Intracardiac echocardiography during percutaneous pulmonary valve replacement.

The patient is a 26-year-old female with a history of tetralogy of Fallot with severe obstruction of the right ventricular outflow tract (RVOT), and she was operated during the first few months of life with the insertion of an aorto-pulmonary shunt (BTS); in 1986, a valved conduit (Jonescu-Shiley 20) was inserted between the right ventricle and the pulmonary artery. She developed significant pulmonary valve regurgitation due to the conduit obstruction as shown by the cardio MRI (Panel 1A: white arrow, conduit; yellow arrow, native pulmonary artery). The patient was then scheduled for percutaneous pulmonary valve implantation. The procedure was monitored also by using the intracardiac echocardiography (ICE) that was performed with the AcuNav 8 Fr catheter (Biosense Webster, Inc. Diamond Canyon Road, Diamond Bar, CA, USA) introduced from the left femoral artery and advanced under fluoroscopic guidance to the aortic arch and to the aortic isthmus. The anatomy was confirmed with both an angiogram (Panel 1B: white arrow, conduit; yellow arrow, native pulmonary artery) and with the ICE (Panel 1C: yellow arrow, native pulmonary artery).

The angiography was used to determine the anatomy of the RVOT and branch pulmonary arteries so as to determine feasibility, to select the appropriate site of deployment, and to aid the choice of a delivery system; a balloon was inflated into the conduit in order to pre-dilate the stenotic valve and also to get a measurement of the conduit. The angiographic information (Panel 2A) was completed with the ICE images (Panels 2B and 2C).

A 20 mm Melody valve (Medtronic, Inc, Minneapolis, MN, USA) was implanted, and the angiography was repeated after valve implantation (Panel 3A). The ICE images after valve implantation gave complete anatomic (Panel 3B) and functional (Panel 3C) information.

Funding to pay the Open Access publication charges for this article was provided by Biosense Webster Inc.