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(Circulation. 2008;117:e304-e305.)
© 2008 American Heart Association, Inc.

Images in Cardiovascular Medicine

Real-Time 3-Dimensional Transesophageal Echocardiography

Novel Utility in Atrial Fibrillation Ablation With a Prosthetic Mitral Valve

Hyun Suk Yang, MD; Komandoor Srivathsan, MD; Eric Wissner, MD; Krishnaswamy Chandrasekaran, MD

From the Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, Ariz.

Correspondence to Krishnaswamy Chandrasekaran, MD, Professor of Medicine, College of Medicine, Division of Cardiovascular Disease, Mayo Clinic, 13400 East Shea Blvd, Scottsdale, AZ 85259. E-mail kchandra{at}mayo.edu

With the increase in cardiac transcatheter interventions, multiplane 2-dimensional transesophageal echocardiography (TEE) and intracardiac echocardiography have emerged as guiding tools, but they have potential limitations in clarifying the spatial relationship of the catheters relative to surrounding structures.¹ Recently, the use of real-time 3-dimensional (3D) transthoracic echocardiography has been reported in Amplatzer closure device procedures² and in endomyocardial diagnostic and therapeutic procedures.³ The real-time 3D technology now has been merged with TEE to provide superior high resolution for the real-time volume image from the transesophageal window without the limitations of the transthoracic window. We demonstrate the utility of this real-time 3D TEE in guiding radio frequency (RF) catheter ablation of atrial fibrillation.

A 72-year-old woman who had twice undergone mitral valve replacement underwent RF ablation for symptomatic atrial fibrillation not amenable to medical therapy. During the electrophysiological study, a single transseptal puncture was performed with the guidance of real-time 3D TEE (Figure 1 and Movie I) using an x7–2t transducer on a Philips iE33 ultrasound machine (Philips, Andover, Mass), which has both multiplane 2-dimensional and real-time 3D capabilities. A 7-Fr steerable RF ablation catheter was advanced via the transseptal sheath into the left atrium and the pulmonary vein (Figure 2 and Movies II and III) for electroanatomic mapping using the CARTO Biosense System (Cordis-Webster, Marlton, NJ). The real-time 3D TEE allowed easy navigation of the mapping catheter in the left atrium by demonstrating its spatial relationship relative to the bioprosthetic mitral valve (Figure 3 and Movies IV and V) and its relationship to the pulmonary vein at the same time during ablation.

View larger version (42K): [in this window] [in a new window]   Figure 1. Real-time 3D TEE demonstrates tenting of fossa ovalis (black arrowhead) by the transseptal catheter (white arrowhead) tip seen from the left atrial perspective (A and Movie I) and the course of an ablation catheter from the right atrium (RA) to the left atrium (LA) after penetration of the fossa ovalis membrane (B).

View larger version (35K): [in this window] [in a new window]   Figure 2. Real-time 3D TEE demonstrates the course of an ablation catheter tip in the left atrium through the ostium of the left upper pulmonary vein (A and Movie II) and its movement into the left lower pulmonary vein (B and Movie III).

View larger version (59K): [in this window] [in a new window]   Figure 3. Real-time 3D TEE reveals the exact location of the ablation catheter tip along the annulus of the mitral prosthesis in the left atrial perspective (A and Movie IV) and the left ventricular perspective (B and Movie V). POST indicates posterior; ANT, anterior; LA, left atrium; and LV, left ventricle.

	Disclosures

Top Disclosures References

 
None.

	Footnotes

 
The online-only Data Supplement, which contains Movies I through V, is available with this article at http://circ.ahajournals.org/cgi/content/full/ 117/14/e304/DC1.

	References

Top Disclosures References

 
1. Lang RM, Mor-Avi V, Sugeng L, Nieman PS, Sahn DJ. Three-dimensional echocardiography: the benefits of the additional dimension. J Am Coll Cardiol. 2006; 48: 2053–2069.[Abstract/Free Full Text]

2. Chen FL, Hsiung MC, Hsieh KS, Li YC, Chou MC. Real time three-dimensional transthoracic echocardiography for guiding Amplatzer septal occluder device deployment in patients with atrial septal defect. Echocaridography. 2006; 23: 763–770.[CrossRef]

3. Baklanov DV, de Muinck ED, Simons M, Moodie KL, Arbuckle BE, Thompson CA, Palac RT. Live 3D echo guidance of catheter-based endomyocardial injection. Catheter Cardiovasc Interv. 2005; 65: 340–34.[CrossRef][Medline] [Order article via Infotrieve]

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This Article Extract Full Text (PDF) Data Supplement Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yang, H. S. Articles by Chandrasekaran, K. Search for Related Content PubMed PubMed Citation Articles by Yang, H. S. Articles by Chandrasekaran, K. Related Collections Ablation/ICD/surgery Echocardiography