Three-dimensional intracardiac echocardiography and pulmonary embolism

Abstract

Background: Three-dimensional intracardiac echocardiography (3D ICE) with wide azimuthal elevation is a novel technique performed for assessment of cardiac anatomy and guidance of intracardiac procedures, being able to provide unique views with good spatial and temporal resolution. Complications arising from this invasive procedure and the value of 3D ICE in the detection and diagnosis of acute cardiovascular pathology are not comprehensively described. This case illustrates a previously unreported iatrogenic complication of clot displacement from the intravascular sheath upon insertion of a 3D ICE catheter and the value of 3D ICE in immediate diagnosis of clot in transit through the heart with pulmonary embolism. Case presentation: We conducted a translational study of 3D ICE with wide azimuthal elevation to guide implantation of a left ventricular assist device (Impella CP®) in eight adult sheep. A large-bore 14 Fr central venous sheath was used to enable right atrial and right ventricular access for the intracardiac catheter. Insertion of the 3D ICE catheter was accompanied by a sudden severe cardiorespiratory deterioration in one animal. 3D ICE revealed a large highly mobile mass within the right heart chambers, determined to be a clot-in-transit. The diagnosis of pulmonary clot embolism resulting from the retrograde blood entry into the large-bore sheath introducer, rapid clot formation and consequent displacement into venous circulation by the ICE catheter was made. The sheep survived this life-threatening event following institution of cardiovascular support allowing completion of the primary research protocol. Conclusion: This report serves as a serious warning to the researchers and clinicians utilizing long large-bore sheath introducers for 3D ICE and illustrates the value of 3D ICE in detecting clot-in-transit within right heart chambers.

Three‐dimensional and catheter‐based intracardiac echocardiographic characterization of the interatrial septum in 2 horses with suspicion of a patent foramen ovale

“…Functionalities such as color Doppler, tissue Doppler, 2D speckle tracking and integration with a 3D mapping system are increasingly available. Via a venous introducer, the ICE probe can be navigated towards the heart using mechanical steering and rotation 13,14 . Hence, the technique does not suffer from body conformation and provides detailed imaging with high resolution 15 .…”

“…Via a venous introducer, the ICE probe can be navigated towards the heart using mechanical steering and rotation. 13 , 14 Hence, the technique does not suffer from body conformation and provides detailed imaging with high resolution. 15 However, this can make interpretation challenging and contributes to the steep learning curve.…”

A Proposed Approach for the Management of Clot-in-Transit

“…Yastrebov et al stated that 3-Dimensional (3D) intracardiac echocardiography gives a precise and better picture of the heart’s anatomy and pathology compared to 2-Dimensional (2D) echoes. It offers the benefit of diagnosing CIT and also providing accurate details like exact location, size, and relation to nearby structures [ 12 ]. This additional information facilitates the selection of an appropriate treatment plan.…”

Intracardiac Echocardiography for Point-of-Care Guided Left Ventricular Assist Device Implantation: Surgical Implications for COVID-19

“…There is further risk of clot formation inside the large vascular sheath and resulting pulmonary embolism. 8 There is also an ever-present risk of incorrect identification of structures during early adoption of the technique, leading to misdiagnosis or severe complications. Limitations in spatial and temporal resolution of 3D ICE make imaging of thin guidewires with diameter of ≤.018′ unreliable.…”