ICE was performed in the remainder. Mean closure device diameter was 27 mm. Mean preprocedural arterial oxygen saturation of 86.7% improved to 95.9% immediately after closure, with color Doppler and agitated saline revealing the absence of (n = 5) or mild (n = 5) shunting. In-hospital major complications were limited to one patient with a transient ischemic attack after an initially unsuccessful closure attempt. CONCLUSIONS: Percutaneous closure of IASDs in a heterogeneous group of patients with hypoxia can be safely and effectively performed. The procedure results in immediate arterial saturation improvement and reduced right-to-left shunting.     

Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman

Background: Left atrial appendage occlusion (LAAO) is mostly performed by transesophageal echocardiography (TEE) guidance. Intracardiac echocardiography (ICE) may be an alternative imaging modality for LAAO that precludes the need for general anesthesia or sedation. Methods and Results: All consecutive single center, single operator LAAO candidates were analyzed. Baseline clinical and procedural characteristics and in‐hospital outcomes were compared between patients in whom a Watchman was implanted with ICE vs. TEE guidance. In 76 consecutive patients the Watchman device was deployed under ICE in 32 patients (42%) and under TEE guidance in 44 patients (58%). Baseline characteristics were comparable between groups, except that patients in the TEE group were older (81 [75–85] years vs. 75 [68–80] years, P = 0.007). Total injected contrast media as well as fluoroscopy time were comparable between groups (90 ml [54–140] vs. 85 ml [80–110], P = 0.86 and 7.9 min [6.4–15.5] vs. 9.8 min [7.0–13.2], P = 0.51, for TEE vs. ICE, respectively). However, time from femoral venous puncture to transseptal puncture and to closure was longer in the ICE group (14 min [7.3–20] vs. 6 min [3.3–11], P = 0.007 and 48 min [40–60] vs. 34.5 min [27–44], P = 0.003, respectively). In the TEE group one patient suffered esophageal erosion with bleeding, which was managed conservatively and one non‐LAAO related in‐hospital mortality occurred in an 88‐year‐old patient. Device implantation success rate was 100% in both groups. No device embolization, no significant peri‐device leak, no tamponade, no stroke, and no access site bleeding occurred in any patient. Total hospital stay for stand‐alone LAAO was comparable between groups (2 days [2–2] vs. 2 days [2–3.3], P = 0.17, in ICE vs. TEE, respectively). Conclusions: ICE guidance for LAAO with the Watchman device is feasible and comparable to TEE and may become the preferred imaging modality for LAAO. © 2016 Wiley Periodicals, Inc.     

Safety and feasibility of day case patent foramen ovale (PFO) closure facilitated by intracardiac echocardiography

Ultrasound guided patent foramen ovale (PFO) closure has traditionally utilized transoesophageal echocardiography (TOE) under general anaesthesia. Some centres use fluoroscopic guidance alone to facilitate day case PFO closure. Intracardiac echocardiography (ICE) is performed via femoral vein access using an 11 Fr sheath providing accurate guidance without the necessity for general anaesthesia. The safety and feasibility of PFO closure using ICE guidance as a day case procedure have not been documented. We present a consecutive series of patients undergoing planned day case PFO closure under ICE guidance with transthoracic echocardiogram (TTE) follow up. Patients excluded from day case PFO closure were those with early pregnancy or unfavourable social circumstances. 53 consecutive adult patients (44.2+/-11.0 years; 24 males) were planned for day case PFO closure facilitated by ICE. Referral indications were stroke or TIA (n=39), peripheral embolism (n=6), decompression sickness (n=7) and severe migraine (n=1). All 53 patients underwent ICE, with 9/53 (17%) having an atrial septal aneurysm. In 5 patients no PFO was found. In the remaining 48 patients, PFO closure was achieved using the HELEX occluder (n=47) or the Amplatzer device (n=1). Mean procedure and fluoroscopy times were 31.0+/-12.4 and 5.3+/-3.9 min respectively. One patient failed same day discharge due to groin haematoma. There were no other complications. At 3 month follow up, 45/48 (94%) had no residual shunt, with 3 patients having small residual shunts on colour flow Doppler. In conclusion, percutaneous PFO closure as a day case procedure is safe and feasible when facilitated by ICE.     

Interatrial defect sizing by intracardiac and transesophageal echocardiography compared with fluoroscopic measurements in patients undergoing percutaneous transcatheter closure.

The purpose of this study was to evaluate prospectively the feasibility and accuracy of using echocardiographic measurements by transesophageal and intracardiac echocardiography (TEE and ICE, respectively) for interatrial septal defect sizing during percutaneous transcatheter closure. Forty-two patients underwent balloon sizing of interatrial septal defects using TEE in 21 of them and ICE in the other half. These measurements were correlated with quantitative fluoroscopic analysis and evaluated for bias and agreement between methods using a Bland-Altman analysis. Echocardiographic measurements were obtained by ICE and TEE in all patients. An excellent correlation was found between TEE and quantitative fluoroscopy (r = 0.898; P < 0.001) and between ICE and quantitative fluoroscopy (r = 0.876; P < 0.001), with a significant agreement (P < 0.001) and minimal positive bias toward the echocardiographic measurements. Both TEE and ICE are excellent methods of interatrial defect sizing when compared with quantitative fluoroscopic measurements.     

Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography.

Transesophageal echocardiography (TEE) has been employed successfully for guiding transcatheter device closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO). However, the use of TEE for device closure requires general anesthesia. Intracardiac echocardiography (ICE) can provide similar anatomical views that might replace the use of TEE for device closure. Eleven patients (eight female/three male) with secundum ASD and PFO associated with strokes underwent attempts at transcatheter closure of their defects under sequential TEE and ICE guidance (six patients) and under ICE alone (five patients). The ages of the patients ranged from 6.6 to 74.7 yr, and their weights ranged from 23 to 124.5 kg. The sizes of the defects, as measured by TEE (six patients), ranged from 3 to 27 mm and, as measured by ICE (11 patients), from 3 to 27 mm. The balloon-stretched diameter of the ASD, as measured by TEE (six patients), ranged from 16 to 38 mm and, as measured by ICE (11 patients), from 16 to 35 mm. Both techniques correlated well for the measured two-dimensional diameter and for the balloon-stretched diameter (r = 0.97 and 0.98, respectively). Both TEE and ICE provided similar views of the defects and the various stages of device deployment. Owing to the proximity of the left atrium to the esophagus, however, the images obtained by ICE were more helpful and informative than those obtained by TEE. All patients experienced successful device placement (six patients under both TEE and ICE; five patients under ICE guidance alone); complete closure of the defects was effected in nine patients, whereas two patients had small residual shunts. There were no complications. We conclude that ICE provides unique images of the atrial communications and measurements similar to those obtained by TEE. ICE potentially could replace TEE as a guiding imaging tool for ASD and PFO device closure, thus eliminating the need for general anesthesia.     

An evolving role of transesophageal echocardiography for the monitoring of interventional catheterization in children

BACKGROUND AND HYPOTHESIS: Transesophageal echocardiography (TEE) is increasingly utilized for the monitoring of interventional cardiac catheterization in children. The initial nondiscriminant use is giving way to a more selective approach. The current role and usefulness of this imaging modality are described. METHODS: Between 1991 and 1995, 44 patients (mean age 7.4 +/- 5 years, weight 22.8 +/- 14.2 kg) underwent interventional cardiac catheterizations performed under TEE monitoring. The interventional procedures included (1) those involving creation, enlargement, or closure of an interatrial communication; (2) balloon dilatation of stenotic lesions; and (3) occlusion of arterial ducts. Transesophageal echocardiographic monitoring was judged to be either of great value, contributory, or of little use if the interventional procedure and choice of instrument relied heavily upon, was guided, or not affected by the information obtained from the ultrasonic investigation, respectively. RESULTS: Transesophageal echocardiography was judged to be of great value in the monitoring of 18 (40%) procedures involving either the creation, enlargement, or closure of interatrial communications. This included 4 transseptal punctures, 4 blade septectomies for relieving restrictive atrial septal defects (n = 3) and an enlargement of the communication between the superior and inferior chambers of the divided left atrium in cortriatriatum, and 11 closures of a secundum atrial septal defect. Only the ultrasonic monitoring could clearly visualize the interatrial partition to provide real-time guidance on the positioning of the instrument to carry out the invasive procedures. Transesophageal echocardiography provided clear images of the hinge points of the aortic and mitral valves, the dimension of the narrowed pulmonary venous pathway in patients after venous switch operation. This facilitated the choice of the correct size of the balloon for dilatation in 11 patients (24%) and provided immediate postdilatation hemodynamic assessment. As for balloon dilation of subvalvar ventricular outflow tract obstruction (n = 3), aortic coarctation (n = 6), and occlusion of persistent arterial duct (n = 7), TEE offered no obvious advantage over fluoroscopy with angiography. The monitoring was judged to be of little value for the 16 (36%) procedures. CONCLUSION: Transesophageal echocardiographic monitoring is of great value in interventional procedures involving the atrial septum and enhances interventional procedures involving obstructive lesions of the left heart in children.     

New echocardiographic diameter for Amplatzer sizing in adult patients with secundum atrial septal defect: preliminary results.

Anatomical atrial septal defect (ASD) diameter measured by transesophageal echocardiography (TEE) underestimates the Amplatzer septal occluder (ASO) size for ASD closure. The aim of this study is to investigate whether a new echocardiographic diameter (procedural ASD diameter) may enable precise measurements of ASO device size. Fifty adult patients with secundum ASD were evaluated by TEE for percutaneous closure. The procedural ASD diameter was measured using the steadier rim borders where thickness was 2.5 mm. Out of the 50 patients, 12 were considered unsuitable for Amplatzer device closure. The other 38 patients underwent percutaneous closure. The mean anatomical ASD diameter was 14.8 +/- 7.0 mm, the mean procedural ASD diameter measured 19.5 +/- 8.1 mm, and the mean stretched balloon diameter (SBD) was 20.0 +/- 8.0 mm. ASO device size was 20.1 +/- 8.0 mm. At linear regression analysis, a high correlation (r = 0.99) was found between procedural ASD diameter and SBD. Procedural ASD diameter correlates with SBD and may allow reliable prediction of Amplatzer device in an adult population undergoing percutaneous ASD closure.     

Transcatheter atrial septal defect closure assisted by intracardiac echocardiography: 3-year follow-up

Intracardiac echocardiographic (ICE) evaluation of secundum atrial septal defect (ASDs) shows several advantages over transesophageal echocardiography (TEE). The aim of our study is to describe the 3-year results of transcatheter ASDs closure using the Amplatzer septal occluder (ASO) and ICE as the sole imaging tool both to select the device size and to monitor the procedure. Under local anesthesia, 135 consecutive eligible patients with ASDs (male/female = 45/90; mean age 42.2 +/- 19.2 years; BSA 1.71 +/- 0.7 m(2); mean pulmonary arterial pressure 30.4 +/- 11.5 mmHg; mean Qp/Qs ratio 2.1 +/- 0.6) underwent transcatheter closure using ASO and ICE. A 9F-9MHz mechanical transducer was used. Two orthogonal views on the transverse aortic valve and on the longitudinal four-chamber planes were obtained for quantitative ICE measurements, from which the diameters of the implanting ASO waist were to be derived. In all cases, we obtained a proper evaluation of ICE ASDs dimensions, leading to an optimal device size selection (mean size 25.0 +/- 6.7 mm). Moreover, the ICE allowed us to monitor device deployment and to verify the effectiveness of the ASDs stented by ASO. There were no complications related to the procedure or to the use of ICE. During a mean follow-up period of 21.5 +/- 12 months, the cumulative complete occlusion rates were 97.7, 97.0, 97.1, and 98% at 24 hours, 3 month, and 1 and 3 years, respectively. ICE is an effective and safe alternative to TEE and balloon-sizing maneuver during ASDs transcatheter closure procedures, allowing us to avoid the need of general anesthesia and leading to a similarly high percentage of occlusion rates with respect to the conventional method.     

Safety and feasibility of percutaneous closure of patent foramen ovale without intra-procedural echocardiography in 825 patients

BACKGROUND: Percutaneous closure of patent foramen ovale (PFO) is generally performed using intra-procedural guidance by transoesophageal (TEE) or intracardiac (ICE) echocardiography. While TEE requires sedation or general anaesthesia, ICE is costly and adds incremental risk, and both imaging modalities lengthen the procedure. METHODS: A total of 825 consecutive patients (age 51 +/- 13 years; 58% male) underwent percutaneous PFO closure solely under fluoroscopic guidance, without intra-procedural echocardiography. The indications for PFO closure were presumed paradoxical embolism in 698 patients (95% cerebral, 5% other locations), an embolic event with concurrent aetiologies in 47, diving in 51, migraine headaches in 13, and other reasons in 16. An atrial septal aneurysm was associated with the PFO in 242 patients (29%). RESULTS: Permanent device implantation failed in two patients (0.2%). There were 18 procedural complications (2.2%), including embolization of the device or parts of it in five patients with successful percutaneous removal in all cases, air embolism with transient symptoms in four patients, pericardial tamponade requiring pericardiocentesis in one patient, a transient ischaemic attack with visual symptoms in one patient, and vascular access site problems in seven patients. There were no long-term sequelae. Contrast TEE at six months showed complete abolition of right-to-left shunt via PFO in 88% of patients, whereas a minimal, moderate or large residual shunt persisted in 7%, 3%, and 2%, respectively. CONCLUSIONS: This study confirms the safety and feasibility of percutaneous PFO closure without intra-procedural echocardiographic guidance in a large cohort of consecutive patients.