Nonfluoroscopic navigation of the phasedarray ICE catheter through the lower-extremity veins. The acute angle between the left common iliac vein (LCIV) and the inferior vena cava (IVC) is initially evident as a loss of echo clear space at the tip of the imaging transducer.
This long-axis view through the tricuspid valve, the "home view," is easily obtained from the mid-RA. Most basic intracardiac views can be obtained with clockwise rotation of the ICE catheter from this imaging plane.
This clip was obtained with clockwise rotation of the imaging catheter from the home view; this directs the imaging plane leftward and posterior. The tricuspid valve gives way to a long-axis view of the aortic root (45Åã CW). The mitral annulus and LAA are then seen (90Åã CW).
The LPVs are visualized. The inferior vein (left) and superior vein (right) are separated by a prominent carina.
Laminar color Doppler flow from the LPVs is visualized. The inferior vein (left) and superior vein (right) are separated by a prominent carina.
This clip opens with color Doppler flow from the right inferior PV. After clockwise rotation of the ICE catheter, the right superior vein is visualized. The RPVs are not often seen in the same imaging plane.
This clip shows a common anatomical variation of the RPVs with a separate middle vein ostium. The right inferior vein is seen to the left and the right superior vein to the right of the middle branch in the clip.
From the home view, the ICE catheter is deflected anteriorly and advanced through the tricuspid valve into the right ventricle.
After the ICE catheter is placed into the right ventricle, clockwise rotation of the imaging plane through the interventricular septum brings the left ventricle into view. This important view allows the operator to rapidly assess both the LV function and the presence of a pericardial effusion.
The ICE catheter is rotated clockwise in the right ventricular outflow to view the aortic root in short axis. This is an important view to differentiate the ostium of the left superior vein from the LAA.
The fossa ovalis is directly visualized from the mid RA. This patient has a large interatrial septal aneurysm which is deviated toward the RA. The aneurysm is more prominent along the anterior aspect of the fossa, and becomes less prominent with posterior (clockwise) rotation of the imaging catheter.
The transseptal needle tents the IAS toward the LPVs. A prior transseptal sheath is seen crossing the IAS inferior to the needle.
After the needle punctures the septum, relief of tenting is noted. The transseptal dilator extends just past the end of the transseptal sheath in the LA. A second sheath is seen more inferiorly, extending across the atrial septum.
We routinely use a circular mapping catheter to create the LA geometry with electroanatomical mapping. ICE is extremely valuable in defining spatially complex 3D structures such as the ridge between the left veins and the LAA. In this view, obtained from the RVOT, the circular mapping catheter is seen sweeping across the ridge.
The tissue edema from acute ablation lesions can often be visualized as tissue brightening adjacent to the ablation catheter. This clip shows an expanding ablation lesion above the LSPV. The circular mapping catheter is also seen at the ostium of the left superior vein.
When ablating near the esophagus, we routinely reduce power settings and monitor esophageal temperature with a probe. This clip is taken during ablation at the posterior aspect of the right inferior vein. The tip of the ablation catheter is seen in close proximity to the esophagus.
ICE allows rapid detection and treatment of pericardial effusions. This view of the LV is obtained with the ICE catheter in the RV. There is a large, circumferential pericardial effusion noted.
This clip reveals a large thrombus attached to a transseptal sheath during transseptal catheterization. The transseptal dilator is tenting the IAS; however, the thrombus is attached more proximally to the tip of the sheath. This thrombus formed in this patient despite an ACT of 380 sec and an INR of 3.5.
A thickened interatrial atrial septum as seen on ICE.
Video 14.2 A "fly-through" left atrium CT reconstruction.
ICE view of the LA, panning from the MV to the right PVs.
ICE view showing a transseptal puncture.
Moderate pericardial effusion as shown on ICE (LV and RV).
Video 16.1 The movie shows the tenting of the transseptal apparatus over the fossa and the instrumentation of the LA (note the bubbles) after the RF application with the "Bovie" over the external end of the needle, as shown in Figure 16.2.
Video 16.2 The movie displays the tenting of the intraatrial septum (fossa ovalis) by the transseptal apparatus and the instrumentation into the LA (note the bubbles) after the RF application using Baylis needle as shown in Figure 16.2D.
Video 18.1 An example of laser ablation lesions delivered to the right inferior pulmonary vein (RIPV). The leftmost panel shows the live endoscopic view of the RIPV-white represents endocardial contact and red contact with blood. At 12:00 is the blindspot created by the laser generator.
Video 20.1 Procedural steps in VOM ethanol infusion.
Video 23.1 Four PV geometries acquired by the spiral catheter (grey) are fused with the 3D reconstructed CT data (dark red shell). The decapolar diagnostic catheter is placed in the CS (yellow). The roving ablation catheter is displayed with a green tip and is used for approval of the registration.
Video 23.2 Rotation of 3D CT in NavX after successful ablation of perimitral flutter. PPI map shows reentrant circuit around mitral valve. Ablations (red points) were performed in the mitral isthmus (2 lines endocardially) and from the CS (epicardially, yellow points) with site termination of the tachycardia (green point).
Video 23.3 Rotation of 3D CT in NavX after successful ablation of roof-dependent AFL around the right PVs. The patient has undergone mitral valve repair with cryoablation previously. The mitral ring can be seen in LAO projection. Ablations (red points) were performed at the roof of LA with site termination of the tachycardia (yellow points).
Video 26.1 Wavefront dynamics during atrial fibrillation from simultaneous bi-atrial Ensite array in paroxysmal AF patient originating from RSPV, shown in Figure 26.4. Rapid and repetitive activities were observed in the RSPV ostium.
Video 26.2 Wavefront dynamics during atrial fibrillation from simultaneous right atrial Ensite array in paroxysmal AF. The high-DF region was compatible with small-radius reentry in the right atrial posterior wall, and linear ablation connecting the conduction channels successfully eliminated and prevented further induction of AF.
Video 28.1 The video shows the articulation and rotations up to 270° of the Artisan catheter, which is composed of two sheaths. The guide catheter is an 8-Fr sheath that navigates in the LA. This is the same size as a regular transseptal sheath.
Videos 28.2 and 28.3 After the insertion of a 14-Fr long sheath (30 cm) over a guidewire (Video 28.2), the Artisan catheter is advanced into the RA using the open irrigated ablation catheter as a guidewire (Video 28.3). Once safely in the IVC, the Artisan could be manually advanced to the RA under fluoroscopic guidance, leading with the steerable ablation catheter.
Videos 28.2 and 28.3 After the insertion of a 14-Fr long sheath (30 cm) over a guidewire (Video 28.2), the Artisan catheter is advanced into the RA using the open irrigated ablation catheter as a guidewire (Video 28.3). Once safely in the IVC, the Artisan could be manually advanced to the RA under fluoroscopic guidance, leading with the steerable ablation catheter.
Video 28.4 After a manual transseptal access is obtained and a guidewire is placed into the tip of the left SPV, the guidewire is used as a marker of the fossa ovalis, along with the trajectory from right to LA. This video shows a safe transseptal placement of the Artisan.
Video 28.5 Following the initial positioning shown in Video 28.4, the outer guide can be advanced for support and the ablation catheter is able to map and ablate into the LA.
Video 28.6 Using the trackball on the Sensei pendant, the operator is orienting the 3D map with the ablation catheter to target the circular mapping catheter at the level of the electrodes 5 and 6.
Video 28.7 PA and AP rotational 3D view of a PV antrum isolation extended to the posterior wall and to CS in a patient with persistent AF. Note the circular mapping catheter at the antrum of the left PVs.
Video 28.8 The video shows the artisan catheter advanced robotically into the CS to obtain CS isolation guided by a mapping decapolar catheter positioned manually into the CS in patients with long-standing persistent AF. The circular mapping catheter is positioned into the LA.