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Intracardiac Echocardiography Considerations During
Implantation of the GORE ® HELEX Septal Occluder
Continued from cover...
An eight-year-old girl presented for
transcatheter ASD closure at a weight
of 24.6 kg. A prior transthoracic
echo showed a defect diameter
of approximately 10 mm, and the
posterosuperior (SVC), anterosuperior
(aortic), anteroinferior (tricuspid
valve), posteroinferior (IVC), and
posterosuperior (pulmonary
vein) rims were all adequate.
Using general anesthesia and
heparin anticoagulation, cardiac
catheterization revealed normal right
heart pressures and a Q p
/ Q s
of 1.3.
ICE imaging was performed using an
8F ACUNAV Intracardiac Echo Catheter
through a contralateral venous sheath.
As part of the usual imaging protocol,
a complete ICE evaluation was
completed as follows:
Note: Any control knob adjustments
of the ICE catheter are best made by
moving the locking ring clockwise
to the locked position first and then
moving the A / P or L / R control knob
as needed, thereby maintaining their
position.
1. “Home” view (Figure 1): the ICE
catheter arrow indicator at the control
end corresponds to the transducer
orientation at the catheter tip, and
Right Atrial Disk
Left Atrial Disk
Figure 2 Implanted GORE ® HELEX Septal Occluder
in hypothetical heart model.
this should be oriented toward patient
left and slightly anterior; the tricuspid
valve is seen with the right atrium
above and the right ventricle below;
superior is screen right, and inferior is
screen left; occasionally adjusting the
control knob slightly to the Anterior
(A) location is necessary.
2. Using both hands (right hand
at control knob area, left hand on
catheter near introducer sheath entry),
the catheter is rotated clockwise (when
looking from patient’s feet to head) or
away from operator; during this slow
rotation, one may see a prominent
Eustachian valve or Chiari network,
but typically the coronary sinus starts
“rounding” out, and subsequently
the LV and RV outflow tracts are
seen; variations in cardiac anatomy
and position often require gentle
adjustment of the L / R control knob to
optimize the image.
3. With further clockwise rotation,
the mitral valve, left atrial appendage,
and a fully round cross-section of the
coronary sinus are visible (Figures 2
and 3); the atrial septum is well seen;
as clockwise rotation continues,
the left-sided pulmonary veins are
typically seen as an upside down
“Y” connection, with the left superior
vein to screen right and the left
inferior vein to screen left; color flow
is red / orange as the direction of flow
is toward the transducer, which is
situated in the right atrium (Figure 4).
4. As one continues a clockwise
rotation around the back of the heart,
the descending aorta is seen next in
a horizontal orientation.
5. Just to patient right of the
descending aorta are the right-sided
pulmonary veins, again found by
clockwise rotation beyond the
descending aorta. Without any
control knob adjustment, these most
commonly appear as a foreshortened
upside down “Y” connection;
significantly enhanced imaging of the
right-sided veins can be achieved by
locking the L / R control knob toward
Figure 1. Home view.
Figure 3. View of the left atrial appendage
and mitral valve. The atrial is also well seen.
Figure 4. Left superior and inferior pulmonary
veins.