Real-Time 3-Dimensional Transesophageal Echocardiography
Novel Utility in Atrial Fibrillation Ablation With a Prosthetic Mitral Valve
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.
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.