Use of Real Time Three-Dimensional Transesophageal Echocardiography in Intracardiac Catheter Based Interventions

Background: Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. Methods: The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n = 25), percutaneous mitral valve repair (e-valve clipping; n = 3), mitral balloon valvuloplasty for mitral stenosis (n = 10), left atrial appendage obliteration (n = 11), left atrial or pulmonary vein ablation for atrial fibrillation (n = 5), percutaneous closures of prosthetic valve dehiscence (n = 10), percutaneous aortic valve replacement (n = 6), and percutaneous closures of ventricular septal defects (n = 2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. Results: The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face'' view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. Conclusion: RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures. (J Am Soc Echocardiogr 2009; 22: 865-82.)