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Brain & Heart

REVIEW ARTICLE
Minimalist approach to left atrial appendage

occlusion through three-dimensional
intracardiac echocardiography: Procedural steps

and single-center experience

1
2
Ashok Chaudhary * , John Trovato , and Ragitha Subodh 1
1 Division of Cardiology, Rutgers Robert Wood Johnson Medical School, New Jersey, United States
of America
2 Rutgers Robert Wood Johnson Medical School, New Jersey, United States of America
(This article belongs to the Special Issue: Structural Heart Disease: Recent Updates)

Abstract

Atrial fibrillation (AF), the most prevalent arrhythmia worldwide, is associated with
an annual risk of ischemic stroke of up to 5%, with approximately 98% of thrombi
originating from the left atrial appendage (LAA). Direct oral anticoagulants or vitamin
K antagonists remain the gold standard for preventing systemic thromboembolism in
patients with AF. LAA occlusion (LAAO) is an alternative stroke prevention technique
for patients with AF who cannot tolerate long-term anticoagulation. Percutaneous
LAAO typically employs a multimodal imaging approach with contrast fluoroscopy
*Corresponding author:
Ashok Chaudhary and transesophageal echocardiography (TEE) for visualization, device selection and
(ashok.chaudhary@rutgers.edu) deployment, and complication monitoring. TEE is also used for follow-up imaging.
Citation: Chaudhary A, Trovato J, However, it necessitates general anesthesia or deep sedation and is associated with
Subodh R. Minimalist approach a high risk of adverse events. Three-dimensional intracardiac echocardiography
to left atrial appendage occlusion (3D ICE) has been proposed as a viable alternative to TEE for LAAO procedures. In
through three-dimensional
intracardiac echocardiography: this review, we summarized the current evidence regarding ICE guidance in LAAO
Procedural steps and single- procedures. We also presented a case series of consecutive patients presenting at
center experience. Brain & Heart. our center who underwent LAAO, which was performed by a single operator using a
2024;2(4):4018.
doi: 10.36922/bh.4018 minimalist approach of moderate sedation, 3D ICE, and same-day discharge. We also
presented a summary of the minimalist approach to LAAO using 3D ICE and detailed
Received: June 22, 2024 procedural steps of 3D ICE catheter manipulation for successful LAAO intervention.
Accepted: August 30, 2024
Published Online: October 18, 2024 Keywords: Left atrial appendage occlusion; Intracardiac echocardiography;
Copyright: © 2024 Author(s). Transesophageal echocardiography; Watchman; Atrial fibrillation; Stroke; Oral
This is an Open-Access article anticoagulation
distributed under the terms of the
Creative Commons Attribution
License, permitting distribution,
and reproduction in any medium,
provided the original work is 1. Introduction
properly cited.
1.1. Advantages and limitations of intracardiac echocardiography (ICE)
Publisher’s Note: AccScience
Publishing remains neutral with guidance in left atrial appendage occlusion (LAAO) procedures
regard to jurisdictional claims in
published maps and institutional The ICE-guided LAAO procedure can be performed with moderate sedation, eliminating
affiliations. the risks associated with general anesthesia and endotracheal intubation, which are

Volume 2 Issue 4 (2024) 1 doi: 10.36922/bh.4018