Echo-fluoroscopy fusion (EFF) imaging integrates real-time echocardiography with fluoroscopy to improve guidance during interventional procedures with established use in adult cardiology. Its pediatric application was limited by the absence of suitable probes but is now feasible in patients under 30kg due to pediatric-specific 3D probes. This study aimed to evaluate the feasibility, safety, and clinical utility of EFF imaging in pediatric catheterization for congenital heart disease (CHD).

A prospective study was conducted between September and December 2024 using EchoNavigator (Philips Healthcare) to co-register the new echocardiography probe (X11-4T) with fluoroscopy (Allura Azurion 7). The quality, accuracy, and utility of 2D/3D EFF imaging were assessed on a 5-point Likert scale.

Twenty-two children (median [range] age 5.4 years [1.2–17.8 years]; weight 18.5 [8–61] kg) were enrolled from the pediatric cardiology unit at the Children's Hospital of Toulouse. EFF imaging was successfully implemented in all procedures with excellent fusion stability. Two patients underwent diagnostic catheterization, while atrial septal defect (ASD) and ventricular septal defect closures were performed in 11 and 9 patients, respectively, using various devices. The quality of 2D EFF imaging was rated 5/5 (95% CI: 4–5), while the quality of 3D EFF imaging was 4/5 (95% CI: 4–5). The accuracy of EFF imaging was rated 5/5 (95% CI: 5–5), and its utility was 3/5 (95% CI: 3–4). No complications related to probe insertion or image fusion occurred. EFF imaging provided clear real-time guidance for accurate device placement, particularly in complex cases like double ASDs and enhanced anatomical visualization, facilitating procedural navigation in complex CHD like cc-TGA with dextrocardia.

EFF imaging is a feasible and safe technique for guiding pediatric interventional procedures in CHD. It significantly improves anatomical visualization, device placement, and communication between the interventionalist and echocardiographer, especially in complex cases. This technology holds promise for advancing pediatric cardiac interventions.