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European Journal of Echocardiography 2004 5(1):8-11; doi:10.1016/j.euje.2003.11.005
© 2004 by European Society of Cardiology
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Copyright © 2003, The European Society of Cardiology

Fantastic voyage through the cardiovascular system

James B Seward*

Nasseff Professor of Cardiology and Professor of Medicine and Pediatrics, Mayo Medical School; Consultant, Division of Cardiovascular Diseases, Internal Medicine; and Pediatric Cardiology, Mayo Clinic, Rochester, MN, USA

accepted after revision 20 November 2003.

* Tel.: +1-507-284-23581; fax: +1-507-284-1732.

Please see page 34 for the article by Jongbloed et al. (doi: 10.1016/S1525-2167(03)00051-9) and page 93 for the article by Scholten et al. (doi: 10.1016/S1525-2167(03)00049-0) to which this editorial pertains.

In 1963 Isaac Asimov published the science fiction novel entitled Fantastic Voyage.1 The novel begins with a scientific breakthrough of Promethean proportions signally certain victory for the side that possesses this revolutionary technology. Scientists developed miniaturization allowing large objects to be made small. Everyone was quick to see the strategic role of miniaturization. However, the chief scientist who was completing the development of the project sustained a blood clot deep in the brain and the only conceivable means of saving this genius was to apply his own miniaturization invention. A crew of scientists boarded a small submarine named Proteus. The submarine and its crew were miniaturized and injected into the blood stream of the stroke victim. Using a map of the circulatory system, the crew of the Proteus navigated the delicate and treacherous vascular system to the site of the blood clot. The rest is history. Laser lysis of the clot was successful, the crew of the Proteus returned safely, and the patient was saved. Apropos to the two articles by Jongbloed et al.3 and Scholten et al.2 in this month's issue of the European Journal of Echocardiography, miniaturization of ultrasound transducers capable of navigating the vascular system makes the mystique of science fiction's Fantastic Voyage come alive.

Over the past two decades, two different ultrasound catheter technologies capable of navigating and visualizing within the larger cavities and vessels of the cardiovascular system have evolved. The mechanical ultrasound transducer tipped catheter utilized by Scholten and colleagues2 evolved from the smaller mechanical intra-coronary artery ultrasound catheter technology, which had been introduced in the 1980s.4 These larger mechanical ultrasound catheterizes (8 French) utilize a lower frequency transducer (9 MHz) for deeper penetration, which are optimized for heart and large vessel imaging. A motor drives a cable within the catheter, which in turn rotates a piezoelectric crystal in the radial dimension perpendicular to the catheter shaft. Other coronary ultrasound catheter technologies utilizing individual piezoelectric elements spaced around the circumference of the catheter have not evolved to intracardiac use because of beam divergence at greater depths and inherent image degradation. Furthermore, these types of catheters do not accommodate additional ultrasound features such as simultaneous Doppler color flow and hemodynamics.

The phased-array ultrasound catheter system utilized by Jongbloed and colleagues3 evolved by down-engineering larger diameter transesophageal endoscopic mounted ultrasound transducers.5,6 The phased-array ultrasound catheter was introduced in the 1990s.7 An array of closely aligned piezoelectric elements (64 elements) using beam focusing technology form a 90° sector field, which is oriented in the long axis of the catheter. The phased-array solution incorporates all the features of a state-of-the-art ultrasound instrument including simultaneous Doppler color flow, hemodynamics, etc. The two articles featured in the European Journal of Echocardiography2,3 highlight two novel applications of intracardiac ultrasound catheter technology. The two articles show some apparent advantages and limitations to the current ultrasound catheter solutions (Table 1). Most of the current limitations such as shaft size and the addition of additional catheter accouterments (i.e., guidewire, pressure, and therapeutic device ports) are being actively addressed by industry.


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  		Table 1
 
With the current evolution of interventional catheterization, it has become increasingly apparent that projection X-ray fluoroscopy and contrast angiography are inadequate means of visualizing detailed 3-dimensional anatomy and function of the cardiovascular system and surrounding structures. As a consequence, lower frequency ultrasound catheters capable of detailed visualization of large organ structures are increasingly utilized in both cardiovascular and non-cardiovascular invasive diagnostic and therapeutic applications8,9 (Table 2).


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  		Table 2 Applications of ultrasound tipped catheters

 
Two additional technical innovations must be addressed if catheter based ultrasound is to become fully functional and receive universal user friendly application. The first issue can be characterized as "lost in space". Within the confines of the cardiovascular system, landmarks and image orientation change continuously. Using current tomographic imaging the inexperienced operator is easily disoriented with regard to the image orientation and spatial relationships. Using structure recognition a trained operator can ultimately recognize landmarks and determine orientation, however, the learning curve can be protracted. Comparable to gaming technology the problem of "lost in space" will be solved with the use of navigational aids to assist comprehension and appreciation of spatial orientation.20 A navigational aid would markedly improve acquisition of anatomic landmarks and assessment of related structural and hemodynamic changes.

A second issue is likened to "having your nose on the mirror". Objects are so close to the transducer that the operator receives little information regarding contiguous anatomy and is unable to appreciate nearby pathophysiological happenings. The problem of "having your nose on the mirror" will be solved with incorporation of higher-dimensional and parametric imagery.15 The addition of wide fields of view and geometric display of physiology (i.e., parametric imagery) will only be accomplished with a fundamental change in ultrasound information acquisition, display and management. With the incorporation of navigational aids and higher-dimensional and parametric imagery, the "fantastic voyage" will truly become a reality.

The novel applications presented in this month's issue of European Journal of Echocardiography bring us another step closer to the goal of navigating and performing interventional tasks throughout the vascular system. One can only imagine the intrigue and discovery of future voyages within the body's vascular system.


   References
Top
 References
 

  1. Asimov Isaac. Fantastic voyage. (1963) Bantam Books.
  2. Scholten MF, Szili-Torok T, Thornton AS, Roelandt JRTC, Jordaens LJ. Visualization of a coronary sinus valve using intracardiac echocardiography. Eur J Echocardiogr 2004;5:93–96.
  3. Jongbloed MRM, Bax JJ, Borger van der Burg AE, Van der Wall EE, Schalij MJ. Radiofrequency catheter ablation of ventricular tachycardia guided by intracardiac echocardiography. Eur J Echocardiogr 2004;5:34–40.
  4. Yock P.G, Linker D.T, Thapliyal H.V, Arenson J.W, Samstad S, Saether O, et al. Real-time, two-dimensional catheter ultrasound: a new technique for high resolution intravascular imaging. J Am Coll Cardiol (1988) 11:130A.
  5. Seward J.B, Khandheria B.K, McGregor C.G.A, Locke T.J, Tajik A.J. Transvascular and intracardiac two-dimensional echocardiography. Echocardiography (1990) 7:457–464.[Medline]
  6. Schwartz S.L, Pandian N.G, Kusay B.S, Kumar R, Weintraub A, Katz S.E, et al. Real-time intracardiac two-dimensional echocardiography: An experimental study of in vivo feasibility, imaging planes and echocardiographic anatomy. Echocardiography (1990) 7:443–455.[Medline]
  7. Seward J.B, Packer D.L, Chan R.C, Curley M, Tajik A.J. Ultrasound cardioscopy: embarking on a new journey. Mayo Clin Proc (1996) 71:629–635.[Abstract]
  8. Sheikh I, Dinesh Kumar, Zheng Liu, Kantharia B, MacMillan R, Fyfe B.S, et al. Novel uses of intracardiac echocardiography with a phased-array imaging catheter. J Am Soc Echocardiogr (2003) 16:1073–1077.[CrossRef][Web of Science][Medline]
  9. Bruce C.J, Friedman P.A. Intracardiac echocardiography. Eur J Echocardiogr (2001) 2:234–244.[Abstract/Free Full Text]
  10. Marrouche N.F, Martin D.O, Wazni O, Gillinov A.M, Klein A, Bhargava M, et al. Phased-array intracardiac echocardiography monitoring during pulmonary vein isolation in patients with atrial fibrillation. Impact on outcome and complications. Circulation (2003) 107:2710–2716.[Abstract/Free Full Text]
  11. Li P, Dairywala I.T, Liu Z, Stewart S.R, Mathew B, Bowie D, et al. Anatomic and hemodynamic imaging using a new vector phased-array intracardiac catheter. J Am Soc Echocardiogr (2002) 15:349–355.[CrossRef][Web of Science][Medline]
  12. Mullen M.J, Dias B.F, Walker F, Siu S.C, Benson L.N, McLaughlin P.R. Intracardiac echocardiography guided device closure of atrial septal defects. J Am Coll Cardiol (2003) 41:285–292.[Abstract/Free Full Text]
  13. Hijazi Z.M, Wang Z, Cao Q.-L, Koenig P, Waight D, Lang R. Transcatheter closure of atrial septal defects and patent foramen ovale under intracardiac echocardiographic guidance: feasibility and comparison with transesophageal echocardiography. Catheter Cardiovasc Interv (2001) 52:194–199.[CrossRef][Web of Science][Medline]
  14. Szili-Torok T, Kimman G.P, Theuns D, Res J, Roelandt J.R.T.C, Jordaens L.J. Transseptal left heart catheterization guided by intracardiac echocardiography. Heart (2001) 86:e11.[Abstract/Free Full Text]
  15. Dalal A, Asirvatham S.J, Candrasekaran K, Seward J.B, Tajik A.J. Intracardiac echocardiography in the detection of pacemaker lead endocarditis. J Am Soc Echocardiogr (2002) 15(9):1027–1028.[CrossRef][Web of Science][Medline]
  16. Seward J.B, Belohlavek M, Kinter T.M, Greenleaf J.F. Evolving era of multidimensional medical imaging. Mayo Clin Proc (1999) 74:399–414.[Abstract]
  17. Bartel T, Eggebrecht H, Ebradlidze T, Baumgart D, Erbel R. Optimal guidance for intimal flap fenestration in aortic dissection by transvenous two-dimensional and Doppler ultrasonography. Circulation (2003) 107:e17–e18.[Free Full Text]
  18. Bruce C.J, O'Leary P, Hagler D.J, Seward J.B, Cabalka A.K. Miniaturized transesophageal echocardiography in newborn infants. J Am Soc Echocardiogr (2002) 15:791–797.[CrossRef][Web of Science][Medline]
  19. Kohl T, Westphal M, Trumper D, Achenbach S, Halimeh S, Petry P, et al. Multimodal fetal transesophageal echocardiography for fetal cardiac intervention in sheep. Circulation (2001) 104:1757–1760.[Abstract/Free Full Text]
  20. Robb RA, Cameron BM, Seward JB. Graphic navigational guides for accurate image orientation and navigation. US patent 6,049,622. April 2000.

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Related articles in Eur J Echocardiogr:

Radiofrequency catheter ablation of ventricular tachycardia guided by intracardiac echocardiography
M.R.M Jongbloed, J.J Bax, A.E Borger van der Burg, E.E Van der Wall, and M.J Schalij
Eur J Echocardiogr 2004 5: 34-40. [Abstract] [Full Text]  

Visualization of a coronary sinus valve using intracardiac echocardiography
M.F. Scholten, T. Szili-Torok, A.S. Thornton, J.R.T.C. Roelandt, and L.J. Jordaens
Eur J Echocardiogr 2004 5: 93-96. [Abstract] [Full Text]  



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