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)