Percutaneous intrapericardial echocardiography during catheter ablation: a feasibility study

Background: Percutaneous pericardial access, epicardial mapping, and ablation have been used successfully for catheter ablation procedures. Objectives: The purpose of this study was to evaluate the safety and feasibility of closed-chest direct epicardial ultrasound imaging for aiding cardiac catheter ablation procedures. Methods: An intracardiac ultrasound catheter was used for closed-chest epicardial imaging of the heart in 10 patients undergoing percutaneous epicardial access for catheter ablation. All patients underwent concomitant intracardiac echocardiography and preprocedural transesophageal echocardiography. Using a double-wire technique, two sheaths were placed in the pericardium, and a phased-array ultrasound catheter was manipulated within the pericardial sinuses for imaging. Results: Multiple images from varying angles were obtained for catheter navigation. Notably, image stability was excellent, and structures such as the left atrial appendage were seen in great detail. No complications resulting from use of the ultrasound catheter in the pericardium occurred, and no restriction of movement due to the presence of the additional catheter in the pericardial space was observed. Wall motion was correlated to voltage maps in five patients and showed that areas of scars correlated with wall-motion abnormalities. Normal wall-motion score correlated to sensed signals of 4.2 ± 0.3 mV (normal myocardium >1.5 mV), and scores >1 correlated to areas with signals <0.5 mV in that territory). Conclusion: Intrapericardial imaging using an ultrasound catheter is feasible and safe and has the potential to provide additional valuable information for complex ablation procedures.