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

Abstract

Percutaneous left atrial appendage (LAA) occlusion is commonly performed under general anesthesia and trans-esophageal echocardiography (TEE) guidance. Experience is limited with LAA occlusion under intra-cardiac echocardiography (ICE) guidance. Previously ICE guidance for LAA occlusion has been performed from the right atrium or coronary sinus where visualization of the LAA anatomy is uncertain. Our goal was to evaluate the feasibility, efficacy and safety of LAA occlusion using ICE guidance from the left atrium (LA) under local anesthesia and conscious sedation. Twenty-three consecutive patients (mean age 75 IQR 65-85) with atrial fibrillation, high risk of thromboembolic complications (CHA2DS2VASc score ≥ 2) and long term contra-indication to anticoagulation underwent LAA closure with the Amplatzer Cardiac Plug (ACP)TM (St.Jude Medical Inc.) under conscious sedation and ICE guidance. The ICE catheter (8-Fr Acunav, Biosense Webster Inc.) and ACP delivery sheath were advanced into the LA through separate transseptal punctures. Baseline patient characteristics, procedural and follow-up data were prospectively recorded. Clinical and TEE follow-up was performed 3 months after the procedure. Procedural success was defined as the implantation of the closure device at the intended delivery site with adequate occlusion (grade 3 or more by angiography and ICE). Mean CHADSVASC and HASBLED scores were respectively 4.4±1.4 and 3.5±0.8. Procedural success was achieved in 22 of 23 patients (96%) with a mean procedural time was 105±27 minutes. There were no major procedural complications. The only failure was due to challenging “chicken wing” LAA anatomy where an adequate device position could not be secured. Median hospital stay was 1 day. In all cases, ICE provided adequate procedural guidance, closure assessment and LAA and device visualization, including their relation with adjacent structures (figure 1). Best appreciation of the LAA anatomy was achieved with the ICE catheter placed in a mid-LA location or just above the mitral plane. There were no lost to follow-up. Two patients died of causes not related to the procedure or device. Three-month TEE (n = 20) showed complete LAA exclusion in all but one patient. Initial experience suggests LAA occlusion with the Amplatzer Cardiac PlugTM under ICE guidance from the left atrium in conscious patients is feasible, reproducible and safe.