1、Intracardiac Echocardiography and Electrophysiology,Steven C. Hao, MDDirector of Electrophysiology Northern California Heart Care San Francisco, CA,Disclosures,Biosense Webster- consultant, investigatorAcuson/Siemens- consultant,Current Clinical Applications for Intracardiac Echocardiography (ICE),E
2、lectrophysiologyTransseptal punctureVT ablation Aortic Cusp and RVOT AblationLV AblationsComplex left-sided proceduresAtrial flutter ablationPlacement and removal of pacing leadsBi-Ventricular pacing for cardiac resynchronization,ICE Imaging - Transseptal,左边影象证明了房间隔穿刺后的tenting现象，请注意tenting在肺静脉平面是最大的
3、，以利于在肺静脉、肺静脉前庭以及左房后壁的控制。 右图证明了正确的房间隔穿刺。,Using ICE to Guide Transseptal Puncture,在ICE的帮助下，可以避免不恰当的房间隔穿刺 左侧影像表明穿刺针/鞘位置靠前，几乎从左房前部穿出 右侧影像表明在尝试穿房间隔时穿刺针从右房穿入主动脉根部,Aortic Cusp VT Ablation,这些图象演示了在标测一个局部VT消融时，从动脉瓣膜看动脉根部的影像。利用多普勒影像能通过直接的可视化图形确认冠状动脉开口。这可以帮助指导在这个区域的安全的消融。,LV Ablation,这些图片显示的是合并巨大基底动脉瘤的左室影像。注意导
4、管的位置在动脉瘤边缘。 右上图显示在射频消融因局部过热产生的微泡,Use of Intracardiac Echo (ICE) Imaging for LA Ablation,Transseptal puncture Pre ablation anatomical orientation Confirmation of catheter positioning Assessment of lesion formation Detection of complications,Abnormal LA Anatomy,这是一个复杂的解剖案例。CT图演示了在左上及左下肺静脉分叉之前的共干及巨大的左大
5、前庭开口。左图证明左肺静脉共干前庭开口为2.9cm。,这个CT图演示了三个左肺静脉。ICE可以形象化的演示异常左肺静脉，减少了肺静脉消融的危险性。,这是一个很罕见的左房，常见的低位开口。ICE证实后位开口（上图）及巨大的左上肺静脉（下图）。 ICE能直接的显示这类复杂解剖病例的病变部位,畸形左房。左肺静脉共前庭，右上肺静脉靠前，右下肺静脉靠后，左房顶部正中有一单独肺静脉。3D CT图象扫描和ICE能对这种复杂的解剖结构的标测和消融有帮助。,Identify Anatomy,Use Color Doppler and Spectral Doppler to Evaluate LAA,ICE能在直
6、视或多普勒超声影像下区分左心耳及左上肺静脉 这可以减少不适当的左心耳操作，从而减少左心耳穿孔的风险,Left Pulmonary Veins,左图演示了LASSO进入了一个共干的左肺静脉口的左下分支，右图是正常的LASSO放置位置，正确的放置能改善隔离、消融GAP。,Color Doppler with Cryocath Balloon,ICE能帮助定位ARRAY导管的大小及位置。多普勒超声能进一步证实位置的准确性,Esophagus,Insert barium swallow,ICE放置右房能显示食道，通过上图能显示左右肺静脉和消融导管。,Right Pulmonary Veins,右侧肺静
7、脉的横切面（左图）及纵切面（右图）可通过房间隔后斜进入而显示,该患者有三支右肺静脉，有一束组织从右上及右中肺静脉之间的突起处延伸至后壁 直接显示肺静脉及该束组织能指导Lasso及消融导管在该部位的操作,Intra-procedural early detection of complications,ACT 350 sec; between 1.5 and 12% after transseptal access,在左房手术中，我们抗凝较积极，维持INR在2-3， ACTs 350s以防止在标测及消融导管上的血栓形成。低于该标准的抗凝则需要房间隔穿刺以及心内导管的操作很精确。如果血栓形成则在I
8、CE能看见并能回缩至鞘内或者直接拉回右房,Scattered “Micro-bubbles”,Brisk shower of dense “Micro-bubbles”,ICE显示非灌注射频消融技术的损伤，过热能导致POP现象的产生，识别微POP现象能减少能量输出和防治大POP现象。,Intra-procedural detection of Potential Complications,过热能导致过度的心内膜损伤（左图），导致内膜下基质暴露，从而形成血栓,在左房和心室消融中，过热能产生结痂形成和导致中风的潜在原因，在适当的能量和冷消融导管能防止结痂（左图显示在LASSO上和右图显示大头）,
9、% patients,Ultrasound 33 pts,Temperature control 482 pts,ICE + Bubbles 270 pts,p = 0.029,p = 0.2,Embolic complications,过去的一项研究表明通过ICE监测微泡的形成以防止过热能显著减少在复杂左房消融中脑卒中的风险,Monitor for Pericardial Effusion,Cardiac Tamponade,在这个图片中ICE导管能早期监控和诊断心包渗出。,Evaluate Pulmonary Venous Flow,Left Inferior and Superior P
10、ulmonary Veins,功能显像能证实在左房消融前后通过肺静脉血流是否正常,Results - Severe PV Stenosis,n=75 n=25 n=102 n=100 n=310,20.0%,2.9%,2.0%,0%,15.5%,通过确认适当的肺静脉前庭损伤，而不是深部肺静脉的损伤，ICE已经被显示防止肺静脉狭窄。,Visually Assists with Anatomical Map,Unusual anatomical variantsvertical or horizontal heartscongenital anomaliesany post-operative h
11、eart Common left ostium Rapid branching of either vessel Multiple branches of right veins,CARTO and Ultrasound,与精确标测系统的三维图像融合能直观地显示复杂解剖结构 在CT壳下显示导管位置能准确地显示病变位置及导管稳定性，从而减少放射线暴露,LUPV,ICE能帮助CT图象重构选择位点。,Landmark Registration,在复杂的左房消融时，我们通常在左房内标记三点（左上肺静脉的后上，左下肺静脉后下及右上肺静脉的后上）,Left Atrium and Pulmonary Vei
12、ns,CARTOMERGE形象化的提供在复杂解剖结构中动态的多种工具。,CARTOSOUND,Overview of the CARTOSOUND Image Integration Module and the SOUNDSTAR 3D Catheter,CARTOSOUND Module Features Accuracy Beam Orientation CARTOSOUND Module Maps Tip to Tissue Contact Visualization CARTOMERGE Module Synergy,CARTOSOUND,Beam OrientationDispla
13、ying the real-time ultrasound beam in 3D space improves ease of use and allows for easierinterpretation of ICE,CARTOSOUND,Beam Orientation,Displaying the real-time ultrasound beam in 3D space improves ease of use and allows for easier interpretation of ICE,CARTOSOUND,CARTOSOUND Module MapsAllows for
14、 faster and more accurate mapsSafely create left sided maps from the right side,CARTOSOUND,Tip to Tissue ContactImproves physician confidence with real-time tip to tissue visualization,在实时的ICE图象和重建的3D ICE图象能显示导管位置在上图中。,CARTOSOUND,CARTOMERGE Module Synergy,First ICE & 3D mapping integration Enhancing
15、 safety & ease of use,Two years of proven accuracy & experienceFull anatomical details of pre- acquired registration,综和ICE和3D系统能实时显示大头、解剖、3D重建图和三维标测系统。,Conclusions,ICE provides real-time 2D and functional imaging to help guide catheter manipulation in difficult anatomy, monitor lesion formation, prevent and/or monitor for complicationsIntegration of ICE with 3D mapping systems provides an intuitive, accurate tool that can improve outcomes, decrease complications, and minimize fluoroscopy during electrophysiology procedures,
