Use of Real Time Three-Dimensional Transesophageal Echocardiography in Intracardiac Catheter Based Interventions  Gila Perk, MD, Roberto M. Lang, MD, Miguel Angel Garcia-Fernandez, MD, Joe Lodato, MD, Lissa Sugeng, MD, John Lopez, MD, Brad P. Knight, MD, David Messika-Zeitoun, MD, Sanjiv Shah, MD, James Slater, MD, Eric Brochet, MD, Mathew Varkey, RDMS, Ziyad Hijazi, MD, Nino Marino, MD, Carlos Ruiz, MD, Itzhak Kronzon, MD  Journal of the American Society of Echocardiography  Volume 22, Issue 8, Pages 865-882 (August 2009) DOI: 10.1016/j.echo.2009.04.031 Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 1 ASD anatomy. (A) Secundum ASD as seen in an en face view from the right atrial perspective. The presence of adequate tissue rim surrounding the defect is clearly demonstrated. The visualization of adequate anatomy for percutaneous device closure is depicted (3D zoom mode acquisition). (B) Using commercially available quantitative volumetric software (QLab; Philips Medical Systems, Andover, MA), exact measurement of the true ASD diameter and area is obtainable (full-volume acquisition with offline processing). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 2 ASD closure procedure. (A) Monorail catheter passing through an ASD as seen from the left atrial perspective (3D zoom mode acquisition). (B) Closure device properly placed, as seen from the left atrial perspective (3D zoom mode acquisition). View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 3 Malpositioned ASD closure device. (A) Closure device positioned in an ASD seen from the left atrium. A residual defect is clearly demonstrated on an en face view of the device (3D zoom mode acquisition). (B) Agitated saline injection (viewed from the left atrium) demonstrating large shunt across the residual ASD. Multiple microcavitations (“bubbles”) are noted in the left atrium (3D zoom mode acquisition). (C) Concurrent transesophageal 2D images of the malpositioned occluder device. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 4 Fenestrated ASD. (A) Fenestrated ASD as seen from the left atrium. The guiding catheters can be seen each passing through a different part of the defect (3D zoom mode acquisition). (B) Two closure devices successfully placed occluding the two defects with an excellent result. (Left) En face view from the left atrium. The darker area below the closure device is not a residual defect but rather a “tissue dropout” artifact. (Right) Side view showing the interatrial septum wedged between the two sides of the occlusion device (full-volume acquisition with offline processing). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 5 ASD with tissue strip across. (A) ASD in an en face view from the left atrium, with a catheter passing through the defect. The tissue strip across the defect is clearly demonstrated (3D zoom mode acquisition). (B) Sizing balloon in place, “pushing” the tissue strip toward the edge of the ASD, as seen from the left atrium (3D zoom mode acquisition). (C) Successful placement of an occlusion device has been achieved (side view). The tissue strip is caught between the two sides of the device (3D zoom mode acquisition). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 6 Normal mitral valve in a “surgical” view. (A) Systolic frame showing clear depiction of mitral valve anatomy as seen from the left atrium. The two leaflets are demonstrated, as well as the 3 scallops of the posterior mitral leaflet (p1, p2, and p3) (3D zoom mode acquisition). (B) Early diastolic frame visualized from the left atrial perspective (3D zoom mode acquisition). AL, Anterior leaflet. View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 7 Transseptal puncture. The interatrial septum is seen from the left atrial side. The puncture needle is tenting the interatrial septum at the puncture site. Its relative location in the left atrium and to the mitral valve is clearly delineated (narrow-angle mode acquisition). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 8 Mitral valve clipping procedure. (A1) Guiding catheter passing through the transseptal puncture, seen from the left atrium. The tip of the catheter is clearly seen as it crosses the mitral valve (3D zoom mode acquisition). (A2) Simultaneous 2D transesophageal image. The catheter “disappears” in the left atrium, and the tip is not clearly visualized, when in fact it is across the mitral valve. (B1) The clip is introduced into the left atrium, approaching the mitral valve leaflets. The orientation of the arms is adjusted such that they are perpendicular to the mitral valve closure line (3D zoom mode acquisition). (B2) Simultaneous 2D transesophageal image demonstrating the clip in place with the mitral valve leaflets “caught” in it. The orientation of the clip arms is not discernable in this image. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 9 Mitral valve clipping with two clips. (A) Mitral valve with the first clip in place seen from the left atrium. A double orifice mitral valve has been created (O1, O2). However, color Doppler interrogation demonstrated significant residual MR, so a second clip was deemed necessary. The guiding catheter is seen directed toward the larger part of the mitral valve orifice (O2) to place another clip in the mitral valve (3D zoom mode acquisition). (B) Two clips have been deployed in the mitral valve, resulting in a 3-orifice mitral valve. The image shows an en face view of the mitral view, as seen from the left atrium. The 3 orifices (O2, O2, and O3) are noted (3D zoom mode acquisition). (C) Color Doppler demonstration of the result of the procedure. (Left) Before the procedure, severe MR is clearly demonstrated. (Right) After the procedure, only mild MR can be seen. View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 10 Mitral balloon valvuloplasty. (A) En face view of a stenosed mitral valve, with restricted opening, as seen from the left atrial perspective (3D zoom mode acquisition). (B) Guiding catheter with a balloon placed across the mitral valve commisures, as seen from the left atrium (3D zoom mode acquisition). (C) En face view of the mitral valve after commissural tears have been created as seen from the left atrial side. The mitral valve orifice is visibly larger than it was before commissurotomy (3D zoom mode acquisition). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 11 Successful LAA obliteration. En face view from the left atrium into the LAA showing proper positioning of a LAA occlusion device. The device is sitting perpendicular to the plane of the mouth of the appendage, creating a complete seal of the appendage (3D zoom mode acquisition). View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 12 LAA obliteration with suboptimal positioning. (A) En face view from the left atrium into the LAA showing off-angle LAA occlusion device. The device is not perpendicular to the opening of the LAA, and a residual potential communication between the LAA and the main left atrium is still noticeable (3D zoom mode acquisition). (B) Two-dimensional imaging of the off-angle closure device with color Doppler (asterisk) demonstrating residual flow between the LAA and the main left atrium. View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 13 Pulmonary vein ablation. (A1) En face view from the left atrium showing the opening of the LAA, the left upper pulmonary vein and the ridge between them (3D zoom mode acquisition). (A2) Simultaneous 2D transesophageal image demonstrating the ridge between the LAA and the pulmonary vein. Although it is seen and appreciated on this 2D image, the depth perspective and the width of this ridge are much more clearly recognized on the 3D image. (B) Ablation catheter placed on the ridge between the LAA and the pulmonary vein, as seen from the left atrium (3D zoom mode acquisition). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 14 Prosthetic valve dehiscence occlusion. (A) Dehisced mitral tissue prosthesis (MTP) as seen from the left atrial side (3D zoom mode acquisition). (B) Catheter placed through the dehisced portion of the prosthetic valve, avoiding the mitral valve orifice, as seen from the left atrial perspective (3D zoom mode acquisition). (C1) Successful placement of a closure device, with excellent result, seen from the left atrial side (3D zoom mode acquisition). (C2) Systolic frame from a 2D image demonstrating significant reduction in the mitral regurgitation. View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 15 Percutaneous aortic valve replacement. (A) Guiding catheter seen passing through the aortic valve (3D zoom mode acquisition). (B1) Systolic and (B2) diastolic frames of a percutaneously implanted aortic valve as seen from the left ventricular perspective (3D zoom mode acquisition). (C) The proximal left main coronary artery, as seen from the left ventricular perspective. Patency of the ostium of the left main coronary artery is confirmed after valve implantation (3D zoom mode acquisition). Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions

Figure 16 Percutaneous closure of postinfarction VSD. (A) Transthoracic echocardiographic 2D image demonstrating an apical VSD. Color Doppler clearly demonstrates left-to-right shunting, but delineation of the VSD anatomy is not available. (B1) RT3D image from transthoracic echocardiography showing apical septal thinning and a VSD (narrow-angle mode acquisition). (B2) En face view of the apical VSD as seen from the left ventricular perspective (full-volume acquisition with offline processing). (C) RT3D transesophageal echocardiographic image showing a guiding catheter placed via a retrograde approach (from the aorta through a femoral puncture) into the left ventricle (LV; narrow-angle mode acquisition). (D) RT3D transesophageal echocardiographic image clearly demonstrating a closure device in the apical interventricular septum (narrow-angle mode acquisition). LA, Left atrium; RA, right atrium, RV, right ventricle. Reprinted with permission from the European Journal of Echocardiography.47 View video clip online. Journal of the American Society of Echocardiography 2009 22, 865-882DOI: (10.1016/j.echo.2009.04.031) Copyright © 2009 American Society of Echocardiography Terms and Conditions