PO-03-164 FEASIBILITY OF GADOLINIUM CONTRAST FLUOROSCOPY TO FACILITATE WATCHMAN FLX IMPLANTATION USING INTRACARDIAC ECHOCARDIOGRAPHY

Abstract

In patients with non-valvular atrial fibrillation, left atrial appendage closure (LAAC) is an alternative to oral anticoagulation for stroke-risk reduction. The standard imaging used during LAAC procedures is transesophageal echocardiography with iodinated contrast media. The recent worldwide supply chain shortage in April 2022 resulted in a global shortage of these contrast agents, limiting the ability to perform LAAC. Alternatives to iodinated contrast agents are needed to combat the impact of the contrast shortage on patient care. Limited published experience has shown effective use of IV gadolinium contrast for coronary angiography. We sought to validate the use of gadolinium contrast for LAAC in lieu of iodinated contrast agents. Thirty consecutive patients referred for LAAC underwent Watchman FLX implant with intracardiac echo (ICE) using gadolinium (Gadovist) for intra-procedural LAA angiography and device assessment prior to device release. Ultrasound imaging was performed with an 8 Fr. ICE catheter (AcuNav). Light sedation was used. Patients were managed with antithrombotic therapy for 12-weeks post implant with CT imaging at 4 months. Of the total cohort of 32 patients, two were excluded for creatinine clearance < 30 mL/min. The 30 remaining patients had successful closure of the LAA with no peri-device leaks (PDL) using an average of 11 mL (10-15) gadolinium contrast and ICE imaging. The workflow consisted of a pigtail angiogram of the LAA using 5 mL gadolinium with the remainder used through the Watchman delivery sheath post-deployment to visualize the tug test and assess for PDL. ICE verified Watchman FLX position at multiple angles. Procedure time was 42 min (30-59) with an average of 1.5 deployments per case (1-3). At 4 months, 26 (87%) had complete closure (20 by CT, 6 by TEE). Four patients had a PDL of 1.5 mm (1-3 mm) by CT. No device-related thrombus was noted. There were no complications noted during the first 4 months post implant. Gadolinium contrast may be used as an alternative to iodinated contrast agents for LAA angiography to facilitate Watchman FLX implantation with ICE with both efficacy and safety. Operators should have sufficient experience with Watchman FLX LAAC to minimize the need for multiple angiographic views and use ultrasound imaging to assess for PDL. Gadolinium contrast can be a valuable option during efforts to conserve IV iodinated contrast, but also for patients with iodinated contrast allergy.