Four patients with pulmonary valve (PV) disease and patent foramen ovale (PFO) presented with dyspnea on exertion. Work-up revealed hypoxemia secondary to right-to-left intracardiac shunt. We demonstrate that correction of the primary culprit right heart overload lesion via PV replacement enabled safe PFO repair and resolution of hypoxemia.

Purpose: Intra-Cardiac Echocardiography (ICE) is a powerful imaging modality for guiding cardiac electrophysiology and structural heart interventions. ICE provides real-time observation of anatomy and devices, while enabling direct monitoring of potential complications. In single operator settings, the physician needs to switch back-and-forth between the ICE catheter and therapy device, making continuous ICE support impossible. Two operators setup are therefore sometimes implemented, with the challenge of increase room occupation and cost. Two operator setups are sometimes implemented, but increase procedural costs and room occupation. Methods: ICE catheter robotic control system is developed with automated catheter tip repositioning (i.e. view recovery) method, which can reproduce important views previously navigated to and saved by the user. The performance of the proposed method is demonstrated and evaluated in a combination of heart phantom and animal experiments. Results: Automated ICE view recovery achieved catheter tip position accuracy of 2.09 +/-0.90 mm and catheter image orientation accuracy of 3.93 +/- 2.07 degree in animal studies, and 0.67 +/- 0.79 mm and 0.37 +/- 0.19 degree in heart phantom studies, respectively. Our proposed method is also successfully used during transeptal puncture in animals without complications, showing the possibility for fluoro-less transeptal puncture with ICE catheter robot. Conclusion: Robotic ICE imaging has the potential to provide precise and reproducible anatomical views, which can reduce overall execution time, labor burden of procedures, and x-ray usage for a range of cardiac procedures. Keywords: Automated View Recovery, Path Planning, Intra-cardiac echocardiography (ICE), Catheter, Tendon-driven manipulator, Cardiac Imaging

We describe a 64-year-old woman with subclavian pseudoaneurysm after aortic coarctation repair, treated using a hybrid approach involving true three-dimensional analysis and image fusion-guided placement of thoracic endovascular aortic repair stents. This case illustrates the potential complications of coarctation repair and need for lifelong surveillance in these patients. (Level of Difficulty: Advanced.).

We describe a 31-year-old woman with pulmonary homograft rupture and ventricular fibrillation arrest complicating a transcatheter pulmonary valve (TPV) procedure. She underwent extracorporeal membrane oxygenation (ECMO) with immediate surgical repair including bioprosthetic pulmonary valve replacement. She had difficulty weaning off ECMO due to hyperacute failure of the valve and ultimately underwent successful hybrid TPV with complete recovery. This case illustrates the importance of the heart team approach during catheter and surgical interventions in adult congenital heart disease.

BACKGROUND:In adults with congenital heart disease, anatomically complex culprit collateral vessels may cause life-threatening hemoptysis and require catheter-based embolization. Techniques using conventional 2-dimensional (2D) fluoroscopy can be challenging. TECHNIQUE:We describe a technique using 2D/3-dimensional (3D) image fusion for intraprocedural guidance to embolize aortopulmonary collaterals. Two fluoroscopic images of the thorax at least 30° apart with pigtail catheter in the ascending aorta were used for image fusion with preprocedural computed tomography (CT) angiography using the spine and pigtail catheter as landmarks. 3D planning information was overlaid on 2D fluoroscopy for cannulation and embolization. RESULTS:Between November 2018 and June 2019, a total of 6 sessions of aortopulmonary collateral embolization using CT-fluoroscopy image-fusion guidance were conducted in 3 patients with adult congenital heart disease. In 3/6 sessions, the indication for embolization was hemoptysis. Common target vessels were left and right bronchial arteries (4 and 3 sessions, respectively). The spine and a pigtail catheter in the aorta were frequently used as landmarks for image fusion (67%). Particle embolization was used in 100% of cases. Mean procedure and fluoroscopy times were 3 hours, 23 minutes and 1 hour, 3 minutes, respectively. On average, 169 mL (350 mg iodine/mL) of contrast material was used in each session and total skin dose of radiation exposure was 1538 mGy. Successful collateral embolization was confirmed by postprocedure angiography that showed negligible or no flow through culprit collaterals. CONCLUSION:Use of CT-fluoroscopy image-fusion guidance can aid in embolization of aortopulmonary collaterals with complex anatomy in 3D space.

Intra-cardiac Echocardiography (ICE) is a powerful imaging modality for guiding electrophysiology and structural heart interventions. ICE provides real-time observation of anatomy, catheters, and emergent complications. However, this increased reliance on intraprocedural imaging creates a high cognitive demand on physicians who can often serve as interventionalist and imager. We present a robotic manipulator for ICE catheters to assist physicians with imaging and serve as a platform for developing processes for procedural automation. Herein, we introduce two application modules towards these goals: (1) a view recovery process that allows physicians to save views during intervention and automatically return with the push of a button and (2) a data-driven approach to compensate kinematic model errors that result from non-linear behaviors in catheter bending, providing more precise control of the catheter tip. View recovery is validated by repeated catheter positioning in cardiac phantom and animal experiments with position- and image-based analysis. We present a simplified calibration approach for error compensation and verify with complex rotation of the catheter in benchtop and phantom experiments under varying realistic curvature conditions. Results support that a robotic manipulator for ICE can provide an efficient and reproducible tool, potentially reducing execution time and promoting greater utilization of ICE imaging.

Multiple techniques exist for detecting Mycobacteria, each having its own advantages and drawbacks. Among them, automated culture-based systems like the BACTEC-MGIT™ are popular because they are inexpensive, reliable and highly accurate. However, they have a relatively long “time-to-detection” (TTD). Hence, a method that retains the reliability and low-cost of the MGIT system, while reducing TTD would be highly desirable.