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Left atrial appendage occlusion (LAAO) is a suitable alternative to oral anticoagulant therapy to prevent stroke in patients with AF. Most procedures are performed under transoesophageal echocardiography (TOE) guidance, which facilitates transseptal puncture, reduces the risk of procedurerelated complications and provides an additional method for device selection and real-time monitoring during device deployment. However, TOE has significant shortcomings, including the need for general anaesthesia/deep sedation as well as a significant risk of procedure-related adverse events. More recently, intracardiac echocardiography has been proposed as an alternative to TOE guidance during LAAO procedures. In this review, we summarise the available evidence as well as providing a step-by-step approach for intracardiac echocardiography-guided LAAO.

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BACKGROUND: Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. METHODS: All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. RESULTS: Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I2 = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I2 = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04). CONCLUSION: ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

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Resumen La ablación con catéter se ha convertido en un enfoque práctico para el tratamiento de las arritmias cardiacas, sobre todo cuando el manejo farmacológico óptimo no logra controlarlas. De esta manera se reduce la readmisión hospitalaria y se mejora la calidad de vida de los pacientes, incluso de aquellos en quienes no se logra la resolución completa de la arritmia. Hasta la fecha se han utilizado varias modalidades entre las que se incluyen la radiofrecuencia y la crioablación. Los principios de la criobiología se establecieron por primera vez con investigaciones sobre la congelación de los tumores y datos actuales sugieren que es necesaria una temperatura entre -30 a -40 °C para inducir muerte celular, ya sea por mecanismos inmediatos, como ruptura celular, lesión hipotérmica o daño vascular, o tardíos, como apoptosis. Se presenta el primer caso en Colombia de mapeo de alta densidad y crioablación como estrategias combinadas para el tratamiento efectivo de un paciente con alta carga de arritmia ventricular sintomática originada en el músculo papilar anterolateral, sin recurrencia de la arritmia en el tiempo de seguimiento.

Abstract Catheter ablation has become a practical approach for the treatment of cardiac arrhythmias, especially when optimal pharmacological management does not achieve adequate control of it, thus reducing hospital readmission and improving quality of life, even in patients in whom the complete resolution of the arrhythmia is not achieved. To date, a variety of modalities have been used, including radiofrequency and cryoablation. The principles of cryobiology were established for the first time with research on the freezing of tumors and current data suggest that a temperature of -30 to -40 °C is necessary to induce cell death either by immediate or delayed mechanisms; immediate as cellular rupture or hypothermic injury as well as vascular damage or apoptosis among the late. The first case in Colombia of high-density mapping and cryoablation is presented as combined strategies for the effective treatment of a patient with a high load of symptomatic ventricular arrhythmia originating in the anterolateral papillary muscle, without recurrence of the arrhythmia at the time of follow-up with symptoms, so it was to successful cryoablation, as the first case with this technique.

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BACKGROUND: Accessory pathway (AP)-related arrhythmias are frequent in patients with Ebstein anomaly (EA), and arrhythmia recurrence after catheter ablation remains high despite current technological developments. METHODS: Case series report of patients with EA who were taken to an accessory pathway ablation procedure and where clinical, procedure, and follow-up data are described. In all cases, mapping of the true tricuspid annulus guided by intracardiac ultrasound was used. RESULTS: Six patients with EA underwent an ablation procedure using ICE to delineate the true tricuspid annulus. The duration of the procedure was 253.33 ± 60.92 min, with an acute success of 100%. After a mean follow-up of 16.16 ± 7.7 months, no recurrences of tachycardia were documented, and all patients were free of antiarrhythmic medications. CONCLUSION: Intraprocedural ICE helps to delineate the true tricuspid annulus that contains the APs, facilitating mapping and ablation. We hypothesize that the systematic use of ICE in this scenario improves ablation efficacy while reducing complications, but this must be verified in prospective studies.

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BACKGROUND: Catheter ablation of ventricular arrhythmias (VAs) arising from the left ventricular Summit (LVS) is challenging and requires high-dose fluoroscopy to limit vascular damage of the coronary arteries. Ionizing radiation can increase the incidence of malignancies to both patient and operator. This study describes outcomes of catheter ablation of LVS VAs using intracardiac echo-facilitated 3D electroanatomical mapping (ICE-3D) to avoid fluoroscopy. METHODS: Twenty-six patients (47 ± 17 years old; 52% males; median ejection fraction 55 ± 13%) with premature ventricular contractions or ventricular tachycardia underwent catheter ablation. VAs were localized using ICE-3D with arrhythmia foci being mapped at the LVS. Focal ablation was performed using a 3.5-mm open-irrigated, contact force sensing radiofrequency catheter. RESULTS: Acute success and recurrence rates were 84% and 24%, respectively. Holter burden was significantly reduced (24 ± 15% to 1.5 ± 2%; P = 0.01) after ablation. The use of zero fluoroscopy was achieved in 100% of cases. No major complications were observed. CONCLUSIONS: Zero fluoroscopy catheter ablation of LVS VAs using ICE-3D mapping is feasible and effective.

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Catheter-based ablation of isthmus-dependent common atrial flutter results in very high success rates and almost no complications. However, bidirectional conduction block through the isthmus may be challenging in a small percentage of patients regarding the use of high power and high temperature settings during radiofrequency delivery. Anatomical and physiological circumstances may be the reason for such difficulties to achieve bidirectional block at the cavo-tricuspid isthmus. However, in the present case we show edema formation after multiple shots of radiofrequency delivery at the cavo-tricuspid isthmus, which complicates the achievement of bidirectional conduction block.

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Catheter-based ablation of isthmus-dependent common atrial flutter results in very high success rates and almost no complications. However, bidirectional conduction block through the isthmus may be challenging in a small percentage of patients regarding the use of high power and high temperature settings during radiofrequency delivery. Anatomical and physiological circumstances may be the reason for such difficulties to achieve bidirectional block at the cavo-tricuspid isthmus. However, in the present case we show edema formation after multiple shots of radiofrequency delivery at the cavo-tricuspid isthmus, which complicates the achievement of bidirectional conduction block.

La ablación con catéter del flutter de tipo común dependiente del istmo es un procedimiento con elevada tasa de éxito y rara vez complicaciones. Sin embargo, en un pequeño porcentaje de casos puede resultar complicado conseguir el objetivo de bloquear bidireccionalmente el istmo durante el procedimiento de ablación a pesar de incrementar la potencia y temperatura del catéter de radiofrecuencia. Las características anatómicas y fisiológicas del istmo cavo-tricuspídeo pueden ocasionar dificultades en la consecución del bloqueo bidireccional. Sin embargo, en el presente caso mostramos cómo la propia aplicación de radiofrecuencia puede ocasionar edema importante tras múltiples aplicaciones con las consiguientes dificultades para conseguir el bloqueo bidireccional del istmo.

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Objetivo: determinar la utilidad del ecocardiograma intracardiaco como ayuda para la implantación de dispositivo de cierre percutáneo de foramen ovale permeable. Material y métodos: se expone el caso de un paciente de género masculino, de 38 años de edad, con antecedentes de isquemia cerebral transitoria, diagnosticada un año antes, quien presentó cuadro de accidente cerebrovascular isquémico criptogénico y se le detectó foramen ovale permeable por ecocardiograma transesofágico. Se candidatizó para cierre percutáneo con dispositivo de cierre tipo Amplatzer, y se programó el procedimiento con ecocardiograma intracardiaco mediante sonda AcuNav para guiar la colocación del Amplatzer, junto con el ecocardiograma transesofágico tradicional requerido en estos casos. Resultados: se realizó cierre del foramen ovale permeable mediante la técnica aceptada, guiado por ecocardiografía intracardiaca y se verificó mediante angiografía y ecocardiograma transesofágico. Se obtuvieron imágenes de la anatomía cardiaca mediante ecocardiograma intracardiaco en tiempo real sin interferencia, con lo cual pudo hacerse el implante del dispositivo en forma rápida y adecuada. Se corroboró su correcta implantación a través de angiografía y ecocardiograma transesofágico. En este caso, el procedimiento de cierre percutáneo con dispositivo de Amplatzer fue exitoso, rápido y sin complicaciones. Conclusiones: el ecocardiograma intracardiaco es útil para guiar la implantación de dispositivos de cierre del foramen ovale permeable así como en casos de comunicación interauricular. Es una técnica fácil y segura. La introducción de la sonda de ecocardiograma intracardiaco, su manipulación y su posicionamiento en el atrio derecho fueron rápidos y sencillos. Se obtuvieron imágenes adecuadas con una buena identificación de las estructuras del septum que permitieron el cierre exitoso del foramen ovale permeable con dispositivo tipo Amplatzer. Según esta investigación, en la literatura no se reporta el ecocardiograma intracardiaco como ayuda para guiar este procedimiento, por lo que se considera que pudiera ser el primer caso realizado en Colombia. De otra parte, se hace necesario el uso más generalizado de la sonda intracardiaca para realizar ecocardiograma intracavitario e implementarlo en lugar del ecocardiograma transesofágico como guía para cierre de comunicación interauricular y foramen ovale permeable. Es conveniente llevar a cabo más estudios que permitan valorar mejor esta ayuda que puede suprimir la necesidad del ecocardiograma transesofágico en estos pacientes y a su vez el requerimiento de anestesia general para estos procedimientos.

Objective: to determine the utility of intracardiac echocardiography to assist in the implantation of the device for percutaneous closure of patent foramen ovale. Material and methods: we report the case of a 38 years old male patient with a history of transient cerebral ischemia diagnosed a year earlier, who presented a clinical picture of ischemic cryptogenic stroke. A transesophageal echocardiogram showed a patent foramen ovale. He was scheduled for percutaneous closure of the patent foramen ovale with Amplatzer closure device, and the procedure was programmed with intracardiac echocardiography probe through AcuNav to guide the placement of the Amplatzer, along with the traditional TEE required in these cases. Results: we performed foramen ovale closure using the accepted technique, guided by intracardiac echocardiography and verified by angiography and transesophageal echocardiography. We obtained images of cardiac anatomy using intracardiac echocardiography in real time without interference, which made possible the implant of the device quickly and appropriately. Proper implementation was confirmed by angiography and transesophageal echocardiography. In this case, the procedure of percutaneous closure with Amplatzer device was successful, fast and without complications. Conclusions: intracardiac echocardiography is useful to guide the implantation of devices for closure of patent foramen ovale as well as in cases of atrial septal defect. This technique is easy and safe. The introduction of intracardiac echocardiography catheter, its handling and positioning in the right atrium were quick and easy. Adequate images were obtained with a good identification of the structures of the septum that allowed the successful closure of the foramen ovale with Amplatzer device. According to this research, the literature does not report intracardiac echocardiography as an assistance to guide this procedure, so that we believe this may be the first case performed in Colombia. Moreover, it is necessary a more widespread use of intracardiac catheter for intracavitary echocardiography and implement it instead of transesophageal echocardiography as guide for closure of atrial septal defect and patent foramen ovale. It is convenient to carry out more studies to better assess this assistance which may eliminate the need of transesophageal echocardiography in these patients and in turn the requirement of general anesthesia for these procedures.

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Intracardiac echocardiography (ICE) is a relatively new method of ultrasound images useful during cardiac percutaneous interventional procedures. The first human experience with this method was published in 2000 and, since then, several original trials have enrolled this useful method, proving similar and more useful than transesophageal echocardiography in percutaneous treatment of several congenital cardiopathies, like interatrial communication, permeable oval foramen, mitral stenosis, and atrial fibrillation ablation. In this presentation, we publish a single case report of percutaneous mitral valvuloplasty under ICE guidance.

La ecocardiografía intracardiaca (EIC) es un método relativamente nuevo de imágenes por ultrasonido que utilizamos principalmente durante procedimientos de cateterismo intervencionista. La primera experiencia en seres humanos con este método fue reportada en 2000 y, desde entonces, se han publicado diversos artículos sobre su utilidad como procedimiento de control sustituto de la ecocardiografía transesofágica, en el tratamiento por cateterismo de la comunicación interatrial, comunicación interventricular, foramen oval permeable, estenosis mitral y ablación de fibrilación auricular. En esta ocasión presentamos un caso de estenosis mitral y valvuloplastía percutánea, guiado por EIC.

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La utilización de ecocardiografía intracardíaca es una alternativa reciente en el control de procedimientos en la sala de hemodinámica. Presentamos el resultado de un estudio piloto, en 10 pacientes sometidos a corrección total de su cardiopatía, en quienes la valoración inmediata de los resultados quirúrgicos se realizó en base a la aplicación de ecocardiografía intracardíaca (EIC) en sala de operaciones. En todos los pacientes fue posible obtener imágenes adecuadas con EIC, sólo se presentó un caso falso negativo, postoperado de corrección de conexión anómala de venas pulmonares, en el que no se identificó obstrucción de venas pulmonares derechas. Concluimos que EIC es una alternativa en la evaluación de resultados quirúrgicos inmediatos.

The utilization of intracardiac echocardiography (ICE) is a recent alternative in the control of procedures in the Cath Lab. In this paper we presents the results of a pilot study, in 10 patients submitted to total correction of its congenital heart disease, in who the analysis of the surgical results was done in base to the application of intracardiac echocardiography in operations room. In all the patients it was possible to obtain adequate images with ICE, there was a case false negative, a Total anomalous return Pulmonary Veins, in whom there not indentified a obstruction in right pulmonary veins flow. We conclude that ICE is a good alternative in the evaluation of surgical results.

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