First-in-man Application Of Triple Fusion (echocardiography, Mri, Fluoroscopy) For Guidance Of Percutaneous Structural Heart Interventions
Luigi Pirelli, Dillon Weiss, Nirav C. Patel, Derek R. Brinster, Jonathan M. Hemli, Jacob S. Scheinerman, Chad A. Kliger.
Lenox Hill Hospital, New York, NY, USALenox Hill Hospital, New York, NY, USA

Objective: Pre-procedural and intra-procedural imaging plays a key role in planning and guidance of transcatheter interventions. Transesophageal echocardiogram, volume-rendered 3D gated computed tomography angiography (CTA), and magnetic resonance imaging (MRI) are all useful tools when combined with fluoroscopy for both interventionalists and surgeons to identify optimal approaches, select adequate devices and apply structural heart therapies while minimizing risks to the patient. To date, fusion softwares have been able to only merge CT with fluoroscopy (CT-fluoro fusion) and/or TEE with fluoroscopy (Echo-fluoro fusion) for guidance. This case describes a novel, first-in-man application of fusion technology with the ability to merge multiple imaging modalities for transcatheter procedures.
Methods: A 21 year-old patient with a 24mm ostium secundum-type, atrial septal defect (ASD) with a deficient retroaortic rim and congestive heart failure presented for percutaneous closure. Cardiac MRI was performed and confirmed a Qp:Qs of 2.3:1 with normal pulmonary venous drainage. MRI-fluoro and Echo-fluoro fusion were performed; triple fusion of all imaging modalities onto live fluoroscopy was generated with landmarks placed to identify the ASD and left upper pulmonary vein (LUPV). En face and perpendicular c-arm positions for deployment were identified.
Results: Successful placement of a 26mm Septal Occluder device was positioned and deployed across the ASD based on triple fusion landmarks, without echocardiographic evidence of residual shunt. LUPV landmark aided in placement of the 10F delivery system. Optimal fluoroscopic angles correlated with predicted values.
Conclusions: Multimodality imaging is fundamental for successful transcatheter structural heart interventions. Triple fusion allows the merger of multiple imaging technologies onto fluoroscopy in a single viewing image for the interventionalist and surgeon with landmarks of important cardiac structures. This case describes the first successful application of this technology for procedural guidance. Future evaluation is necessary to understand its full potential applications within complex structural heart interventions, cardiac surgery or hybrid procedures.LEGEND: Figure: (A) Triple fusion technology. TEE landmarks of the ASD (pink circle), retroaortic rim (yellow dot) and posterior rim (orange dot) along with the MRI landmarks of the ASD (white arrowhead) and LUPV ostium (black arrowhead) overlayed simultaneous onto fluoroscopy. Delivery system is visualized crossing the ASD. (B) MRI-fluoro fusion. Cardiac MRI with landmark of the ASD (green circle) placed on coronal view. (C) TEE-Fluoro fusion. 3D TEE short axis view demonstrates the ASD (pink circle) with associated 2D images. (D) TEE Post-ASD Closure. TEE with color doppler reveals appropriate position of 26mm septal occluder without residual shunt.