Special Article
Echocardiographic and Fluoroscopic Fusion Imaging for Procedural Guidance: An Overview and Early Clinical Experience

https://doi.org/10.1016/j.echo.2016.01.013Get rights and content

Highlights

  • Echocardiographic-fluoroscopic fusion has the potential to improve procedural guidance in the future.

  • Echocardiographic-fluoroscopic fusion allows real-time imaging, an advantage over other modalities.

  • Integration of color Doppler imaging is a unique advantage of echocardiographic-fluoroscopic fusion.

  • Registration error in the direction of the fluoroscopic beam is an important limitation.

  • Additional work is needed to assess this technology’s accuracy and clinical value.

There has been significant growth in the volume and complexity of percutaneous structural heart procedures in the past decade. Increasing procedural complexity and accompanying reliance on multimodality imaging have fueled the development of fusion imaging to facilitate procedural guidance. The first clinically available system capable of echocardiographic and fluoroscopic fusion for real-time guidance of structural heart procedures was approved by the US Food and Drug Administration in 2012. Echocardiographic-fluoroscopic fusion imaging combines the precise catheter and device visualization of fluoroscopy with the soft tissue anatomy and color flow Doppler information afforded by echocardiography in a single image. This allows the interventionalist to perform precise catheter manipulations under fluoroscopy guidance while visualizing critical tissue anatomy provided by echocardiography. However, there are few data available addressing this technology’s strengths and limitations in routine clinical practice. The authors provide a critical review of currently available echocardiographic-fluoroscopic fusion imaging for guidance of structural heart interventions to highlight its strengths, limitations, and potential clinical applications and to guide further research into value of this emerging technology.

Section snippets

Technical Considerations and Sources of Image Registration Error

The first step in fusion imaging is the process of image registration, which involves reorientation of one image (e.g., the echocardiographic image) to match the orientation of a second image (e.g., the fluoroscopic image). The currently available platform (EchoNavigator; Philips Healthcare, Best, The Netherlands) is a software-based solution that provides automated registration of two-dimensional (2D) and 3D transesophageal echocardiographic (TEE) images with x-ray fluoroscopy. Because no

Application of Fusion Imaging in the Clinical Setting

Our early clinical experience with echocardiographic-fluoroscopic fusion imaging includes 34 cases and is summarized in Table 1. We used a Philips iE33 echocardiographic system for the first 22 cases and an EPIQ machine for the remaining 12 cases (Philips Healthcare). This was coupled with a Philips Allura Xper FD20/10 fluoroscopic system (Philips Healthcare). The central processing unit running the fusion imaging software was housed in the catheterization laboratory control room and operated

Future Perspectives

Echocardiographic-fluoroscopic fusion imaging supplemented by advances in spatial and temporal resolution of 3D echocardiography will likely influence our approach to guidance of complex structural heart procedures and could serve as an imaging platform for development of future catheter-based beating-heart interventional therapies. As an example, echocardiographic guidance for transcatheter mitral valve repair is essential for procedural success and remains challenging in current clinical

Conclusions

Echocardiographic-fluoroscopic fusion imaging is now possible in the clinical setting, providing automated, real-time fusion images for the guidance of structural heart interventions. This technology provides simultaneous visualization of fine catheter manipulations under fluoroscopic guidance with detailed cardiac structural anatomy and color Doppler hemodynamic information provided by echocardiography. The system also allows the placement of fiducial markers within the echocardiographic space

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Dr. Nijhof is a full-time employee of Philips (Best, The Netherlands) and is responsible for early prototypes and development of the EchoNavigator system.

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