2021: The Birth of Four-Dimensional Intracardiac Echocardiography

Dear Readers,

Ultrasound has been used for many years to guide cardiac interventions. Phased-array intracardiac echocardiography (ICE) is increasingly being used during EP procedures to image cardiac structures, guide transseptal catheterization, evaluate the position of ablation catheters, assess for occlusion of the pulmonary vein during cryoballoon ablation, and to exclude complications such as pericardial tamponade and thrombus formation.¹ Transesophageal echocardiography (TEE) can also be used to guide cardiac interventions and is commonly used during structural heart procedures such as percutaneous valve interventions and left atrial appendage closure (LAAC) procedures. A disadvantage of using a TEE probe to guide procedures in the EP lab is the need for general anesthesia and a dedicated imaging specialist to manipulate the TEE probe. Some operators are now using a 2D ICE catheter placed in the left atrium to guide LAAC procedures,² but it does not offer the 3D views and digital steering of a TEE probe. There is a need for 3D ICE in real time (4D) in the EP lab.

During the late-breaking clinical trials at Heart Rhythm 2021, which took place July 28-31 in Boston, Dr. Vivek Reddy presented the first in-human multicenter experience with a new 3D/4D ICE catheter (NUVISION, Biosense Webster, Inc., a Johnson & Johnson company) during EP procedures. The ICE catheter is 10 French and capable of real-time volumetric imaging with a 90° x 90° field of view, both 2D and 4D color Doppler flow ability, independent distal tip rotation, and imaging penetration depth up to approximately 15 cm. The 4D ICE catheter was used by 9 different operators in 28 patients to successfully guide a variety of catheter ablation and LAAC procedures. All safety and performance endpoints were met.

Also at Heart Rhythm 2021, Philips shared information at their booth showing representative images related to the first use of their 4D ICE catheter (VeriSight Pro ICE catheter) during structural heart procedures at the Mayo Clinic³ and during EP procedures at the Northwestern Medicine Bluhm Cardiovascular Institute.⁴ A formal multicenter registry is planned.

The advent of matrix transducers made commercial availability of 3D TEE possible over 20 years ago. It is now a standard imaging tool used by cardiologists and cardiac anesthesiologists. For two decades, the field has waited for industry to miniaturize the same technology and apply it to an ICE catheter to allow for digital steering, X-plane, and 3D/4D imaging. Although much more experience is needed and additional costs will have to be considered, it seems inevitable that ICE imaging in the EP lab will quickly move from 2D to 4D. 

Bradley P. Knight, MD, FACC, FHRS

@DrBradleyKnight
Editor-in-Chief,

EP Lab Digest

Disclosures: Dr. Knight reports that he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AtriCure, Baylis Medical, Biosense Webster, BIOTRONIK, Boston Scientific, CVRx, Medtronic, Philips, and Sanofi. He has no equity or ownership in any of these companies.

References

1. Kim SS, Hijazi Z, Lang RL, Knight BP. The use of intracardiac echocardiography and other intracardiac imaging tools to guide noncoronary cardiac interventions. J Am Coll Cardiol. 2009;53(23):2117-2128.

2. Berti S, Pastormerlo LE, Korsholm K, et al. Intracardiac echocardiography for guidance of transcatheter left atrial appendage occlusion: an expert consensus document. Catheter Cardiovasc Interv. 2021 Jun 4. Online ahead of print. doi: 10.1002/ccd.29791

3. Malloy T. Mayo Clinic first to use next generation 4D ICE imaging to help patients with structural heart disease. Mayo Clinic. Published July 2, 2021. Accessed August 23, 2021. https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-first-to-use-next-generation-4d-ice-imaging-to-help-patients-with-structural-heart-disease/

4. Northwestern Medicine first in United States to use live 3D intracardiac echo for heart rhythm procedure. Northwestern Medicine. Published July 20, 2021. Accessed August 23, 2021. https://www.newswise.com/articles/northwestern-medicine-first-in-united-states-to-use-live-3d-intracardiac-echo-for-heart-rhythm-procedure