Fig. 4.

Tools in fusion imaging: markers (a) and overlay imaging (b). During the MitraClip intervention, the main mitral lesion can be labeled by the echocardiographer using a marker (red dot placed on the mitral valve). This marker is automatically demonstrated in real time on the fluoroscopy image (a). Using the overlay mode (b, showing an atrial septal defect), the echocardiographic image is overlaid on top of the fluoroscopy image in the correct position and angulation. The interventional cardiologist can choose between the purple and the green echo views given by xPlane echocardiography. In this case, the green view better demonstrates the anatomy for puncture purposes. The overlay mode highlights the orientation difficulties that SHD teams face during an intervention. In the modified TEE bicaval view, the superior vena cava is located to the right, while the coronary sinus is to the left, connected by the horizontally orientated interatrial septum. During fluoroscopy for transseptal puncture, the orientation of the C-arm is mostly neutral (in our example, LAO 13.5°, CRAN 0°). This leads to a completely different orientation: the superior vena cava is cranial, while the coronary sinus is at the bottom and to the lateral, with a more or less vertical interatrial septum. SVC, superior vena cava; CS, coronary sinus; IAS, interatrial septum. Blue arrow: depicting the left ventricular lead in the CS. a Adapted from Sündermann et al. [32••]