Key details on the use of ICE to guide structural heart procedures
The use of intracardiac echocardiography (ICE) has gained significant traction in recent years, particularly with the introduction of advanced 3D and 4D imaging capabilities. These systems are now increasingly being used for structural heart procedures, either as a standalone imaging system or in combination with traditional transesophageal echo (TEE)
D. Scott Lim, MD, medical director of the Advanced Cardiac Valve Center and co-director of the Adult Congenital Heart Disease Center at the University of Virginia (UVA) Health, shared his insights in a video interview on how ICE is revolutionizing structural heart procedures. He uses the Biosense Webster NuVision ICE catheter in structural heart procedures, including left atrial appendage occlusion (LAAO), tricuspid and mitral valve interventions.
"We found that there are a couple of benefits from the newer 3D/4D ICE platforms. One thing is it allows us for some cases to do away with concomitant TEE, which then would require usually general anesthesia and initial intubation. So for our more frail patients, this is a plus. The other thing is, because the ICE probe is situated within the blood pool inside the heart, it allows excellent 2D imaging of the structure of interest. That's so important for right-sided structures like the tricuspid valve, where TEE sometimes has to deal with shadowing from the base of the heart or other structures, versus ICE can see around that and give us really unparalleled images," Lim explained.
Advantages of ICE over TEE
Another key benefit of ICE is its ability to overcome imaging challenges posed by prior cardiac surgeries.
"If a patient has a surgical aortic or mitral valve replacement, the metal sewing ring can create shadows that obstruct the septal leaf or the tricuspid valve, making it more challenging to image by TEE. With intracardiac echo, since we're imaging from the right atrium, we really can see that area quite nicely," Lim said.
Beyond tricuspid valve procedures, ICE is also playing a pivotal role in LAAO procedures, which can be performed without the need for TEE, an interventional echocardiographer or general anesthesia.
"We used it for left atrial appendage work, and in fact, I would say the majority of our LAAO work now is done by intracardiac echo only, not TEE. It definitely helps with the logistics, because then we're not trying to coordinate the anesthesia team and a TEE team and the cath lab team. It's just one team," he explained.
He also uses ICE for mitral procedures, particularly in patients who for whatever reason could not get in TEE imaging.
ICE offers technical benefits and operator control
He said the new-generation ICE platforms, such as Biosense Webster’s NuVision and Philips VeriSight, offer improved image quality and maneuverability.
"They provide us really excellent 2D images that can be then done in multiplane, or reformatted from the 3D image. So we can electronically steer the image plane to see what we need to. For example, if we're doing a tricuspid transcatheter edge-to-edge repair procedure where we're trying to clip the edge of one leaflet to the other, we really need that high degree of temporal in spatial resolution to do that procedure with confidence. And I think we've found that in the new ICE platforms," Lim explained.
One key advantage of ICE is that the interventional operator can directly manipulate the catheter, rather than relying on an echocardiographer for image acquisition. He said this enables greater efficiency. However, he added, the heart team still values the expertise of echocardiographers and they often still collaborate with the team in the lab to optimize imaging and procedural outcomes.
Learning curve and best practices with ICE
While ICE technology offers significant advantages, there is a learning curve for operators. Lim advises starting with simpler structural heart cases before progressing to complex anatomies. For straightforward pathologies and simple cases, ICE can be used as a standalone imaging modality. However, for more intricate cases, having TEE available as well remains beneficial, he said.
One of the challenges with ICE is the need to navigate around shadowing caused by device delivery systems. All valve replacement, repair or LAAO devices have delivery systems that can create shadowing on ultrasound. The ability of the ICE to move around that shadowing to see what is needed during procedures has been very helpful, but he said you need to understand the characteristics of the ICE catheters being used.
"Depending on the ICE probe, some are a little bit thinner, some are a little bit thicker, and some lend themselves to more manipulations or would be better with less manipulations. All of that is just part of the learning process. The operators do need to plan on moving the catheter at least a little bit to see around the shadows created by a delivery system," Lim explained.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com