Usefulness of phased-array intracardiac echocardiography for the assessment of left atrial mechanical “stunning” in atrial flutter and comparison with multiplane transesophageal echocardiography

doi:10.1016/S0002-9149(02)02601-2

The American Journal of Cardiology

Volume 90, Issue 7, 1 October 2002, Pages 741-746

https://doi.org/10.1016/S0002-9149(02)02601-2 Get rights and content

Abstract

We compared transesophageal and phased-array intracardiac echocardiography (TEE/ICE) for the 2-dimensional and spectral Doppler assessment of left atrial (LA) mechanical function. TEE is commonly used to assess LA body and LA appendage mechanical function in patients who are undergoing radiofrequency ablation of typical atrial flutter. Fifteen patients underwent TEE and ICE imaging before and after ablation of typical atrial flutter. The following parameters were measured: (1) LA appendage emptying velocity and fractional area change, (2) severity of LA spontaneous echo contrast (graded 0 to 4), (3) maximal inflow velocity of the left and right upper pulmonary veins, and (5) maximal mitral valve E- and A-wave inflow velocities in sinus rhythm. Diagnostic quality imaging was achieved in all patients with TEE and ICE. Comparing TEE and ICE, the following absolute values and linear correlation coefficient (R) were obtained: preablation LA appendage emptying velocity: 0.45 ± 0.21 versus 0.44 ± 0.21 m/s (r = 0.95, p = <0.001); postablation LA appendage velocity: 0.33 ± 0.24 versus 0.34 ± 0.24 m/s (r = 0.97, p <0.001); LA appendage fractional area change: 35.3 ± 13.7 versus 35.9 ± 17.1% (r = 0.81, p <0.001); left upper/right upper pulmonary vein inflow velocity: 0.50 ± 0.17/0.49 ± 0.18 versus 0.51 ± 0.17/0.47 ± 0.20 m/s (r = 0.93/0.90, p <0.001); mitral valve E/A wave: 0.66 ± 0.14/0.31 ± 0.14 versus 0.69 ± 0.17/0.35 ± 0.23 (r = 0.84/0.97, p <0.002); LA spontaneous echo contrast (pre- and postablation): 1.1 ± 1.2/1.3 ± 1.2 versus 1.2 ± 1.3/1.4 ± 1.3 (r = 0.92/0.90, p <0.001). No patients were identified with LA appendage thrombus. Thus, TEE and phased-array ICE provided equivalent imaging data with high statistical correlation. ICE may be an imaging alternative to TEE in the evaluation of a “stunned” left atrium.

Section snippets

Study population

The study population consisted of 15 patients (mean age 64 ± 9 years; 12 men) who underwent radiofrequency ablation for either chronic or paroxysmal typical isthmus dependent atrial flutter (Table 1). A baseline transthoracic echocardiogram performed before referral was available for review in all patients. Mean LA size was mildly enlarged at 4.3 ± 0.7 cm (range 3.1 to 5.2) and 13 of 15 patients had a left ventricular ejection fraction of ≥50%.

Study protocol

This study represents a pilot preliminary

Results

Successful flutter ablation was performed in all patients. The mean fluoroscopic time was 26 ± 9 minutes. FIGURE 1, FIGURE 2, FIGURE 3 represent the standard ICE imaging views of the left atrium, LA appendage, and mitral valve and pulmonary veins used in the study.

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Intracardiac Echocardiography, Computed Cardiac Tomography, and Magnetic Resonance Imaging for Guiding Mapping and Ablation
2019, Catheter Ablation of Cardiac Arrhythmias
Cardiac imaging studies play an essential role in contemporary invasive electrophysiologic mapping and ablation procedures. From guiding appropriate patient selection, to preprocedure definition of the substrate, to intraprocedural demonstration of catheter movement, tissue contact, and lesion formation, to postprocedure evaluation for both procedural success and development of complications, imaging is integrated into the workflow of mapping and ablation procedures. Intracardiac echocardiography, perfectly suited to intraprocedural use with its provision of real-time information and its ability to be incorporated into 3-dimensional mapping software; cardiac magnetic resonance, providing anatomic and functional information without exposure to ionizing radiation and highly accurate for the definition of myocardial fibrosis; and cardiac computed tomography, ideally suited for provision of anatomic information including regarding the epicardial coronary arteries but also able to provide data on myocardial fibrosis and cardiac physiology, are all readily available in many clinical environments and must be appropriately selected on an individual case basis. Future developments in these technologies promise improved integration into 3-dimensional mapping systems, improved real-time catheter guidance in the absence of fluoroscopy, and the provision of more detailed real-time information regarding the arrhythmia substrate, the interaction of the ablation catheter with its 3-dimensional environment, and ablation lesion formation.
Accuracy and clinical outcomes of CT image integration with Carto-Sound compared to electro-anatomical mapping for atrial fibrillation ablation: A randomized controlled study
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Citation Excerpt :
Similar equivalence has been reported with new radiographic mapping technologies (3D rotational angiography) [11] and early data on robotic sheath navigation [12]. The efficacy of intracardiac echocardiography (ICE) for guiding ablation at the pulmonary vein ostia [13,14], within the cavotricuspid isthmus [15] and for detection of left atrial thrombus and assessment of left atrial appendage mechanical function has been demonstrated [16]. Carto-Sound integrates ICE into a 3D mapping system, such that the system can visualize the location and orientation of a specialized ICE catheter to enable the construction of a 3D geometry from a series of 2D ultrasound slices.
Carto-Sound integrates 2D intra-cardiac ultrasound imaging into a 3D environment to allow left atrial mapping from the right atrium without fluoroscopic assistance. We conducted an open randomized controlled study to compare procedural, clinical and accuracy parameters between CT integrated Carto-Sound and electro-anatomic mapping (EAM) for AF ablation.
Sixty index AF ablation patients were randomized equally to either the Carto-Sound or EAM mapping/navigation for their procedure performed at a single institution. Procedure and X-ray times, X-ray dose, navigational accuracy and clinical success were assessed. The study was powered to the primary outcome of fluoroscopy time.
Total procedure (232 ± 60 vs 223 ± 48 min; p = 0.51), ablation (p = 0.84) and mapping times (p = 0.11) were similar in each group. In contrast, Carto-Sound reduced total X-ray time (65 ± 18 vs 51 ± 12 min; p = 0.001), via a reduction in both mapping (p < 0.001) and remaining procedure X-ray time (p = 0.03). Left atrial access time (p = 0.03) was also reduced using Ultra-sound assisted 3D mapping compared to the EAM group. Carto-Sound maps demonstrated equivalent mean navigational accuracy (p > 0.17) compared to EAM. Ultra-sound assisted 3D mapping did not improve single procedure drug free clinical success (EAM: 13/30 [43%] vs Carto-Sound: 15/30 [50%]) at a mean of 13 ± 5 months (p = 0.79).
In the context of long left atrial procedures with high radiation doses, reduced X-ray and left atrial access times using CT integrated Carto-Sound mapping/navigation may have implications for patients and laboratory staff, albeit at an extra financial cost and the requirement of an additional access site for a right sided catheter.
Trial registration number: ACTRN12612000089831
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Intracardiac Echocardiography: Evolution, Recent Advances, and Current Applications
2006, Journal of the American Society of Echocardiography
Citation Excerpt :
ICE can be used to screen for clots and spontaneous contrast. In a study comparing ICE and TEE for evidence of LA stunning in patients with atrial flutter who undergo ablation,48 the LA appendage (LAA) emptying velocity, LAA fractional area change, left upper and right upper pulmonary venous inflow velocity, mitral inflow velocities, presence of spontaneous echocontrast, and clot in the LA and LAA were found to be similar using both modalities. Similarly, ICE was found to be instrumental in detection of LA49 and LAA50 clots in patients who undergo atrial fibrillation ablation.
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Usefulness of intracardiac Doppler assessment of left atrial function immediately post-pulmonary vein antrum isolation to predict short-term recurrence of atrial fibrillation
2004, American Journal of Cardiology
Doppler assessments of pulmonary venous (PV) and left atrial appendage flows are useful surrogates of left atrial (LA) function, but it is unknown if these can predict atrial fibrillation (AF) recurrence after pulmonary vein antrum isolation. We compared Doppler surrogates of LA function immediately after pulmonary vein antrum isolation in patients with AF recurrence versus matched patients without recurrence. Patients with a 6-month recurrence had significantly lower LA appendage peak emptying velocity (19 ± 10 vs 29 ± 11 cm/s) and lower peak PV systolic wave velocity (36 ± 17 vs 46 ± 22 cm/s) compared with those without, suggesting that intracardiac Doppler assessment of LA function after AF ablation predicts AF recurrence.

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^☆: This work was supported in part by grants from the Sylvia and Charles Viertel Foundation, and the National Heart Foundation of Australia. Dr. Morton was supported by a National Heart Foundation of Australia postgraduate medical research scholarship, Australia. Dr. Sanders was supported by by a National Health and Medical Research Council of Australia postgraduate medical research scholarship, Australia.

^*: All intracardiac echo catheters (Acunav, Acuson Corp., Mountain View, California) used in this study were purchased at commercial prices and no financial sponsorship has been obtained from Acuson for the conduct of this study.

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Usefulness of phased-array intracardiac echocardiography for the assessment of left atrial mechanical “stunning” in atrial flutter and comparison with multiplane transesophageal echocardiography*☆,

Abstract

Section snippets

Study population

Study protocol

Results

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Usefulness of phased-array intracardiac echocardiography for the assessment of left atrial mechanical “stunning” in atrial flutter and comparison with multiplane transesophageal echocardiography^*☆,