Intracardiac echocardiography off piste? Closure of the left atrial appendage using ICE and local anesthesia

Abstract

Left atrial appendage (LAA) occlusion is increasingly accepted to reduce the risk of stroke in patients with atrial arrhythmia who are unsuitable for routine anticoagulation. It is generally performed under general anesthesia, guided by transoesophageal echocardiography with accurate imaging being essential for correct deployment of the device. We present a case where LAA occlusion was done under local anesthesia in a high-anesthetic risk patient, using novel placement of an intracardiac echo probe via a Mullins sheath in the right ventricular outflow tract and pulmonary artery. This allowed accurate visualization of device deployment in the LAA. This technique may increase the spectrum of patients who may benefit from the procedure and decrease procedure time, fluoroscopy, and procedure-related morbidity.

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

“…Intracardiac echocardiography (ICE), commonly used for atrial septal defect or patent foramen ovale closure, offers guidance for structural interventional procedures in awake patients. LAA closure with ICE guidance has been reported in case reports or small case series with ICE performed from the right atrium (RA), 7,8 pulmonary artery, 9 or other right-sided locations. 10 More recently, Berti et al published a larger experience of LAA closure using right atrial ICE guidance, 11 reporting a technical success rate of 97.5% (117 of 121).…”

Usefulness of intracardiac echocardiography with a mechanical probe for catheter‐based interventions: A 10‐year prospective registry

“…17 A number of case series and studies have already demonstrated the ability of electronicprobe ICE to guide not only simple congenital [18][19][20] but also complex structural heart disease interventions, such as mitral valvuloplasty and clips, and left atrial appendage closure 21,22 and obviously in electrophysiology procedures. Moreover, mechanical-probe ICE was able to define accurately the anatomy in the case of tiny ostium primum, sinus defect, or the presence of anomalous pulmonary venous return, leading to a switch from catheter-based to surgical intervention.…”

Role of Imaging in Left Atrial Appendage Occlusion

“…The catheters are inserted from the ipsilateral or contralateral femoral vein via large venous sheaths and advanced from the inferior vena cava to the working position. The ICE probe can be positioned in the RA, the coronary sinus [56], the pulmonary artery [62] or the LA via a single-transseptal approach or after a second transseptal puncture [57]. Once the desired position is achieved, the probe can be set in that position with a lock mechanism.…”