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Canadian Journal of Cardiology

Transcatheter Left Atrial Appendage Closure Using Intracardiac Echocardiographic Guidance From the Left Atrium

      Abstract

      Background

      Most commonly, left atrial appendage (LAA) occlusion procedures are performed using transesophageal echocardiography (TEE) guidance and general anaesthesia. Intracardiac echocardiography (ICE) offers potential advantages over TEE, however, ICE-guided LAA occlusion experience is limited and has been typically performed from a right-sided location where LAA visualization might be suboptimal. We sought to evaluate the efficacy and safety of percutaneous LAA occlusion using ICE guidance performed from the left atrium.

      Methods

      Thirty-seven patients with atrial fibrillation, significant risk for stroke, and long-term contraindication to anticoagulation underwent LAA closure with the Amplatzer Cardiac Plug (St Jude Medical, Inc, St Paul, MN) with mild sedation and ICE guidance. The ICE catheter was introduced in the left atrium through a second transseptal puncture. Patients underwent preprocedural TEE to rule out thrombus and 3-month follow-up TEE to assess occlusion grade. Patient characteristics, procedural data, effectiveness of ICE imaging, quality of occlusion, and complications were prospectively recorded.

      Results

      Procedural success was achieved in 36 of 37 patients (97%). Closure was complete or near complete (grade ≥3 according to ICE and angiography) in all cases where the device was released. In all cases, ICE imaging yielded good LAA and surrounding structure visualization and adequate procedural guidance. Three major procedural or in-hospital complications occurred. Median length of stay was 1 day. Follow-up TEE documented the absence of any residual peri-device leak in all but 1 (29 of 30) case.

      Conclusion

      Initial experience suggests LAA occlusion with the Amplatzer Cardiac Plug using ICE guidance from the left atrium is feasible, reproducible, and safe.

      Résumé

      Introduction

      Les interventions d’occlusion de l’appendice auriculaire gauche (AAG) sont le plus fréquemment réalisées sous guidage par échocardiographie transœsophagienne (ETO) et anesthésie générale. L’échocardiographie intracardiaque (EIC) offre des avantages potentiels par rapport à l’ETO. Cependant, l’occlusion de l’AAG sous guidage EIC qui repose sur une expérience limitée et a généralement été réalisée à partir du coeur droit où la visualisation de l’AAG peut-être sous-optimale. Nous avons cherché à évaluer l’efficacité et l’innocuité de l’occlusion de l’AAG par voie percutanée sous guidage EIC réalisée à partir de l’oreillette gauche.

      Méthodes

      Trente-sept patients avec fibrillation auriculaire, risque significatif d’accident vasculaire cérébral et présentant une contre-indication à l’anticoagulation à long terme ont subi la fermeture de l’AAG à l’aide d’une prothèse Amplatzer Cardiac Plug (St Jude Medical Inc., St Paul, MN) sous sédation légère et guidage EIC. Le cathéter d’EIC a été introduit dans l’oreillette gauche après une seconde ponction transseptale. Les patients ont subi une ETO avant l’intervention pour éliminer le thrombus et une ETO de suivi après 3 mois pour évaluer le degré d’occlusion. Les caractéristiques du patient, les données de l’intervention, l’efficacité de l’imagerie par EIC, la qualité de l’occlusion et les complications ont été enregistrées de manière prospective.

      Résultats

      L’intervention a été réussie chez 36 des 37 patients (97 %). La fermeture a été complète ou presque complète (degré ≥ 3 selon l’EIC et l’angiographie) dans tous les cas où le dispositif a été libéré. Dans tous les cas, l’imagerie par EIC a donné une bonne visualisation de l’AAG et des structures environnantes et un guidage adéquat au cours de l’intervention. Trois complications interventionnelles et intrahospitalières importantes sont survenues. La durée médiane du séjour a été de 1 jour. L’ETO de suivi a rendu compte de l’absence de toute fuite résiduelle péri-dispositif dans tous les cas sauf 1 (29 sur 30).

      Conclusion

      L’expérience initiale suggère que l’occlusion de l’AAG à l’aide de la prothèse Amplatzer Cardiac Plug sous guidage EIC à partir de l’oreillette gauche est réalisable, reproductible et sûre.
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      References

        • Wolf P.A.
        • Abbott R.D.
        • Kannel W.B.
        Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.
        Stroke. 1991; 22: 983-988
        • Gallagher A.M.
        • Rietbrock S.
        • Plumb J.
        • van Staa T.P.
        Initiation and persistence of warfarin or aspirin in patients with chronic atrial fibrillation in general practice: do the appropriate patients receive stroke prophylaxis?.
        J Thromb Haemost. 2008; 6: 1500-1506
        • Glazer N.L.
        • Dublin S.
        • Smith N.L.
        • et al.
        Newly detected atrial fibrillation and compliance with antithrombotic guidelines.
        Arch Intern Med. 2007; 167: 246-252
        • Onalan O.
        • Crystal E.
        Left atrial appendage exclusion for stroke prevention in patients with nonrheumatic atrial fibrillation.
        Stroke. 2007; 38: 624-630
        • Holmes D.R.
        • Reddy V.Y.
        • Turi Z.G.
        • et al.
        Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.
        Lancet. 2009; 374: 534-542
        • Reddy V.Y.
        • Mobius-Winkler S.
        • Miller M.A.
        • et al.
        Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology).
        J Am Coll Cardiol. 2013; 61: 2551-2556
        • Vaina S.
        • Ligthart J.
        • Vijayakumar M.
        • et al.
        Intracardiac echocardiography during interventional procedures.
        EuroIntervention. 2006; 1: 454-464
        • Ronco F.
        • Pascotto A.
        • Barbierato M.
        • Grassi G.
        Percutaneous left atrial appendage closure in awake non intubated patient: multimodality intraprocedural imaging.
        Cardiovasc Revasc Med. 2012; 13: 360-361
        • MacDonald S.T.
        • Newton J.D.
        • Ormerod O.J.
        Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia.
        Catheter Cardiovasc Interv. 2011; 77: 124-127
        • Ho I.C.
        • Neuzil P.
        • Mraz T.
        • et al.
        Use of intracardiac echocardiography to guide implantation of a left atrial appendage occlusion device (PLAATO).
        Heart Rhythm. 2007; 4: 567-571
        • Berti S.
        • Paradossi U.
        • Meucci F.
        • et al.
        Periprocedural intracardiac echocardiography for left atrial appendage closure: a dual-center experience.
        JACC Cardiovasc Interv. 2014; 7: 1036-1044
        • Ren J.F.
        • Callans D.J.
        • Marchlinski F.E.
        Intracardiac echocardiographic imaging of the left atrial appendage and detection of a peridevice leak after device occlusion.
        JACC Cardiovasc Interv. 2015; 8: 124-126
        • Blendea D.
        • Heist E.K.
        • Danik S.
        • et al.
        Analysis of the left atrial appendage morphology by intracardiac echocardiography in patients with atrial fibrillation.
        J Interv Card Electrophysiol. 2011; 31: 191-196
        • Kappetein A.P.
        • Head S.J.
        • Genereux P.
        • et al.
        Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document.
        J Am Coll Cardiol. 2012; 60: 1438-1454
        • Chue C.D.
        • de Giovanni J.
        • Steeds R.P.
        The role of echocardiography in percutaneous left atrial appendage occlusion.
        Eur J Echocardiogr. 2011; 12: i3-10
        • Daoud E.G.
        • Kalbfletsch S.J.
        • Hummel J.D.
        Intracardiac echocardiography to guide transseptal left heart catheterization for radiofrequency catheter ablation.
        J Cardiovasc Electrophysiol. 1999; 10: 358-363
        • Guerios E.E.
        • Schmid M.
        • Gloekler S.
        • et al.
        Left atrial appendage closure with the Amplatzer cardiac plug in patients with atrial fibrillation.
        Arq Bras Cardiol. 2012; 98: 528-536
        • Park J.W.
        • Bethencourt A.
        • Sievert H.
        • et al.
        Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience.
        Catheter Cardiovasc Interv. 2011; 77: 700-706
        • Lopez-Minguez J.R.
        • Eldoayen-Gragera J.
        • Gonzalez-Fernandez R.
        • et al.
        Immediate and one-year results in 35 consecutive patients after closure of left atrial appendage with the Amplatzer cardiac plug.
        Rev Esp Cardiol (Engl Ed). 2013; 66: 90-97
        • Urena M.
        • Rodés-Cabau J.
        • Freixa X.
        • et al.
        Percutaneous left atrial appendage closure with the Amplatzer cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy.
        J Am Coll Cardiol. 2013; 62: 96-102
        • Kefer J.
        • Vermeersch P.
        • Budts W.
        • et al.
        Transcatheter left atrial appendage closure for stroke prevention in atrial fibrillation with Amplatzer cardiac plug: the Belgian Registry.
        Acta Cardiol. 2013; 68: 551-558
        • Wiebe J.
        • Bertog S.
        • Franke J.
        • et al.
        Safety of percutaneous left atrial appendage closure with the Amplatzer cardiac plug in patients with atrial fibrillation and contraindications to anticoagulation.
        Catheter Cardiovasc Interv. 2014; 83: 796-802
        • Singh S.M.
        • Douglas P.S.
        • Reddy V.Y.
        The incidence and long-term clinical outcome of iatrogenic atrial septal defects secondary to transseptal catheterization with a 12F transseptal sheath.
        Circ Arrhythm Electrophysiol. 2011; 4: 166-171
        • Hammerstingl C.
        • Lickfett L.
        • Jeong K.M.
        • et al.
        Persistence of iatrogenic atrial septal defect after pulmonary vein isolation–an underestimated risk?.
        Am Heart J. 2006; 152: 362.e1-362.e5
        • Budts W.
        • Troost E.
        • Voigt J.U.
        • Gewillig M.
        Intra-cardiac echocardiography in atrial septal interventions: impact on hospitalization costs.
        Acta Cardiol. 2010; 65: 147-152
        • Alboliras E.T.
        • Hijazi Z.M.
        Comparison of costs of intracardiac echocardiography and transesophageal echocardiography in monitoring percutaneous device closure of atrial septal defect in children and adults.
        Am J Cardiol. 2004; 94: 690-692