Novel System for Real-Time Integration of 3-D Echocardiography and Fluoroscopy for Image-Guided Cardiac Interventions: Preclinical Validation and Clinical Feasibility Evaluation

Abstract

Real-time imaging is required to guide minimally invasive catheter-based cardiac interventions. While transesophageal echocardiography allows for high-quality visualization of cardiac anatomy, X-ray fluoroscopy provides excellent visualization of devices. We have developed a novel image fusion system that allows real-time integration of 3-D echocardiography and the X-ray fluoroscopy. The system was validated in the following two stages: 1) preclinical to determine function and validate accuracy; and 2) in the clinical setting to assess clinical workflow feasibility and determine overall system accuracy. In the preclinical phase, the system was assessed using both phantom and porcine experimental studies. Median 2-D projection errors of 4.5 and 3.3 mm were found for the phantom and porcine studies, respectively. The clinical phase focused on extending the use of the system to interventions in patients undergoing either atrial fibrillation catheter ablation (CA) or transcatheter aortic valve implantation (TAVI). Eleven patients were studied with nine in the CA group and two in the TAVI group. Successful real-time view synchronization was achieved in all cases with a calculated median distance error of 2.2 mm in the CA group and 3.4 mm in the TAVI group. A standard clinical workflow was established using the image fusion system. These pilot data confirm the technical feasibility of accurate real-time echo-fluoroscopic image overlay in clinical practice, which may be a useful adjunct for real-time guidance during interventional cardiac procedures.

Maximizing the Effectiveness of Ablation for Arrhythmias in the Congenital Heart Patients

“…Techniques have been developed to integrate real-time 3D TEE with X-ray fluoroscopy to improve catheter to tissue spatial orientation (Fig. 5) [69]. Pilot data from routine adult electrophysiological cases testing this real-time image integration platform can potentially be extrapolated for use in complex CHD ablations [69,70].…”

An image fusion tool for echo‐guided left ventricular lead placement in cardiac resynchronization therapy: Performance and workflow integration analysis

“…LV regional function was estimated in accordance with the 17-Segment American Heart Association (AHA) model. 24 The apical segments (ie, segments [13][14][15][16][17] and the septal segments (ie, segments 2, 3, 8, and 9) were not considered as possible targets for lead placement, 4,25 and therefore were not included in the model. Following the procedure outlined by the STARTER 11 trial, strain curves were analyzed for the remaining 8 free wall segments imaged using short-axis views at mitral valve and papillary muscle level.…”

“…Cardiac resynchronization therapy implantation is performed under X‐ray guidance which provides an excellent visualization of catheters and pacing leads but lacks detailed information on cardiac function and structure. Studies have demonstrated that multimodality image fusion could be used to overcome these limitations. However, they rely on techniques and imaging modalities which are not part of the clinical routine for CRT candidates.…”

“…[9][10][11][12][13] Cardiac resynchronization therapy implantation is performed under X-ray guidance which provides an excellent visualization of catheters and pacing leads but lacks detailed information on cardiac function and structure. Studies 8,12,[14][15][16][17][18][19][20] have demonstrated that multimodality image fusion could be used to overcome these limitations.…”

Use of Fluoroscopy–Echocardiography Fusion Imaging in Transcatheter Aortic Valve Replacement

“…). Thereafter, a specific algorithm repeatedly and rapidly repositions the reconstructed projection by tracking the TEE probe position updating the echocardiography image as the ×‐ray C‐arm moves. The TAVR valve requires an ×‐ray angle where the aortic valve sinuses are aligned such that the virtual annulus is perpendicular to the fluoroscopy plane and hence to the TAVR valve (coplanar view).…”