2.2 LAAC with ICE imaging
LAAC with ICE imaging was performed under local anesthesia without
conscious sedation. Double right femoral vein access was obtained with
an 11F 20-cm Terumo sheath (Terumo Europe, Leuven, Belgium) for
introducing the
10F
ICE catheter (Sound-Star, Biosense Webster, Diamond Bar, CA) and another
8.5F Swartz long sheath (SL1; AF Division, SJM, Minneapolis, MN). The
geometry map of the left atrium (LA) including LAA was created by ICE
probe manipulation at the right median atrial septum and at the coronary
sinus ostium under CARTO3 three-dimensional mapping system (Biosense
Webster, Inc). Shortly after successful ICE-guided transseptal puncture
with a needle (BRK, SJM), a 6F pigtail catheter was advanced to the LAA
to perform LAA angiography, with LA pressure≥12mmHg, at right anterior
oblique and caudal projections. The angiographic diameters of LAA ostium
and landing zone then were measured. After the pigtail catheter was
removed, a guidewire was inserted through Swartz sheath to the left
superior pulmonary vein (LSPV) under the ICE guidance. The Swartz sheath
was further exchanged with a 10F delivery sheath to pre-dilate the
transseptal puncture site. Then the delivery sheath was retracted into
the
inferior vena cava to allow the ICE catheter advance into LA through the
same site which was tagged on the CARTO-Sound image guided by CARTO3
system without the need of any fluoroscopic guidance. The
echocardiographic LAA ostium and landing zone diameters were measured
using the “FLAVOR (F our L ong-A xisV iews a round Or ifice)” approach at 90°,
135°, 0° and 45° (Fig. 1 and 2). The 10F delivery sheath was advanced
again to the LA over the guidewire placed in LSPV through the same
transseptal puncture site with caution. The appropriate size of LAmbre
device was selected based on both angiographic and echocardiographic
measurements. Guided by fluoroscopy and ICE, the umbrella of the device
was fully deployed at the landing zone by pushing the delivery cable,
and the cover of the device was then deployed at the LAA ostium by
unsheathing the delivery catheter. The position of the device and the
degree of residual flow were assessed with ICE (Fig. 2). The device was
released when the COST criteria (including Umbrella deployed beyondC ircumflex artery; Umbrella was fully O pen;
Peri-device optimal S ealing (leak ≤ 3mm); Device stability
confirmed by T ug test) were met and the cover of the device had
no impingement on mitral valve and/or pulmonary vein ostium. Otherwise,
recapture and/or resizing of the device would be attempted. Additional
ICE assessment with ” FLAVOR ” approach would be performed after release
of the device.
2.3 “FLAVOR” (F our L ong-A xis V iews
around Or ifice) approach
The constructed LA geometry map at the antero-posterior projection was
adjusted rightward and upward until LAA orifice was adequately exposed.
The ICE probe was manipulated with caution to achieve the proposed 4
imaging planes (the angle between adjacent imaging planes was
approximately 45°) for comprehensive evaluation of the LAA or device.
Each plane was adjusted to show the long-axis view of LAA or the device.
The ICE probe was initially advanced to the top of LA with slight
posterior flexion to obtain the first view (similar to the TEE 90°
view), which we defined as the 90°
view. The second view (similar to the TEE 45° view) could be achieved
through right and ante-flexion (R+A flex) of the ICE probe. The ICE
probe was usually placed outside the left upper pulmonary vein ostium,
and we defined as the 135° view. Next, the ICE probe was usually
positioned between the left upper and lower pulmonary veins on the LA
posterior wall to form the third view (similar to the TEE 0° view) by
further rightward flexion (R flex), and we defined as the 0° view.
Finally, the ICE catheter was rotated anticlockwise and advanced to
mitral isthmus or across the mitral valve with posterior flexion to form
the fourth view (similar to the TEE 135° view),which we defined as the
45° view. This systematic approach allowed comprehensive evaluation of
LAA or devices mimicking TEE echo windows (Fig. 1 and 2).
2.4LAAC
with TEE imaging
LAAC with TEE imaging also was performed under local anesthesia without
conscious sedation. Transseptal puncture was performed with the 8.5F
Swartz long sheath and transseptal puncture needle placed via right
femoral venous access under fluoroscopic guidance. Then, a 6F pigtail
catheter was inserted along the Swartz sheath for LAA angiography at the
right anterior oblique and caudal projections. The sizes of the landing
zone and the orifice were measured. The appropriate device size was
selected according to the intraoperative angiographic and preoperative
echocardiographic measurements and the device was implanted as
aforementioned. Multi-planar TEE imaging (0º,45º,90º and 135º) under
local laryngeal anesthesia with tetracaine were performed until no
significant peri-device leak was detected by multi-projection
cineangiography and the stability was confirmed by tag test. The device
would only be released when COST criteria were met. TEE exams were
performed by two experienced echocardiographers.