Echocardiographic Guidance of Procedures

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26 Echocardiographic Guidance of Procedures

Stuart J. Hutchison, Deborah Isaac, Mark Johnson, Robert Moss, Brad Munt

Jugular Venous Cannulation

Rationale and Role

To simplify jugular venous access by direct visualization and guidance

To minimize complications such as hematomas due to jugular venous transfixion, carotid artery puncture, jugular venous to carotid arterial fistula, pneumothoraces, multiple puncture, and failed procedures

Sequence

Place the patient in Trendelenburg position to increase the size of the neck veins.

With the skin cleaned and sterile, introduce the probe into a sterile plastic sheath.

Image from the anterior neck in the mid-portion, which overlies the internal jugular vein and the common carotid artery. The jugular vein, depending on the central venous pressure, may be (usually is) larger than the common carotid artery, but in volume-contracted or dehydrated patients, the vein may be smaller than the artery. The vein may lie to the side of, anterolateral to (this is its usual location in the mid-neck), anterior but slightly lateral to, or completely anterior to the artery.

The most desirable site for cannulation is where the vein is substantially at least lateral to the artery, so that inadvertent transfixion of the vein runs little risk of inadvertently puncturing the common carotid artery. Avoid locations where the jugular vein is directly anterior to the artery.

The vein is identified by the following:

• Distention with a partial Valsalva maneuver

• Compressibility and anterior flattening by slight pressure application with the probe

If the vein is generously full, the needle is inserted carefully through the taut anterior wall of the vein until the tip is a few millimeters into the lumen.

If the vein is full but limp, have the patient make a partial Valsalva maneuver to distend the vein, providing a larger target for the needle puncture and a more taut anterior wall.

It is easiest if the patient is told to take a breath (inspire) before he or she is told to strain (perform a Valsalva maneuver). Guiding the patient in practicing the performance of a Valsalva maneuver before the procedure is helpful for patients who are not familiar with it.

Visualize the wire extending from the needle.

Visualize the sheath within the lumen following its insertion.

Be aware of the presence of jugular venous valves, a normal aspect of anatomy. Insertion beneath the valves may simplify the procedure.

Be aware of the appearance of jugular venous thrombus, a common residua of prior catheter and wire insertions

Pro

With practice and experience, a high degree of proficiency can be achieved.

Cons

Some dexterity and proficiency with the technique of direct ultrasound imaging guidance are needed, resulting in a learning curve (Figs. 26-1 to 26-3).

Endomyocardial Biopsy

To reliably diagnose heart transplant rejection, right ventricular endomyocardial biopsy (percutaneous procurement of endomyocardial samples from the right ventricle ^1,²) remains the gold standard. Right ventricular endomyocardial biopsy also is a valuable way to assist with diagnosis and management of suspected myocarditis, infiltrative cardiomyopathy, or other unexplained ventricular dysfunction.

Percutaneous right ventricular endomyocardial biopsy most commonly is performed using cannulation of the right internal jugular vein. In circumstances where this vessel is not usable, the femoral vein can be used for this purpose. Cardiologists traditionally have relied on fluoroscopic guidance for placement of the bioptome. Using frontal-plane fluoroscopic guidance, the bioptome is directed toward the right ventricular septum to obtain right ventricular samples. Bioptome contact with the right ventricular septum is confirmed by the presence of ventricular ectopic beats, and samples are taken from that site. Typically at least four biopsy samples are obtained, because a minimum of three adequate biopsy samples are required for histologic diagnosis. The use of fluoroscopy to guide right ventricular endomyocardial biopsy has a number of drawbacks: it provides only approximate bioptome placement information; exposes both the patient and physician to radiation; and requires use of the cardiac catheterization laboratory—a facility in high demand. Using fluoroscopic guidance, the complication rate ranges from 6% to 14%,^3,⁴ with possible complications including myocardial perforation, tricuspid valve apparatus disruption, arrhythmias, coronary artery to right ventricular fistula, and inadvertent arterial punctures. A significant limitation of fluoroscopic guidance for right ventricular endomyocardial biopsies is that the bioptome placement and subsequent sampling area are limited due to inability to place the bioptome precisely, leading to repeated sampling from the same area. This contributes to biopsies that consist predominantly of scar from previous biopsy sites, which are inadequate for histologic assessment, and to reduced sensitivity due to the potentially focal nature of rejection or other cardiac histologic processes.

Rationale and Role

Real-time visualization

Of venipuncture to lessen access complications

Of bioptome placement/biopsy sampling

• To lessen complications

• To increase diagnostic yield

Sequence

Echocardiographically guided endomyocardial biopsy usually is performed in the echocardiography laboratory, with the assistance of an echosonographer and a nurse.

The person performing the biopsy procedure stands at the head of the bed, with the echosonographer and echocardiography machine to the patient’s left and the nurse and sterile tray to the patient’s right.

Echocardiographic images are obtained prior to venous cannulation to determine the optimal window and views for visualization of the right atrium and ventricle; to briefly assess left and right ventricular systolic function, the presence and amount of pericardial fluid present, and the presence and degree of tricuspid regurgitation; and to estimate right ventricular systolic pressure. Preprocedure imaging also determines the ideal patient positioning. In many cases supine imaging is adequate, but patients may be moved into the left lateral lying position after initial insertion of the jugular venous sheath to optimize visualization of the right-sided cardiac structures. Ultrasound assessment of the right internal jugular vein may be done at this time, to assist in venous cannulation.

Venous access is obtained using standard Seldinger technique via the right internal jugular vein, with a sheath left in place.

The bioptome is then inserted through the venous sheath into the right atrium.

Using echocardiographic imaging to visualize the right-sided chambers and tricuspid valve and apparatus, the bioptome is then passed across the tricuspid valve into the right ventricle. The endocardial surfaces of the right ventricle are visualized, and the sonographer “follows” the advancement of the bioptome, keeping the forceps head of the bioptome clearly imaged throughout the procedure. The operator maneuvers the bioptome to the desired location, avoiding the moderator band and tricuspid apparatus. Once the bioptome is approximated next to the endomyocardial surface in the desired position, the jaws of the bioptome are opened, and the bioptome is advanced gently against the endomyocardium. Once in place, the jaws are closed and, with a very gentle tug, the biopsy sample is obtained. The bioptome is removed, the sample is placed in sterile saline, and the procedure is repeated until an adequate number of samples have been obtained.

Samples may be taken from the mid to distal right ventricular septum, apex, and free wall in post–cardiac transplant patients, but are usually restricted to the mid- to distal right ventricular septum in non–transplant patients.

Post-procedure echocardiographic imaging assesses for changes in the presence or degree of tricuspid regurgitation and/or pericardial fluid.

Two decades ago, Miller published his successful results using echocardiographic guidance for right ventricular endomyocardial biopsy.⁵ Despite this and other reports of reduced costs and an improved safety profile using echocardiography to guide right ventricular endomyocardial biopsy in adults and children,⁶^–¹⁰ this technique has not gained widespread popularity.

Pros

Echocardiographic guidance of right ventricular endomyocardial biopsy affords considerable benefits over traditional fluoroscopic guidance.

Improved safety

• As well as elimination of radiation exposure, there is less likelihood of cardiac damage caused by poor visualization—such as inadvertently entering the coronary sinus or damage to tricuspid apparatus—because of the superior means to identify anatomic cardiac landmarks. Intracardiac leads and catheters can be easily visualized and avoided for bioptome placement.

• The uncommon complication of pericardial effusion development can be immediately identified and addressed if endomyocardial biopsy is performed under echocardiographic guidance.

• Ultrasound guidance can be used to assist with difficult venous cannulation, which affords both a safety and convenience advantage by reducing inadvertent carotid artery punctures and repeated/multiple access attempts.

Provision of additional information

• A brief assessment of left and right ventricular systolic function, valvular regurgitation, right ventricular/pulmonary artery systolic pressure, and presence of pericardial fluid can be performed to provide current and additional structural and functional information.

• Although most patients will undergo right ventricular biopsy in the echocardiography laboratory, biopsies may be performed in the rooms of critically ill patients in the cardiac intensive care unit, saving staff time and eliminating the inconvenience of transporting the patient.

Improved sampling

• An expanded endomyocardial sampling area improves the sensitivity for the diagnosis of rejection, which may be a focal process. In adequate samples may be obtained in up to 8% of biopsies performed under fluoroscopy and as low as 0%⁶ under echocardiographic guidance.

• Using echocardiography, the bioptome can be directed away from scarred previous biopsy sites, and samples can be obtained safely from sites along the mid- to distal right ventricular septum and apex.

• In patients who are more than 6 to 8 weeks post–cardiac transplantation, biopsies may be safely obtained from the patient’s right ventricular free wall by experienced operators.⁵ Biopsy samples should be limited to the right ventricular septum in patients who are within 6 to 8 weeks after cardiac transplantation, and in those with native hearts.

Directed biopsies

• Echocardiographic biopsy guidance allows for targeted biopsy of intracardiac (i.e., within the right ventricle and right ventricular outflow tracts) masses due to the ability to clearly image the target area and the bioptome.

• Performance of right ventricular biopsy under echocardiographic guidance reduces costs up to 50%⁷ because it avoids the use of the cardiac catheterization laboratory, and it requires fewer staff resources—typically, one nurse and one echocardiography technician are needed, compared to the need for a scrub nurse, a circulating nurse, and a monitoring technician in the catheterization laboratory.

Despite valid and compelling benefits, there has been reluctance to adopt echocardiographically guided right ventricular biopsy. A typical argument against the technique is the perception that it is difficult to get adequate echocardiographic images in some patients. In 90% of patients, however, the standard apical four-chamber view can be used to view the bioptome head,⁶ although modifications of this view may be necessary to provide optimal imaging during bioptome manipulation.

Cons

Need for the operator to develop confidence (Figs. 26-4 to 26-10)

Pericardiocentesis

Rationale and Role

Echocardiography provides the most versatile means to guide pericardiocentesis by guiding access site selection and needle entry orientation, visual confirmation of needle entry into the pericardial space, avoidance of cardiac perforation, and verification of successful drainage.

Sequence

• Standard transthoracic study to establish the location and distribution of the pericardial fluid

• Determination of the site that provides shortest distance to enter the pericardial fluid and the best orientation to minimize needle trauma to the heart (by orienting into the fluid space away from the heart chambers)

During the procedure

• Visual identification of the needle orientation and entrance into the pericardial space

• Visual confirmation of the wire within the pericardial space, with or without visual confirmation of the injection of agitated saline within the pericardial space

• Visualization of reduction of the pericardial fluid

Unlike chest CT scan, real-time imaging by echocardiography of the heart’s motion within the pericardial space enables determination of the dimension of pericardial fluid throughout the cardiac cycle, which can vary considerably between diastole and systole.

During the procedure, use of a sterile sleeve to enable scanning immediately beside the site of puncture allows for real-time imaging.

Pros

Portability: can be performed at any bedside

Real-time imaging during the procedure maximizes procedural awareness.

Con

Learning eye–hand coordination to image the needle and wires requires willingness (Figs. 26-11 to 26-17).

Transseptal Puncture

Rationale and Role

Visual guidance by transesophageal echocardiography (TEE) of interatrial septal puncture to lessen risk of inadvertent puncture complications and identify any complications that do occur

Guidance of complex transseptal punctures in cases of kyphosis or scoliosis where the heart orientation (specifically that of the interatrial septum) within an abnormal chest cavity is unclear without imaging

Sequence

Visualization of the catheter and needle approaching the heart (inferior vena cava/bicaval view)

Visualization of the needle contacting the interatrial septum away from the margin of the septum

Visualization of the needle tenting the interatrial septum away from the margin of the septum

Visualization of the needle/catheter in the left atrium

Visualization of the catheter flush (small bubbles) in the left atrium

Pros

Straightforward

Identification of the presence of a patent foramen ovale alerts one that the interatrial septum may be inadvertently/quickly crossed.

Con

Performing TEE on a supine patient requires attention and measures to protect the airway (Fig. 26-18).

Catheter Mitral Balloon Valvuloplasty

Rationale and Role

TEE guidance of catheter balloon valvuloplasty affords a means by which to

• Guide atrial septal puncture in difficult cases

• Assess the degree of post–balloon inflation mitral insufficiency in cases of preprocedure moderate mitral regurgitation (MR) where there is concern about precipitating severe MR.

Sequence

As described for atrial septal puncture guidance

Color Doppler flow mapping and pulmonary venous sampling to determine the degree of mitral insufficiency incurred by balloon inflation

Pro

Useful when contrast sparing is desirable (e.g., renal insufficiency). Contrast ventriculography is otherwise used to assess the degree of mitral insufficiency post–balloon inflation.

Cons

Not needed for the average case

Performing TEE on a supine patient requires attention and measures to protect the airway (Figs. 26-19 to 26-22).

Percutaneous Aortic Valvuloplasty

Rationale and Role

Traditional aortic valve replacement is performed via median sternotomy, cardiopulmonary bypass, aortotomy, resection of the native aortic valve, and insertion of a prosthetic aortic valve. Approximately 60,000 aortic valve surgeries are performed per year in North America; however, many patients in need of aortic valve surgery never undergo it due to prohibitive and generally noncardiac risks.

Percutaneous aortic valve (PAV) replacement, as an alternative to open-chest aortic valve replacement, is emerging and is undergoing clinical investigation as an alternative to conventional surgery. Valves can be inserted percutaneously via retrograde aortic cannulation or anterogradely via a small thoracotomy.

Two PAV prostheses currently are in clinical use:

The CoreValve prosthesis (Fig. 26-23)

The Edwards-Sapien prosthesis (Fig. 26-24)

Echocardiography has an integral role in PAV implantation pre-, intra-, and post-procedurally, as two-dimensional imaging, especially by TEE, is generally very well-suited to delineate left ventricular outflow tract and aortic valve anatomy, and the hemodynamics of stenosis and insufficiency.

Sequence

Preprocedural Assessment

Severity/morphology of aortic stenosis

Routine transthoracic echocardiography (TTE) is done to assess for aortic stenosis, including ensuring that the stenosis is valvular and determining, at a minimum, the valve gradient and aortic valve area. (Other values such as the dimensionless index may be helpful in some situations.)

Valve morphology

• Tricuspid versus bicuspid valve

• Aortic valve calcium distribution and extent

Aortic root geometry

TEE may be required to yield accurate root dimensions if TTE is technically difficult. The contribution of gated cardiac CT also should be considered for dimensional measurements

The number of key measurements depends on the PAV used:

For the CoreValve prosthesis

• Aortic annulus diameter

• Sinus of Valsalva diameter

• Sinotubular junction diameter

• Aortic annulus–coronary ostial distance (aortic valve area–ostial height)

For the Edwards-Sapien prosthesis

• Aortic annulus diameter

Aortic annulus

The aortic annulus is a critical measurement in determining patient eligibility and is useful in device sizing. The aortic annulus is not a planar anatomic structure but, rather, a complex 3-dimensional “crown-like” configuration formed by the insertion of the aortic cusps into the aortic wall. Small variations in image plane can produce significantly differing annular measurements. Hence, careful alignment of the aortic root is essential in producing an accurate and reproducible measurement.

Parasternal long-axis view on TTE and the midesophageal long-axis view on TEE

Measure on a frozen zoomed end-diastolic frame (beginning of the QRS complex after closure of the mitral valve and before opening of the aortic valve).

Aortic root walls should be parallel and the aortic valve orifice central in a trileaflet valve. The cross-plane (biplane) feature on three-dimensional probes can be helpful in aligning the aortic root.

Measured diameters are intraluminal, from aortic wall to aortic wall, ignoring any protuberant calcium from the measurement.

Annulus diameter is perpendicular to the long axis of the root, measured between the endocardial site that trisects the posterior aortic wall, noncoronary cusp hinge and the anterior mitral leaflet hinge, and the point that bisects the anterior aortic wall and the right coronary cusp hinge.

Our recommendation is to obtain three reproducible measurements:

Sinus of Valsalva diameter

• Perpendicular to the long axis of the root, parallel to the aortic annulus, the widest intraluminal distance within the sinuses.

Sinotubular junction diameter

• Intraluminal diameter parallel to the sinus of Valsalva diameter, where the sinuses narrow and join the ascending aorta

Aortic valve area–ostial height

• Distance of the right coronary ostium to the aortic annulus

These dimensions are critical for sizing the percutaneous prosthesis.

Subaortic geometry

Assessment for noncompliant subaortic disease: protuberant calcium in the left ventricular outflow tract, moderate to severe septal hypertrophy

CoreValve recommends that implantation should not be performed if subaortic disease is sufficient to cause stenosis or if the septal wall thickness is 17 mm or more.

Hypertrophic cardiomyopathy with significant left ventricular outflow tract obstruction is a contraindication for both devices.

• If the obstruction is subaortic, then, clearly, both devices are contraindicated.

Other valve pathology/cardiac disease

Baseline assessment of left ventricular (LV) systolic and diastolic function, regional wall motion abnormalities, right ventricular (RV) function, and pulmonary artery pressure

• Assess for significant mitral valve disease (MR and extensive mitral annular calcification are common).

• The CoreValve is contraindicated if the severity of MR is greater than grade 2+.

Other test modalities that factor prominently into the preprocedural assessment of percutaneous aortic valve implantation procedures include

• Cardiac catheterization for assessment of aortic stenosis severity assessment and detection of the presence of concurrent valvular problems and complications

• Coronary angiography for the delineation of coronary artery disease extent and severity

• Electrocardiographically gated cardiac CT scan for assessment of dimensions

Intraprocedural Role

The CoreValve prosthesis often is implanted without intraoperative TEE guidance, whereas the Edwards-Sapien valve usually is implanted under TEE guidance.

The long-axis view (~130 degrees) is used to guide deployment of the Edwards prosthesis. Ideally, the undeployed Edwards valve on the delivery system should be positioned across the aortic valve coaxial to the aorta. The ventricular end should be positioned up to 5 mm below the native aortic valve area, because there is a tendency for the percutaneous heart valve (PHV) deployment system to propagate incrementally toward the aortic root during deployment. The aortic end should be close to the tips of the native aortic valve leaflets to ensure full leaflet capture with deployment.

Identification of the ventricular and aortic rims of the prosthesis can be challenging, and knowledge of the PHV length (this may differ in the deployed and undeployed states), the use of high-frequency imaging, and manipulation of the probe are required to improve visualization. It should also be remembered that different iterations of the deployment systems have subtly different imaging characteristics.

Hemodynamic instability often is observed during device positioning. This may be due to critical output obstruction by the undeployed PHV, but is thought sometimes to be related to reflexive changes in vagal output. Correct deployment position of the Edwards valve is essential so that the fabric portion of the prosthesis is fully opposed to the aortic annulus. Deployment in a position that is too ventricular is serious; it may result in immediate and life-threatening aortic regurgitation; incomplete capture of native aortic valve leaflets and restriction of anterior mitral valve leaflet motion also may be seen. Deployment in a position that is too aortic can result in coronary artery obstruction and can compromise the stability of the valve, risking valve embolization.

Edwards-Sapien valves usually are implanted under TEE guidance:

• To confirm valve annulus size

• In assisting the crossing of the aortic valve with a wire

• In assisting in positioning and monitoring aortic balloon valvuloplasty (performed prior to valve implantation)

• To assess the degree of aortic regurgitation post–balloon valvuloplasty

• To guide positioning of the prosthesis prior to balloon deployment

• Assess PAV position stability, leaflet motion, and degree and location of aortic regurgitation (a valve may be expanded further with another balloon inflation if more than mild paravalvular regurgitation is present)

• To assist in determining the etiology of hypotension post–PAV deployment

• In determining PAV gradients (from retroflexed transgastric views)

TEE can be helpful in assessing for aortic pathology that may occur during the procedure (e.g., dissection).

Post-procedural Assessment

Immediate post-procedural assessment by TEE

PHV position and stability

• When correctly positioned, the ventricular end of the PHV should lie 2 to 4 mm ventricular to the aortic annulus, while the aortic end should fully capture the aortic leaflets, displacing leaflet calcium into the aortic root.

Aortic regurgitation

• Trivial or mild posterior paravalvular regurgitation often is noted and is of little concern. If there is greater than mild paravalvular regurgitation, the prosthetic valve may be expanded further with another balloon inflation. Trivial valvular aortic regurgitation also is commonly seen.

Unusual complications include the following:

• Coronary ostial occlusion (displaced bulky calcium)

• Cardiac trauma (pericardial effusion/tamponade)

• Fragmented aortic debris or thrombus in relation to the PHV

• Aortic root rupture during deployment,

• Aortic dissection or rupture by the delivery system

• Mitral valve dysfunction (this is unusual; functional MR often improves following PHV implantation)

PHV gradients (best obtained from deep transgastric views)

Post-procedural Follow-up by Transthoracic Echocardiography

TTE for follow-up of PAV hemodynamics (gradients, area, regurgitation)

TTE for follow up of hemodynamic and morphologic response to PAV implantation (e.g., change in pulmonary artery pressure, LV mass changes)

TTE or TEE for assessment of symptoms that develop after valve implantation (e.g., imaging for suspected endocarditis; Figs. 26-25 to 26-30)

Intra-Aortic Counterpulsation Balloon Tip Localization

Rationale and Role

Identification of the correct location of the intra-aortic balloon in both intra-aortic and intra-cardiac assist devices

Sequence

The tip of the intra-aortic counterpulsation balloon (IABP) is verified post-insertion by fluoroscopy or chest radiography. However, it is somewhat prone to movement, especially in patients who are transported.

TEE is readily able to verify the tip location of the balloon. It should be in the very proximal descending aorta.

Pros

A practical means to use at the bedside to ensure correct placement of the IABP within the proximal descending aorta and to exclude misplacement, such as within the inferior vena cava

A practical means to identify some complications of IABP insertion such as iatrogenic dissection

Cons

Fluoroscopy generally is used to guide IABP placement, especially because most are placed in the cardiac catheterization laboratory. The role of TEE is limited to verification of correct placement without fluoroscopy (Figs. 26-31 and 26-32).

Impella and Left Ventricular Assist Device Insertion ^*

Rationale and Role

The Impella percutaneous ventricular assist devices (Abiomed, Inc., Danvers, MA) typically are inserted percutaneously via the femoral artery (Impella 2.5) or via surgical cut-down (Impella 2.5 or 5). The device is advanced retrograde up the aorta, and positioned across the aortic valve such that the intake is within the LV, and the output is above the aortic valve. The component of the device within the LV is best oriented along the long axis of the LV. The presence of significant aortic insufficiency would preclude the device achieving efficiency.

Echocardiography is useful to exclude significant aortic valve disease (i.e., aortic stenosis that would preclude delivery of the device into the left ventricle and aortic insufficiency that would impair efficiency). TEE usually is employed to verify the correct location/position of the intake component within the left ventricle and of the output component within the aorta.

Although these devices are deployed with fluoroscopic guidance, the combination of fluoroscopy and echocardiography—both two-dimensional and color Doppler—provides visualization of the wire and device (fluoroscopy and echocardiography) and the cardiac structures (echocardiography) such that the position and orientation of the device ensures optimal functioning

Sequence

Transthoracic echocardiography

To exclude significant aortic valvar stenosis

To exclude significant aortic valvar insufficiency

To exclude ‘mechanical’ complications of infarction

Transesophageal echocardiography

After exclusion of significant aortic valve disease and mechanical complications of infarction

• Obtain a suitable long-axis view of the left ventricle, left ventricular outflow tract, aortic valve, and aortic root.

• Confirm that the guide wire has been advanced to and then across the aortic valve into the left ventricle.

• Confirm that the device has been advanced a suitable distance into the left ventricle such that the intake is 4 to 5 cm beyond the aortic valve into the left ventricle.

The location of the intake can be determined as follows:

• If the device is not on: by the bright reflections from the metallic body just distal to the actual intake

• If the device is on: by color Doppler flow mapping that reveals continuous flow

Confirm that the device is oriented to have the distal part along the long axis of the left ventricle toward the apex, rather than toward the wall.

Confirm that the output component is ejecting blood within the aorta beyond the aortic valve.

Pros

A practical means to use in the operating room or cardiac catheterization laboratory to ensure correct placement of the intake and the output components of the Impella device on their appropriate sides of the aortic valves

TTE may yield sufficient images, but TEE achieves more reliable visualization because most patients with cardiogenic shock are mechanically ventilated.

Cons

Visualization of the length of the Impella 5 device within the LV necessitates obtaining a long-axis view along which the device falls. If the plane of the device varies from that of the imaging plane, visual misunderstanding about the location of the end of the device may occur because it may be assumed that the last visualized portion of the device is the end.

Familiarity with devices and with the two-dimensional and color Doppler imaging findings of their components is essential (Figs. 26-33 to 26-40).

Surgical Ventricular Assist Device Placement and Function

Rationale and Role

Identification of the correct location of both intra-aortic and intra-cardiac assist devices

Sequence

The tip of the IABP is verified post-insertion by fluoroscopy or chest radiography. However, it is somewhat prone to movement, especially in patients who are transported.

TEE is readily able to verify the tip location of the balloon. It should be in the very proximal descending aorta.

Pros

A practical means for use at the bedside to ensure correct placement of the IABP within the proximal descending aorta, and to exclude misplacement such as within the inferior vena cava

A practical means to identify some complications of IABP insertion, such as iatrogenic dissection

Cons

Fluoroscopy generally is used to guide IABP placement, especially because most are placed in the cardiac catheterization laboratory. The role of TEE is limited to verification of correct placement without fluoroscopy (Fig. 26-41).

Figure 26-1 Top: The different positions of the internal jugular vein (purple) relative to the common carotid artery (red) vary depending on the location of the neck and somewhat between patients. Bottom: Identification of the internal jugular vein and its venipuncture. Among other techniques, the internal jugular vein is identified by its compressibility in response to light pressure from the transducer, which flattens the near wall, and also by near-wall tenting/indentation in response to needle pressure.

Figure 26-2 Internal jugular venous cannulation guided by a transthoracic ultrasound probe, within a sterile sheath, for endomyocardial biopsy. Upper left: The internal jugular vein and the common carotid artery are seen in short-axis view. Upper right: With compression by the transducer, the jugular vein becomes partially flattened. Middle images: Before (left) and after (right) insertion of the needle through the anterior wall of the jugular vein. Lower left: The internal jugular vein is seen in longitudinal axis and the wire is seen along its oblique course through the overlying soft tissue and down and into the jugular vein. Lower right: The internal jugular vein is again seen in longitudinal axis and the Cordis catheter (Cordis Corporation) is seen within the lumen of the vein.

Figure 26-3 A venous valve within the internal jugular vein seen in longitudinal axis (upper images) and in short axis (lower images).

Figure 26-4 Upper images: Guidance of the internal jugular venipuncture is performed with ultrasound. Middle images: The sheath is advanced into the internal jugular vein and its position verified by ultrasound. Lower images: Bioptome in the closed (left) and open (right) positions. The ultrasonographic appearance of the bioptome tip can be expected to be more prominent when it is in the open position.

Figure 26-5 Upper left: Internal jugular venous access is the preferred route to perform endomyocardial biopsy. Upper right: The bioptome is advanced under ultrasound guidance. Middle left: The bioptome is introduced through the sheath, down the superior vena cava. Middle right: The bioptome is introduced into the heart, and its tip can be seen within the right atrium. Lower left: The bioptome tip is being advanced into the right ventricle. Lower right: An endomyocardial biopsy sample.

Figure 26-6 Upper left: The bioptome tip has been advanced slightly past the tricuspid valve level. Upper right: The bioptome tip has been advanced toward the apical portion of the interventricular septum. Middle left: The bioptome has been opened, resulting in a more prominent appearance by two-dimensional ultrasound imaging. Middle right: Traction has been placed on the bioptome as the endomyocardial sampling is performed, slightly distorting the septal curvature. As the bioptome separates from the septum there is a slight but brisk motion of the septum as it assumes its normal curvature. Lower left: The bioptome with the endomyocardial biopsy sample has been withdrawn to the right atrium. Lower right: The bioptome with the endomyocardial biopsy sample has been withdrawn out of the heart.

Figure 26-7 Upper left: The bioptome tip can be seen within the right atrium. Upper right: The bioptome tip can be seen within the right ventricle, being advanced forward. Middle left: The bioptome tip is being advanced toward the apical portion of the interventricular septum. Middle right: The bioptome has been opened at the distal aspect of the right side of the interventricular septum. In its open position, the bioptome is more ultrasonographically obvious. Lower left: The bioptome, now with an endomyocardical biopsy sample, has been withdrawn into the body of the right ventricle. Lower right: The endomyocardial bioptome has been withdrawn out of the heart. Note the electrocardiographic tracing across the bottom of the images. At the time of contact of the bioptome during sampling, ventricular ectopy is generated.

Figure 26-8 Upper left: The bioptome has been inserted to the level of the tricuspid valve annulus. Upper right: The bioptome has been directed against the right ventricular freewall. Lower left: The bioptome has “bitten” the right ventricular freewall, and traction on it has retracted inward/tented the freewall. Lower right: The bioptome, now with a biopsy sample, has released the freewall, is located within the right ventricular cavity, and is being withdrawn.

Figure 26-9 Upper left: The bioptome has been applied against the distal septum. Upper right: The bioptome has engaged the mid-septum. Lower left: The bioptome has been opened, as indicated by the larger echo reflection, to acquire the biopsy. Lower right: The bioptome has been closed, as indicated by a smaller echo reflection.

Figure 26-10 Upper left: Before intracardiac insertion of the bioptome. Upper right: The bioptome has been advanced to the tricuspid valve level. Lower left: The bioptome has been advanced into the right ventricle toward the right ventricle’s freewall. Lower right: The bioptome, with sample, has been withdrawn into the right ventricular cavity.

Figure 26-11 Pericardiocentesis from an apical approach guided by transthoracic ultrasound (within a sterile sleeve) beside the puncture. Upper left: The optimal site and orientation of needle entry are established. From this site and with this orientation there is approximately 2 cm of soft tissue to traverse and approximately 2 cm of fluid over the apicolateral wall of the left ventricle. Upper right: The needle is visualized within the soft tissue having just entered the pericardial space. The orientation of the needle is actually more toward the heart than tangentially beside the heart, and the swinging motion of the apex has brought it within a few millimeters of the needle tip. Middle left: Shallow view demonstrating the bevel of the needle tip within the pericardial space. Middle right: The J-wire is visualized within the pericardial fluid. Lower left: The J-wire is has been advanced further into the fluid, as can be seen from the position of the J-shaped tip. Lower right: The catheter has been advanced over the wire into the pericardial space. Its appearance is different from that of the wire.

Figure 26-12 Pericardiocentesis from an apical approach guided by transthoracic ultrasound (within a sterile sleeve) beside the puncture. Upper left: The optimal site and orientation of needle entry are established; from this site and with this orientation there is approximately 2 cm of soft tissue to traverse and 3–4 cm of fluid over the apicolateral wall of the left ventricle. Upper right: Shallow view of the same are to “set up” the puncture. Middle left: The needle has been introduced into the pericardial space. A segment of needle is visualized in the more shallow soft tissue, but the tip and actual site of entry into the pericardial space are not seen on this plane of imaging. The bubbles from an agitated saline injection, however, corroborate entry of the needle tip into the pericardial space. Middle right: The wire is visualized within the pericardial space, and due to slight adjustment of the imaging plane, the entry of the wire into the pericardial space is seen. Lower left: The dilator over the wire is visualized within the pericardial space. Lower right: The drainage catheter is visualized within the pericardial space. Note the difference in the appearances of the wire, the dilator, and the drainage catheter.

Figure 26-13 Left: A shallow apical view to set up needle introduction into the pericardial space. There are only a few millimeters of fluid over the true apex; the safest site to enter is beside the apex, and the safest orientation is tangential to the apicolateral wall. Right: The needle has been introduced at the correct site and with the correct orientation.

Figure 26-14 Transthoracic echocardiographically guided pericardiocentesis. The plane of imaging perfectly follows the plane of the needle advancement, because the two are joined by a guide device. On these serial images the needle can be seen arriving at the parietal pericardium (upper right), tenting the parietal pericardium (middle left and right), entering the pericardial space (lower left), and having entered the pericardial space (lower left). Finally, the guidewire can be seen further entering the pericardial space (lower right).

Figure 26-15 Tenting of the parietal pericardium during pericardiocentesis. Left: Mild pressure with the needle has produced a shallow indentation/inversion of the curvature of the parietal pericardium. Right: Stronger pressure has resulted in more marked indentation/inversion of the parietal pericardium. In this case, the parietal pericardium was thickened from chronic pericarditis, and the effusion was effusoconstrictive.

Figure 26-16 Left: Shallow apical view pretap/predrainage shows a large pericardial effusion. Right: Standard apical four-chamber view post-drainage: no fluid remains within the pericardial space, as seen on this plane of imaging.

Figure 26-17 Transthoracic echocardiographic guidance during pericardiocentesis. Left: During insertion, the needle is ambiguously visualized, because there are four linear entities that all appear to enter the pericordial space from the orientation of the needle. Right: Injection of agitated saline clearly demonstrates that the needle is within the pericordial space despite the poor/ambiguous visualization of the needle.

Figure 26-18 Transesophageal guidance of the interatrial septal puncture to perform mitral valvuloplasty. Upper left: A superior cable view depicting the mid-portion of the inner atrial septum (septum primum) and the superior portion of the inner atrial septum (septum secundum). The superior vena cava is seen extending on the far side of the inner atrial septum toward the right side of the image. Upper right: A guidewire passed from the femoral vein to the heart has passed upward to the superior vena cava. Middle left: The Brockenbrough needle has been advanced into the lower mid–right atrium but is not in contact with the inner atrial septum. Middle right: The Brockenbrough needle is being pressed against the inner atrial septum and is tenting it prominently. The tip of the needle is a safe distance away from the superior margin of the left atrium. Lower left: The needle tip can be visualized within the left atrium Lower right: The saline flush can be seen to be within the left atrium.

Figure 26-19 Upper left: Transesophageal four-chamber view. The mitral valve morphology is clearly domed, and there is prominent thickening at the top of the anterior mitral leaflet in particular. There is right ventricular hypertrophy. A catheter is in the far interior part of the right ventricle. Upper right: A wire has been passed through the inner atrial septum and is visualized in the body of the left atrium and crossing the mitral valve. Middle left: Initial inflation of the balloon within the mitral valve orifice can be seen to widen the orifice slightly, but a long waist remains on the balloon. Middle right: Subsequent inflation of the balloon yields a smaller waist, indicative of better opening of the mitral valve. Lower left: Color Doppler flow mapping at the mitral stenosis orifice demonstrates a small to moderate sized proximal isovelocity surface area consistent with a gradient, but not a severe one. Lower right: Color Doppler flow mapping of mild mitral insufficiency.

Figure 26-20 These images were obtained following mitral valvuloplasty. Upper left: A zoom view from the peristernal long-axis orientation of the mitral valve. There are two jets of mitral insufficiency, one of which is highly eccentric and anterior. Upper right: Transesophageal view of the mitral valve shows a rupture of the anterior leaflet at its basal insertion into the mitral-aortic fibrosa. Lower views with color Doppler flow mapping demonstrate flow across the site of rupture of the anterior mitral leaflet and across the central mitral orifice.

Figure 26-21 Mitral valve gradients and the corresponding spectral Doppler display, which yields gradient calculation.

Figure 26-22 Hemodynamic tracings performed during catheter balloon valvuloplasty. Left: The pulmonary artery (PA) tracing reveals systemic levels of pulmonary hypertension. Middle: The left ventricular and pulmonary venous capillary tracings yield the mitral valve gradient (MVG). The gradient is 20 mm, and the calculated mitral valve area (MVA) by the Gorlin relation is 0.9 cm²Right: Following mitral valvuloplasty, the pulmonary capillary wedge to left ventricular gradient has fallen to 7 mm, and the area has increased to 1.4 cm².

Figure 26-23 The CoreValve prosthesis.

(Courtesy of CoreValve ReValving System, CoreValve Inc., Irvine, California.)

Figure 26-24 The Edwards-Sapien prosthesis.

(Courtesy of Edwards Life-Sciences Inc., Irvine, California.)

Figure 26-25 Transesophageal echocardiographic midesophageal long-axis view of the aortic root at end-diastole, with measurements of the aortic annulus (A), sinus of Valsalva (B), sinotubular junction (C), and the sinus of Valsalva height (D).

Figure 26-26 Three-dimensional transesophageal echocardiographic cross-plane midesophageal long- axis (left) and modified short-axis (right) view of the aortic valve during rapid ventricular pacing and aortic valvuloplasty. The right image is inverted in relation to the regular short-axis view, with the intra-atrial septum on the right. These images show a fully deployed aortic valvuloplasty balloon with no waisting of the balloon and displacement of the native aortic valve tissue into the sinuses of Valsalva.

Figure 26-27 Transesophageal echocardiographic midesophageal long-axis view of the aortic root pre-deployment of the Edwards-Sapien aortic prosthesis. The crimped Edwards-Sapien valve can be seen on its delivery system crossing the stenotic aortic valve. The ventricular and aortic ends of the crimped valve are marked by arrows. This image shows the correct positioning of the valve pre-deployment.

Figure 26-28 Transesophageal echocardiographic midesophageal long-axis view of the aortic root pre-deployment of the Edwards-Sapien aortic prosthesis. The crimped Edwards-Sapien valve can be seen on its delivery system crossing the stenotic aortic valve. Blue arrows mark the ventricular and aortic ends of the crimped valve; a green arrow marks the level of the aortic annulus. This valve is positioned too ventricularly for deployment.

Figure 26-29 Top: Transesophageal echocardiographic (TEE) color Doppler midesophageal long-axis view of the aortic root post-deployment of the Edwards-Sapien aortic prosthesis. Severe paravalvular aortic regurgitation secondary to a low valve deployment (i.e., too ventricular). Bottom: TEE color Doppler midesophageal short-axis view of the aortic root post-deployment of the Edwards-Sapien aortic prosthesis. Severe paravalvular regurgitation can be seen around the posterolateral border of the percutaneous heart valve.

Figure 26-30 Transesophageal echocardiographic color Doppler midesophageal long-axis view of the aortic root post-deployment of the Edwards-Sapien aortic prosthesis. There is mild posterior paravalvular aortic regurgitation. Trivial central aortic regurgitation also is present secondary to the guidewire across the aortic valve.

Figure 26-31 Transesophageal echocardiographic (TEE) and chest radiograph images of a patient with an intra-aortic balloon pump. The short-axis (left) and long-axis (right) TEE images of the proximal descending aorta do not reveal the distal tip of the balloon pump, and the chest radiographs indicate a somewhat low placement in the thoracic aorta.

Figure 26-32 Transesophageal echocardiographic (TEE) images of a patient in cardiogenic shock. Upper left: The left main lumen is significantly narrowed. Upper right: Color Doppler flow mapping demonstrates flow acceleration in the mid-distal left mainstem artery. Middle left: Spectral Doppler recording at the site of flow acceleration reveals the diastolic dominant pattern typical of left coronary flow with elevation of flow velocity. Middle right: Cusp shot during coronary angiography prompted by the TEE findings reveals critical narrowing of the distal left main artery. Lower left: The ostial right coronary artery has a normal appearance. Lower right: The spectral Doppler display of flow recording of the right coronary artery is unremarkable in comparison to that of the left mainstem artery.

Figure 26-33 Chest fluoroscopy and radiography images of an Impella 5 device. Upper left: The transesophageal echocardiography probe is apparent in the fluoroscopy image as the heavy radiopaque motor and inlet components are obvious. The pigtail is evident, but less obvious. Upper right: With optimization of penetration on the radiograph, the Impella device components are more visible. Lower images: Migration of the device can be surmised by the motor housing having moved higher in the aorta (right versus left lower image).

Figure 26-34 Transesophageal echocardiographic images of an Impella 5 device. Upper images: The angulation of the device, which allows it to follow the long axes of the left ventricular outflow tract and of the left ventricle, can be seen. Middle and lower left images: Color Doppler flow mapping is useful to confirm the location of the intake and to allow measurement from the intake site (which is apparent as continuous color Doppler flow signal) to the aortic valve. Lower right image: Color Doppler flow imaging is useful to determine the output location in the aorta.

Figure 26-35 Transesophageal echocardiographic images of an Impella 5 device inserted too deeply into the left ventricle. Upper left: The distal extent of the device is indicated by the pigtail at the inferior aspect of the left ventricular apex. Upper right: The measurement from the intake to the aortic valve initially is 6.6 cm; subsequently, after withdrawal of the device (lower images), it is a more appropriate 5.1 cm.

Figure 26-36 Systolic (left images) and diastolic (right images) scans in long-axis (upper images) and short-axis (lower images) views of the Impella device across the aortic valve and into the left ventricular outflow tract (LVOT). In systole, little flow is depicted by color Doppler flow mapping ejected out the LVOT, due to the dominance of flow by the device. In diastole, a small central jet of aortic insufficiency can be seen, a common occurrence due to a small amount of coaptation failure imparted by the device. The prominent color flow Doppler mapping signal seen on the short-axis images between 6 and 9 o’clock is the flow within the device.

Figure 26-37 Chest radiography and fluoroscopic images of an Impella unit. There is slight motion artifact on the fluoroscopic image. The detail afforded by the ideally penetrated chest radiograph is at least comparable to that of the fluoroscopic image. Also note the endotracheal tube and pulmonary artery catheter seen on the chest radiograph, and the transesophageal echocardiographic probe seen on the fluoroscopy image. The long radiopaque marker of the device can be seen along its length and down the aorta.

Figure 26-38 Transesophageal echocardiographic (TEE) and transthoracic measurements indicating the depth of the intake unit into the left ventricular cavity. The TEE images afford clear visualization of the device. The transthoracic image (lower right) is confounded by reverberation artifact, which happens to fall nearly along the line/axis of the device. The most echoreflective component is the metal housing by the intake. The device initially was inserted slightly too far, as seen in upper left image and the other TEE images. It was withdrawn so that the intake component was 4 to 5 cm beyond the aortic valve. Note that on all the images, the “hockey stick” angulation is misoriented, directing the distal component toward the posterior wall.

Figure 26-39 Diastolic (left) and systolic (right) views of a patient with massive infarction due to left main thrombosis. The fractional area change is minimal, as the ejection fraction was 10%. The Impella device has not yet been inserted.

Figure 26-40 Serial transesophageal echocardiographic imaging of the left ventricular outflow tract, aortic valve, and aortic root during insertion of the Impella device. Upper left: Baseline view. Upper right: The J-shaped guidewire has been advanced into the right aortic valve cusp/sinus. Middle left: The guidewire has been advanced across the aortic valve into the left ventricle. Middle right: The device has been advanced over the guidewire to the level of the aortic root. Lower left: The device has been advanced across the aortic valve into the left ventricular cavity. Lower right: Transthoracic view of unusually good quality demonstrates that the device is imperfectly oriented, as the hockey stick angulation is directing the distal component of the device against the posterior wall, rather than along the long axis of the left ventricle toward the apex.

Figure 26-41 Malpositioning of an extracorporeal membrane oxygenation (ECMO) catheter. Upper left: Pre-insertion view of the right atrium. Color Doppler demonstrates a patent foramen ovale (PFO). Upper right: Eight days following insertion, this transesophageal echocardiographic view reveals that the inferior vena cava (IVC) catheter is pushing/pressing against the interatrial septum. Second row, left image: This long-axis view reveals the IVC catheter pushing/pressing against the interatrial septum along its height. Second row, right image: Color Doppler reveals a jet of flow on the left atrial side of the septum, where the catheter has stretched/pressed open the PFO. Third row, left image: Color Doppler demonstrates that this jet pours along the roof of the left atrium and down and across the mitral valve to the left ventricle (right-to-left flow). Third row, right image: Spectral display confirms flow into the left atrium and ventricle from this jet. Lower left: After repositioning, the catheter has been retracted down toward the lower part of the interatrial septum and is no longer pressing on and distorting the interatrial septum PFO. Lower right: Color Doppler post repositioning demonstrates residual bidirectional/right-to-left flow across the PFO due to the right ventricular failure from protracted H1N1 pneumonitis.

1. Caves P.K., Stinson E.B., Billingham M., Shumway N.E. Percutaneous transvenous endomyocardial biopsy in human heart recipients. Experience with a new technique. Ann Thorac Surg. 1973;16(4):325-336.

2. Billingham M. Endomyocardial biopsy diagnosis of acute rejection in cardiac allografts. Prog Cardiovasc Dis. 2009;33:11-18.

3. Deckers J.W., Hare J.M., Baughman K.L. Complications of transvenous right ventricular endomyocardial biopsy in adult patients with cardiomyopathy: a seven-year survey of 546 consecutive diagnostic procedures in a tertiary referral center. J Am Coll Cardiol. 1992;19(1):43-47.

4. Sakakibara S., Konno S. Endomyocardial biopsy. Jpn Heart J. 1962;3:537-543.

5. Miller L.W., Labovitz A.J., McBride L.A., et al. Echocardiography-guided endomyocardial biopsy. A 5-year experience. Circulation. 1988;78(5 Pt 2):III99-III102.

6. Blomstrom-Lundqvist C., Noor A.M., Eskilsson J., Persson S. Safety of transvenous right ventricular endomyocardial biopsy guided by two-dimensional echocardiography. Clin Cardiol. 1993;16(6):487-492.

7. Weston M.W. Comparison of costs and charges for fluoroscopic- and echocardiographic-guided endomyocardial biopsy. Am J Cardiol. 1994;74(8):839-840.

8. Williams G.A., Kaintz R.P., Habermehl K.K., et al. Clinical experience with two-dimensional echocardiography to guide endomyocardial biopsy. Clin Cardiol. 1985;8(3):137-140.

9. Ragni T., Martinelli L., Goggi C., et al. Echo-controlled endomyocardial biopsy. J Heart Transplant. 1990;9(5):538-542.

10. Appleton R.S., Miller L.W., Nouri S., et al. Endomyocardial biopsies in pediatric patients with no irradiation. Use of internal jugular venous approach and echocardiographic guidance. Transplantation. 1991;51(2):309-311.

^* This section was contributed by Gregory Schnell, MD.

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