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

Introduction: Data on use of ICE guidance in TEER procedure is limited to case reports and small case series. Our study aims to assess the feasibility, safety, utilization patterns and clinical outcomes of mitral TEER procedure with ICE guidance using a nationally representative real-world cohort of patients.Hypothesis: There is no difference between ICE-guided TEER and TEE-guided TEER in the clinical outcomes and complications. Methods: 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. Results: A total of 38,770 weighted cases of mitral TEER were identified. Of the included patients 665 patients underwent ICE-guided TEER while 38,105 had TEE-guided TEER. 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 versus TEE-guided TEER. 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 TEER (median: 1 vs. 2, p<0.01) with no differences in costs of hospitalization ($137,312 vs. $153,773, p=0.06), Conclusions: In conclusion, ICE-guided mitral TEER is safe when compared with TEE guided TEER with no significant differences in in-hospital mortality, cardiac, bleeding, respiratory, and renal complications. The length of stay in ICE group is shorter as compared with the TEE group.

Introduction: Transesophageal echocardiography (TEE) has been widely used for imaging guidance during Transcatheter aortic valve replacement (TAVR) . However, the use of intracardiac echocardiography (ICE) is being recognized as a promising alternative imaging modality without the need for general anesthesia while providing high-resolution images. Real-world data on clinical outcomes comparing TEE- and ICE-directed TAVR remains limited. This study aimed to explore the in-hospital outcomes associated with ICE- versus TEE-guided TAVR using the US National Inpatient Sample (NIS). Methods: Using the NIS database from 2020 to 2022, we found adult patients who underwent TAVR with either TEE or ICE guidance. The possible confounders were adjusted through multivariable regression analyses. The evaluated outcomes included all-cause in-hospital mortality and complications such as atrial fibrillation, ventricular fibrillation, cardiogenic shock, acute kidney injury (AKI), stroke, and procedural complications. A p-value of <.05 was considered significant. Results: In a subpopulation of 9,248 patients, 85.9% (n=7,947) had TEE-guided and 14.1% (n=1,301) had ICE-guided TAVR. Majority of the population were males (57% vs 42%) and whites (87%) and the mean age group was 77 years. On unadjusted analysis, ICE-guided TAVR was associated with lower all-cause mortality (0.7% vs 1.7%, p=0.012), ventricular fibrillation (0.1% vs 0.9%, p=0.004), cardiogenic shock (1.3% vs 3.2%, p<0.0001), and AKI (6.7% vs 12.2%, p<0.0001). After adjustment, ICE-guided TAVR remained significantly associated with reduced odds of ventricular fibrillation (adjusted OR 0.22; 95% CI: 0.05–0.91; p=0.037), cardiogenic shock (aOR 0.48; 95% CI: 0.28–0.83; p=0.01), and AKI (aOR 0.65; 95% CI: 0.48–0.87; p=0.004) while the periprocedural complication rates including pericarditis, pericardial effusion and tamponade, pneumothorax, dissection and pacemaker implantation remained similar in both the groups. The ICE group had a mean length of stay that was 1.38 days shorter (2.65 vs 4.03 days, p<0.001), and the total hospitalization cost was significantly lower by $57,595 (ICE: $203,710 vs TEE: $266,105; p<0.001). Conclusions: ICE-guided TAVR was associated with favorable in-hospital outcomes, reflecting lower rates of ventricular fibrillation, cardiogenic shock, and AKI, as well as significantly shorter hospital stays and reduced costs, compared to TEE-guided TAVR.

Intracardiac Echocardiographic Guidance During Transcatheter Device Closure of Atrial Septal Defect and Patent Foramen Ovale

PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION UNDER INTRA-CARDIAC ECHOCARDIOGRAPHY GUIDANCE FROM THE LEFT ATRIUM

Transesophageal echocardiography (TEE) has been used for percutaneous atrial septal defect (ASD) closure, with intracardiac echocardiography (ICE) guidance recently being introduced. The Japanese Structural Heart Disease Registry was established by the Japanese Association of Cardiovascular Intervention and Therapeutics. This study analyzed data from the Registry for 2,859 consecutive cases undergoing percutaneous ASD closure between January 2015 and December 2020. ASD closure was performed under ICE guidance (n=519; 18.2%), TEE guidance (n=1,428; 49.9%), or TEE plus ICE guidance ("Both"; n=900 cases; 31.5%). The success rates were similar in the TEE, ICE, and both groups (99.0%, 99.2%, vs. 98.0%, respectively; P=0.054), as were complication rates (1.2%, 0.5%, vs. 2.1%, respectively; P=0.24). In the TEE and Both groups, 92.4% and 79.6% of patients required general anesthesia, compared with only 2.9% of patients in the ICE group (P<0.001). Fluoroscopic time was longer in the ICE and Both groups than in the TEE group (median [interquartile range] 19 [14-28] and 21 [13-30] vs. 12 [8-19] min, respectively; P<0.001). Rim deficiency and larger defect diameter were inversely related, whereas hospital volume was positively related to ICE guidance. Percutaneous transcatheter ASD closure was as feasible under ICE as under TEE guidance. ICE guidance is used for less challenging cases in high-volume centers in Japan.

Left atrial decompression (LAD) using transseptal puncture followed by balloon atrial septostomy recently has been described as a palliative minimally invasive procedure in dogs with advanced degenerative mitral valve disease (DMVD). We report herein the first use of intracardiac echocardiography (ICE) guidance combined with 3-dimensional transesophageal echocardiography (3D-TEE) to ensure the safety of the LAD procedure from a caudal approach, as performed in humans, in 2 American College of Veterinary Internal Medicine (ACVIM) stage C and D DMVD dogs (Jack Russell Terrier and Cavalier King Charles Spaniel) with recurrent episodes of acute pulmonary edema. Both LAD procedures were successful, as confirmed by markedly decreased systolic left atrial pressures (17 and 25 mmHg vs. 42 and 80 mmHg before LAD, respectively). Both dogs remained free of left-sided congestive heart failure signs for 8 and 10 months, respectively. The addition of ICE guidance to 3D-TEE is feasible and valuable in medium-sized dogs for safe LAD procedures.

Transcatheter closure of atrial septal defects (ASD) and patent foramen ovale (PFO) can be performed with transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) guidance, but data comparing both modalities in contemporary practice is lacking. Using ICD-10 codes, patients who underwent transcatheter ASD/PFO closure between 2016 and 2020 using ICE or TEE in the Nationwide Readmissions Database (NRD) were identified. Propensity-score matching was performed to compare in-hospital adverse events, length of stay (LOS), cost, and 30-day non-elective readmissions. A total of 964 patients underwent ASD/PFO closure with ICE (38.3 %, n = 369) or TEE (61.7 %, n = 595) between 2016 and 2020. Propensity score matching yielded 327 patients in each group, which were well balanced. Median (IQR) age was 59.0 (46.0, 72.0) years and 54.7 % were female. No difference was observed in the rate of in-hospital major adverse events between groups. ICE guidance was associated with a lower median cost (ICE $20,140.1 (14,622.3, 25,027.0) vs TEE $20,740.4 (14,137.5, 33,045.3), p < 0.04). In conclusion, ICE guided ASD/PFO closure was associated with lower hospitalization cost without increasing in-hospital adverse events when compared with TEE guidance.

CE-452771-1 IMPACT OF INTRACARDIAC VS. TRANSESOPHAGEAL ECHOCARDIOGRAPHY GUIDED LEFT APPENDAGE CLOSURE ON PROCEDURAL CHARACTERISTICS AND LAB EFFICIENCY: A META ANALYSIS

This registry aimed to describe the safety and feasibility of a single trans-septal (TS) access technique for left intracardiac echocardiography (ICE) guidance of left-atrial appendage (LAA) closure procedure. LAA closure is currently accepted as an alternative to oral anticoagulation (OAC) in patients with non-valvular atrial fibrillation (NVAF) who are at high-risk for bleeding. Currently, LAA closure procedure is typically performed under trans-esophageal echocardiogram (TEE) guidance. Although, ICE has the advantage of not requiring profound sedation/anesthesia, ICE-LAA imaging quality is often limited from the right atrium requiring double TS access. Twenty-two patients with NVAF underwent LAA closure using the Amplatzer Amulet™ device (St Jude Medical) under ICE guidance from the left atrium. The ICE AcuNav catheter (Biosense Webster) and the Amulet delivery sheath were advanced into the LA through single TS puncture technique. The population was predominately male (59.1%) with a mean age of 74 ± 9.3 years, at high-risk for stroke (mean CHADS2 score of 3.8 ± 1.1) and bleeding (mean HAS BLED score of 3.5 ± 1.3). The Amplatzer AmuletTM device was successfully implanted in all patients. No procedural related complications including device embolization were noted. No major cardiovascular events occurred and all patients were discharged alive. At 30-day follow-up all patients remained alive, free of ischemic stroke and with no residual leak or device thrombus on TEE. This initial experience suggests that LAA occlusion with the Amplatzer Amulet device using ICE guidance from the left atrium via a single trans-septal technique is feasible and safe.

In selected patient populations, percutaneous closure of patent foramen ovale has been shown to be beneficial in preventing cerebral ischaemic events. In most cases, this procedure requires echocardiographic guidance, which may be transesophageal, transthoracic or intracardiac. Intracardiac echocardiography (ICE) has the advantage of not requiring general anaesthesia but usually requires a second vascular access. The aim of this study was to evaluate the safety and efficacy of the single femoral vein puncture technique for double veinous access compared to conventional bilateral double puncture during patent foramen ovale (PFO) closure under intracardiac echocardiography (ICE) guidance. A retrospective study including all patients who underwent PFO closure under ICE guidance between January 2018 and April 2024 in University Hospital of Dijon, comparing the single puncture technique, defined as a single vascular hole for two sheaths, with those who underwent bilateral puncture. We collected baseline patient characteristics as well as intra- and post-procedural data, especially significant vascular complications (bleeding, false aneurysm, deep vein thrombosis, arteriovenous fistula) and procedural success (defined as successful placement of the prosthesis, meeting stability criteria, without embolization). In addition, patients were asked to rate the comfort of the procedure on a scale of 0 to 10 after the procedure. We analyzed 179 consecutive patients, of whom 126 received a femoral vein approach using the two-in-one technique and 53 received a bilateral femoral vein puncture. PFO closure was successful in all cases regardless of group. No tamponade, device migration, or death was observed during hospitalization. Vascular complication rate was comparable (3 (1.6%) vs. 2 (3.8%); p = 0.582). In addition, the single puncture technique was associated with an increased comfort score compared with the bilateral puncture technique (9.20 ± 1.55 vs. 8.44 ± 1.93; p = 0.044), shorter procedure time (40 min [32; 50] vs. 60 min [48; 70]; p < 0.001), hospital stay duration (0.82 ± 1.02 days vs. 2.04 ± 0.83 days; p < 0.001) and fluoroscopy time (5.71 min [4.28; 8.33] vs. 9.57 min [7.42; 13.11]; p < 0.001). The single femoral vein puncture technique for double femoral vein access is safe and effective for PFO closure under ICE guidance. It is also associated with increased patient comfort and reduced fluoroscopy time, although large multicenter studies are needed to confirm these results.

Intra-cardiac echocardiography guided trans-septal puncture in patients with dilated left atrium undergoing percutaneous transvenous mitral commissurotomy

Valve surgery is indicated and can be life-saving in patients with infective endocarditis (IE). We evaluated the impact of hospital valvular surgery volume on utilization and outcomes of surgery for IE. National Inpatient Sample (NIS) database was used for IE hospitalizations from 2008 to 2015. Hospitals were divided into quartiles based on valve surgery volume with quartile 1 (Q1) indicating lowest volume and quartile 4 (Q4) highest volume. Primary outcome was utilization of valve surgery in patients hospitalized with IE and secondary outcomes were in-hospital mortality and length of stay for IE patients undergoing valve surgery. Volume-outcome relationship was analysed both as categorical (quartiles) and continuous variable (restricted cubic splines). A total of 36 471 hospitalizations for IE were identified using the NIS database from 2008 to 2015 of which 17.33% underwent any valve surgery. Utilization rates of valve surgery for IE were significantly higher in Q4 hospitals (Q1: 6.73%; Q2: 10.39%; Q3: 14.91%; Q4: 2321%). Amongst the admissions for IE endocarditis undergoing valve surgery, there was no significant difference in in-hospital mortality when analysed as a categorical variable (as quartiles). However, when analysed as a continuous variable we note significant variation in outcomes across the Q4 hospitals, with highest volume centres having reduced mortality rates and length of stay. Hospital valvular surgery volume has direct impact on utilization and outcomes of surgery for IE. Given rising rates of IE and ongoing intravenous drug pandemic, there is need for regionalization of care for IE patients and development of 'endocarditis centres of excellence' for improved patient outcomes.

Transesophageal echocardiography (TEE) has been successfully used for guiding transcatheter device closure of secundum atrial septal defect (ASD) and patent foramen ovale (PFO). However, the use of TEE for device closure requires general anesthesia. Experience with intracardiac echocardiographic (ICE) guidance to close ASD and PFO is limited. One hundred eleven patients (76 female/35 male) with secundum ASD (82 patients) and PFO (29 patients) associated with a stroke underwent an attempt of transcatheter closure of their defects under ICE guidance using the new AcuNav catheter. The median age of patients was 40 years (range 2.5-80.7) and the median weight was 66 kg (range 12.7-128 kg). The median two-dimensional size of secundum defects as measured by ICE was 17 mm (range 3-32 mm). The median balloon stretched diameter of the ASDs was 22 mm (range 4-36 mm). Five patients had more than one defect that required placement of two devices to close the defects. The median Qp/QS ratio for patients with secundum ASD was 2.1 (range 1-18). ICE provided adequate views of the defects and surrounding structures and the various stages of device deployment. All patients had successful device placement, including the patients who received simultaneous two devices with immediate complete closure of the defects in 100 patients, whereas four and seven patients had trivial and small residual shunt, respectively. The median fluoroscopy time was 10.2 minutes (range 3.7-38.4 minutes) and the median total procedure time was 60 minutes (range 28-180 minutes). There were no complications related to the use of the AcuNav catheter. We conclude that ICE provided unique images of the atrial communications and facilitated device closure of secundum ASD and PFO in children and adults. We believe ICE should replace TEE as a guiding imaging tool for ASD and PFO device closure, thus eliminating the need for general anesthesia.

Periprocedural Outcomes of Fluoroscopy-Guided Patent Foramen Ovale Closure With Selective Use of Intracardiac Echocardiography

PO-03-165 INTRACARDIAC OR TRANSESOPHAGEAL ECHOCARDIOGRAPHY-GUIDED LEFT ATRIAL APPENDAGE OCCLUSION: CLINICAL PROTOCOL AND OUTCOMES