Background: Simultaneous atrial fibrillation (AF) catheter ablation and left atrial appendage closure (LAAC) is sometimes recommended for both rhythm control and stroke prevention. However, the advantages of intracardiac echocardiography (ICE) guidance for this combined procedure have been scarcely reported. To evaluate the clinical outcomes and safety of ICE guided LAAC within a zero-fluoroscopy catheter ablation procedure. Methods and Results:From April 2019 to April 2020, 56 patients with symptomatic AF underwent concomitant catheter ablation and LAAC. ICE with a multi-angled imaging protocol mimicking the TEE echo windows was used to guide LAAC. Successful radiofrequency catheter ablation and LAAC was achieved in all patients. Procedure-related adverse event rate was 3.6%. During the 12-month follow-up, 77.8% of patients became free of arrhythmia recurrences and oral anticoagulants were discontinued in 96.4% of patients. No ischemic stroke occurred despite two cases of device-related thrombosis versus an expected stroke rate of 4.8% based on the CHA2DS2-VASc score. The overall major bleeding events rate was 1.8%, which represented a relative reduction of 68% versus an expected bleeding rate of 5.7% based on the HAS-BLED score of the patient cohort. The incidence of iatrogenic atrial septal defect secondary to a single transseptal access dropped from 57.9% at 2 months to 4.2% at 12 months TEE follow-up. Conclusion:The combination of catheter ablation and LAAC under ICE guidance was safe and effective in AF patients with high stroke risk. ICE with our novel protocol was technically feasible for comprehensive and systematic assessment of device implantation.

Introduction: We aimed to investigate whether a modified implantation method facilitating a fully open umbrella can reduce the pericardial effusion/pericardial tamponade (PE/PT) rate after left atrial appendage closure (LAAC) with the LAmbre device compared with the conventional method (CM) in patients with non-valvular atrial fibrillation (NVAF). Methods and results: Patients with NVAF who received either isolated LAAC or combined catheter ablation and LAAC using the LAmbre device at the First Affiliated Hospital of Wenzhou Medical University from January 2018 to December 2019 were enrolled. CM was used for device implantation in the initial 59 patients, while a modified method (MM) was used in the remaining 165 patients. Successful implantation was achieved in 98.3% of patients in the CM group and in 98.8% in the MM group. A higher rate of a fully open umbrella (98.8% vs 69%, P<0.001), less requirement for recapture (46% vs 62.1%, P=0.036), and a lower incidence of delayed PE/PT (1.2% vs 8.6%, P=0.005) were found in the MM group compared with in the CM group. All of the five delayed PT events occurred in patients with combined treatment. An umbrella that was not fully open was the only factor associated with delayed PE/PT events in a multivariable Cox model. Conclusions: LAAC with the LAmbre device using an MM significantly increases the rate of a fully open umbrella and decreases the requirement for recapture and the incidence of delayed PE/PT. This method is more effective in patients with combined treatment.

Introduction: Transesophageal echocardiography (TEE) fails to display optimal views to guide left atrial appendage closure (LAAC) procedure in some patients due to atrio-esophageal anatomical limitation. We aimed to investigate if intracardiac echocardiography (ICE) conducted from left atrium (LA) achieves comparable multi-planar views and clinical outcomes as TEE during LAAC. Methods and Results: This study prospectively enrolled 102 consecutive patients with non-valvular atrial fibrillation receiving LAmbre implants under local anesthesia at the First Affiliated Hospital of Wenzhou Medical University from August 2018 to July 2019. The procedures were guided by either ICE (n=40), TEE (n=50) or combined ICE-TEE (n=12). A novel multi-angled “FLAVOR” approach was used in ICE group for assessment. ICE allowed visualization of implanted device in all patients at all proposed angles with long-axis views, while TEE failed to do so in at least one of the angles in 36% of cases. In the combined ICE-TEE cohort, TEE failed peri-device leak assessment in 2 patients. Rates of procedural success, recapture, resizing and complications were similar between ICE and TEE groups. Fluoroscopy time, radiation dose and volume of contrast use in ICE group were significantly lower than the TEE cohort. At 45-day TEE follow-up, rate and degree of peri-device leaks were similar between the ICE and TEE groups. Conclusions: A systematic approach using ICE to guide LAmbre LAA occlusion was safe and feasible. This method was more reliable in comprehensive, multi-angled imaging assessment, and achieving shorter fluoroscopy time, lower radiation dose and less contrast use than TEE.