Abstract
BackgroundThree-dimensional intracardiac echocardiography (3D ICE) with wide azimuthal elevation is a novel technique performed for assessment of cardiac anatomy and guidance of intracardiac procedures, being able to provide unique views with good spatial and temporal resolution. Complications arising from this invasive procedure and the value of 3D ICE in the detection and diagnosis of acute cardiovascular pathology are not comprehensively described. This case illustrates a previously unreported iatrogenic complication of clot displacement from the intra-vascular sheath upon insertion of a 3D ICE catheter and the value of 3D ICE in immediate diagnosis of clot in transit through the heart with pulmonary embolism.Case presentationWe conducted a translational study of 3D ICE with wide azimuthal elevation to guide implantation of a left ventricular assist device (Impella CP®) in eight adult sheep. A large-bore 14 Fr central venous sheath was used to enable right atrial and right ventricular access for the intracardiac catheter. Insertion of the 3D ICE catheter was accompanied by a sudden severe cardiorespiratory deterioration in one animal. 3D ICE revealed a large highly mobile mass within the right heart chambers, determined to be a clot-in-transit. The diagnosis of pulmonary clot embolism resulting from the retrograde blood entry into the large-bore sheath introducer, rapid clot formation and consequent displacement into venous circulation by the ICE catheter was made. The sheep survived this life-threatening event following institution of cardiovascular support allowing completion of the primary research protocol.ConclusionThis report serves as a serious warning to the researchers and clinicians utilizing long large-bore sheath introducers for 3D ICE and illustrates the value of 3D ICE in detecting clot-in-transit within right heart chambers.
Highlights
Three-dimensional intracardiac echocardiography (3D Intracardiac echocardiography (ICE)) with wide azimuthal elevation is a novel technique performed for assessment of cardiac anatomy and guidance of intracardiac procedures, being able to provide unique views with good spatial and temporal resolution
This report serves as a serious warning to the researchers and clinicians utilizing long large-bore sheath introducers for three dimensional (3D) ICE and illustrates the value of 3D ICE in detecting clot-in-transit within right heart chambers
The tip of the ICE catheter is usually positioned within right heart chambers and coronary sinus [2], left atrial imaging is possible after atrial septal puncture [3]
Summary
Intracardiac echocardiography (ICE) is increasingly used for diagnostic procedures and imaging guidance during interventions. The intracardiac echocardiographic catheter is inserted through a vascular sheath following central venous catheterization [1]. The central venous sheath introducer is usually a single-lumen vascular catheter with the inner bore diameter larger than the ICE catheter, incorporating a hemostatic valve and a side port. For the initial echocardiographic assessment, an AcuNav Volume 12.5 Fr, 90 cm four-ways steerable ICE catheter (Siemens Medical Solutions, USA Inc., Mountain View, CA) was inserted through the haemostatic valve of the vascular sheath approximately 5 min following removal of the dilator during which time systemic heparinisation had not been administered until immediately prior to the ICE catheter insertion. Minor retroflection of the intracardiac catheter provided a clear and complete view (Fig. 1 Panel b, Movie 1 in Additional Files) of the mass traversing the tricuspid valve from the right atrium into a severely dilated right ventricle. The interventricular septum was bowing towards the left ventricle, creating an
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