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Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str 7, Kiel, D-24105 Germany
(Email: lutter{at}kielheart.uni-kiel.de).
Intracardiac procedures are currently performed under fluoroscopic and two-dimensional (2D) echocardiographic guidance, despite the fact that the displayed resolution is not optimal. In addition, all existing visualization methods, such as computed tomography, magnetic resonance imaging, or 2D echocardiography allow only time-delayed visualization or are interpretable only by clinicians with extensive experience.
The work by Mihaljevic and colleagues [1] brings direct intracardiac in vivo imaging a step forward. Fiberoptic imaging during the cardiopulmonary bypass using a separate circulatory system with crystalloid solution allowed a clear view of left and right ventricular structures. With this direct view, native intracardiac anatomy can be visualized in real-time with high resolution on a beating heart. Where can it be utilized? Percutaneous and transapical valve repairs and replacements, septal or ventricular defect repairs, and selective endomyocardial cytokine application may in the future be optimized through this visualization technology.
In experimental cardiac surgery this technology will also prove to be of great benefit; for example, in endovascular and intracardiac microsurgery procedures, direct fiberoptic imaging affords a much better view compared with indirect imaging [2]. The risk of adverse effects from surveying and mapping of the target region for valved stent deployment in percutaneous and transapical approaches may be brought to a minimum through optimized direct imaging. In addition, this technology would be useful for education and training because the images offer an improved view of cardiac anatomy [3].
Only recently is it possible to view detailed cardiac structures with real-time 3D echocardiography (RT3DE). Current studies have described RT3DE as an excellent method for obtaining stereoscopic views to show complicated spatial relations of cardiac structures and lesions, making exact assessments of function of atrium and ventricle, and simulating surgical views to plan and control the operation [4]. As already reported, RT3DE-guided intracardiac operations have been performed experimentally.
Despite the mentioned advantages, some issues require further investigation. Perfusion with Krebs-Henseleit solution is known to result in a myocardial edema with consecutive hemodynamic instability. Therefore, it will be necessary to quantify any myocardial damage and to analyze survival data from long-term studies.
The feasibility of cardioscopy has been shown, but any incomplete isolation, such as from venous return, results in impaired visualization; therefore, the method must be improved. Development of an advanced percutaneous or transapical technology with a safe and easy isolation of vessels is necessary so that cardioscopy can be used in a clinical setting.
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