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Dimitriadis K, Pyrpyris N, Karampinos K, Malainou CP, Beneki E, Koulouriotis A, Pitsiori D, Aznaouridis K, Aggeli K, Tsioufis K. Iatrogenic atrial septal defects in structural heart interventions: Opening the Pandora's box. Catheter Cardiovasc Interv 2024. [PMID: 39300820 DOI: 10.1002/ccd.31237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2024] [Revised: 09/06/2024] [Accepted: 09/12/2024] [Indexed: 09/22/2024]
Abstract
In the modern era of structural heart interventions, the total number of transseptal procedures is growing exponentially, thus increasing the rate and need for management of iatrogenic atrial septal defects (iASDs). To date, there are no official guidelines on the assessment and management of iASDs, due to inconclusive evidence on whether patients benefit more from the percutaneous closure of iASD than from conservative management and vigorous follow-up. Despite the abundance of observational studies on iASDs, there is still a lack of randomized studies. Evidence so far show that percutaneous closure is no superior over conservative treatment in patients with iASDs, however, it has been demonstrated that patients with spontaneous closure of iASDs experience less heart failure (HF) hospitalizations. On the other hand, researchers have investigated the beneficial nature of interatrial shunt therapy in patients with HFpEF and, more recently, with HFrEF, due to the presumed hemodynamic benefits. Herein, we provide an updated review of relevant literature, focusing on iASD persistence rates, predicting factors for their persistence, and clinical outcomes of iASD persistence, to summarize available evidence and discuss future directions in the field.
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Affiliation(s)
- Kyriakos Dimitriadis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Nikolaos Pyrpyris
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Karampinos
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Christina Panagiotis Malainou
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Eirini Beneki
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Alexandros Koulouriotis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Daphne Pitsiori
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Aznaouridis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantina Aggeli
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Hippokration General Hospital, Athens, Greece
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Serpa F, Rivera A, Fernandes JM, Braga MAP, Araújo B, Ferreira Felix I, Ferro EG, Zimetbaum PJ, d'Avila A, Kramer DB. Intracardiac vs transesophageal echocardiography for left atrial appendage occlusion: An updated systematic review and meta-analysis. Heart Rhythm 2024:S1547-5271(24)03145-X. [PMID: 39154871 DOI: 10.1016/j.hrthm.2024.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 08/07/2024] [Accepted: 08/10/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Multiple studies continue to evaluate the use of intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) for guiding left atrial appendage occlusion (LAAO). OBJECTIVE The purpose of this study was to conduct an updated meta-analysis comparing the effectiveness and safety outcomes of both imaging modalities. METHODS PubMed, Cochrane, and Embase were searched for studies comparing ICE vs TEE to guide LAAO. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. The primary effectiveness endpoint was procedural success. The primary safety endpoint included the overall complications rate. Additional safety outcomes were assessed as secondary endpoints. Subgroup analysis of primary endpoints was conducted according to device type (Amulet, LAmbre, Watchman, Watchman FLX) and study region (American, Asia, Europe). R Version 4.3.1 was used for all statistical analyses. RESULTS Our meta-analysis included 19 observational studies encompassing 42,474 patients, of whom 4415 (10.4%) underwent ICE-guided LAAO. Compared with TEE, ICE was associated with a marginally higher procedural success (OR 1.33; 95% CI 1.01-1.76; P = .04; I2 = 0%). There was no significant difference in the overall complications rate (OR 1.02; 95% CI 0.77-1.36; P = .89; I2 = 5%). However, ICE showed higher rates of pericardial effusion (OR 2.11; 95% CI 1.47-3.03; P <.001; I2 = 0%) and residual iatrogenic atrial septal defect (iASD) (OR 1.52; 95% CI 1.15-2.03; P <.004; I2 = 0%). Subgroup analysis revealed variations in procedural success within the ICE group across study regions (P = .02). CONCLUSION In this updated meta-analysis, the increasing adoption of ICE-guided LAAO demonstrated higher procedural success rates compared to TEE, although with limited statistical significance. Overall complication rates were similar; however, ICE showed higher rates of pericardial effusion and residual iASD.
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Affiliation(s)
- Frans Serpa
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Division of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - André Rivera
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | - Julia M Fernandes
- Department of Medicine, Albert Einstein University, São Paulo, Brazil
| | | | - Beatriz Araújo
- Department of Medicine, Nove de Julho University, São Bernardo do Campo, Brazil
| | | | - Enrico Giuseppe Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Peter J Zimetbaum
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andre d'Avila
- Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Daniel B Kramer
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts; Division of Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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Korsholm K, Iriart X, Saw J, Wang DD, Berti S, Galea R, Freixa X, Arzamendi D, De Backer O, Kramer A, Cademartiri F, Cochet H, Odenstedt J, Aminian A, Räber L, Cruz-Gonzalez I, Garot P, Jensen JM, Alkhouli M, Nielsen-Kudsk JE. Position Statement on Cardiac Computed Tomography Following Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2024; 17:1747-1764. [PMID: 39142755 DOI: 10.1016/j.jcin.2024.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/10/2024] [Accepted: 04/26/2024] [Indexed: 08/16/2024]
Abstract
Left atrial appendage occlusion (LAAO) is rapidly growing as valid stroke prevention therapy in atrial fibrillation. Cardiac imaging plays an instrumental role in preprocedural planning, procedural execution, and postprocedural follow-up. Recently, cardiac computed tomography (CCT) has made significant advancements, resulting in increasing use both preprocedurally and in outpatient follow-up. It provides a noninvasive, high-resolution alternative to the current standard, transesophageal echocardiography, and may display advantages in both the detection and characterization of device-specific complications, such as peridevice leak and device-related thrombosis. The implementation of CCT in the follow-up after LAAO has identified new findings such as hypoattenuated thickening on the atrial device surface and left atrial appendage contrast patency, which are not readily assessable on transesophageal echocardiography. Currently, there is a lack of standardization for acquisition and interpretation of images and consensus on definitions of essential findings on CCT in the postprocedural phase. This paper intends to provide a practical and standardized approach to both acquisition and interpretation of CCT after LAAO based on a comprehensive review of the literature and expert consensus among European and North American interventional and imaging specialists.
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Affiliation(s)
| | - Xavier Iriart
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Dee Dee Wang
- Henry Ford Health System, Detroit, Michigan, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Roberto Galea
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Hubert Cochet
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Adel Aminian
- Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium
| | - Lorenz Räber
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
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Frazzetto M, Sanfilippo C, Costa G, Contrafatto C, Giacalone C, Scandura S, Castania G, De Santis J, Sanfilippo M, Di Salvo ME, Tamburino C, Barbanti M, Grasso C. Watchman vs. Amulet for Left Atrial Appendage Closure: Current Evidence and Future Perspectives. J Clin Med 2024; 13:4651. [PMID: 39200792 PMCID: PMC11355803 DOI: 10.3390/jcm13164651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Revised: 07/25/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
Left atrial appendage closure (LAAC) is a crucial intervention for stroke prevention in patients with non-valvular atrial fibrillation who are unsuitable for long-term anticoagulation. Amulet and Watchman are the most implanted devices worldwide for performing LAAC, and the aim of this review is to provide a comprehensive comparison focusing on their efficacy, safety, and short- and long-term outcomes. The Watchman device, the first to gain FDA approval, has been extensively studied and demonstrates significant reductions in stroke and systemic embolism rates. The Amulet device, a newer alternative, promises enhanced design features for more efficient appendage sealing. Current data highlight that both devices offer similar efficacy and safety for LAAC. While the two devices differ in terms of intraprocedural complication rates, they offer similar short- to long-term outcomes in terms of peri-device leaks, device-related thrombosis, and mortality. Both devices are indicated for patients who are unable to tolerate OAC, given their similar risk and safety profiles. Newer clinical studies are directed at establishing the efficacy of both devices as the primary method for stroke prevention in AF as an alternative to OAC.
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Affiliation(s)
- Marco Frazzetto
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Claudio Sanfilippo
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Giuliano Costa
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Claudia Contrafatto
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Chiara Giacalone
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Salvatore Scandura
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Giuseppe Castania
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Jessica De Santis
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Maria Sanfilippo
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Maria Elena Di Salvo
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Corrado Tamburino
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
| | - Marco Barbanti
- Faculty of Medicine and Surgery, Università degli Studi di Enna “Kore”, 94100 Enna, Italy;
- Division of Cardiology, Ospedale Umberto I, ASP 4 di Enna, 94100 Enna, Italy
| | - Carmelo Grasso
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico San Marco”, 95123 Catania, Italy; (C.S.); (G.C.); (C.C.); (C.G.); (S.S.); (G.C.); (J.D.S.); (M.S.); (M.E.D.S.); (C.T.); (C.G.)
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Stout K, Craig C, Rivington J, Lyden E, Payne JJ, Goldsweig AM. Clinical Protocol for Selecting Intracardiac or Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion. Am J Cardiol 2024; 222:87-94. [PMID: 38642870 DOI: 10.1016/j.amjcard.2024.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 03/24/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echo (TEE) to guide left atrial appendage occlusion (LAAO). We established a protocol to select patients appropriate for ICE guidance. Patients who underwent LAAO with the Watchman or Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) from January 2018 to March 2022 at a large United States center were included. The novel protocol prospectively selected TEE or ICE guidance beginning in January 2020; previous LAAO procedures were retrospectively included. ICE was selected for patients with uninterrupted anticoagulation and appropriate LAA anatomy, renal function, and moderate sedation tolerance. In-hospital outcomes with successful implantation without conversion to TEE guidance, no peridevice leak, and no procedural complications were compared. Composite 1-year outcome included freedom from peridevice leak, device-related thrombus, stroke, and all-cause mortality. A total of 234 patients were included; the mean age was 76.1 ± 8.3 years old, and 42.3% were female. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (risk difference 0.102, 96.8% vs 86.5%, 95% confidence interval 0.003 to 0.203, p = 0.029). In comparison to the TEE-guided group, ICE-guided procedures were shorter (89.1 ± 26.3 vs 99.8 ± 30.0 min, p = 0.0087) with less general anesthesia (26.6% vs 98.8%, p <0.0001). One-year composite adverse outcomes did not differ significantly (80.7% vs 88.9%, p = 0.17). In conclusion, the protocol to select appropriate patients for ICE versus TEE guidance for LAAO is safe and effective. Larger studies are indicated to validate this approach to improve outcomes, shorten procedures, and avoid general anesthesia.
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Affiliation(s)
- Kara Stout
- Division of Cardiovascular Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia; Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Calvin Craig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jaclyn Rivington
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elizabeth Lyden
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jason J Payne
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Department of Cardiology, Baystate Medical Center, Springfield, Massachusetts
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Goyal SK, Bhimani AA, Kella DK, Tyagi A, Polsani V, Deering TF. Inter-atrial septal balloon dilation to facilitate intracardiac echocardiography guided left atrial appendage occlusion. J Cardiovasc Electrophysiol 2024; 35:1078-1082. [PMID: 38509774 DOI: 10.1111/jce.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 02/17/2024] [Accepted: 02/27/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Percutaneous left atrial appendage occlusion (LAAO) is traditionally performed under general anesthesia with trans-esophageal echocardiography guidance. Intracardiac echo (ICE)-guided LAAO closure is increasing in clinical use. The ICE catheter is crossed into LA via interatrial septum (IAS) after the septum is dilated with LAAO delivery sheath. This step can be time-consuming and requires significant ICE catheter manipulation, which increases the risk of cardiac perforation. Pre-emptive septal balloon dilation can potentially help with ICE advancement in the LA. We sought to evaluate the effect of pre-dilation of the IAS with an 8 mm balloon on the ease of crossing the ICE catheter, fluoroscopy time for crossing, and overall procedure time. METHODS The Piedmont LAAO registry was used to identify consecutive patients who underwent LAAO. The initial 25 patients in whom balloon dilation of the IAS was performed served as the experimental cohort, and the 25 consecutive patients before that in whom balloon dilation was not performed served as controls. In the experimental group, after a trans-septal puncture, the sheath was retracted to the right atrium with a guidewire still in the LA. An 8 × 40 mm Evercoss™ over the wire balloon was inflated across the IAS. The ICE catheter was then crossed into the LA using the fluoroscopic landmark of the guide wire and the ICE imaging. The sheath was then advanced along the ICE catheter via the transseptal puncture (TSP) and the procedure continued. Follow-up compputed tomography imaging was obtained at 4-8 weeks. RESULTS Each group consisted of 25 patients. There were no significant differences in baseline characteristics. All procedures were performed successfully under conscious sedation and ICE guidance. There was a significant reduction in the overall procedure time, fluoroscopy time, and time for transseptal puncture to ICE in LA. There was no difference in the size of the acute residual interatrial shunt, as measured via ICE, or the size and presence of iatrogenic ASD at follow-up. CONCLUSION Balloon dilation of TSP is safe and is associated with increased efficiency in ICE-guided LAAO procedures.
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Affiliation(s)
- Sandeep K Goyal
- Division of Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Ashish A Bhimani
- Division of Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Danesh K Kella
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anahita Tyagi
- Division of Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | | | - Thomas F Deering
- Division of Electrophysiology, Piedmont Heart Institute, Atlanta, Georgia, USA
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Hashem A, Khalouf A, Agrawal A, Mohamad MS, Nayfeh T, Kashou A, Chaaya RGB, Rai D, Verghese B, Little SH, Goldsweig A, Naidu S, Goel SS. Feasibility and Safety of Intracardiac Echocardiography Guidance in Mitral Transcatheter Edge-to-Edge Repair: Analysis of the National Inpatient Sample Data From 2015 to 2020. Curr Probl Cardiol 2024; 49:102042. [PMID: 37595856 DOI: 10.1016/j.cpcardiol.2023.102042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 08/15/2023] [Indexed: 08/20/2023]
Abstract
Data on the use of intracardiac echocardiography (ICE) guidance in mitral transcatheter edge-to-edge repair (mTEER) procedure is limited to case reports and small case series. Our study aims to assess the feasibility, safety, utilization patterns, and clinical outcomes of mTEER procedure with ICE guidance using a nationally representative real-world cohort of patients. This study used the National Inpatient Sample database from quarter 4 of 2015 to 2020. We used a propensity-matched analysis and adjusted odds ratios for in-hospital outcomes/complications. A P value of < 0.05 was considered significant. A total of 38,770 weighted cases of mTEER were identified. Of the included patients 665 patients underwent ICE-guided mTEER while 38,105 had TEE-guided mTEER. There were no differences in the in-hospital mortality between both groups (2.5% vs 3.0%, P = 0.58). Adjusted odds of in-hospital mortality (aOR 0.83, 95%CI [0.42-1.64]) were not significantly different. There were no differences in periprocedural complications including cardiac (aOR 0.85, 95%CI [0.54-1.35]), bleeding (aOR 1.45, 95%CI [0.93-2.33]), respiratory (aOR 0.88, 95%CI [0.61-1.25]), and renal (aOR 0.89, 95%CI [0.66-1.20]) complications between patients undergoing ICE-guided vs TEE-guided mTEER. There was no difference in GI complications between both groups (aOR 1.11, 95%CI [0.46-2.70]). The adjusted length of stay was less among ICE-guided mTEER (median: 1 vs 2, P < 0.01) with lower inflation-adjusted costs of hospitalization ($35,513 vs $47,067, P < 0.01). ICE-guided mTEER is safe when compared with TEE guided mTEER with no significant differences in in-hospital mortality, cardiac, bleeding, respiratory, and renal complications.
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Affiliation(s)
- Anas Hashem
- Department of Medicine, Rochester General Hospital, Rochester, NY
| | - Amani Khalouf
- Department of Medicine, Rochester General Hospital, Rochester, NY
| | - Ankit Agrawal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Tarek Nayfeh
- Evidence-based Medicine, Mayo Clinic School of Medicine, Rochester, MN
| | - Anthony Kashou
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, MN
| | - Rody G Bou Chaaya
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Devesh Rai
- Department of Cardiovascular Medicine, Sands-constellation Heart Institute, Rochester, NY
| | - Basil Verghese
- Department of Medicine, Rochester General Hospital, Rochester, NY
| | - Stephen H Little
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
| | - Andrew Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, Springfield, MA
| | - Srihari Naidu
- Department of Cardiovascular Medicine, Westchester Medical Center, Westchester, NY
| | - Sachin S Goel
- Department of Cardiovascular Medicine, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX.
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Diaz JC, Bastidas O, Duque M, Marín JE, Aristizabal J, Niño CD, Hoyos C, Matos CD, Gabr M, Steiger NA, Kapur S, Sauer WH, Romero JE. Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis. J Cardiovasc Electrophysiol 2024; 35:44-57. [PMID: 37927196 DOI: 10.1111/jce.16118] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. METHODS All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. RESULTS Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I2 = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I2 = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04). CONCLUSION ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.
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Affiliation(s)
- Juan Carlos Diaz
- Cardiac Arrhythmia and Electrophysiology Service, Universidad CES Medical School, Division of Cardiology, Clinica Las Vegas, Medellin, Colombia
| | - Oriana Bastidas
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobon Uribe, Medellin, Colombia
| | - Mauricio Duque
- Cardiac Electrophysiology Service, Hospital San Vicente Fundación, Rionegro, Colombia
| | - Jorge E Marín
- Department of Medicine, Cardiac Arrhythmia and Electrophysiology Service, Division of Cardiology, Clinica Las Americas, Medellin, colombia, Medellin, Colombia
| | - Julian Aristizabal
- Cardiac Electrophysiology Service, Hospital San Vicente Fundación, Rionegro, Colombia
| | - Cesar D Niño
- Cardiac Arrhythmia and Electrophysiology Service, Hospital Pablo Tobon Uribe, Medellin, Colombia
| | - Carolina Hoyos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Carlos D Matos
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed Gabr
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nathaniel A Steiger
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sunil Kapur
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William H Sauer
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jorge E Romero
- Cardiac Arrhythmia Service, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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9
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Ferro EG, Alkhouli M, Nair DG, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Price MJ, Roy K, Allocco DJ, Yeh RW, Piccini JP. Intracardiac vs Transesophageal Echocardiography for Left Atrial Appendage Occlusion With Watchman FLX in the U.S. JACC Clin Electrophysiol 2023; 9:2587-2599. [PMID: 37831030 DOI: 10.1016/j.jacep.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/25/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Intraprocedural imaging is critical for device delivery in transcatheter left atrial appendage occlusion (LAAO). Although pivotal trials of LAAO devices were conducted using transesophageal echocardiography (TEE), intracardiac echocardiography (ICE) is an emerging imaging modality. OBJECTIVES This study compared outcomes after ICE- and TEE-guided Watchman FLX implantation in the SURPASS (SURveillance Post Approval AnalySiS Plan) nationwide LAAO registry. METHODS Baseline characteristics were compared using chi-square and t-tests. Outcomes were reported in unadjusted and adjusted comparisons via propensity weighting. RESULTS Between August 2020 and September 2021, LAAO was attempted in 39,759 patients at 698 sites, including 2,272 cases (5.7%) with ICE and 31,835 (80.0%) with TEE. ICE and TEE patients had similar baseline characteristics and mean procedural times (ICE 82 minutes vs TEE 78 minutes). ICE patients were less likely to receive general anesthesia (54% vs 98%, P < 0.01). Successful device implantation (98.3% vs 97.6%) and complete seal rates at 45 days were similar (n = 25,280; 83% vs 82%). Most adverse event rates were similar; unadjusted mortality rates at 45 days were 1.1% for ICE vs 0.8% for TEE (P = 0.14), and 1.0% vs 0.7% (P = 0.27) in adjusted analyses. Even after adjustment, pericardial effusion rates requiring intervention were significantly higher with ICE at 45 days (1.0% vs 0.5%; P = 0.02). This rate decreased as operators performed more ICE-guided procedures, although 82% of operators had performed <10 ICE-guided procedures overall. CONCLUSIONS In the largest comparison to date, ICE use was infrequent. ICE and TEE both achieved high rates of complete LAAO. ICE was associated with significantly higher rates of pericardial effusion requiring intervention.
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Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Devi G Nair
- St Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Kristine Roy
- Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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10
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Korsholm K, Jensen JM, Nielsen-Kudsk JE. Left atrial appendage occlusion guided by intracardiac echocardiography in a patient with a 34 mm atrial septal defect occluder: a case report. Eur Heart J Case Rep 2023; 7:ytad571. [PMID: 38046651 PMCID: PMC10691873 DOI: 10.1093/ehjcr/ytad571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/29/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023]
Abstract
Background Intracardiac echocardiography (ICE)-guided left atrial appendage occlusion (LAAO) is increasingly common. Patients with previous atrial septal defect closure constitute a significant challenge for transseptal access. Case summary A 49-year-old man with persistent atrial fibrillation, hypertension, and reduced left ventricular function was considered for LAAO after a life-threatening intrathoracic bleeding while on oral anticoagulation. Percutaneous atrial septal defect closure was performed 15 years before with a 34 mm Amplatzer Septal Occluder. Preprocedural cardiac computed tomography demonstrated the atrial septal occluder device with a small native interatrial septum at the inferior margin. The left atrial appendage landing zone measured 17 × 22 mm. The LAAO was performed under local analgesia. A steerable sheath was used to guide the transseptal puncture, and the ICE probe was traced along a guidewire across the atrial septum. A 12-F Amulet delivery sheath was advanced through the same transseptal hole. Under ICE and fluoroscopy guidance, a 25 mm Amplatzer Amulet was deployed. Follow-up imaging showed a well-positioned device with a small peridevice leak at the disc. Discussion This case report illustrates the feasibility of LAAO performed with ICE guidance from the left atrium in a patient with a large Amplatzer Septal Occluder with a small native interatrial septum. It demonstrates that prior atrial septal defect closure should not be considered as a contraindication for LAAO but warrants careful preprocedural planning.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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11
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Ding X, Xiang K, Qian C, Hou X, Wu F. Intracardiac echocardiography is a promising strategy for guiding closure of the left atrial appendage. Health Sci Rep 2023; 6:e1762. [PMID: 38116174 PMCID: PMC10728371 DOI: 10.1002/hsr2.1762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background and Aims Percutaneous transcatheter left atrial appendage (LAA) closure (LAAC) is an effective approach for preventing ischemic stroke in nonvalvular atrial fibrillation patients. Intracardiac echocardiography (ICE), a new imaging modality, is a promising strategy for guiding LAAC. This review highlights the various strategies for ICE-guided-LAAC as an option for clinical policy. Methods A comprehensive literature search was conducted of PubMed, ScienceDirect, Ovid Web of Science, SpringerLink, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to ICE and its application in the guidance of LAAC. Results Various methods are used to evaluate the spatial structure and dimensions of the LAA. The main techniques for guiding LAAC are transesophageal echocardiography (TEE), cardiac computed tomography (CTA), and ICE. Among these techniques, the advantages of ICE typically include (1) multiangle and real-time assessment of intracardiac structure, (2) a reduction in procedural fluoroscopy, (3) reduced operation time and improved workflow in the catheterization laboratory, and (4) the avoidance of general anesthesia and the early detection of complications. Conclusion ICE is a promising strategy for the guidance of LAAC. Among the most advanced and recent technological innovations in cardiovascular imaging in general and volume imaging in particular, ICE offers greater efficacy and safety.
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Affiliation(s)
- Xueyan Ding
- Department of CardiologySir Run Run Shaw Hospital Zhejiang University School of MedicineHangzhouZhejiangP.R. China
| | - Kefa Xiang
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Congli Qian
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Xu Hou
- Bengbu Medical CollegeBengbuAnhuiP.R. China
| | - Feng Wu
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
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12
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Pastormerlo LE, Tondo C, Fassini G, Nicosia A, Ronco F, Contarini M, Giacchi G, Grasso C, Casu G, Romeo MR, Mazzone P, Limite L, Caramanno G, Geraci S, Pagnotta P, Chiarito M, Tamburino C, Berti S. Intra-Cardiac versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion with a Watchman FLX Device. J Clin Med 2023; 12:6658. [PMID: 37892796 PMCID: PMC10607018 DOI: 10.3390/jcm12206658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
This study aimed to compare the peri-procedural success and complication rate within a large registry of intra-cardiac echocardiography (ICE)- vs. transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) procedures with a Watchmann FLX device. Data from 772 LAAO procedures, performed at 26 Italian centers, were reviewed. Technical success was considered as the final implant of a Watchmann FLX device in LAA; the absence of pericardial tamponade, peri-procedural stroke and/or systemic embolism, major bleeding and device embolization during the procedure was defined as a procedural success. One-year stroke and major bleeding rates were evaluated as outcome. ICE-guided LAA occlusion was performed in 149 patients, while TEE was used in 623 patients. Baseline characteristics were similar between the ICE and TEE groups. The technical success was 100% in both groups. Procedural success was also extremely high (98.5%), and was comparable between ICE (98.7%) and TEE (98.5%). ICE was associated with a slightly longer procedural time (73 ± 31 vs. 61.9 ± 36 min, p = 0.042) and shorter hospital stay (5.3 ± 4 vs. 5.8 ± 6 days, p = 0.028) compared to the TEE group. At one year, stroke and major bleeding rates did not differ between the ICE and TEE groups. A Watchmann FLX device showed high technical and procedural success rate, and ICE guidance does not appear inferior to TEE.
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Affiliation(s)
- Luigi Emilio Pastormerlo
- Diagnostic and Interventional Cardiology Department, Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (L.E.P.); (M.R.R.)
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Heart Rhythm Center at Monzino Cardiac Center, IRCCS, 20138 Milan, Italy; (C.T.); (G.F.)
| | - Gaetano Fassini
- Department of Clinical Electrophysiology and Cardiac Pacing, Heart Rhythm Center at Monzino Cardiac Center, IRCCS, 20138 Milan, Italy; (C.T.); (G.F.)
| | - Antonino Nicosia
- Dipartimento Cardio-Neuro-Vascolare, Ospedale GP II—Asp di Ragusa, 97100 Ragusa, Italy;
| | | | - Marco Contarini
- Cardiology Department, Umberto I Hospital, ASP 8 Siracusa, 96100 Syracuse, Italy; (M.C.); (G.G.)
| | - Giuseppe Giacchi
- Cardiology Department, Umberto I Hospital, ASP 8 Siracusa, 96100 Syracuse, Italy; (M.C.); (G.G.)
| | - Carmelo Grasso
- AOU Policlinico ‘G. Rodolico-San Marco’, Centro Alte Specialità e Trapianti—C.A.S.T., 95123 Catania, Italy; (C.G.); (C.T.)
| | - Gavino Casu
- Cardiologia Clinica e Interventistica, Azienda Ospedaliero Universitaria Sassari, 07100 Sassari, Italy;
| | - Maria Rita Romeo
- Diagnostic and Interventional Cardiology Department, Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (L.E.P.); (M.R.R.)
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute University, 20132 Milan, Italy; (P.M.); (L.L.)
| | - Luca Limite
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Vita-Salute University, 20132 Milan, Italy; (P.M.); (L.L.)
| | | | - Salvatore Geraci
- Ospedale San Giovanni di Dio, 92100 Agrigento, Italy; (G.C.); (S.G.)
| | - Paolo Pagnotta
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (P.P.); (M.C.)
- Humanitas Research Hospital IRCCS, 20089 Rozzano, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (P.P.); (M.C.)
- Humanitas Research Hospital IRCCS, 20089 Rozzano, Italy
| | - Corrado Tamburino
- AOU Policlinico ‘G. Rodolico-San Marco’, Centro Alte Specialità e Trapianti—C.A.S.T., 95123 Catania, Italy; (C.G.); (C.T.)
| | - Sergio Berti
- Diagnostic and Interventional Cardiology Department, Fondazione Toscana Gabriele Monasterio, 54100 Massa, Italy; (L.E.P.); (M.R.R.)
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13
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Jhand A, Goldsweig AM. The Emerging Role of Intracardiac Echocardiography (ICE) in Left Atrial Appendage Closure (LAAC). Curr Cardiol Rep 2023; 25:1223-1232. [PMID: 37610598 DOI: 10.1007/s11886-023-01940-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE OF REVIEW Intracardiac echocardiography (ICE) has emerged as a powerful imaging tool to guide percutaneous left atrial appendage closure (LAAC). Herein, we review an imaging protocol for ICE-guided LAAC and discuss the evidence for its use. RECENT FINDINGS Standardized imaging protocols have been proposed but have not been fully validated. ICE imaging yields similar procedural and clinical outcomes when compared to transesophageal echocardiography (TEE) to guide LAAC. Despite benefits of avoiding general anesthesia, TEE, and multiple physicians for LAAC procedures, ICE imaging remains under-utilized. Novel ICE catheters with 3D imaging capabilities may improve accuracy and efficiency of LAAC device implantation. ICE guidance is feasible, safe, and effective for LAAC. As the field evolves, further studies will be necessary to assess this technological advancement in imaging guidance.
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Affiliation(s)
- Aravdeep Jhand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01199, USA.
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14
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Chen Y, Chen Y, Lam YY, Wang L, Fang Y, Huang W, Xiao F. Intracardiac echocardiographic imaging with a cartosound module for guidance of left atrial appendage closure: a comparative study with transesophageal echocardiographic imaging. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:1667-1675. [PMID: 37233916 DOI: 10.1007/s10554-023-02880-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 05/16/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE In most clinical trials, intracardiac echocardiography (ICE) has provided fewer views than the four standard views provided by transesophageal echocardiography (TEE) when assessing left atrial appendage closure (LAAC) devices. This study aimed to determine if ICE guided by the CartoSound system achieve adequate high-quality views and similar clinical outcomes as TEE during LAAC. METHODS This study prospectively enrolled 202 patients who underwent LAAC using either ICE (n = 69), TEE (n = 121), or a combination of ICE and TEE (n = 12) as the procedural imaging under local anesthesia. A novel multi-angled "FLAVOR" approach was used for assessment in the ICE group. RESULTS ICE allowed visualization of the implanted devices in all patients at all proposed angles with long-axis views while two-dimensional (2D) TEE showed short-axis views in 1 or 2 angles in 24.2% of cases, which was more prevalent when the pulmonary ridge was covered by the occluder. In the combined ICE-TEE cohort, 2D-TEE failed to detect peri-device leak in 1 patient. The complication rates were similar between the ICE and TEE groups. Shorter fluoroscopy time, lower radiation dose and contrast usage were founded in the ICE group. At first TEE follow-up, the rate and degree of peri-device leak were similar between the ICE and TEE groups. CONCLUSION A systematic ICE protocol using a CartoSound module to guide LAAC was reliable for comprehensive long-axis imaging assessment compared with 2D/3D TEE under local anesthesia with a shorter fluoroscopy time, lower radiation dose, and less use of contrast.
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Affiliation(s)
- Yanyan Chen
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China
| | - Yihe Chen
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China
| | - Yat-Yin Lam
- Hong Kong Asia Heart Center, Canossa Hospital, Canossa, 1 Old Peak Road, Hong Kong
| | - Liangguo Wang
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China
| | - Ying Fang
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China
| | - Weijian Huang
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China
| | - Fangyi Xiao
- Department of Cardiology, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China.
- Department of Cardiology, the Key Lab of Cardiovascular Disease of Wenzhou, the First Affiliated Hospital of Wenzhou Medical University, Nanbaixiang, Wenzhou, 325000, P.R. China.
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15
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Aminian A, Leduc N, Freixa X, Swaans MJ, Ben Yedder M, Maarse M, Sanchis L, Cepas-Guillen P, Cruz-González I, Blanco-Fernandez F, Eschalier R, Boersma LVA. Left Atrial Appendage Occlusion Under Miniaturized Transesophageal Echocardiographic Guidance and Conscious Sedation: Multicenter European Experience. JACC Cardiovasc Interv 2023; 16:1889-1898. [PMID: 37587597 DOI: 10.1016/j.jcin.2023.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 05/29/2023] [Accepted: 06/13/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) procedures are widely guided by standard transesophageal echocardiography (TEE) probes, requiring general anesthesia in most patients. The use of miniaturized TEE probes allows for LAAO guidance under local anesthesia and offers an attractive imaging alternative to standard TEE probes. OBJECTIVES The aim of this study was to assess the safety and efficacy of miniaturized TEE probes for procedural guidance of LAAO. METHODS Multicenter retrospective observational study of LAAO procedures performed under miniaturized TEE guidance and conscious sedation. The primary efficacy endpoint was technical success. The secondary efficacy endpoint was procedural success (technical success without major periprocedural complications). The safety outcome was a composite of major periprocedural complications. RESULTS A total of 546 consecutive LAAO procedures were performed in 5 European centers. Technical success was achieved in 534 (98.0%) patients. Sixteen major periprocedural complications occurred in 15 (2.9%) patients, yielding a procedural success rate of 97.0%. Conversion to general anesthesia was required in 4 (0.7%) patients. Short-term imaging follow-up was available in 422 patients with an incidence of major (>5 mm) TEE-detected residual leaks of 0.7%, complete LAA occlusion of 82.2% on cardiac computed tomography, and device-related thrombus of 5%. As compared with procedural 2-dimensional imaging for device sizing, preprocedural assessment by 3-dimensional imaging resulted in improved technical success (100% vs 95.0%; P < 0.001). CONCLUSIONS LAAO under conscious sedation and miniaturized TEE guidance is safe and feasible with a high rate of technical success and a low rate of periprocedural complications.
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Affiliation(s)
- Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium.
| | - Nina Leduc
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Mohamed Ben Yedder
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Moniek Maarse
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | | | - Ignacio Cruz-González
- Instituto de Investigación Biomédica de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, University Hospital Salamanca, Salamanca, Spain
| | - Fabian Blanco-Fernandez
- Instituto de Investigación Biomédica de Salamanca, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, University Hospital Salamanca, Salamanca, Spain
| | - Romain Eschalier
- Department of Cardiology, Hôpital Gabriel Montpied, Clermont-Ferrand, France
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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16
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Alkhouli M, Nielsen-Kudsk JE. The Case for Intracardiac Echo to Guide Left Atrial Appendage Closure. Card Electrophysiol Clin 2023; 15:151-156. [PMID: 37076227 DOI: 10.1016/j.ccep.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage closure (LAAC) has become a commonly used alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. There is a growing interest in adopting a minimally invasive procedural approach using intracardiac echocardiography (ICE) and moderate sedation. In this article, we review the rational for and the data supporting ICE-guided LAAC and discuss the pros and cons of this approach.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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17
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Zhang ZY, Li F, Zhang J, Zhang L, Liu HH, Zhao N, Yang F, Kong Q, Zhou YT, Qian LL, Wang RX. A comparable efficacy and safety between intracardiac echocardiography and transesophageal echocardiography for percutaneous left atrial appendage occlusion. Front Cardiovasc Med 2023; 10:1194771. [PMID: 37293288 PMCID: PMC10244765 DOI: 10.3389/fcvm.2023.1194771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/09/2023] [Indexed: 06/10/2023] Open
Abstract
Background Accumulated clinical studies utilized intracardiac echocardiography (ICE) to guide percutaneous left atrial appendage occlusion (LAAO). However, its procedural success and safety compared to traditional transesophageal echocardiography (TEE) remained elusive. Therefore, we performed a meta-analysis to compare efficacy and safety of ICE and TEE for LAAO. Methods We screened studies from four online databases (including the Cochrane Library, Embase, PubMed, and Web of Science) from their inception to 1 December 2022. We used a random or fixed-effect model to synthesize the clinical outcomes and conducted a subgroup analysis to identify the potential confounding factors. Results A total of twenty eligible studies with 3,610 atrial fibrillation (AF) patients (1,564 patients for ICE and 2,046 patients for TEE) were enrolled. Compared with TEE group, there was no significant difference in procedural success rate [risk ratio (RR) = 1.01; P = 0.171], total procedural time [weighted mean difference (WMD) = -5.58; P = 0.292], contrast volume (WMD = -2.61; P = 0.595), fluoroscopic time (WMD = -0.34; P = 0.705; I2 = 82.80%), procedural complications (RR = 0.82; P = 0.261), and long-term adverse events (RR = 0.86; P = 0.329) in the ICE group. Subgroup analysis revealed that ICE group might be associated with the reduction of contrast use and fluoroscopic time in the hypertension proportion <90 subgroup, with lower total procedure time, contrast volume, and the fluoroscopic time in device type subgroup with multi-seal mechanism, and with the lower contrast use in paroxysmal AF (PAF) proportion ≤50 subgroup. Whereas, ICE group might increase the total procedure time in PAF proportion >50 subgroup and contrast use in multi-center subgroup, respectively. Conclusion Our study suggests that ICE may have comparable efficacy and safety compared to TEE for LAAO.
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18
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Korsholm K, Kramer A, Andersen A, Saw J, Nørgaard BL, Jensen JM, Nielsen-Kudsk JE. Left atrial appendage sealing performance of the Amplatzer Amulet and Watchman FLX device. J Interv Card Electrophysiol 2023; 66:391-401. [PMID: 35951214 PMCID: PMC9977851 DOI: 10.1007/s10840-022-01336-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The left atrial appendage (LAA) sealing properties of the Amplatzer Amulet and Watchman FLX devices were compared using cardiac computed tomography (CT) follow-up. METHODS Single-center cohort study of patients undergoing LAAO between 2017 and 2020. Two consecutive cohorts were enrolled, one treated with the Amplatzer Amulet (n = 150) up till 2019, and a second cohort treated with the Watchman FLX (n = 150) device from 2019. Cardiac CT was performed 2 months postprocedure. The primary outcome was complete LAA occlusion defined as no visible peri-device leak (PDL) and absence of contrast patency in the distal LAA. Secondary outcomes included PDL, contrast patency without visible PDL, PDL area, and periprocedural complications. RESULTS Complete occlusion was achieved in 39 (30.5%) of the Amulet group, compared to 89 (71.8%) of the FLX group, p < 0.001. A PDL at the Amulet disc was present in 65 (50.8%), at the lobe in 16 (12.5%), and at both the disc and lobe in 13 (10.2%). For FLX, a PDL was present in 20 (16.1%). Contrast patency without visible PDL was observed in 24 (18.8%) and 15 (12.1%) of the Amulet and FLX group, respectively. The PDL area at the Amulet mid-lobe was 92 mm2 (59-158) and 32 mm2 (IQR 28-96) for FLX, p = 0.019. Device-related thrombosis occurred in 1 (0.7%) and 2 (1.3%), respectively (p = 0.99), with periprocedural adverse events occurring in 6 (4%) and 8 (5.3%) of the Amulet and FLX group (p = 0.79). CONCLUSION Complete LAA occlusion was achieved in a significantly higher proportion treated with the Watchman FLX compared to the Amulet device. PDL was smaller with the FLX than the Amulet. Conceptual device design differences make interpretation of results complex, and additional studies with clinical outcomes are needed.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jacqueline Saw
- Department of Cardiology, Vancouver General Hospital, Vancouver, Canada
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark.
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Nielsen-Kudsk JE, Berti S, Caprioglio F, Ronco F, Arzamendi D, Betts T, Tondo C, Christen T, Allocco DJ. Intracardiac Echocardiography to Guide Watchman FLX Implantation: The ICE LAA Study. JACC Cardiovasc Interv 2023; 16:643-651. [PMID: 36764917 DOI: 10.1016/j.jcin.2022.10.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 10/04/2022] [Accepted: 10/11/2022] [Indexed: 02/10/2023]
Abstract
BACKGROUND Intracardiac echocardiography (ICE) is increasingly used to guide left atrial appendage closure (LAAC). OBJECTIVES The aim of this study was to investigate the efficacy and safety of ICE-guided LAAC with the Watchman FLX device. METHODS The ICE LAA (I Can See Left Atrial Appendage) study was a prospective, multicenter study with independent adjudication of echocardiographic data by a core laboratory and clinical events by a clinical events committee. Patients with atrial fibrillation with CHA2DS2-VASc scores ≥2 and clinical indications for LAAC were eligible. Preplanning with either cardiac computed tomography or transesophageal echocardiography (TEE) within 7 days prior to LAAC was mandatory. Intraprocedural ICE was carried out from the left atrium. The primary outcome was the rate of significant peri-device leaks (>5 mm) at 45-day TEE. RESULTS A total of 100 patients were enrolled. The mean age was 76 ± 8 years, the mean CHA2DS2-VASc score was 4.0 ± 1.5, and the mean HAS-BLED score was 2.5 ± 0.9. The incidence of the primary outcome of significant peridevice leak (>5 mm) was 0%; all patients evaluated by TEE at 45 days had effective LAAC. All patients received Watchman FLX devices, and technical success was 100%. The number of devices per case was 1.0 ± 0.1. ICE successfully guided the assessment of device release criteria, including device compression (19.2% ± 7.1%; recommended range: 10%-30%). No subject required conversion to TEE. Procedural complications were 4 access-site bleeds. There was no stroke, transient ischemic attack, systemic embolization, pericardial effusion, device embolization, or device-related thrombus during the procedure or 45-day follow-up. CONCLUSIONS ICE can be used to successfully guide LAAC with the Watchman FLX, with excellent procedural success, a high rate of effective LAAC, and minimal periprocedural complications. (I Can See Left Atrial Appendage [ICELAA] Clinical Study; NCT04196335).
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Affiliation(s)
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | | | | | | | | | - Claudio Tondo
- Heart Rhythm Center at Monzino Cardiac Center, IRCCS, Department of Biomedical, Surgical and Dentist Sciences, University of Milan, Milan, Italy
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Ma Y, Guo L, Li J, Liu H, Xu J, Du H, Wang Y, Li H, Yi F. Iatrogenic Atrial Septal Defect after Intracardiac Echocardiography-Guided Left Atrial Appendage Closure: Incidence, Size, and Clinical Outcomes. J Clin Med 2022; 12:jcm12010160. [PMID: 36614961 PMCID: PMC9821275 DOI: 10.3390/jcm12010160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/09/2022] [Accepted: 12/20/2022] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The data on iatrogenic atrial septal defect (iASD) after left atrial appendage closure (LAAC), especially intracardiac echocardiography (ICE)-guided LAAC, are limited. Compared with transesophageal echocardiography (TEE)- or digital subtraction angiography (DSA)-guided LAAC, the transseptal puncture (TP) ICE-guided LAAC is more complicated. Whether or not ICE-guided TP increases the chances of iASD is controversial. We investigate the incidence, size, and clinical outcomes of iASD after ICE-guided LAAC. METHODS A total of 177 patients who underwent LAAC were enrolled in this study and were assigned to the ICE-guided group (group 1) and the TEE- or DSA-guided group (group 2). Echocardiography results and clinical performances at months 2 and 12 post-procedure were collected from the electronic outpatient records. RESULTS A total of 112 and 65 patients were assigned to group 1 and group 2, respectively. The incidence of iASD at follow-up (FU) month 2 was comparable between the groups (21.4% in group 1 vs. 15.4% in group 2, p = 0.429). At month 12 of FU, the closure rate of iASD was comparable to that of group 2 (70.6% vs. 71.4%, p = 1.000). No right-to-left (RL) shunt was observed among the iASD patients during the FU. Numerically larger iASD were observed in group 1 patients at month 2 of FU (2.8 ± 0.9 mm vs. 2.2 ± 0.8 mm, p = 0.065). No new-onset of pulmonary hypertension and iASD-related adverse events were observed. Univariable and multivariable logistic regression analysis showed that ICE-guided LAAC was not associated with the development of iASD (adjusted OR = 1.681; 95%CI, 0.634-4.455; p = 0.296). CONCLUSIONS The ICE-guided LAAC procedure does not increase the risk of iASD. Despite the numerically large size of the iASD, it did not increase the risk of developing adverse complications.
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Jackson LR, Holmqvist F, Parish A, Green CL, Piccini JP, Bahnson TD. Safety of continuous left atrial phased-array intracardiac echocardiography during left atrial ablation for atrial fibrillation. Heart Rhythm O2 2022; 3:673-680. [PMID: 36589913 PMCID: PMC9795249 DOI: 10.1016/j.hroo.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background Pulmonary vein (PV) isolation using radiofrequency ablation (RFA) to treat atrial fibrillation (AF) requires delivery of contiguous transmural lesions at the PV antra while avoiding injury to the esophagus. Continuous 2-dimensional phased-array intracardiac echocardiography (ICE) from within the left atrium (LA) can provide consistent high-resolution images of catheter tip contact and location during ablation. Objective The purpose of this study was to compare near-term safety outcomes of therapeutic AF ablation with and without ICE imaging from within the LA. Methods The study cohort included 590 consecutive patients undergoing RFA for AF including continuous ICE imaging during ablation from within either the right atrium (RA) or the LA. Subjects were followed prospectively, and periprocedural complications within 30 days were identified and recorded. Results All subjects had RA ICE imaging to guide transseptal catheterization. Ultrasound imaging from both RA and LA was used in 243 (41.2%). Respectively, the LA vs RA only imaging cohorts were comparable with respect to age (median 64 [interquartile range 57.4-71.2] years vs 64 [56.2-70.6] years; P = .425); history of hypertension (64.0% vs 67.2%; P = .421); diabetes mellitus (23.1% vs 19.4%; P = .268); previous cerebrovascular accident/transient ischemic attack (10.8% vs 8.4%; P = .331); and AF type (P = .241). There were no significant differences in major complications within 30 days between the 2 cohorts (P = .649) and no identified cases of esophageal or phrenic nerve injury or PV stenosis. Conclusions Routine continuous LA ICE imaging seems to be safe and holds potential to facilitate lesion delivery during RFA for AF.
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Affiliation(s)
- Larry R. Jackson
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Health System, Durham, North Carolina
| | - Fredrik Holmqvist
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Health System, Durham, North Carolina
- Department of Cardiology, Skane University Hospital, Lund, Sweden
| | - Alice Parish
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Cynthia L. Green
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Health System, Durham, North Carolina
| | - Tristram D. Bahnson
- Duke Center for Atrial Fibrillation and Clinical Cardiac Electrophysiology Section, Duke University Health System, Durham, North Carolina
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Zahid S, Gowda S, Hashem A, Khan MZ, Ullah W, Kaur G, Nasir U, Rai D, Faza NN, Little SH, Valderrabano M, Goel SS. Feasibility and Safety of Intracardiac Echocardiography Use in Transcatheter Left Atrial Appendage Closure Procedures. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100510. [PMID: 39132376 PMCID: PMC11307399 DOI: 10.1016/j.jscai.2022.100510] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 08/13/2024]
Abstract
Background Left atrial appendage closure (LAAC) is usually performed under the guidance of transesophageal echocardiography (TEE). Data on the safety of intracardiac echocardiogram (ICE)-guided LAAC from a real-world population in the United States remain limited. In this study, the aim was to evaluate the trends and outcomes of ICE-guided LAAC procedures using the US National Inpatient Sample. Methods This study used the National Inpatient Sample database from quarter 4 of 2015 to 2019. We used a propensity-matched analysis and adjusted odds ratios for in-hospital outcomes/complications. A P value of <.05 was considered significant. Results We identified 61,995 weighted LAAC cases. Of these, 1410 patients had ICE-guided LAAC with a lower median age than the patients who had TEE-guided LAAC (75 vs 77 years; P ≤ .01). The use of ICE-guided LAAC increased from 1.7% in 2015 to 2.2% in 2019 (P trend = .75). Major, cardiovascular, neurologic, and pulmonary complications were similar for ICE-guided and TEE-guided LAAC on adjusted analysis. On propensity-matched analysis, the overall vascular complication rates were similar. However, retroperitoneal bleeding remained significantly higher (0.7% vs 0%) with ICE. Gastrointestinal bleeding complications were more frequent in TEE-guided LAAC (3.5% vs 2.1%). The length of stay was similar for both groups (median = 1 day; P = .23); however, ICE was associated with $1769 excess cost of hospitalization ($25,112 vs $23,343; P = .04). Conclusions ICE-guided LAAC is safer than TEE-guided LAAC, with similar rates of major complications. However, ICE use was associated with lower rates of gastrointestinal bleeding and higher rates of retroperitoneal bleeding. In addition, ICE-guided LAAC is associated with a similar length of stay but higher costs of hospitalization.
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Affiliation(s)
- Salman Zahid
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Smitha Gowda
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Anas Hashem
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart and Vascular Institute, Morgantown, West Virginia
| | - Waqas Ullah
- Department of Cardiovascular Medicine, Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Usama Nasir
- Department of Medicine, Reading Hospital and Medical Center, Reading, Pennsylvania
| | - Devesh Rai
- Department of Medicine, Rochester General Hospital, Rochester, New York
| | - Nadeen N. Faza
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Stephen H. Little
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Miguel Valderrabano
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | - Sachin S. Goel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
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Ge J, Chen T, Ma C, Maduray K, Zhong J. Can intracardiac echocardiography completely replace transesophageal echocardiography to guide left atrial appendage closure?-The comparisons of intracardiac echocardiography with transesophageal echocardiography. J Card Surg 2022; 37:2766-2775. [PMID: 35726669 DOI: 10.1111/jocs.16695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/27/2022]
Abstract
Left atrial appendage closure (LAAC) is an effective means of preventing ischemic stroke in patients with nonvalvular atrial fibrillation. Transesophageal echocardiography (TEE) is the primary imaging technique to guide LAAC. Its shortcomings, namely the use of general anesthesia and tracheal intubation, inevitably increase procedural risks. Intracardiac echocardiography (ICE), a novel imaging modality for guiding LAAC, has proven more advantageous over TEE due to use of local anesthesia, shortened procedural time, and reduced radiation exposure. This review highlights the differences between ICE and TEE guided LAAC, aiming to provide a reference for clinical decision-making.
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Affiliation(s)
- Junye Ge
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tongshuai Chen
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhen Ma
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kellina Maduray
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jingquan Zhong
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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24
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Korsholm K, Jensen JM, Nørgaard BL, Nielsen-Kudsk JE. Temporal changes and clinical significance of peridevice leak following left atrial appendage occlusion with Amplatzer devices. Catheter Cardiovasc Interv 2022; 99:2071-2079. [PMID: 35582829 PMCID: PMC9541112 DOI: 10.1002/ccd.30178] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 12/05/2022]
Abstract
Background The natural history of peridevice leak (PDL) following left atrial appendage occlusion (LAAO) is unknown. This study sought to investigate changes of PDL from 2 until 12 months after LAAO, using cardiac computed tomography (CT), and to assess the potential association between persistent PDL and clinical outcomes Methods Single‐center observational study of Amplatzer LAAO implants between 2010 and 2017 (n = 206). Patients with 2 and 12 months cardiac CT were included in the study (n = 153). Images were blindly analyzed. PDL was characterized by frequency and size at the device disc, lobe, and left atrial appendage contrast patency. Patients were followed for the composite outcome of ischemic stroke, transient ischemic attack, systemic embolism, or all‐cause death. Median follow up from LAAO was 3.1 (2.3–4.3) years. Results Contrast patency was present in 101 (66%) and 72 (47%) (p < 0.001) at 2 and 12 months, respectively. PDL was identified at the disc in 103 (67%) patients at 2 months versus 93 (61%) at 12 months (p = 0.08), and at the lobe in 29 (19%) at both time points. PDL area at the disc did not change significantly over time, ∆ area: −8.95 mm (95% confidence interval [CI]: −18.9; 1.01) p = 0.08. Permanent atrial fibrillation was independently associated with persistent PDL. Persistent versus no PDL was associated with a 62% worse clinical outcome, however not statistically significant, hazard ratio (HR): 1.62 (95% CI: 0.9–2.93), p = 0.11. Conclusion Persistent PDL was frequently observed following LAAO with Amplatzer devices. The PDL frequency and size appeared unchanged between 2 and 12 months. Persistent PDL was not significantly associated with worse clinical outcomes, yet this needs further delineation in future studies.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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25
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Alkhouli M, Nielsen-Kudsk JE. The Case for Intracardiac Echo to Guide Left Atrial Appendage Closure. Interv Cardiol Clin 2022; 11:153-158. [PMID: 35361460 DOI: 10.1016/j.iccl.2021.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Left atrial appendage closure (LAAC) has become a commonly used alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. There is a growing interest in adopting a minimally invasive procedural approach using intracardiac echocardiography (ICE) and moderate sedation. In this article, we review the rational for and the data supporting ICE-guided LAAC and discuss the pros and cons of this approach.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark
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26
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Vanneman M, Kothari P, Bodmer NJ, Convissar D, Desai GA, Kumar N, Iyer MH, Neuburger PJ, Essandoh MK, Cronin B, Dalia AA. The Year in Electrophysiology: Selected Highlights from 2021. J Cardiothorac Vasc Anesth 2022; 36:1526-1539. [DOI: 10.1053/j.jvca.2022.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 01/28/2022] [Indexed: 11/11/2022]
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27
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Turagam MK, Neuzil P, Hala P, Mraz T, Dukkipati SR, Reddy VY. Intracardiac Echocardiography-Guided Left Atrial Appendage Closure With a Novel Foam-Based Conformable Device: Safety and 1-Year Outcomes. JACC Clin Electrophysiol 2022; 8:197-207. [PMID: 35210077 DOI: 10.1016/j.jacep.2021.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/22/2021] [Accepted: 10/08/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This is a first report of the safety and 1-year outcomes of left atrial appendage closure (LAAC) using a novel foam-based conformable device, guided by intracardiac echocardiography (ICE). BACKGROUND Limitations of current transcatheter LAAC devices include the need for precise coaxial delivery into the left atrial appendage (LAA), potential for traumatic implantation, incomplete LAA seal, and device-related thrombus. METHODS The device (Conformal Left Atrial Appendage Seal, Conformal Medical Inc) is a self-expanding occluder consisting of a cylindrical nitinol endoskeleton with low-profile anchor barbs around the midpoint, covered with a porous foam cup. In a prospective single-center series, under conscious sedation, the device was delivered under fluoroscopic and ICE guidance. After positioning, a transesophageal echocardiography probe was placed to confirm ICE findings before device release. After closure, dual antiplatelet therapy was administered for 6 months. Follow-up imaging was planned for 45 days and 6 and 12 months. RESULTS A total of 15 patients (age 71.3 ± 10.8 years, 33% men, CHA2DS2-VASc 4.1 ± 1.7, HAS-BLED 3.4 ± 1.4) underwent LAAC, 100% successfully. There were no procedure/device-related complications requiring intervention. Asymptomatic pericardial effusion occurred in 2 patients. The 45-day, 6-month, and 12-month follow-up imaging in 11, 9, and 13 patients, respectively, revealed adequate LAA seal (leak ≤5 mm) in all patients; device-related thrombus was detected in 1 patient at 6 months. Over 1-year follow-up, there were no ischemic strokes and 1 minor bleed. Nonprocedure-/device-related death occurred in 2 patients. CONCLUSIONS This first report indicates that LAAC with the conformable implant guided by ICE imaging is feasible with encouraging 1-year clinical outcomes. (The Conformal Prague Study; NCT04193826).
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA. https://twitter.com/mohitkturagam
| | - Petr Neuzil
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Pavel Hala
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Tomas Mraz
- Department of Cardiology, Homolka Hospital, Prague, Czech Republic
| | - Srinivas R Dukkipati
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Cardiology, Homolka Hospital, Prague, Czech Republic.
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Morcos R, Megaly M, Saad M, Barakat AF, Rubens M, Saxena A, Elbadawi A, Kucharik M, Luna M, Garcia S, Veledar E, Maini B, Khalili H. In‐hospital outcomes of transesophageal versus intracardiac echocardiography guided left atrial appendage closure. Catheter Cardiovasc Interv 2022; 99:1572-1581. [DOI: 10.1002/ccd.30086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 01/07/2022] [Indexed: 11/05/2022]
Affiliation(s)
- Ramez Morcos
- Division of Cardiology Florida Atlantic University Boca Raton Florida USA
| | - Michael Megaly
- Division of Cardiology Banner University Medical Center/University of Arizona Phoenix Arizona USA
| | - Marwan Saad
- Division of Cardiology Brown University Providence Rhode Island USA
| | - Amr F. Barakat
- Division of Cardiology University of Pittsburgh Medical Center Pittsburgh Pennsylvania USA
| | - Muni Rubens
- Baptist Health South Florida Miami Florida USA
- School of Public Health Florida International University Miami Florida USA
| | - Anshul Saxena
- Baptist Health South Florida Miami Florida USA
- School of Public Health Florida International University Miami Florida USA
| | - Ayman Elbadawi
- Section of Cardiology Baylor College of Medicine Houston Texas USA
| | - Michael Kucharik
- Charles E. Schmidt College of Medicine Florida Atlantic University Boca Raton Florida USA
| | - Michael Luna
- School of Medicine University of Texas Southwestern Dallas Texas USA
| | - Santiago Garcia
- Minneapolis Heart Institute Abbott Northwestern Hospital Minneapolis Minnesota USA
| | - Emir Veledar
- Baptist Health South Florida Miami Florida USA
- School of Public Health Florida International University Miami Florida USA
| | - Brijeshwar Maini
- Division of Cardiology Florida Atlantic University Boca Raton Florida USA
| | - Houman Khalili
- Division of Cardiology Florida Atlantic University Boca Raton Florida USA
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29
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Chen YH, Wang LG, Zhou XD, Fang Y, Su L, Wu SJ, Huang WJ, Xiao FY. Outcome and safety of intracardiac echocardiography guided left atrial appendage closure within zero-fluoroscopy atrial fibrillation ablation procedures. J Cardiovasc Electrophysiol 2022; 33:667-676. [PMID: 35040537 DOI: 10.1111/jce.15370] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/12/2021] [Accepted: 12/26/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Simultaneous atrial fibrillation (AF) catheter ablation and left atrial appendage closure (LAAC) is sometimes recommended for both rhythm control and stroke prevention. However, the advantages of intracardiac echocardiography (ICE) guidance for this combined procedure have been scarcely reported. We aim to evaluate the clinical outcomes and safety of ICE guided LAAC within a zero-fluoroscopy catheter ablation procedure. METHODS AND RESULTS From April 2019 to April 2020, 56 patients with symptomatic AF underwent concomitant catheter ablation and LAAC. ICE with a multi-angled imaging protocol mimicking the TEE echo windows was used to guide LAAC. Successful radiofrequency catheter ablation and LAAC were achieved in all patients. Procedure related adverse event rate was 3.6%. During the 12-month follow-up, 75.0% of patients became free of arrhythmia recurrences and oral anticoagulants were discontinued in 96.4% of patients. No ischemic stroke occurred despite two cases of device-related thrombosis versus an expected stroke rate of 4.8% based on the CHA2 DS2 -VASc score. The overall major bleeding events rate was 1.8%, which represented a relative reduction of 68% versus an expected bleeding rate of 5.7% based on the HAS-BLED score of the patient cohort. The incidence of iatrogenic atrial septal defect secondary to a single transseptal access dropped from 57.9% at 2 months to 4.2% at 12 months TEE follow-up. CONCLUSION The combination of catheter ablation and LAAC under ICE guidance was safe and effective in AF patients with high stroke risk. ICE with our novel protocol was technically feasible for comprehensive and systematic assessment of device implantation. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Yi-He Chen
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Liang-Guo Wang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Xiao-Dong Zhou
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Ying Fang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Lan Su
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Sheng-Jie Wu
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Wei-Jian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
| | - Fang-Yi Xiao
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, 325000, Nanbaixiang, Wenzhou, Zhejiang, China
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30
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Ben H, Changsheng M, Shulin W. 2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:535-555. [PMID: 35032332 PMCID: PMC9314806 DOI: 10.1111/pace.14448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).
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Affiliation(s)
- He Ben
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ma Changsheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wu Shulin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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31
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Korsholm K, Damgaard D, Valentin JB, Packer EJS, Odenstedt J, Sinisalo J, Putaala J, Næss H, Al-Jazi MA, Karlsson JE, Pontoppidan J, Modrau B, Hjort J, Matzen KL, Johnsen SP, Nielsen-Kudsk JE. Left atrial appendage occlusion vs novel oral anticoagulation for stroke prevention in atrial fibrillation: rationale and design of the multicenter randomized occlusion-AF trial. Am Heart J 2022; 243:28-38. [PMID: 34537184 DOI: 10.1016/j.ahj.2021.08.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 08/28/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) is increasing globally, which is a major clinical and public health concern due to the 5-fold increased risk of stroke. Oral anticoagulation with novel oral anticoagulants (NOACs) is the current primary option for stroke prevention in patients with AF, although it increases the risk of major bleeding. Patients with prior ischemic cerebrovascular events are at particularly high risk of both recurrent ischemic events and major bleeding. Left atrial appendage occlusion (LAAO) provides an alternative option for stroke prevention in high-risk patients, however, with currently limited evidence. Thus, randomized trials comparing LAAO to NOACs are needed. OBJECTIVE The Occlusion-AF trial is designed to assess whether LAAO is non-inferior to NOAC therapy for reduction of the combined endpoint of stroke, systemic embolism, major bleeding (Bleeding Academic Research Consortium ≥ 3) and all-cause mortality in patients with AF and a recent ischemic stroke or transient ischemic attack (TIA). METHODS AND ANALYSIS Investigator-initiated multicenter, multinational, randomized open-label non-inferiority trial with blinded outcome evaluation (PROBE design). Patients with documented AF, and an ischemic stroke or TIA within 6 months will be eligible for enrollment. Major exclusion criteria are modified Rankin Scale > 3 at enrollment, glomerular filtration rate < 15 ml/min, and life-expectancy less than 2 years. A total of 750 patients will be randomized 1:1 to receive either a NOAC or LAAO using the Amplatzer Amulet (Abbott, MN, USA) or Watchman FLX (Boston Scientific, MN, USA) with subsequent life-long aspirin 75 mg daily. Follow-up will be based on in-office and telephone follow-up in combination with long-term follow-up (10 years) through national hospital discharge registries in the individual Nordic countries. The primary outcome will be a composite endpoint of stroke, systemic embolism, major bleeding (BARC ≥ 3) and all-cause mortality at 2-year follow-up. CONCLUSIONS The Occlusion-AF trial is designed to compare LAAO to NOAC therapy for secondary stroke prevention in AF patients with a high risk of recurrent thromboembolic events, i.e. with previous ischemic stroke or TIA, and otherwise eligible for anticoagulation. The results are expected to contribute significantly to the understanding of the effects of LAAO compared to the standard contemporary pharmacological treatment in these patients.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark; Department of Cardiology, Regional Hospital, West Jutland, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | | | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Juha Sinisalo
- Heart and Lung Center, Helsinki University Central Hospital, and Helsinki University Helsinki, Finland
| | - Jukka Putaala
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Halvor Næss
- Department of Neurology, Haukeland University Hospital, Bergen, Norway
| | | | - Jan-Erik Karlsson
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jacob Pontoppidan
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Boris Modrau
- Department of Neurology, Aalborg University Hospital, Aalborg, Denmark
| | - Jakob Hjort
- Clinical Trial Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
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32
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Hagemeyer D, Ali FM, Ong G, Fam NP. The Role of Intracardiac Echocardiography in Percutaneous Tricuspid Intervention: A New ICE Age. Interv Cardiol Clin 2021; 11:103-112. [PMID: 34838293 DOI: 10.1016/j.iccl.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The prevalence of severe tricuspid regurgitation in older patients is high, and the clinical relevance is perceived more and more in recent years. Many of these patients are not suitable for surgery because of their age and comorbidities. Therefore, a variety of percutaneous interventions have been developed to address this unmet need. Procedural success strongly depends on adequate imaging during the intervention. Although transesophageal echocardiography is the standard of care, imaging may be limited due to anatomic factors and adverse acoustic shadowing. In this review, we discuss the current and future role of intracardiac echocardiography in tricuspid valve interventions.
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Affiliation(s)
- Daniel Hagemeyer
- Division of Cardiology, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada. https://twitter.com/DanielHagemeyer
| | - Faeez M Ali
- Division of Cardiology, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada; Waikato Hospital, 183 Pembroke Street, Hamilton 3204, New Zealand
| | - Geraldine Ong
- Division of Cardiology, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada
| | - Neil P Fam
- Division of Cardiology, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.
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33
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Kramer AD, Korsholm K, Kristensen A, Poulsen LH, Nielsen-Kudsk JE. Left atrial appendage occlusion in haemophilia patients with atrial fibrillation. J Interv Card Electrophysiol 2021; 64:95-102. [PMID: 34822042 DOI: 10.1007/s10840-021-01090-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Advanced targeted therapy has resulted in increasing life expectancy and incidence of age-related cardiovascular diseases like atrial fibrillation in patients with haemophilia. Oral anticoagulation constitutes a significant dilemma in this patient category as the risks of stroke and bleeding are difficult to balance. We sought to demonstrate the feasibility of left atrial appendage occlusion (LAAO) in patients with haemophilia and atrial fibrillation. METHODS All patients with haemophilia treated with LAAO at Aarhus University Hospital, Denmark, were identified from a local prospective database comprising all consecutive LAAO procedures from 2010 up to November 2020. Based on review of the medical records, a retrospective descriptive analysis was performed. RESULTS Seven patients with haemophilia A and atrial fibrillation underwent LAAO after multidisciplinary conference. Peri-procedural coagulation management was guided by factor VIII activity and treated with repeated bolus administrations of recombinant factor VIII targeting an activity of 100%. The implantation was successful in all patients with only minor bleeding complications post-procedurally. Based on these experiences, a suggested regime has been formulated. CONCLUSIONS LAAO is feasible in haemophilia patients with concurrent atrial fibrillation. However, special care including intravenous substitution with coagulation factors must be given in the periprocedural management.
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Affiliation(s)
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Andreas Kristensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway
| | - Lone Hvitfeldt Poulsen
- Department of Haematology, Haemophilia Centre West, Aarhus University Hospital, Aarhus, Denmark
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34
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Pommier T, Guenancia C, Richard C, Sagnard A, Fichot M, Salignon-Vernay C, Porot G, Laurent G, Lorgis L. Safety and efficacy of left atrial appendage occlusion with the ACP or Watchman device guided by intracardiac echocardiography from the left atrium. Clin Cardiol 2021; 44:1402-1408. [PMID: 34498285 PMCID: PMC8495078 DOI: 10.1002/clc.23696] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 06/22/2021] [Accepted: 06/29/2021] [Indexed: 12/03/2022] Open
Abstract
Background There is a paucity of randomized data regarding the safety and efficacy of the use of intracardiac echocardiography (ICE) from the left atrium (LA) to guide left atrial appendage occlusion (LAAO) procedures under local anesthesia using either of the available devices. Hypothesis The aim of this study was to compare the efficacy and safety of ICE from the LA with transesophageal echocardiography (TEE) for guidance during transcatheter LAAO procedures. Methods Single‐center, cohort study of patients undergoing LAAO with the Amplatzer Cardiac Plug or Watchman device. Procedures were guided by ICE from the LA with local anesthesia (n = 175) or TEE under general anesthesia (n = 49). Efficacy outcomes were procedural success and peri‐device leaks 6 weeks after LAAO. The safety outcome was a composite of procedure‐related complications. Results Procedural success was similar between groups: 100% in the TEE‐guided group, and 98% in the ICE‐guided group. Procedure‐related complications such as death, embolism, migration, or major vascular complications occurred similarly between groups (p = 0.590). The rate and degree of peri‐device leaks or presence of a thrombus on the device did not differ between groups on follow‐up CT. Turnover time in the catheter laboratory and use of contrast agent were reduced with ICE. Conclusions ICE in the left atrium to guide LAAO procedures appears to be as effective and safe as TEE. There was no increase in procedure‐related complications, whatever the device used. ICE resulted in similar procedural success while decreasing procedure time and requiring only local anesthesia.
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Affiliation(s)
- Thibaut Pommier
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Charles Guenancia
- Department of Cardiology, Dijon University Hospital, Dijon, France.,Laboratory of Cerebro-Vascular Pathophysiology and epidemiology, University of Burgundy, Dijon, France
| | - Carole Richard
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Audrey Sagnard
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Marie Fichot
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | | | - Guillaume Porot
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Gabriel Laurent
- Department of Cardiology, Dijon University Hospital, Dijon, France
| | - Luc Lorgis
- Department of Cardiology, Dijon University Hospital, Dijon, France.,Laboratory of Cerebro-Vascular Pathophysiology and epidemiology, University of Burgundy, Dijon, France
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35
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Eleid MF, Alkhouli M, Thaden JJ, Zahr F, Chadderdon S, Guerrero M, Reeder GS, Rihal CS. Utility of Intracardiac Echocardiography in the Early Experience of Transcatheter Edge to Edge Tricuspid Valve Repair. Circ Cardiovasc Interv 2021; 14:e011118. [PMID: 34474586 DOI: 10.1161/circinterventions.121.011118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Jeremy J Thaden
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Firas Zahr
- Department of Cardiovascular Medicine, Oregon Health and Sciences University, Portland (F.Z., S.C.)
| | - Scott Chadderdon
- Department of Cardiovascular Medicine, Oregon Health and Sciences University, Portland (F.Z., S.C.)
| | - Mayra Guerrero
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Guy S Reeder
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (M.F.E., M.A., J.J.T., M.G., G.S.R., C.S.R.)
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36
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Berti S, Pastormerlo LE, Korsholm K, Saw J, Alkhouli M, Costa MP, Odenstedt J, Packer EJ, Tondo C, Santoro G, Nielsen-Kudsk JE. Intracardiac echocardiography for guidance of transcatheter left atrial appendage occlusion: An expert consensus document. Catheter Cardiovasc Interv 2021; 98:815-825. [PMID: 34086394 DOI: 10.1002/ccd.29791] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 11/12/2022]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in selected patients with atrial fibrillation. Intraprocedural imaging is a crucial for a successful intervention, with transesophageal echocardiography (TEE) as the current gold standard. Since some important limitations may affect TEE use, intracardiac echocardiography (ICE) is increasingly used as an alternative to TEE for guiding LAAO. The lack of a standardized imaging protocol has slowed the adoption of ICE into clinical practice. On the basis of current research and expert consensus, this paper provides a protocol for ICE support of left atrial appendage occlusion.
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Affiliation(s)
- Sergio Berti
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa
| | - Luigi E Pastormerlo
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacqueline Saw
- Interventional Cardiology, Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Marco P Costa
- Serviço de Cardiologia, Centro Hospilatar e Universitário de Coimbra, Coimbra, Portugal
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Js Packer
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Claudio Tondo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gennaro Santoro
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy
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37
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Turagam MK, Neuzil P, Petru J, Hala P, Mraz T, Baroch J, Lekesova V, Prokopova M, Dukkipati SR, Reddy VY. Intracardiac echocardiography-guided implantation of the Watchman FLX left atrial appendage closure device. J Cardiovasc Electrophysiol 2021; 32:717-725. [PMID: 33533089 DOI: 10.1111/jce.14927] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/23/2020] [Accepted: 12/29/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The next-generation Watchman FLX left atrial appendage closure (LAAC) device has: (1) an atraumatic closed distal end, (2) reduced height, (3) a recessed screw hub to decrease device-related thrombus (DRT), (4) two rows of J-shape anchors so redeployment is possible after full recapture, and (5) ability to treat a greater size range of LAA ostia. OBJECTIVE To report, for the first time, the feasibility and safety of intracardiac echocardiography (ICE)-guided Watchman FLX implantation. METHODS A single-center prospective registry of atrial fibrillation patients planned for LAAC with the FLX device underwent ICE-guided implantation with conscious sedation. Transesophageal echocardiography (TEE) imaging was done preprocedure (to assess LAA size and exclude thrombus) and at clinical follow-up at 6-12 weeks. Clinical outcomes were LAA closure success, complications, leak, or DRT on follow-up TEE and major safety events. RESULTS The study included 30 patients: age 75 ± 8 years, 53% men, CHA2 DS2 -VASc 4.6 ± 1.6, and HAS-BLED 3.4 ± 1.1. The primary indication was prior bleeding in 60% (72% GI bleeding). The LAA orifice width and length were 22.7 ± 3.1 and 25.7 ± 5.7 mm, respectively. Technical success was 100% (the first-choice device was used in 28 of 30). Procedure time was less than 30 min in 27 of 30 cases, with 36 ± 15 ml contrast used. The final device size was 29.2 ± 4.7 mm with 21.6 ± 4.5% compression. There were no procedure-related complications. Follow-up TEE at a median 47 days follow-up showed 100% device success with no DRT or peridevice leak ≥5 mm. Major safety events occurred in 6.6% (2/30). CONCLUSION The Watchman FLX device can be safely implanted with intraprocedural ICE imaging instead of TEE.
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Affiliation(s)
- Mohit K Turagam
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Petr Neuzil
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Jan Petru
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Pavel Hala
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Tomas Mraz
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Jiri Baroch
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Veronika Lekesova
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Milena Prokopova
- Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
| | - Srinivas R Dukkipati
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Vivek Y Reddy
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Cardiovascular Medicine, Homolka Hospital, Prague, Czech Republic
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38
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Gianni C, Della Rocca DG, Natale A, Horton RP. Interventional Treatment for Stroke Prevention. Korean Circ J 2021; 51:1-14. [PMID: 33377326 PMCID: PMC7779816 DOI: 10.4070/kcj.2020.0416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022] Open
Abstract
Closure of the left atrial appendage using percutaneous transcatheter occlusion devices is used for stroke prevention as an alternative for patients with a high risk or contraindications for long-term oral anticoagulation use. Herein, we will discuss the practical aspects of five among the available devices used for interventional left atrial appendage occlusion: Watchman, Amulet, WaveCrest, LAmbre, and Lariat.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- HCA National Medical Director of Cardiac Electrophysiology, USA
- Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Department of Biomedical Engineering, University of Texas, Austin, TX, USA.
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39
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Freixa X, Aminian A, De Backer O, Berti S, Nielsen-Kudsk JE. Left atrial appendage occlusion in COVID-19 times. Eur Heart J Suppl 2020; 22:P47-P52. [PMID: 33390871 PMCID: PMC7757719 DOI: 10.1093/eurheartj/suaa173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The coronavirus disease 2019 pandemic is having a major impact on healthcare systems worldwide. Several months after the COVID-19 outbreak, waiting lists of non-urgent structural heart (SH) interventions continue to increase. Limitations in terms of ICU beds and anesthesiology represent a major limitation to conduct non-urgent SH interventions and are a valid reason to move towards less invasive approaches. The field of left atrial appendage occlusion (LAAO) reflects this challenging situation perfectly. The aim of this paper is to describe the possibilities for pre-procedural LAA assessment, performance of the LAAO procedure and post-procedural surveillance in these challenging times.
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Affiliation(s)
- Xavier Freixa
- Department of Cardiology, IDIBAPS, Hospital Clinic of Barcelona, c/Villarroel 170. Escala 3 Planta 6, 08015 Barcelona, Spain
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, The Heart Centre, Copenhagen, Denmark
| | - Sergio Berti
- Department of Cardiology, Fondazione Toscana G. Monasterio, Ospedale del Cuore G. Pasquinucci, Massa, Italy
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40
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Ebelt H, Domagala T, Offhaus A, Wiora M, Schwenzky A, Hoyme M, Anacker J, Röhl P. Fusion Imaging of X-ray and Transesophageal Echocardiography Improves the Procedure of Left Atrial Appendage Closure. Cardiovasc Drugs Ther 2020; 34:781-787. [PMID: 32761486 PMCID: PMC7674364 DOI: 10.1007/s10557-020-07048-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is an alternative treatment strategy for patients with atrial fibrillation who are at risk for thromboembolic events and considered not suitable for oral anticoagulation (OAC). LAAC is mainly performed under the guidance of transesophageal echocardiography (TEE) and fluoroscopy. The study presented here should analyze whether fusion imaging (FI) of transesophageal echocardiography and X-ray performed during LAAC is feasible and can improve the results of the procedure. METHODS The data presented here are from a retrospective single center study. Sample size was defined as 50 patients in which LAAC was performed without fusion imaging (control group) and 25 patients were the LAAC procedure was guided by fusion imaging (treatment group). Inclusion criteria were defined as age > 18 years and completion of an LAAC procedure defined as deployment of a WATCHMAN 2.5 LAA occluder. Study endpoints were procedure time, amount of used contrast medium, radiation dose, final position of the WATCHMAN in TEE (deviation from ideal positioning), and clinical endpoints, respectively. RESULTS LAA closure was successfully performed in all patients. No case of device embolism was occurring, and none of the patients experienced a periprocedural stroke/TIA nor a systemic embolism, respectively. Mean procedure time was 15 min shorter in the group of patients where fusion imaging was applied (p < 0.001). Additionally, the use of fusion imaging was associated with a significant reduction of contrast medium (20.6 ml less than in control; p < 0.045). Regarding the final position of the WATCHMAN, no relevant differences were found between the groups. The use of fusion imaging significantly reduced procedure time and the amount of contrast medium in patients undergoing LAAC.
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Affiliation(s)
- Henning Ebelt
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany.
| | - Thomas Domagala
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Alexandra Offhaus
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Matthias Wiora
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Andreas Schwenzky
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Matthias Hoyme
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Jelena Anacker
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
| | - Peter Röhl
- Department for Medicine II, Catholic Hospital "St. Johann Nepomuk", Haarbergstr. 72, 99097, Erfurt, Germany
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Korsholm K, Samaras A, Andersen A, Jensen JM, Nielsen-Kudsk JE. The Watchman FLX Device. JACC Clin Electrophysiol 2020; 6:1633-1642. [DOI: 10.1016/j.jacep.2020.06.028] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/18/2020] [Accepted: 06/20/2020] [Indexed: 11/29/2022]
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Comparison of Intracardiac Echocardiography and Transesophageal Echocardiography for Image Guidance in Percutaneous Patent Foramen Ovale Closure. MEDICINA-LITHUANIA 2020; 56:medicina56080401. [PMID: 32784843 PMCID: PMC7466370 DOI: 10.3390/medicina56080401] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/28/2020] [Accepted: 08/05/2020] [Indexed: 11/17/2022]
Abstract
Background and Objectives: Transesophageal echocardiography (TEE) guidance is the current gold standard for catheter-based procedures in the treatment of structural heart diseases. Intracardiac echocardiography (ICE), which can be performed under local anesthesia, has been recently introduced and is becoming more widely used. We aimed to compare the efficacy and safety of ICE and TEE in patent foramen ovale (PFO) device closure. Materials and Methods: All 74 patients with a history of cryptogenic stroke undergoing PFO closure for secondary prophylaxis were selected from our registry. Intraprocedural TEE was performed by echocardiographer-cardiologists with the patient under general anesthesia. Conversely, ICE was performed with the patient under local anesthesia. Baseline characteristics, procedural details, and immediate outcomes were compared between the TEE and ICE groups (n = 49 and n = 25, respectively). Results: Although patients in the ICE group were older (47 ± 10 vs. 57 ± 7 years, p < 0.001), sex and comorbidity variables were similar between the two groups. The degree of inducible right-to-left shunt via the PFO, assessed using preprocedural TEE, was also comparable. Notably, fluoroscopy time (22 ± 18 vs. 16 ± 7 min, p = 0.030), radiation dose (498 ± 880 vs. 196 ± 111 mGy, p = 0.022), and total procedural time in the catheter laboratory (99 ± 30 vs. 67 ± 12 min, p < 0.001) were significantly lower in the ICE group than those in the TEE group. The entire hospital stay was similar between groups (3.8 ± 2.2 vs. 3.4 ± 1.3 days, p = 0.433). No procedural complications, such as device embolization, pericardial hemorrhage, major bleeding, mortality, or access-related vascular injury were reported in either group. Conclusions: ICE-guided PFO device closure is quicker and less hazardous in terms of radiation exposure than the TEE-guided procedure, with similar procedural outcomes and duration of hospital stay.
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Chu H, Du X, Shen C, He B, Feng M, Liu J, Fu G, Wang B. Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance. J Formos Med Assoc 2020; 119:1586-1592. [PMID: 32703696 DOI: 10.1016/j.jfma.2020.07.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/26/2020] [Accepted: 07/14/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND/PURPOSE Left atrial appendage closure (LAAC) is conventionally guided by fluoroscopy and transesophageal echocardiography. We introduce an LAAC technique without fluoroscopy exposure using intracardiac echocardiography (ICE) and electroanatomic mapping system (EAMS) under local anesthesia. METHODS Seven non-valvular atrial fibrillation patients who underwent LAAC with the LAmbre devices under the ICE and EAMS guidance were compared to 7 patients following the conventional approach by propensity score matching. ICE probe was advanced into the left atrium (LA) to guide sizing and device implantation following the orthogonal tri-axial technique (Axis-X: from left pulmonary veins [PVs] to LAA; Axis-Y: from right PV ostium to LAA; Axis-Z: from lower LA to LAA). RESULTS The mean diameters of ostia and landing zone were 21.4 ± 3.9 mm and 20.4 ± 4.2 mm, respectively. LAmbre devices with a mean umbrella diameter of 23.7 ± 4.2 mm and cover disc diameter of 29.4 ± 3.6 mm were successfully implanted and acute complete LAA sealing without peri-device leak (PDL) were achieved in all cases. Neither fluoroscopy exposure nor contrast consumption was recorded. No procedure related complications were documented. The mean procedural time and PDLs at follow-ups were comparable to those in the conventional group. No stroke or thromboembolic events were documented. CONCLUSION The fluoroscopy exposure could be minimized, even to zero, in the ICEguided LAAC procedures feasibly and safely using LAmbre devices. The orthogonal triaxial technique is considered efficacious and safe for the procedures.
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Affiliation(s)
- Huimin Chu
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China.
| | - Xianfeng Du
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Caijie Shen
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Bin He
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Mingjun Feng
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Jing Liu
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Guohua Fu
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
| | - Binhao Wang
- Cardiac Arrhythmia Center, Ningbo First Hospital, Ningbo, 315010, China
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Salmon MK, Hammer KE, Nygaard JV, Korsholm K, Johansen P, Nielsen-Kudsk JE. Left atrial appendage occlusion with the Amulet device: to tug or not to tug? J Interv Card Electrophysiol 2020; 61:199-206. [PMID: 32661863 DOI: 10.1007/s10840-020-00821-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 07/05/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE Left atrial appendage occlusion (LAAO) involves a "tug test," in which implanters pull on the device delivery cable to ensure stable occluder placement. The aim of this study was to evaluate the recommendation to perform the tug test, by comparing forces exerted on the device during deployment and subsequent tug test. A secondary objective was to simulate forces experienced on left atrial appendage tissue by placement of a 20-mm device. METHODS The AMPLATZER™ Amulet™ device was used for occlusion. A force transducer recorded forces in the delivery cable during deployment and tug test in 23 patients. Four patients were excluded due to improper transducer placement or technical errors in data collection. For a 20-mm device, the force imparted on the circumferential contact with left atrial appendage wall tissue was simulated in a computational model, using the measured externally applied forces as inputs. RESULTS For devices < 25-mm in diameter, disc deployment force (mean ± standard deviation) was 1.72 ± 0.43 N, and tug force was 1.01 ± 0.59 N. For devices ≥ 25 mm in diameter, disc deployment force was 2.96 ± 0.57 N, and tug force was 1.04 ± 0.24 N. The increase in disc deployment force compared with tug test force was statistically significant for small devices (< 25 mm; p = 0.049) and large devices (≥ 25 mm; p < 0.001). CONCLUSIONS Increased force applied on the AMPLATZER™ Amulet™ device during disc deployment compared with during tug test was statistically significant, suggesting that the tug test is redundant in most cases for checking device stability.
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Affiliation(s)
- Mandy K Salmon
- Department of Engineering, Aarhus University, Aarhus, Denmark. .,Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
| | | | | | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Peter Johansen
- Department of Engineering, Aarhus University, Aarhus, Denmark
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Osman M, Busu T, Osman K, Khan SU, Daniels M, Holmes DR, Alkhouli M. Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2020; 6:494-506. [PMID: 32439033 PMCID: PMC7988890 DOI: 10.1016/j.jacep.2019.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO). BACKGROUND Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated. METHODS A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model. RESULTS A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices. CONCLUSIONS In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Tatiana Busu
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khansa Osman
- Michigan Health Specialist, Michigan State University, Flint, Michigan, USA
| | - Safi U Khan
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Matthew Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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Alkhouli M, Chaker Z, Alqahtani F, Raslan S, Raybuck B. Outcomes of Routine Intracardiac Echocardiography to Guide Left Atrial Appendage Occlusion. JACC Clin Electrophysiol 2020; 6:393-400. [DOI: 10.1016/j.jacep.2019.11.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/15/2019] [Accepted: 11/14/2019] [Indexed: 11/28/2022]
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47
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Freixa X, Aminian A, Tzikas A, Saw J, Nielsen-Kudsk JE, Ghanem A, Schmidt B, Hildick-Smith D. Left atrial appendage occlusion with the Amplatzer Amulet: update on device sizing. J Interv Card Electrophysiol 2020; 59:71-78. [PMID: 32166532 DOI: 10.1007/s10840-019-00699-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE The present paper analyzes the role of different imaging modalities for left atrial appendage (LAA) assessment and the recommended specific measurements to improve device selection with regard to the Amulet device. BACKGROUND Morphological LAA assessment is one of the pivotal factors to achieve proper LAA sealing and potentially reduce the risk of complications by minimizing manipulation inside the appendage. METHODS Eight experienced physicians in LAAO were asked to contribute in the preparation of a device sizing consensus manuscript after comprehensive assessment of previous published data on LAA imaging/measurement. RESULTS LAA morphology is often complex and requires more detailed spatial resolution and 3-dimensional assessments to reduce the risk of mis-sizing. Traditionally, upsizing of devices based upon the largest measured LAA diameters have been used. However, this may lead to oversizing in markedly elliptical appendages. Thus, when 3D imaging modalities are available, utilizing the LAA mean diameters might be a better alternative. Operators should also note the systematic biases in differences in measurements obtained with different imaging modalities, with CT giving the largest measurements, followed by 3D-TEE, and then 2D-TEE and angiography. In fact, for 2D imaging techniques (2D-TEE and angiography), LAA diameters tend to be underestimated, and therefore, LAA largest diameters seem to be still the best option for device sizing. Some specific anatomies such as proximal chicken-wing or conic LAAs may require different measurements and implantations to achieve implant success. CONCLUSIONS In conclusion, LAA mean diameters might be a better alternative to largest diameters when 3D imaging modalities are available.
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Affiliation(s)
- Xavier Freixa
- Hospital Clinic de Barcelona, Institut Clínic Cardiovascular, Barcelona, Spain.
| | - Adel Aminian
- Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Jacqueline Saw
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
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48
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Akella K, Murtaza G, Turagam M, Sharma S, Madoukh B, Amin A, Gopinathannair R, Lakkireddy D. Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: a meta-analysis. J Interv Card Electrophysiol 2020; 60:41-48. [DOI: 10.1007/s10840-019-00677-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 11/25/2019] [Indexed: 01/11/2023]
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49
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Khalili H, Patton M, Taii HA, Bansal P, Brady M, Taylor J, Gurung A, Maini B. 4D Volume Intracardiac Echocardiography for Intraprocedural Guidance of Transcatheter Left Atrial Appendage Closure. J Atr Fibrillation 2019; 12:2200. [PMID: 32435343 DOI: 10.4022/jafib.2200] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 07/14/2019] [Accepted: 08/29/2019] [Indexed: 11/10/2022]
Abstract
Background Fluoroscopy and transesophageal echocardiography (TEE) are used to guide transcatheter left atrial appendage (LAA) closure in patients with atrial fibrillation to prevent thromboembolic events. This study examines whether real-time three-dimensional volume ICE guidance (4D volume ICE) can be used as an alternative to TEE during LAA closure (LAAC). Methods and Results Fifteen patients with atrial fibrillation (AF), who had high risk for stroke and contraindication for long-term warfarin therapy, were enrolled in the study. The WATCHMAN device was used for transcatheter LAAC under fluoroscopy. LAA and device sizing was performed using TEE and volume ICE guidance from the right heart. Intraprocedural ICE measurements were consistent with TEE; LAA maximal width and depth, and maximal diameter of the implanted device were moderately correlated (Pearson's coefficient: 0.63, 0.65, and 0.71 respectively; p<0.05) with good agreement (bias: -0.03 cm, -0.07 cm, and 0.003 cm respectively). The average imaging success rate, defined by the number of patients with all the required intraprocedural measurements, was 67% for ICE and 100% for TEE. The WATCHMAN device was successfully implanted in all patients with a device to patient ratio of 1.33. Conclusions 4D volume ICE can be used as an intraprocedural sizing and guidance tool for transcatheter LAAC with measurements comparable to TEE. Challenging patient characteristics significantly degrade the diagnostic image quality when imaging from the right heart. Standardized workflow with proper patient selection and optimal preprocedural planning may improve the diagnostic quality of volume ICE guidance for transcatheter LAAC procedure.
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Affiliation(s)
| | | | - Haider Al Taii
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | - Priya Bansal
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
| | | | | | | | - Brijeshwar Maini
- Tenet Healthcare Corporation, Delray Beach, FL.,Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL
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Berti S, Pastormerlo LE, Santoro G, Brscic E, Montorfano M, Vignali L, Danna P, Tondo C, Rezzaghi M, D'Amico G, Stabile A, Saccà S, Patti G, Rapacciuolo A, Poli A, Golino P, Magnavacchi P, Meucci F, Pezzulich B, Stolcova M, Tarantini G. Intracardiac Versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion: The LAAO Italian Multicenter Registry. JACC Cardiovasc Interv 2019; 11:1086-1092. [PMID: 29880104 DOI: 10.1016/j.jcin.2018.05.008] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/03/2018] [Accepted: 05/03/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVES This study sought to evaluate the feasibility, safety, and efficacy of intracardiac echocardiography (ICE)-guided versus transesophageal echocardiography (TEE)-guided left atrial appendage occlusion (LAAO) by the use of Amplatzer Cardiac Plug or Amulet devices included in a large Italian registry. BACKGROUND TEE is widely used for LAAO procedure guidance. ICE may be a potential alternative imaging modality in LAAO. METHODS Data from 604 LAAO procedures performed in 16 Italian centers were reviewed. ICE-guided LAAO was performed in 187 patients, whereas TEE was used in 417 patients. Procedural success was defined as LAAO without occurrence of pericardial tamponade, stroke, systemic embolism with end organ damage, major bleeding, and device embolization. Stroke, transient ischemic attack, major bleeding, overall and cardiovascular death were analyzed. RESULTS CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65 to 74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores were similar between the ICE and TEE groups. TEE implied lower procedural (delta 12 min) and fluoroscopy time (delta 5 min) when compared with ICE. Procedural success was similarly high (≥94%) between the TEE and ICE groups with a complication rate of 6.5% for TEE versus 4.2% for ICE (odds ratio: 1.468; 95% confidence interval: 0.681 to 3.166; p = 0.327). At median follow-up of 451 days (interquartile range: 162 to 899 days), the rate of cerebral ischemic events was similar between TEE-guided and ICE-guided procedures. CONCLUSIONS ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality after an appropriate learning curve and bearing in mind that pre-procedural computed tomography imaging is mandatory. When comparing ICE with TEE, TEE remains the gold standard.
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Affiliation(s)
- Sergio Berti
- UOC Cardiologia Diagnostica ed Interventistica, Fondazione C.N.R. Reg. Toscana G. Monasterio, Ospedale del Cuore, Massa, Italy.
| | - Luigi Emilio Pastormerlo
- UOC Cardiologia Diagnostica ed Interventistica, Fondazione C.N.R. Reg. Toscana G. Monasterio, Ospedale del Cuore, Massa, Italy
| | - Gennaro Santoro
- UO Cardiologia Generale, Azienda Ospedaliero-Universitaria di Careggi, Firenze, Italy
| | - Elvis Brscic
- UO Cardiologia, Maria Pia Hospital, Turin, Italy
| | - Matteo Montorfano
- UO Cardiologia Interventistica ed Emodinamica, Ospedale San Raffaele, Milan, Italy
| | - Luigi Vignali
- UO Cardiologia, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Paolo Danna
- UO Cardiologia, Ospedale Luigi Sacco, Milan, Italy
| | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Università di Milan, Milan, Italy
| | - Marco Rezzaghi
- UOC Cardiologia Diagnostica ed Interventistica, Fondazione C.N.R. Reg. Toscana G. Monasterio, Ospedale del Cuore, Massa, Italy
| | - Gianpiero D'Amico
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | | | | | - Giuseppe Patti
- UOS di Servizi Cardiologici, Campus Bio-medico, Rome, Italy
| | - Antonio Rapacciuolo
- Department of advanced biomedical sciences, Federico II University, Naples, Italy
| | - Arnaldo Poli
- USD Cardiologia Interventistica-ASST Ovest Milanese-Ospedale Legnano-Magenta, Legnano, Italy
| | - Paolo Golino
- UOC Cardiologia Clinica, Azienda Ospedaliera "Sant'Anna e San Sebastiano" di Caserta, Caserta, Italy
| | - Paolo Magnavacchi
- UO Cardiologia, Policlinico di Modena-Ospedale di Baggiovara, Modena, Italy
| | - Francesco Meucci
- UO Cardiologia Generale, Azienda Ospedaliero-Universitaria di Careggi, Firenze, Italy
| | | | - Miroslava Stolcova
- UOC Cardiologia Diagnostica ed Interventistica, Fondazione C.N.R. Reg. Toscana G. Monasterio, Ospedale del Cuore, Massa, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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