Po-05-106 three-dimensional intracardiac echocardiography to guide left atrial appendage and peri-device leak closure: feasibility of right-sided imaging

Recent studies have indicated that intracardiac echocardiography (ICE) serves as a safe and effective imaging modality in guiding left atrial appendage closure (LAAC). ICE has advantages over transesophageal echocardiography including reduced procedural sedation and attendant complications, oropharyngeal/esophageal injury risks and need for a secondary operator - leading to improved workflow and potentially safety. However, ICE imaging is typically performed by placing the catheter directly in the left atrium (LA). Recently, a three-dimensional (3D) ICE catheter was developed that performs multiplanar reconstruction with improved anatomical sizing potential. The feasibility and outcomes of ICE guided device implantation in non-standard positioning such as the coronary sinus (CS) is not well studied. To assess the feasibility and procedural characteristics of 3D ICE guided LAAC, with a goal for right-sided imaging. We conducted a 2-center retrospective review for patients undergoing LAAC or peri-device leak closure guided by 3D ICE (and fluoroscopy). The 3D ICE catheter (Nuvision; Biosense-Webster Inc.) was first preferentially positioned in the CS and right ventricular outflow tract to the level of pulmonary artery (PA); if CS access was not possible, the ICE catheter was then maneuvered through the transseptal puncture into the LA. The ICE catheter guided anatomical evaluation, sizing and device deployment. The patient cohort (n=89 patients; mean age 77 years; female 35 patients; mean CHA2DS2-VASc 4) underwent either implantation of Watchman Flx (n=62) or Amulet (n=13), peri-device leak closure with coils and/or plugs (n=14); all (100%) were successful. Right-sided positioning of the 3D ICE catheter (CS or PA) was utilized in 69%; the remaining (31%) required LA positioning. No device dislodgement or retraction occurred. The 3D ICE catheter proved to be a feasible and safe imaging tool to guide LAAC procedures, including coiling/plugging of peri-device leaks. There was sufficient spatial and axial resolution when the catheter was positioned in the CS or PA to assess anatomy and guide device deployment. Importantly, in two-thirds of the cohort, right-sided visualization was adequate without a need for direct left atrial imaging.