Intracardiac echocardiography-guided left atrial appendage occlusion: The path to independence.

INTRODUCTION AND OBJECTIVES: Transesophageal echocardiography (TEE) has been the standard method for guiding left atrial appendage occlusion (LAAO) procedures. Recently, intracardiac echocardiography (ICE) has emerged as an alternative to TEE due to several advantages, particularly the avoidance of general anesthesia. This analysis aims to assess the safety, feasibility and efficacy of ICE-guided LAAO procedures. METHODS: We performed a retrospective analysis of ICE-guided LAAO procedures, including a comparison of embolic and bleeding events with the predicted standard scores and a comparison with TEE-guided procedures. RESULTS: A total of 88 patients underwent echocardiography-guided percutaneous LAAO (43 patients with TEE and 45 with ICE), mean age 74.9 years, 68.2% male. In the ICE-guided population, the technical success rate was 93% and the major complication rate was 8.8%. During follow-up, yearly stroke and major bleeding rates were 1.4% and 8.4%, respectively, compared to the 4.0% and 8.7% predicted by the CHA2DS2-VASc and HAS-BLED scores. In the TEE versus ICE analysis (similar baseline characteristics), no statistically significant differences were seen regarding technical success (95.3% vs. 93.3%), procedure-related complications (14.0% vs. 8.9%), device thrombus (2.3% vs. 0%), residual minor peridevice leaks (14.0% vs. 24.4%), one-year all-cause mortality (9.3% vs. 4.4%), stroke (9.3% vs. 2.2%) or major bleeding events (9.3% vs. 11.1%). CONCLUSION: ICE-guided LAAO was a safe and effective therapeutic strategy in a high embolic and bleeding risk population, compared to the event rates predicted by the CHA2DS2-VASc and HAS-BLED scores. The ICE-guided procedure compared well to TEE-guided procedures regarding procedure feasibility, safety, and efficacy.

Uso de ecocardiografía intracardiaca para cierre percutáneo de foramen ovale permeable / Use of intracardiac echocardiography for percutaneous closure of patent foramen ovale

Objetivo: determinar la utilidad del ecocardiograma intracardiaco como ayuda para la implantación de dispositivo de cierre percutáneo de foramen ovale permeable. Material y métodos: se expone el caso de un paciente de género masculino, de 38 años de edad, con antecedentes de isquemia cerebral transitoria, diagnosticada un año antes, quien presentó cuadro de accidente cerebrovascular isquémico criptogénico y se le detectó foramen ovale permeable por ecocardiograma transesofágico. Se candidatizó para cierre percutáneo con dispositivo de cierre tipo Amplatzer, y se programó el procedimiento con ecocardiograma intracardiaco mediante sonda AcuNav para guiar la colocación del Amplatzer, junto con el ecocardiograma transesofágico tradicional requerido en estos casos. Resultados: se realizó cierre del foramen ovale permeable mediante la técnica aceptada, guiado por ecocardiografía intracardiaca y se verificó mediante angiografía y ecocardiograma transesofágico. Se obtuvieron imágenes de la anatomía cardiaca mediante ecocardiograma intracardiaco en tiempo real sin interferencia, con lo cual pudo hacerse el implante del dispositivo en forma rápida y adecuada. Se corroboró su correcta implantación a través de angiografía y ecocardiograma transesofágico. En este caso, el procedimiento de cierre percutáneo con dispositivo de Amplatzer fue exitoso, rápido y sin complicaciones. Conclusiones: el ecocardiograma intracardiaco es útil para guiar la implantación de dispositivos de cierre del foramen ovale permeable así como en casos de comunicación interauricular. Es una técnica fácil y segura. La introducción de la sonda de ecocardiograma intracardiaco, su manipulación y su posicionamiento en el atrio derecho fueron rápidos y sencillos. Se obtuvieron imágenes adecuadas con una buena identificación de las estructuras del septum que permitieron el cierre exitoso del foramen ovale permeable con dispositivo tipo Amplatzer. Según esta investigación, en la literatura no se reporta el ecocardiograma intracardiaco como ayuda para guiar este procedimiento, por lo que se considera que pudiera ser el primer caso realizado en Colombia. De otra parte, se hace necesario el uso más generalizado de la sonda intracardiaca para realizar ecocardiograma intracavitario e implementarlo en lugar del ecocardiograma transesofágico como guía para cierre de comunicación interauricular y foramen ovale permeable. Es conveniente llevar a cabo más estudios que permitan valorar mejor esta ayuda que puede suprimir la necesidad del ecocardiograma transesofágico en estos pacientes y a su vez el requerimiento de anestesia general para estos procedimientos.

Objective: to determine the utility of intracardiac echocardiography to assist in the implantation of the device for percutaneous closure of patent foramen ovale. Material and methods: we report the case of a 38 years old male patient with a history of transient cerebral ischemia diagnosed a year earlier, who presented a clinical picture of ischemic cryptogenic stroke. A transesophageal echocardiogram showed a patent foramen ovale. He was scheduled for percutaneous closure of the patent foramen ovale with Amplatzer closure device, and the procedure was programmed with intracardiac echocardiography probe through AcuNav to guide the placement of the Amplatzer, along with the traditional TEE required in these cases. Results: we performed foramen ovale closure using the accepted technique, guided by intracardiac echocardiography and verified by angiography and transesophageal echocardiography. We obtained images of cardiac anatomy using intracardiac echocardiography in real time without interference, which made possible the implant of the device quickly and appropriately. Proper implementation was confirmed by angiography and transesophageal echocardiography. In this case, the procedure of percutaneous closure with Amplatzer device was successful, fast and without complications. Conclusions: intracardiac echocardiography is useful to guide the implantation of devices for closure of patent foramen ovale as well as in cases of atrial septal defect. This technique is easy and safe. The introduction of intracardiac echocardiography catheter, its handling and positioning in the right atrium were quick and easy. Adequate images were obtained with a good identification of the structures of the septum that allowed the successful closure of the foramen ovale with Amplatzer device. According to this research, the literature does not report intracardiac echocardiography as an assistance to guide this procedure, so that we believe this may be the first case performed in Colombia. Moreover, it is necessary a more widespread use of intracardiac catheter for intracavitary echocardiography and implement it instead of transesophageal echocardiography as guide for closure of atrial septal defect and patent foramen ovale. It is convenient to carry out more studies to better assess this assistance which may eliminate the need of transesophageal echocardiography in these patients and in turn the requirement of general anesthesia for these procedures.