Affiliations:
1- University of Alabama at Birmingham, Department of
Cardiovascular Disease, Birmingham, AL, United States of America
Corresponding author: Mustafa Alkhawam -
(Email:mustafa.alkhawam@gmail.com)
Conflict of interest disclosure statement: NONE
Informed Consent Statement: Informed consent was obtained from
all subjects involved in the study.
Acknowledgments: We would like to acknowledge the help of our
other contributing fellows within the department.
Funding: This research received no external funding
Fusion imaging (FI) technology using Echo-Navigator (EchoNav, Philips
Healthcare, Best, The Netherlands) integrates and overlays
live/real-time transesophageal echocardiography (TEE) images on
real-time fluoroscopy [1]. Here, we describe the novel use of FI
guidance in the placement of a right ventricular assist device (RVAD,
ProtekDuo, LivaNova, London, UK) in the proximal main pulmonary artery
(MPA) beyond the pulmonic valve (PV) in an adult patient with
post-operative right ventricular (RV) failure. The patient was a
45-year-old man presenting with worsening dyspnea and fatigue for
several months. Two-dimensional (2D) transthoracic echocardiogram (TTE)
followed by 2DTEE showed severe bicuspid aortic valve stenosis with
moderate insufficiency and severe mitral regurgitation (MR). The patient
underwent successful mitral repair and aortic valve replacement but
peri-procedurally suffered a ventricular fibrillation arrest (VF)
requiring resuscitation and remained in cardiogenic shock. A subsequent
2DTTE showed severe RV dysfunction, and a decision for emergent
placement of an RVAD via the right internal jugular vein was made. The
device was successfully placed by utilizing FI guidance to visualize the
PV in real-time and live TEE to accurately superimpose imaging. This
helped facilitate the placement of the RVAD cannula tip in the MPA lumen
beyond the PV (Figures 1-3, Video 1). Unlike standard techniques, in
which echocardiographic and fluoroscopic images are interpreted
separately, simultaneous visualization of TEE and fluoroscopic images on
the same screen helped save time and ensure adequate placement, and the
large bore device could be manipulated with improved precision, avoiding
complications such as malposition, valvular damage, or cardiac
perforation.
Thus, FI played a crucial role in the reliable, safe, and rapid
placement of the RVAD device in our patient. In addition, the use of FI
may reduce overall radiation exposure to both the patient and cath lab
personnel during the procedure by placing more dependence on echo
guidance supplemented by intermittent X-ray imaging when necessary.
Furthermore, it may improve efficiency by allowing for more accurate
device placement, avoiding the need for device positioning changes,
streamlining procedural workflow, and reducing the need for equipment
setup, multiple monitors, or conflicting information in the cath lab
[2]. The integration of FI can also improve the education of
trainees. The use of FI has been shown to enhance the learning curve of
interventionists performing advanced structural procedures [3].
Following RVAD implantation and subsequent placement of an implantable
cardiac-defibrillator (ICD), our patient showed improvement in RV
function by 2DTTE, was then weaned off the RVAD, gradually recuperated,
and a month later was able to be discharged in good condition.