Fig. 6.1
Neutral or “Home” view: (a) 2 dimensional image of the tricuspid valve (arrow) and the LVOT coming into view. (b) Color Doppler through the tricuspid valve showing mild tricuspid regurgitation (arrow)
Fig. 6.2
LVOT view: (a) Two dimensional image of the aortic valve and LVOT (arrow). (b) Color Doppler through the aortic valve showing trivial aortic regurgitation (arrow). If the catheter if further rotated clock-wise, the mitral valve will come into view
2.
From the “home view” the ICE catheter is flexed posteriorly and rightward using the two knobs and the position is then locked. Fine adjustments of the posterior and right knobs will then show the inter-atrial septum as well as the pulmonary veins, depending on the exact location of the transducer. This can be referred to as the “septal view” (Fig. 6.3).
Fig. 6.3
Septal/long axis view: (a) Two dimensional image of the short axis view of the septum and small PFO (arrow). The tunnel width and length can be measured from this position. (b) Color Doppler through the septum demonstrates a small left to right shunt through the PFO (arrow). Further cephelad advancement of the probe will display more of the superior vena cava for a true long-axis view
3.
From the “septal view” if the catheter is advanced more cephalad, the superior vena cava (SVC) will come into view giving us the “long axis” view (Fig. 6.3). If more of the SVC needs to be imaged, further cephalad advancement of the catheter will achieve this. This view is comparable to the long-axis view obtained by TEE.
4.
From the above flexed and locked position, the entire catheter and handle are rotated clock-wise (under fluoroscopic guidance) until the catheter tip is near the tricuspid valve annulus and inferior to the aorta. The knobs may need to be adjusted slightly (less rightward and more posterior) until the aortic valve comes into view. This is the “short axis” view (Fig. 6.4) and corresponds well to the short axis view obtained by TEE, except the image is the opposite (near field here is right atrium and far field is left atrium).
Fig. 6.4
Short axis view: (a) Two dimensional short-axis view of the septum with the aorta in view. The PFO tunnel is easily visible (arrow). (b) Color Doppler of the septum in short-axis view demonstrates a small left to right shunt through the PFO (arrow)
5.
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The inter-atrial septum should be interrogated from multiple views and a bubble study should be performed (Fig. 6.5a) to confirm a right to left shunt. The PFO diameter and tunnel length should be measured in multiple views in order to choose the right device size. A sizing balloon may be used according to operator preference (Fig. 6.5b).
Fig. 6.5
Step-wise approach to PFO closure with ICE using a 25 mm Gore Helex device. (a) Bubble study through a catheter it the right atrium shows a positive right to left shunt through the PFO (arrow). (b) Sizing balloon inflated across the PFO allows for measurement of the waist (arrows) at stop-flow diameter. (c) The delivery catheter across the PFO and the left atrial disk deployed far from the septum (arrow). (d) The left atrial disk (arrow) pulled back to the septum under ICE guidance. (e) Right atrial disk (arrow) deployed, short axis view showing good device positioning with the anterior and posterior rims captured. (f) Right atrial disk deployed, long axis view showing good device positioning with the superior and inferior rims captured. (g) Post device release, short axis view of the device showing good positioning, aorta visible. (h) Post device release, long axis view of the device showing good device positioning, superior vena cava visible. (i) Bubble study at the end of the procedure demonstrating no residual right to left shunt
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