Download Intracardiac Echocardiography-Guided Interventions

JACC: CARDIOVASCULAR INTERVENTIONS
VOL. 7, NO. 9, 2014
ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
PUBLISHED BY ELSEVIER INC.
ISSN 1936-8798/$36.00
http://dx.doi.org/10.1016/j.jcin.2014.07.001
EDITORIAL COMMENT
Intracardiac Echocardiography-Guided
Interventions
Do We Need Trials To Prove Equivalency/Superiority to
Transesophageal Echocardiography?*
Ziyad M. Hijazi, MD, MPH,yz Hussam Suradi, MDy
I
t may be surprising to realize that the initial work
Pre-procedural echocardiography is required to screen
in intracardiac echocardiography (ICE) imaging
suitable candidates and to define LAA morphology
appeared in the early 1960s, preceding the devel-
and dimension. Periprocedural echocardiography has
opment of interventional catheterization procedures
a major role in guiding and deployment of the device as
(1). The increasingly sophisticated catheter-based
well as for screening for complications and assessment
structural interventions that have emerged over the
of procedural success. Post-procedural echocardiog-
past decade, stimulated the growth of ICE to become
raphy is important in the surveillance and monitoring
an established imaging modality that holds distinct
of long-term outcome, including complications. TEE is
advantages for use in practice such as transseptal
widely considered the gold standard tool in visualizing
access (2), atrial and ventricular septal defects closure
the LAA and is typically used to guide implantation of
(3), and radiofrequency ablation for cardiac arrhyth-
the LAA device. To obviate the need for endotracheal
mias (4). Furthermore, in our center, we use it
and esophageal intubation, there has been increased
exclusively to guide all congenital and structural
interest in performing the procedure under ICE guid-
interventional procedures. As opposed to transeso-
ance only. Over the past decade, there have been
phageal echocardiogram (TEE), ICE offers compara-
several reports discussing the utilization of ICE in
ble, if not superior, imaging without the need for
guiding LAA closure; however, to date, comparative
general anesthesia. The use of ICE also allows the
studies between the 2 imaging modalities in guiding
interventionalist to simultaneously perform the pro-
LAA closure are lacking (6,7).
cedure as well as the imaging part without the need
In this issue of JACC: Cardiovascular Interventions,
Berti et al. (8) contribute significantly to the current
of additional echocardiographic personnel.
atrial
experience regarding the utility of periprocedural ICE
appendage (LAA) closure into clinical practice has
as an alternative to TEE in guiding LAA occlusion
stirred considerable interest to reduce the risk of
procedures. This is the largest reported observational
thromboembolism in patients with atrial fibrillation,
study from 2 centers addressing the application of
with several clinical trials demonstrating high proce-
ICE as an imaging modality in guiding LAA device
The
introduction
of
percutaneous
left
dural success rates and noninferiority to warfarin for
preventing embolic stroke (5). The procedure is fairly
SEE PAGE 1036
intricate with echocardiographic guidance being
closure. They report the short-term and mid-term re-
an essential tool at all stages of this procedure.
sults from 121 patients with mean age of 77 years, who
underwent ICE-guided percutaneous LAA occlusion
using Amplatzer Cardiac Plug I and II devices (St. Jude
*Editorials published in the JACC: Cardiovascular Interventions reflect the
Medical, St. Paul, Minnesota). All patients had non-
views of the authors and do not necessarily represent the views of JACC:
rheumatic atrial fibrillation with high stroke risk and
Cardiovascular Interventions or the American College of Cardiology.
absolute contraindication for oral anticoagulation. The
From the ySidra Cardiovascular Center of Excellence, Sidra Medical and
ICE catheter was positioned either in the right atrium
Research Center, Doha-Qatar, Qatar; and the zRush Center for Congenital
and Structural Heart Disease, Rush University Medical Center, Chicago,
or coronary sinus. From those positions, the LAA
Illinois. Both authors have reported that they have no relationships
dimension was defined and followed by implantation
relevant to the contents of this paper to disclose.
of the appropriate device size. The LAA dimension
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Hijazi and Suradi
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 9, 2014
SEPTEMBER 2014:1045–7
Intracardiac Echocardiography-Guided Interventions
obtained by ICE correlated well with those obtained
navigating the ICE catheter within the heart and to
by angiography and, to a lesser degree, with pre-
obtain pristine images. Although not explicitly stated
procedural TEE. In the majority of cases, the initial
in the study methodology, it is assumed that all of the
device size selected based on ICE measurements was
operators in the study were highly skilled in ICE
implanted successfully. Excellent technical (96.7%)
imaging. Another unavoidable criticism is that,
and procedural outcomes (93.4%) were achieved with
the investigators report a high level of agreement
4 patients having major adverse events. These data
regarding device size selection based on ICE and pre-
support the pre-existing literature reporting the
procedural TEE imaging. However, the validity of
feasibility of ICE imaging in guiding LAA device closure
such a conclusion is compromised as the operators
as an acceptable alternative to TEE (9). However, what
were not blinded to the 2 imaging modalities. More-
conclusions can be drawn regarding the broad appli-
over, we agree with the investigators that it may be
cability using ICE to assist in such interventions?
inappropriate to generalize the results of the study to
Although we do believe that ICE imaging is able to
all ICE systems, because a wide variety of ICE systems
perform the intraprocedural tasks typically provided
is commercially available with variable transducer
by TEE, nevertheless, as the investigators highlight in
functionality. Finally, patients left with relevant
their discussion, there are several deficiencies in the
residual peridevice leakages experience no real benefit
study that may limit its broad applicability. Because
from the procedure and have to stay on anti-
accurate echocardiographic measurement of the LAA
coagulation therapy. The investigators outline in their
anatomy is critically important for successful device
discussion the importance of residual peridevice leak;
closure, using ICE instead of TEE to routinely guide
however, they do not comment on either the echo-
LAA device implantation would only be clinically
cardiographic or angiographic assessment of device
practical if ICE imaging were able to produce high-
sealing of the LAA, which is an important variable of
quality images consistently. Although we recognize
the success of the procedure.
that there is no generally accepted standard protocol
The investigators should be praised for their excel-
for LAA imaging with ICE, it is self-evident that com-
lent technical and procedural outcomes with results
plete imaging of this complex 3-dimensional structure
very comparable to those reported with TEE-guided
requires multiple 2-dimensional planes at a minimum
implantation (11). Although imaging with ICE is inva-
to properly define its dimensions. In this study, LAA
sive and may increase costs, it offers less procedural
imaging was obtained by positioning the ICE catheter
discomfort for the patient and potentially reduces the
either in the right atrium or coronary sinus; however,
procedural time. It also eliminates the need for an
the investigators offer no consistent methodology
anesthesiologist and echocardiographic personnel,
(views) by which the imaging was performed or
enhancing in turn the cost-effectiveness of using this
description of the quality of the images acquired. In
imaging tool. Although it can be concluded from this
our experience, right atrial views are rarely sufficient
study that the use of periprocedural ICE is feasible and
to visualize the complex anatomy of the LAA, partly
safe in guiding LAA device closure, this study, like most
due to the variable interatrial septum orientation and
observational studies, serves as an initial step toward a
distance from the LAA to the ICE position in the right
pivotal trial that will compare the 2 imaging modalities
atrium (the LAA lies in the echo far field, which often
in relation to LAA device closure. Perhaps future en-
requires lowering the frequency to increase the imag-
deavors should be directed toward eliminating the
ing field depth, resulting in significantly compromised
need for pre-procedural TEE such that all the tasks
far-field tissue resolution). This imaging limitation can
required for LAA device closure can be achieved solely
be easily overcome by placing the ICE catheter in the
by ICE imaging thereby minimizing the excessive cost
left pulmonary artery, in closer proximity to the LAA.
and risk associated with duplicative TEE studies.
Similarly, positioning the catheter in the left pulmonary artery offers superior image quality of the LAA
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
and ease of probe manipulation as opposed to that in
Ziyad M. Hijazi, Sidra Cardiovascular Center of
the coronary sinus (10). Certainly, there is a significant
Excellence, P.O. Box 26999, Doha-Qatar, Qatar.
learning curve in order to gain proficiency in
E-mail: [email protected].
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Hijazi and Suradi
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 7, NO. 9, 2014
SEPTEMBER 2014:1045–7
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KEY WORDS atrial fibrillation, imaging-guided
interventions, intracardiac echocardiogram,
left atrial appendage occlusion, transeophageal
echocardiogram
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