INTRACARDIAC ECHOCARDIOGRAPHY(ICE) & Its

APPLICATIONS IN CARDIAC INTERVENTIONS

Dr SRIKANTH.N
Intra-Cardiac Echo(ICE)
• Types of ICE systems
• Advantages of ICE
• Manipulation of catheters
• Views of ICE
• Interventions commonly used
• Different from TEE
• Examples
 Background
• Developed on technical basis of IVUS to meet demand during EP and structural
cardiac interventions.

• This technology of intravascular ultrasound started in 1970s,but it took nearly

30 years to overcome problems like catheter size , manipulation and poor
tissue penetration.

• ICE allows a real-time assessment of cardiac anatomy during interventional

procedures and guides catheter manipulation in relation to the different
anatomic structures.
 Advantages over TEE
ICE is a unique imaging modality able to provide

• high-resolution real-time visualization of cardiac structures,

• Continuous monitoring of catheter location within the heart,

• early recognition of procedural complications i.e. PE , thrombus

• excellent patient tolerance,

• Reduction of fluoroscopy time,

• No need for any general anaesthesia

• No need of an additional operator for the echo &

• there is no need to invade the sterile field

 AVAILABLE ICE SYSTEMS

Two different ICE technologies are available:

1. Radial or rotational ICE

2. Phased-array ICE
Rotational or Mechanical ICE:
• Single piezo electric crystal mounted on the tip of 6-10 F catheter.
• Produces 360 degree cross sectional image perpendicular to long axis
of the catheter
• Higher frequency (10 -20 Mhz)---limits depth ---near field imaging 5cm
• In EP—Left atrial anatomy, transeptal puncture, verify tip tissue
contact during ablation and monitor early signs of thrombus formation
or stenosis.
• sometimes used to assess leisons in coronary artery and for stent
deployment.
Phased-array ICE:
• It consists of a 64-element transducer mounted on the distal end of
an 8- or 10-French steerable catheter that can be deflected in 4
directions (anterior, posterior, right, and left) and has full colour flow
capability.
• It produces 90 degree sector image perpendicular to long axis of the
catheter.
• It operates at lower frequency(5-10Mhz)---greater depth ---upto
15cm.
• This catheter produces a wedge-shaped image that is displayed on a
conventional ultrasound workstation.
ICE systems
• Acu Nav catheter (Biosense Webster,California)

• View Flex Catheter(EP medsystems,New Jersey)

• Ultra ICE catheter( Boston Scientific,Boston)

 Navigating the ICE Catheter

• Left femoral Venous access

• ICE Catheters- 8F and 10 F sizes.
• Passing the catheter from the femoral vein to the heart can be easily performed
without fluoroscopy by the experienced operator.
• Advance the ICE catheter in vascular or cardiac chamber.
• Always maintain an echographic clear space (black) ahead of the catheter and avoid
pushing when an echogenic space (white) is ahead of the catheter.
• If an acute angle encountered at the tip of catheter, catheter should be slightly
retroflexed, by turning catheter knob counterclockwise.
• Anteflexion/Retroflexion to advance catheter to mid RA.
 ICE CATHETER
Abbott-View Flex- 9F

ICE catheter Connector

Distal tip trasducer
 Echocardiographic views
• Although images quite similar to TOE can be obtained, the relatively
“loose” position of the ultrasound probe in the heart may give the
inexperienced operator a feeling of disorientation.

• To overcome this, structured introduction and steering/manipulation of

the ultrasound tipped catheter can ultimately provide orientation,
supported by recognition of the anatomical landmarks.

• Most of the structural heart interventions can be done by keeping ICE

probe in mid RA, Low RA, RV inflow, RV outflow and Left Atrium.
Echo- cardiographic (ICE) views
• The catheter is placed in the middle part of the RA, thus visualising
the RA, tricuspid valve, and RV .

• This view can be used a “basic point of orientation”, from which other
views can be derived.

• Also known as the ‘Home view’.

1)Homes view
• Counterclockwise rotation with catheter positioned in superior part of RA
provides imaging of the terminal crest

• Whereas clockwise rotation of the catheter from the inferior RA provides a

view of the Eustachian ridge with the tricuspid–caval isthmus(CTI)

• These are important target structures in atrial flutter ablation

 Figure 5

HeartRhythm Case Reports 2020 6115-120DOI: (10.1016/j.hrcr.2019.09.004)

Copyright © 2019 Heart Rhythm Society Terms and Conditions
3) RA-RVOT view
• With catheter in right atrial home position , slight rotation to the
patient left side or clockwise rotation RVOT can be visualised with
aortic valve just above it.
RA-RVOT
3) RA -LVOT
• From the RVOT view ,on rotation of the catheter very slightly
clockwise , aortic valve and the LVOT will begin to appear in the
middle of the screen.
• Sometimes pulmonary artery or pulmonary valve may be seen just
behind the aorta
4) RA-CS-MV-LA-LAA
• From the RVOT view rotate the catheter clockwise---coronary sinus
will be visualised directly below the right atrium in the same plane as
the mitral valve.
• Left atrial appendage can also be seen in the same plane as the mitral
valve as an outpouching
Cs –short axis & CS---long axis
5) LA-LIPV-PSPV
• A slight clockwise rotation of the catheter from the CS view ,we can
visualise the LIPV, with further slight clockwise rotation LSPV may be
visualised.
• As is it sometimes difficult to distinguish between the LAA and the left
superior PV, Doppler capacities can be used to differentiate.
• By increasing the depth setting of the catheter with the transducer
directed at the left atrial posterior wall, imaging of the left and right
pulmonary veins.
• Sometimes called as PANT view.
6) LA-Oesophagus-Desc Aorta
• Further clockwise rotation from the left pulmonary veins view,
Oesophagus and descending aorta may be seen in between left and
right pulmonary veins.
Oesophagus will lie anterior to the ascending aorta behind the left wall.
7)LA-RIPV
• Right pulmonary veins will appear close to the imaging surface
• To see the RIPV , we have to continue clockwise rotation beyond the
left pulmonary veins and beyond the oesophagus view.
• We can utilise the doppler to identify pulmonary inflow.
8) RIPV-RSPV long axis
• From LA-RIPV view , continue a slight clockwise rotation of the
catheter to visualise inferior and superior pulmonary veins in long axis
9)LA-RSPV short axis
• We have to advance the catheter higher in right atrium and continue
clockwise rotation, sometimes with posterior tilt and some right or
left steering will optimise the image.
10)Left ventricle
From the initial home position,on withdrawing the catheter low in the
right atrium ,we can visualise eustachian ridge.
Using the top control on the catheter handle ,knob is rotated
clockwise , which puts an anterior tilt on the catheter tip,later catheter
is advanced through tricuspid valve into the right ventricle,then
anterior steer is released.
Then on clockwise roatation of catheter,imaging beam will show us LV
in long axis
• Finally, by advancing the catheter into the RV, detailed imaging of the LV can
be obtained. Both long and short axis views of the LV can be obtained .
Standard ICE Views
STANDARD ECHOCARDIOGRAPHIC
VIEWS
• From the Right Atrium

• A home view obtained with the ICE catheter placed in the

mid–right atrium (RA) and the transducer in a neutral
position facing the tricuspid valve

• The home viewimaging of the RA, tricuspid valve (TV),

right ventricle (RV), and typically an oblique or short-axis
view of the aortic valve.

• Color flow Doppler is used to evaluate the presence of

tricuspid regurgitation, and continuous wave Doppler can
be used to estimate the RV systolic pressure.
• “Home view” obtained with the ICE catheter in
neutral position at the mid right atrium
• Clockwise rotation of the catheter
• the aortic valve in long axis and the RV outflow tract (RVOT)

• the cusp  closer to the transducer is the noncoronary

cusp
• the opposite cusp right coronary cusp, directly posterior
to the RVOT infundibulum and pulmonic valve.

• Left ventricle is visualized anterior to the most septal

portion of the RA, and the opening of the coronary sinus
(CS) becomes evident
• The long axis of the LV outflow tract is identified, and the
posterior LV is in view just below the non coronary cusp.

• Color Doppler is performed to assess for baseline aortic

stenosis or regurgitation.
STANDARD ECHOCARDIOGRAPHIC
VIEWS
• From the Right Atrium

• A home view obtained with the ICE catheter placed in the

mid–right atrium (RA) and the transducer in a neutral
position facing the tricuspid valve

• The home viewimaging of the RA, tricuspid valve (TV),

right ventricle (RV), and typically an oblique or short-axis
view of the aortic valve.

• Color flow Doppler is used to evaluate the presence of

tricuspid regurgitation, and continuous wave Doppler can
be used to estimate the RV systolic pressure.
• “Home view” obtained with the ICE catheter in
neutral position at the mid right atrium
• Additional clockwise rotation  visualization of the mitral
valve and interatrial septum, with the left atrial appendage
anteriorly and the CS posteriorly

• LA appendage  thrombus at its ostium,

• mitral regurgitation  color Doppler across the valve.

Further clockwise rotation

long-axis view of the upper and lower left pulmonary veins .

• The left superior pulmonary vein appears first because its
location is superior and anterior, whereas the left inferior
pulmonary vein is inferior and posterior.
• Ostium dimensions and flow rates can be assessed in this view.
• Additional clockwise torque will bring into view the posterior
wall of the LA and the esophagus as well as the descending
aorta.

More clockwise torque

and slight advancement

• display the right inferior pulmonary vein, which is posterior

and inferior

• followed by the right superior pulmonary vein, which is

superior and anterior and the most septal of all the
pulmonary veins
• Further clockwise rotation allows visualization of
the RA structures

• First, the posterior RA comes into view, and gentle

posterior deflection opens the superior vena cava
(SVC).
• Next, the crista terminalis seen as a muscular ridge
that separates the smooth walled and trabeculated
portions of the RA
• Finally, the RA appendage is visualized and
becomes the most anterior aspect of the lateral RA
before continued clockwise rotation will return the
imaging plane to the home view.
From the RV
• From the home view, the catheter is anteriorly flexed while the TV is in
view and kept opened in the image plane.

• Then the catheter is advanced gently into the RV, and once the catheter
tip passes through the TV, the deflection is released, obtaining a view of
the inferior RV .

• RV intracavitary structures, the moderator band, and RV papillary

muscles.

• From the RV view, the catheter is gradually clocked to image the LV.

• First, a view of the septum and the LV apex is obtained

• this view may be more sensitive to detect LV apical clots than
transthoracic echocardiography or TEE.
• Then Long-axis view of the LV  the posteromedial papillary
muscle, septal, inferior, and anterior wall

additional clocking

• anterolateral papillary muscle, MV apparatus, septal wall, and

lateral wall

• Advancement of the catheter allows better visualization of the

apex, whereas withdrawal toward the annulus enhances
visualization of more basal structures.

additional clockwise rotation,

• the LV outflow tract comes into view , and with further rotation a
short-axis view of the aortic root is obtained with its typical
trileaflet appearance (Mercedes-Benz sign)
• The left main coronary artery origin at the left coronary
cusp can be visualized , and the course of the left anterior
descending could be easily tracked from this point by
counterclocking the catheter as it travels in the
interventricular groove.

• On the otherside, to image the right coronary artery, 2

views are possible:
• from the RA appendage with slight anteroflexin looking
down toward the TV annulus and the aorta,
• or from the RVOT looking up and clocking after obtaining a
long-axis view of the ascending aorta, just above the right
coronary cusp

• RVOT ,PUL VALVE, Ascending aorta

TEE Vs ICE
 Uses of Intracardiac Echocardiography
• Transseptal Catheterization
• PBMV
• Ablation of Atrial Fibrillation
• Atrial Septal Defect Closure
• Left Atrial Appendage Imaging and Closure Procedures
• Transcatheter Aortic Valve Replacement
• Ablation of Ventricular Arrhythmias
• Congenital- intracardiac baffles and shunts
• Percutaneuos VSD closure
• Others(PDA closure,Mitra clip,Aortic Dissection)
Atrial Septal Puncture

• High frequency excellent realtime imaging of the atrial

septum.

• Major focus is on the morphology of the fossa ovalis and the

limbus
TENTING INTERATRIAL SEPTUM

RA

LA
Septal puncture with Safe sept NF wire

RA

LA
Transeptal Access
RA

LA
PBMV Balloon in LA

LA
PBMV Balloon across MV

LV
PBMV Balloon across MV
POST PBMV
Pulmonary Vein Isolation for Atrial Fibrillation (AF)
Ablation

• Imaging of the pulmonary veins permitting recognition of the

number of veins and their entrance, whether they enter the
LA via separate ostium or via a common ostium
• Imaging View
• catheter tip straight in the body of the RA and facing inter
atrial septum.

• Left pulmonary veins are easily imaged by gently rotating the

catheter clockwise.

• If LA is enlarged, then the catheter tip may require flexion or

extension to look at the left pulmonary veins.
Cryoablation for atrial fibrillation- Role of
ICE

LSPV

Cryo balloon
Guide wire in LSPV

LSPV
• Right pulmonary veins require catheter manipulation
to image their entrance into the LA.

• The right pulmonary veins are adjoining the SVC, they

can be imaged from the SVC, SVC–RA junction, or
from the high RA. In the SVC and SVC–RA junction,
the catheter must be slightly flexed to look down.

• The superior limbus of the fossa ovalis is seen

adjoining the entrance of the pulmonary vein from
this position.
• ICE provides realtime monitoring of adequate
contact of the ablation catheter with atrial wall, and
delivery of radio frequency energy results in
cavitation seen as bubbles on the ICE and lesion
development as there is a change in the tissue
texture

• ICE monitoring during ablation avoids unnecessary

slippage of the catheter into the pulmonary and also
recognize proper tissue contact.

• This prevents over use of the energy and

unnecessary complications
Patent Foramen Ovale/Atrial Septal Defect Closure

• ICE imaging is useful for guidance of device closure of atrial septal

defects, such as secundum atrial septal defect (ASD) or patent
foramen ovale (PFO).

• Transcatheter placement of closure devices for ASD or PFO is

facilitated by ICE guidance in the cardiac catheterization laboratory.

• Intracardiac images provide superior imaging of the atrial septum

• Assessment of the defect(s) and relationship to the surrounding

cardiac structures particularly the inferior rim is critical to a
successful deployment of the closure device and is facilitated by the
ICE.

• Documentation of normal pulmonary venous return to the LA is an

important aspect of ASD closure and is easily accomplished by ICE
• ICE is used to confirm adequate wire position,
• assist with balloon sizing,
• place a long sheath for device delivery,
• release the left-sided disc in the left atrium (LA), and
• release the right-sided disc in the right atrium (RA).

• ICE provides uninterrupted monitoring and is therefore expected to

increase safety, particularly in device closure of complex PFO and
ASD,

• ICE is beneficial in transcatheter closure of ASDs in patients with

impaired left ventricular (LV) function and in closure of multiple
defects requiring either simultaneous or staged deployment of
closure device

• Since many patients with IAC are of reproductive age or younger,

reduction of radiation exposure represents an important advantage.
• Long-axis and short-axis views aid in dimensional analysis of the septal defect
and allow very accurate measurement of both static diameter, and, more
importantly, balloon-stretched diameter (typically used to select the
appropriate device size) when compared to fluoroscopy.

• Spatial relationships of devices in relationship to surrounding cardiac

structures are better visualized by ICE compared to TEE .

• During deployment and subsequent delivery of an occlusion device, there is

no shadowing of the right atrial disc of the device by the left atrial disc when
ICE guidance is utilized.

• ICE imaging provides superior visualization of septal rims in relationship to

device position before final deployment is accomplished, reducing the risk of
device embolization.

• In contrast, when TEE is used for evaluation of device placement, signifi cant
acoustic shadowing from the left atrial disc may preclude adequate imaging of
each disc and its relationship to the atrial septum, increasing the time needed
for imaging prior to delivery of the device in an optimal position.
• Balloon sizing is performed and monitored with ICE and fluoroscopy.

• Usually, the best images for clear measurement of balloon size were
obtained with the long-axis view of the atrial septum.

• Multiple views of the infl ated balloon and atrial septum with color
flow imaging were obtained to show complete defect occlusion and
to exclude other associated atrial defects.

• By fluoroscopy, the balloon size was obtained in both the anterior

and lateral imaging planes.

• Once deployed but before release, the device was again imaged with
ICE in both the long- and short-axis planes to determine appropriate
device positioning in the atrial septum, to exclude the presence of
additional defects, and to ensure that the device did not interfere
with the surrounding structures
• A, Longitudinal view. B, Short-axis view
• A, Longitudinal view
showing left-to right
shunt.
• B, Balloon sizing.
• C, Long sheath with
wire inside.
• D, Opened left-sided
disc in LA.
• E, Release of right-
sided disc in RA.
• F, Wiggle maneuver.
• G, Short-axis view.
• H, Longitudinal
view with the device
in place
Deploying left disk in LA
LAA closure
Left Atrial Appendage Imaging and Closure Procedures

LAA
ICE guided VSD closure
 TRANSCATHETER AORTIC VALVE REPLACEMENT

• Transcatheter aortic valve replacement (TAVR) is considered an

alternative to surgery for high-risk or inoperable patients with severe,
symptomatic aortic stenosis.

• TEE has been established as an important supplement to fluoroscopic

imaging for positioning, and as the primary imaging tool for the
comprehensive assessment of complications following valve implantation.

• Intraprocedural TEE is frequently performed with general anesthesia, it

is not always an ideal tool for TAVR in this patient population.

• ICE more acceptable alternative during procedures ,the main advantage

of ICE imaging is its suitability for monitoring with ultralow doses of
contrast agent, an approach helpful for preserving renal function and for
lowering the occurrence of acute kidney injury
• Longitudinal views from the cavoatrial junction are the primary ICE views ,
display the ascending aorta, native aortic valve, and aortic valve prosthesis.

• After valve deployment, short-axis views rule out annulus rupture and to
check for paravalvular leaks.

• The severity of any regurgitation can be easily graded by a multiparametric

approach.

• ICE can be consistently used to

• (1) assist with guide wire passage through the native valve,
• (2) position the balloon for predilatation and observe balloon inflation,
• (3) position the catheter system that is carrying the valve,
• (4) observe valve deployment and verify adequate prosthetic valve function,
• (5) rule out pericardial hemorrhage, and
• (6) ultimately check LV function from the transventricular view

• The ICE guiding strategy for TAVR is safe, effective, and compatible with
monitored anesthesia care.
• Longitudinal cross-sectional plane for guidance of transcatheter
aortic valve implantation
• The first clinical impressions on using 3D ICE for
TAVR guidance are promising.

• In particular, this technique appears to facilitate

precise final positioning of the valve-carrying
balloon immediately before deployment of the
valve prosthesis .

• Initial experience suggests that 3D capabilities can

augment the advantages of ICE in TAVR
Aortic dissection
• Intraluminal phased-array imaging can demonstrate aortic
dissection; true and false lumina, including entries and
reentries; and important side branches (e.g., the renal arteries).

• IPAI may thereby help lower the complication rate of

percutaneous aortic stent-graft implantation.

• The Doppler beam can be aligned with any flow between true
and false lumen and with blood flow into small branches.

• IPAI can be used to safely guide stent implantation in aortic

coarctation and percutaneous biopsies of intra-aortic masses
suspected to be tumors
• MitraClip implantation
• ICE imaging can be used for transseptal puncture, depicting advancement
and steering of the clip delivery system, and leaflet grasp.

• ICE imaging considered inferior to 3D TEE, which is viewed as the gold

standard to ensure proper positioning of the device and to evaluate
procedural outcome, such as the final double orifice area and severity of
residual mitral regurgitation.

• ICE imaging can be used for guidance during LAA closure procedures and for
excluding thrombi.

• RA views are rarely sufficient to visualize the apex and the complex
anatomy of the LAA.

• Positioning of catheters or devices and color Doppler assessment of peri-

device flow frequently require near-field imaging

• ICE imaging from the left pulmonary artery has been demonstrated to be a
promising alternative
Extracardiac Use of the Intracardiac
Echocardiography Probe
• The intracardiac echo probe has also been used for transesophageal
imaging in small infants during congenital cardiac surgery.

• Th e small size of this probe facilitates its placement in children < 3.0
kg.

• In these small infants, standard biplane pediatric TEE probe cannot be

advanced into the esophagus due to the patient’s small size.

• High quality 2D and Doppler images are obtained by the use of ICE .

• Th major disadvantage of the ICE probe is that it is monoplane.

• Longitudinal imaging is effective; however, the crux of the heart and

the inlet ventricular septum are not adequately visualized.
Role of ICE in detection of procedural complications.

LA thrombus

Iatrogenic aortic insufficiency

Iatrogenic pericardial effusion

Limitations
• 1. The size of the catheters is relatively large and as
such vascular injuries are a potential problem.

• 2. Phased array catheter is expensive when used only

one time.

• 3. The single-plane imaging requires extreme catheter

manipulation that has the potential for complications.
Three-dimensional (3D) ICE is currently under clinical
investigation.

• 4. No standard imaging planes.

Three-Dimensional Intracardiac Echo Imaging

• Three- and four-dimensional ICE imaging is now commercially

available with the Siemens SC2000 platform.

• The 3D ICE probe currently is only available in the 10F size but also
has the same functionality as the 2D catheter.

• The hub of the catheter connecting to the imaging console is

different

• The four-dimensional (4D) images provide realtime 20° 3D images.

• With similar catheter positioning as described with the 2D images,

3D images of the atrial septum, atrioventricular valves, and
semilunar valves can be obtained.
Future Perspectives

• 3D ICE, could become a favored imaging mode for newer, more

complex interventional techniques, such as transcatheter aortic valve
replacement, percutaneous mitral leaflet repair of MR, and
LAA occlusion.
.
 Conclusions
• ICE provides high-quality, near-field images of cardiac structures.
• ICE has partially replaced TEE for the guidance of multiple invasive
cardiac procedures.
• Its main disadvantage is a higher cost.
• Shorter procedural times, avoidance of general anesthesia, and
prevention of complications may result in a favorable cost/benefit
ratio.
• Clinical applications of ICE will continue to expand and the advances
in resolution and 3D image acquisition will consolidate its role in the
treatment of valvular and congenital heart diseases.
THANK YOU