Multimodality imaging in the cardiac catheterization laboratory: a new era in sight

Multimodality imaging in the cardiac catheterization laboratory continues to develop with rapid advancements in the use of intracardiac echocardiography (ICE), 3D echocardiography (3DE) and multidetector computed tomography (MDCT), with fluoroscopic overlay to produce 3D images of intracardiac structures. The improvement in these imaging tools have coincided with innovation and procedural advancement in the field of interventional cardiology, especially with regard to structural and valvular cardiac interventions. As advances in transcatheter interventions continue and the availability of these procedures become more common; an understanding of the various imaging modalities used in the interventional catheterization laboratory is important for practicing clinicians. 2D fluoroscopic and echocardiographic imaging in the catheterization laboratory have been, and will likely continue to be, routine methods for real-time imaging of the heart during transcatheter interventions, given their widespread availability and clinicians’ familiarity with their use. Inherent to fluoroscopic imaging, however, are significant inadequacies in defining accurate dimensions, distances and depth of intracardiac anatomy, especially the nonradiopaque structures found in the heart. These limitations in 2D planar imaging have led to the increasing availability and use of 3DE and MDCT with fluoroscopic overlay to generate 3D, real-time, detailed and accurate images for procedural guidance in the cardiac catheterization laboratory. Although ICE also produces 2D planar views, the images it provides are of greater detail and anatomic accuracy than fluoroscopy and transesophageal echocardiography (TEE) alone. As such, these imaging modalities may reduce procedural time, radiation exposure, TEE probe dwell time and procedural complications, while improving procedural success for many transcatheter interventions. In this article, the authors will demonstrate applications of the commonly used multimodality imaging resources in the contemporary cardiac catheterization laboratory, including 3DE, ICE and computed tomography (CT):fluoroscopy overlay.