Technology concept
Needless to highlight that adequate pre-procedural planning,
intraprocedural imaging is of great importance throughout all phases of
the implantation procedure for LAAO, especially for evaluation of the
left atrial appendage (LAA) anatomy and guidance of device implantation.
Intraprocedural imaging is critical to rule out thrombus, re-assess size
of the LAA ostium, landing zone, length, number of lobes and shape.
Furthermore, imaging is pivotal in guiding trans-septal puncture within
a specific region of the fossa ovalis, sheath placement, device
placement, and assessment of device stability, post-placement leak
evaluation and procedural complications. Despite technology evolution,
angiography remains an important intraprocedural step, but it alone has
several limitations for detailed guidance of LAAO. Then, transesophageal
echocardiography (TEE) has been the gold standard imaging modality for
LAAO since most interventional cardiologists are familiar with
technique. It provides high definition images of the right and left
atrium, interatrial septum and LAA anatomy. In addition, modern TEE
technology provides reliable 3D imaging. Nevertheless, important
limitations exist such as the need for general anesthesia or conscious
sedation, contraindications to TEE (such as esophageal varices), a
dedicated TEE operator as well as interference with fluoroscopy. This
has recently led to the use of Intracardiac echocardiography (ICE) as an
alternative to TEE for guiding LAAO (2,3). Recent data show that ICE is
non-inferior to TEE for guiding LAA occlusion procedures in terms of
procedural success, peri-procedural complications and embolic events at
follow-up (4,5). A recent meta-analysis including a total of 1,122
patients confirmed similar procedural success rate with a trend for less
procedure-related complications in the ICE group and lower volume of
contrast media used in the ICE group (6)