Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7924

Mayo Clin Proc. 2004;79:24-34 24 © 2004 Mayo Foundation for Medical Education and Research

Original Article

Intracardiac Echocardiographic Guidance During Transcatheter DeviceClosure of Atrial Septal Defect and Patent Foramen Ovale

MICHAEL G. EARING , MD; A LLISON K. CABALKA , MD; JAMES B. SEWARD, MD; CHARLES J. BRUCE, MD;GUY S. REEDER, MD; AND DONALD J. HAGLER , MD

From the Division of Pediatric Cardiology (M.G.E., A.K.C., J.B.S.,D.J.H.) and Division of Cardiovascular Diseases and Internal Medi-cine (A.K.C., J.B.S., C.J.B., G.S.R.), Mayo Clinic College of Medicine,Rochester, Minn.

Address reprint requests and correspondence to Donald J. Hagler,MD, Division of Pediatric Cardiology, Mayo Clinic College of Medi-cine, 200 First St SW, Rochester, MN 55905 (e-mail: hagler.donald@mayo.edu).

• Objectives: To describe our experience with intracar-diac echocardiographic (ICE) guidance during transcath-eter device closure of atrial septal defect (ASD) and patentforamen ovale (PFO) and to describe a detailed stepwiseapproach for performing ICE examinations.

• Patients and Methods: We reviewed the ICE results ofall patients who underwent transcatheter device closure ofASD/PFO at the Mayo Clinic in Rochester, Minn, betweenOctober 2000 and November 2002. Conscious sedation wasused, and all ICE studies were performed using a diagnos-tic ultrasound catheter.

• Results: Ninety-four patients (47 male; median age, 51years [range, 17-81 years]) underwent ICE during trans-catheter device closure of ASD/PFO. Total procedure timewas 128 minutes (range, 27-320 minutes). ICE identified apreviously unrecognized anatomical diagnosis in 32 of 94patients. An additional ASD or PFO was found in 16 pa-tients; a redundant atrial septum or an atrial septal aneu-rysm was found in 12 patients. There were few ICE com-plications (4%): 3 patients developed atrial fibrillation,

ASD = atrial septal defect; ICE = intracardiac echocardiog-raphy; PFO = patent foramen ovale; TEE = transesophagealechocardiography; TTE = transthoracic echocardiography

and 1 developed supraventricular tachycardia; of these 4,2 resolved spontaneously, and 2 required cardioversionwith no recurrence.

• Conclusion: ICE provides anatomical detail of ASD/PFO and cardiac structures facilitating congenital cardiacinterventional procedures. ICE eliminates major draw-backs related to the use of transesophageal echocardio-graphic guidance for transcatheter device closure of ASD/PFO, specifically problems related to airway management.Finally, ICE gives the interventional cardiologist the abil-ity to control all aspects of imaging without relying onadditional echocardiographic support. We believe thatICE should be considered the preferred imaging techniquefor guidance of transcatheter device closure of ASD/PFOin adults and larger pediatric patients.

Mayo Clin Proc. 2004;79:24-34

Since first attempted by King and Mills in 1976,transcatheter device closure of atrial septal defect

(ASD) and patent foramen ovale (PFO) has become aneffective and safe alternative to surgery.1-7 Echocardio-graphic guidance during device closure of ASD and PFO isnow standard practice. Transesophageal echocardiography(TEE) has been used most commonly but has associatedlimitations, specifically the need for general anesthesia andpotential problems related to airway management in thesupine patient.8,9 Recently, several small studies haveshown that intracardiac echocardiography (ICE) using theAcuNav diagnostic ultrasound catheter (Acuson Corp,Mountain View, Calif) is a feasible and accurate alternativeimaging modality for transcatheter device closure of ASDand PFO.10-13 Overall experience with ICE-guided trans-

catheter device closure of ASD and PFO is limited; there-fore, we reviewed our experience with ICE guidance dur-ing attempted transcatheter device closure of ASD andPFO. The objectives of this study were to determine thesafety and efficacy of ICE guidance during transcatheterdevice closure of ASD/PFO and to describe a detailedstepwise approach for performing the ICE examination.

For editorial comment, see page 15.

PATIENTS AND METHODSBetween October 2000 and November 2002, 94 patientsunderwent ICE during attempted transcatheter device clo-sure of ASD/PFO at the Mayo Clinic in Rochester, Minn.Before referral, all patients had undergone transthoracicechocardiography (TTE), and 82 of the 94 patients hadundergone TEE.

Intracardiac EchocardiographyOverview.—Femoral venous access (11F sheath) was

obtained after administration of local anesthetic, concur-rent with the use of conscious sedation. ICE studies wereperformed using the AcuNav diagnostic ultrasound cath-

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Mayo Clin Proc, January 2004, Vol 79 Transcatheter Device Closure 25

eter linked to a Sequoia ultrasound-imaging platform(Acuson Corp). The AcuNav ultrasound catheter is a multi-frequency (5.5-10.0 MHz), 64-element vector, phased-array transducer mounted on a 3.3-mm (10F) catheterwith a maneuverable 4-way tip (Figure 1) that is capableof high-resolution 2-dimensional and full Doppler imag-ing (pulsed, continuous-wave, and tissue Doppler). Thelongitudinal plane provides a 90-degree sector image withtissue penetration of 2 to 12 cm. The ICE catheter was ad-vanced to the right atrium under fluoroscopic guidance.Image quality was optimized by adjusting gain, depth, fre-quency, and focal length controls. Complete ICE evaluationof the left and right sides of the heart was then performed.

Detailed Description of ICE Examination.—Move-ments described relate to the manipulation of the controlmechanisms on the handle of the ICE catheter. Movementof the control handle to the left of midline results in move-ment of the catheter tip to the left as visualized from thefront of the probe handle. However, these movements maynot result in movement of the catheter tip in the samedirection as illustrated outside of the body because duringan examination, the imaging palette is also being rotated invarious directions to achieve a particular image plane.Thus, if the probe is oriented to visualize a posterior struc-ture (palette-directed posterior), posterior manipulation ofthe probe handle controls results in a more anterior position(anterior flexion) of the catheter tip. When the catheter isangulated into unusual positions, such as the position re-quired to achieve a short-axis image plane (posterior andrightward control movement), simple rotation of the cath-eter does not result in the longitudinal scanning effect as in

Figure 1. A, Diagnostic ultrasound catheter (AcuNav) placed adjacent to apediatric transesophageal echocardiography probe shows the relatively smallsize of the 10F catheter. B, Close-up of the 3.3-mm-diameter catheter tip (arrows)shows the longitudinally oriented crystal array (palette). C, Overhead view of the4-way tip maneuverability of the diagnostic catheter.

TEE, but rather, the tip of the probe moves in a large 360-degree arc. In practice, either the echo images can befollowed and the probe manipulated to obtain the desiredimages, or the position of the probe tip can be monitored byfluoroscopy to obtain a standard probe position.

By advancing the ICE catheter from the inferior venacava with the control mechanism in a free or neutral posi-tion, the catheter is placed in the mid-right atrium, and atricuspid valve inlet view is obtained by rotating the imag-ing palette of the catheter anteriorly and slightly leftward(Figure 2). The catheter tip is then rotated clockwise tovisualize the aorta and left ventricular outflow tract (Figure3). The lower atrial septum (cardiac crux) and mitral valveare then visualized by further clockwise catheter rotation(Figure 4).

In some cases, with some rightward control movementthere is posterior deflection of the catheter tip, and a classic4-chamber view of the cardiac crux may be obtained asshown in Figure 4, D. With continued posterior (clock-wise) rotation and cranial advancement of the catheter, along-axis view of the atrial septum is obtained (Figure 5).In most cases, additional leftward and posterior or ante-rior control movement with resultant anterior deflectionof the catheter tip is needed to optimize this image bymoving the transducer tip back and away from the atrialseptum.

With further cranial and caudal positioning of the cath-eter and slight counterclockwise and clockwise rotation,the entire atrial septum is evaluated with 2-dimensional andcolor flow imaging. Usually the lipomatous superior mar-gin of the atrial septum (septum secundum) is clearly rec-

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Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7926

Figure 2. Left, Anteroposterior radiograph reveals the intracardiac echocardiographic catheter tip in the right atrium (arrow) with thetransducer palette pointed toward the tricuspid valve. Middle, Lateral radiograph shows the corresponding lateral image with thetransducer tip (arrow) pointed anteriorly. Right, Corresponding intracardiac echocardiographic image of the tricuspid valve and right ventricle(RV) with mild tricuspid insufficiency shown with color flow imaging. L = left; PA = pulmonary artery; RA = right atrium; S = superior.

Figure 3. Left, Anteroposterior radiograph shows the intracardiac echocardiographic catheter (arrow) now rotated slightly clockwise topoint to the left ventricular (LV) outflow tract. Middle, Lateral image of the same catheter position (arrow). Right, Correspondingintracardiac echocardiographic image of the left ventricular outflow tract with color flow imaging. Ao = ascending aorta; L = left; MPA =main pulmonary artery; RA = right atrium; S = superior.

ognized, as is the membrane of the fossa ovalis (Figure 6).A bubble contrast study with injection through the centralvenous catheter/sheath is then performed for documenta-tion of the right-to-left shunt. From this same position,posterior imaging beyond the atrial septum allows visual-ization and evaluation of the left atrium and the left supe-rior and inferior pulmonary veins as they course in front ofthe descending thoracic aorta (Figure 5). They are evalu-ated further by color flow imaging and pulsed wave Dopp-ler interrogation.

Continued clockwise rotation then allows subsequentevaluation of the right inferior pulmonary veins and subse-quently the right superior pulmonary veins (Figure 7), ante-

rior and inferior to the right pulmonary artery. In somepatients, visualization of the right pulmonary veins requiresnot only clockwise rotation but also slight posterior controlmovement (actually moves tip leftward). With slight coun-terclockwise rotation and further posterior control move-ment (anterior flexion) of the catheter tip, the superior venacava is then evaluated (Figure 8). A short-axis image of theatrial septum and aortic root is then obtained with com-bined posterior and rightward control movement (actuallymoves tip of catheter anteriorly and laterally), then withsome clockwise tip rotation, and by directing the tip anteri-orly toward and sometimes across the tricuspid valve annu-lus (Figure 9).

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Mayo Clin Proc, January 2004, Vol 79 Transcatheter Device Closure 27

Figure 4. Upper left, Anteroposterior radiograph shows the intracardiac echocardio-graphic catheter (arrow) further rotated clockwise to image the cardiac crux portion ofthe atrial septum above the mitral valve. Upper right, Lateral image of this catheterposition (arrow). Lower left, Corresponding intracardiac echocardiographic image ofthe cardiac crux (arrow) just above the mitral valve and coronary sinus (CS). Lowerright, Four-chamber view of the cardiac crux shows small right-to-left shunt acrosspatent foramen ovale (arrow). I = inferior; L = left; LA = left atrium; LV = left ventricle;RA = right atrium; RV = right ventricle.

The catheter tip is then repositioned in the mid rightatrium and, with the imaging palette facing the atrial sep-tum, is manipulated with rightward and sometimes poste-rior control movement to move the catheter tip toward theatrial septum to cross it. With the catheter tip seated adja-cent to the atrial septum or, in many cases, across theinteratrial defect, the pulmonary veins are again evaluated.With even further anterior and rightward control movement(catheter flexion), an en face mitral inflow view is obtained(Figure 10). With the catheter across the atrial septum androtated anteriorly (counterclockwise), a detailed short-axisview of the aortic valve is obtained, and with slight clock-wise rotation of the catheter, the right ventricular outflowtract and pulmonary valve are observed (Figure 11).

ASD/PFO Transcatheter Device ClosureAll patients received intravenous heparin, 50 to 100 IU/

kg (maximum, 8000 U) and antibiotic prophylaxis (cefo-

taxime, 35-50 mg/kg). After the initial ICE assessment,prograde right and left heart catheterization was performedthrough a 7F sheath in the contralateral femoral vein.Transcatheter closure was carried out using the previouslydescribed technique.2 Balloon sizing was performed andmonitored with ICE and fluoroscopy. Usually the bestimages for clear measurement of balloon size were ob-tained with the long-axis view of the atrial septum (Figure12). Multiple views of the inflated balloon and atrial sep-tum with color flow imaging were obtained to show com-plete defect occlusion and to exclude other associated atrialdefects. By fluoroscopy, the balloon size was obtained inboth the anterior and lateral imaging planes (Figure 12).Once deployed but before release, the device was againimaged with ICE in both the long- and short-axis planes todetermine appropriate device positioning in the atrial sep-tum, to exclude the presence of additional defects, and toensure that the device did not interfere with surrounding

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Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7928

Figure 5. Upper left, Anteroposterior radiograph of the intracardiac echocardio-graphic (ICE) catheter (arrow) after further clockwise rotation and slight anteriorand lateral retroflexion of the catheter reveals a long-axis ICE image of the atrialseptum. Upper right, Lateral image of the catheter position (arrow) shows the slightanterior flexion of the catheter. Lower left, Corresponding ICE image of the long axisof the atrial septum (arrow) thus obtained. Lower right, Color flow image of leftpulmonary venous return and a small left-to-right atrial shunt (arrow). A = anterior;DAo = descending aorta; LA = left atrium; LLPV = left lower pulmonary vein; LPA =left pulmonary artery; LUPV = left upper pulmonary vein; P = posterior; RA = rightatrium; S = superior.

Figure 6. Left, Intracardiac echocardiographic long-axis image reveals a large patent foramen ovale (PFO) (10 mm) in a 25-year-old patient with a previous stroke. Middle, Corresponding color flow image shows a large right-to-left shunt through the PFO(arrow). Right, The same long-axis image of the PFO with a large resting right-to-left shunt (arrow) shown with an inferiorvena caval agitated saline injection. A = anterior; DAo = descending aorta; LA = left atrium; P = posterior; RA = right atrium; S =superior.

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Mayo Clin Proc, January 2004, Vol 79 Transcatheter Device Closure 29

Figure 7. Upper left, Anteroposterior radiograph reveals intracardiac echocardiographic(ICE) catheter tip position (arrow) after further clockwise catheter rotation to the right toimage the right pulmonary veins. Upper right, Lateral radiograph shows catheter position(arrow). Lower left, Corresponding ICE image shows all 3 right pulmonary veins. Notethat the right upper pulmonary vein (RUPV) courses anterior and then inferior to the rightpulmonary artery (RPA). Lower right, With the catheter tip moved across the atrial defect,the ICE image then reveals a long-axis view of the RPA with the RUPV just inferior to theRPA. LA = left atrium; P = posterior; R = right; RLPV = right lower pulmonary vein;RMPV = right middle pulmonary vein; S = superior; SVC = superior vena cava.

Figure 8. Left, Left anterior oblique radiograh reveals anterior flexion of the catheter (arrow) to scan superiorly into the superior vena cava(SVC). A separate catheter has been placed across the atrial septal defect, and the tip lies in the left upper pulmonary vein. Middle, Lateralimage of the same catheter position (arrow) scanning superiorly. Right, Corresponding intracardiac echocardiographic image shows flowfrom the SVC into the right atrium (RA). The right upper pulmonary vein (RUPV) is noted as it courses anterior (A) and inferior to the rightpulmonary artery (RPA). S = superior.

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Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7930

Figure 9. Left, Anteroposterior radiograph shows retroflexion of the catheter tip anteriorly and leftward and subsequent rotation of thecatheter tip clockwise to place the tip (arrow) extremely near or through the tricuspid valve. Middle, Lateral image reveals the catheterposition (arrow) near the tricuspid valve. Right, Corresponding intracardiac echocardiographic image reveals a typical short-axis image ofthe heart at the level of the aortic valve. A small left-to-right shunt (arrow) is observed through the superior margin of the atrial septaldefect. The main pulmonary artery (MPA) is also noted posterior to the aorta. A = anterior; Ao = ascending aorta; L = left; LA = left atrium;RA = right atrium.

Figure 10. Left, Anteroposterior radiograph shows the intracardiac echocardiographic catheter (arrow) advanced across the atrial septaldefect and flexed inferiorly to obtain an en face view of the mitral valve orifice. Middle, Lateral radiograph reveals the same catheterposition (arrow). Note the posterior location of the catheter in the left atrium. Right, Corresponding intracardiac echocardiographic imageof the en face view of the mitral orifice. I = inferior; L = left; LA = left atrium; LV = left ventricle.

cardiac structures (Figure 13). Once the operator was satis-fied with positioning, the device was then released. Two-dimensional ICE imaging to determine stability, color flowimaging to determine the presence of residual shunts, andbubble contrast imaging to determine the presence of re-sidual right-to-left shunt were then performed.

Statistical AnalysesAll continuous variables are reported as mean ± SD,

median, and range. Nominal variables were compared byχ2 test. Paired continuous variables were compared by a 2-sided paired t test.

RESULTSNinety-four patients (47 male; median age, 51 years [range,17-81 years]; median weight, 79 kg [range, 39-179 kg])underwent ICE and transcatheter device closure. Of the 94patients, 77 (82%) had 1 defect (35 ASD, 42 PFO); 14patients (15%) had 2 defects; and 3 (3%) had multi-fenestrated defects. Twenty-five patients (27%) had anatrial septal aneurysm and 7 (7%) had redundant atrialseptum. The median ASD size by ICE was 13 mm (range,8-32 mm).

ICE was used to identify a previously unrecognized ana-tomical diagnosis in 32 (34%) of the 94 patients (Table 1).

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Mayo Clin Proc, January 2004, Vol 79 Transcatheter Device Closure 31

Figure 11. Upper left, Anteroposterior radiograph of the intracardiac echocardiographiccatheter tip (arrow) placed across the atrial septal defect into the left atrium but rotatedcounterclockwise to an anterior position immediately behind the aortic valve. Upper right,Lateral image of the same catheter position (arrow). Note that the transducer is pointinganteriorly. Lower left, Corresponding intracardiac echocardiographic image shows in theshort axis the fine detail of the aortic valve leaflets. Lower right, With additional clock-wise catheter rotation, a view of the right ventricular outflow tract and main pulmonaryartery (MPA) is obtained. Arrow points to aortic valve and arrowhead points to pulmonaryvalve. A = anterior; Ao = ascending aorta; L = left; TV = tricuspid valve.

Figure 12. Left, Anteroposterior radiograph of the atrial septal defect sizing balloon inflated in the large patent foramen ovale (PFO) illustratedin Figure 5. Arrows indicate the 18.8-mm waist of the tunnel-like PFO. Middle, Lateral radiograph of the same balloon inflation with arrowsindicating the PFO waist. Right, Long-axis intracardiac echocardiographic image of the atrial septum of the same patient. The balloon-stretched PFO diameter was 1.81 cm. LA = left atrium.

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Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7932

Of these patients, 29 (91%) had undergone both TTE andTEE before referral for device closure. The most com-monly unrecognized diagnosis was the presence of an addi-tional ASD or PFO, found in 16 (50%) of the 32 patients.

The second most common additional diagnosis detectedby ICE was atrial septal aneurysm or redundant atrial sep-tum, found in 12 (38%) of the 32 patients. An atrial septalaneurysm was defined as an atrial septum, or part of anatrial septum, that protruded at least 1.5 cm beyond theplane of the atrial septum. A redundant atrial septum wasdefined as an atrial septum, or part of an atrial septum, thatclearly protruded beyond the plane of the septum but didnot meet the criteria for an atrial septal aneurysm.

One patient had anomalous drainage of the left upperpulmonary vein via a vertical vein to the innominate vein.One patient had a stenotic right upper pulmonary veindetected by Doppler imaging. Another patient had a large

right lower lobe pulmonary arteriovenous fistula identifiedat the time of contrast echocardiography. Finally, 1 patienthad a prominent Chiari network, previously misinterpretedas showing multiple atrial septal fenestrations.

For patients with ASDs and PFOs closed with an atrialseptal occluder (Amplatzer, AGA Medical Corp, GoldenValley, Minn), the balloon-stretched diameters measuredby ICE and fluoroscopy were not statistically different(P=.76 and P=.65, respectively). The median balloon-stretched ASD diameter measured by ICE was 16.5 mm(range, 10-37 mm) and by fluoroscopy was 17 mm (range,8-33 mm). The median balloon-stretched PFO diametermeasured by ICE was 12.0 mm (range, 4-19 mm) and byfluoroscopy was 11.0 mm (range, 4-18 mm).

ICE provided high-resolution 2-dimensional images inmultiple longitudinal plane views and was used as theprimary imaging tool in all patients to guide device place-

Figure 13. Upper left, Intracardiac echocardiographic image of the crux of the heart (arrow) revealsthe Amplatzer atrial septal defect (ASD) occluder device (D) as it is being pulled toward the atrialseptum. Upper right, Long-axis image of the ASD occluder in position in the atrial septum but stillattached. The left atrial disks (arrows) are appropriately positioned. There is a small residual centralleft-to-right shunt. Lower left, Short-axis image of the ASD occluder position behind the aorta (Ao).The right and left atrial disks are appropriately positioned. Lower right, After release, a long-axisimage still shows a small central left-to-right shunt (arrow). A = anterior; CS = coronary sinus; I =inferior; L = left; LA = left atrium; LV = left ventricle; P = posterior; RA = right atrium; S = superior.

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Mayo Clin Proc, January 2004, Vol 79 Transcatheter Device Closure 33

ment and deployment. All patients underwent successfuldeployment and release of their devices, including 6 pa-tients who had 2 devices released simultaneously. Overall,79 patients received an Amplatzer septal occluder, 14 pa-tients received an Amplatzer PFO occluder, and 1 patientreceived a CardioSEAL septal occluder (NMT Medical,Inc, Boston, Mass). Immediately after release of the device,72 patients (77%) had trivial left-to-right shunt through thecenter of the device on color flow imaging. An additional 8patients (9%) had trivial right-to-left shunt on contrastechocardiography. All 8 had undergone device closure of aPFO. Median fluoroscopy time was 30 minutes (range, 4-115 minutes); median procedure time was 128 minutes(range, 27-320 minutes). The longest procedure time andfluoroscopy time occurred in the patient who had bothclosure of an ASD and embolization of a right lower lobepulmonary arteriovenous fistula.

There were few complications (4%) related to ICE.Three patients developed atrial fibrillation and 1 developedsupraventricular tachycardia secondary to ICE manipu-lation. In 2 of the 4 (1 each with atrial fibrillation andsupraventricular tachycardia), the tachycardia resolvedspontaneously. Two patients with atrial fibrillation re-quired electrical cardioversion at the end of the procedure.

DISCUSSIONTEE guidance during transcatheter device closure of ASDand PFO is now standard practice.1-7 Echocardiography isused to determine the size and location of the defect and itsrelationship to surrounding structures. However, TEE haslimitations. Because it typically requires general anesthesiaand endotracheal intubation, there is an increased risk foraspiration and the potential for airway obstruction. Also,TEE requires the use of additional echocardiographic per-sonnel to perform the study. Several small studies haveshown that ICE with the AcuNav catheter is a safe andeffective imaging modality for the guidance of transcath-eter device closure of ASD and PFO.10-12,14 However, nolarge series have been published to date, and experiencewith ICE remains relatively limited. Our series of 94 pa-tients confirms both the efficacy and safety of ICE for theguidance of transcatheter device closure of ASD/PFO.

In all 94 patients, ICE provided adequate, completeimaging, which allowed for successful device placementwith extremely few complications. Overall, 100 deviceswere released in 94 patients. In addition, ICE providedaccurate assessment of the atrial septum, position and sizeof the defects, adequacy of the rims, and drainage of thepulmonary veins in all patients. These findings are similarto the results reported by Hijazi et al,11 Mullen et al,12 andrecently by Bartel et al.14 In the Mullen et al series, in whichpatients underwent both ICE and TEE, close agreement

was found between ICE and TEE for assessing the numberof defects, device position before release, and the presenceof residual shunts in 23 patients who underwent trans-catheter device closure of an ASD. However, a secondsmall defect was identified in 1 patient by TEE but not byICE.

In our series, ICE accurately identified the referral diag-nosis in 100% of the cases. In addition, ICE identified apreviously unrecognized anatomical diagnosis in 32 (34%)of the patients. Of these 32 patients, 29 had undergone bothTTE and TEE before referral. Additional diagnoses playeda major role in the successful outcome of the procedure. Inpatients with 2 defects, a device large enough to cover bothdefects is required. If the second defect was too remote, asecond device was placed simultaneously. With an atrialseptal aneurysm, a device large enough to close the defectand entrap and stabilize most of the atrial septal aneurysmwas chosen. In the patient with a Chiari network in the rightatrium, it was important to distinguish the network from thetrue atrial septum and avoid device entrapment in the net-work during deployment.15

Finally, in the setting of previously unrecognized partialanomalous venous return, the need for surgical referralmust be considered. In the patient in our series with partialanomalous pulmonary venous drainage, 3 right pulmonaryveins were clearly defined entering the left atrium. How-ever, only the left lower pulmonary vein could be identifiedentering the left atrium by ICE. This prompted furtherevaluation with angiography, confirming the diagnosis ofanomalous drainage of the left upper pulmonary vein. Thispatient elected to have device closure of the ASD and latercorrection of the left veins via a left thoracotomy.

As reported in previous series, ICE was associated withfew complications in our series. The only associated com-plication was the development of atrial tachycardia during

Table 1. Previously Unrecognized DiagnosesDetected by ICE During Transcatheter Device Closure*

Patients with new diagnosis (N=94) 32 (34)Patients with new diagnosis who underwent

TTE and TEE before referral 29 (91)Diagnoses

Additional defect (ASD or PFO) 16 (50)Atrial septal aneurysm 9 (28)Redundant atrial septum 3 (9)PAPVR 1 (3)RUPV stenosis 1 (3)RLL pulmonary arteriovenous fistula 1 (3)Chiari network of the right atrium 1 (3)

*Values represent number (percentage) of patients. N = 32 unless indi-cated otherwise. ASD = atrial septal defect; ICE = intracardiacechocardiography; PAPVR = partial anomalous pulmonary venous re-turn; PFO = patent foramen ovale; RLL = right lower lobe; RUPV =right upper pulmonary vein; TEE = transesophageal echocardiography;TTE = transthoracic echocardiography.

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Transcatheter Device Closure Mayo Clin Proc, January 2004, Vol 7934

placement and manipulation of the ICE catheter within theright atrium, which occurred in 4% of the patients, similarto the incidence in prior reports.12 There were no vascularcomplications in our series or in the series reported byHijazi et al.11 However, in the series by Mullen et al,12 1patient experienced a persistent palsy of the ipsilaterallateral cutaneous nerve of the thigh. However, it is notablethat all of the patients in our series were of adult size. Thus,the safety profile of ICE may change as it is used morefrequently in younger and smaller patients.

CONCLUSIONIn our series, ICE provided excellent anatomical detail ofthe ASD or PFO with regard to position and size, adequacyof rims, and relationship to surrounding cardiac structures.In addition, ICE imaging provided successful guidanceduring device placement in all 94 patients and was associ-ated with few complications. Furthermore, it eliminated themajor limitations associated with TEE, specifically theneed for general anesthesia and the potential problemsrelated to airway management. Finally, ICE gives theinterventional cardiologist the ability to control all aspectsof imaging during the procedure without additionalechocardiographic support.

We have provided a detailed stepwise approach forobtaining a complete intracardiac assessment of the cardiacanatomy during interventional catheterization procedures.We believe that ICE should be considered the preferredimaging technique for guidance of transcatheter deviceclosure of ASD and PFO in adults and larger pediatricpatients.

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