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Brain & Heart Step by step 3D ICE guided LAA occlusion

required for the transesophageal echocardiography (TEE)- images are visually striking, the main advantage of 3D
guided LAAO procedure. However, TEE is associated with ICE is its ability to digitally rotate the imaging plane, a
major risks. The insertion and manipulation of a TEE probe feature similar to TEE that enables a complete 360° view
during examination can result in various complications, of the left atrial appendage (LAA). By utilizing this digital
ranging from lip pressure injuries, oral mucosal damage, rotation, multiple LAA measurements can be recorded and
dental injuries, and temporomandibular joint dislocation the implanted device can be thoroughly inspected before
to visceral perforations. Although most of these injuries release, thereby minimizing the need for extensive probe
1
affect the upper gastrointestinal tract, respiratory and maneuvering in the left atrium (LA). However, ICE-
9,13
other abdominal complications have been reported guided LAAO may add extra workload on the operator,
occasionally. Although several TEE-related complications who must handle both the procedure and the task of
1
are minor and frequently remain unreported, a few obtaining images. This can be particularly challenging
9,14
complications can be more severe, resulting in significant for less experienced operators. However, with structured
morbidity and even mortality. For instance, esophageal training, even the least experienced operator can become
perforation during TEE examination is a rare but serious more proficient in a relatively short time. Most LAAO
complication, with a incidence of 0.01 – 0.38%. During procedures under ICE guidance can be performed through
TEE probe manipulation, mechanical, compressive, and a single transseptal puncture, although a second transeptal
thermal injuries may cause gastrointestinal bleeding. 1 puncture (TSP) may occasionally be necessary to facilitate

Most patients undergoing structural heart interventions the passage of the ICE catheter into the LA. It remains
sustain some form of TEE-associated injury, with prolonged controversial whether this method can increase the
procedural duration and poor or suboptimal image quality incidence of iatrogenic atrial septal defect (iASD). A study
contributing to a higher risk. The mechanism underlying by Ma et al. indicated that 21.4% of patients developed
esophageal and gastric injuries is likely multifactorial, iASD after 2 months of ICE-guided LAAO, with a 70.6%
which includes direct mechanical injury due to blind probe closure rate achieved at 12 months. Although the iASD size
insertion and manipulation, contact pressure from the probe, was larger than that reported in other guidance methods,
and thermal injury. Prolonged image acquisition times and ICE-guided LAAO did not increase the risk of persistent
patients’ underlying comorbidities further exacerbate such iASD, pulmonary hypertension, or other complications,
injuries. Esophagogastroduodenoscopy can detect TEE- and there were no cases of right-to-left shunt. 15
2
related lesions in up to 86% of patients undergoing structural
cardiac interventions. Of these patients, 40% experience 2. Baseline characteristics
complex lesions such as hematomas or lacerations. Most We conducted a retrospective analysis of 20 consecutive
of these lesions are not detected during routine clinical patients who underwent LAAO at a single center (in New
evaluations and may only manifest as discomfort. Jersey) between October 19, 2023, and June 14, 2024.
3,4
The incidence of clinically detected major TEE-related All patients exhibited elevated CHA2DS2-VASc and
complications in patients undergoing high-risk structural HAS-BLED scores, making them unsuitable for long-
procedures, including LAAO, has been reported to be 6.1%. term anticoagulation. The LAAO procedure for the first
3
In structural heart procedures, TEEs are performed by highly seven patients (Group 1) was performed under both TEE
skilled echocardiographers with a minimum of 1 year of guidance and 3D ICE guidance (the primary operator
experience; however, despite such expertise, >80% of patients was blinded to the measurements obtained on TEE).
experience complications following TEE. In addition, TEE The LAAO procedure for the subsequent 13 patients
1,5
has certain limitations, as it cannot be performed in up to (Group 2) relied solely upon 3D ICE guidance. The mean
2% of patients due to anatomical constraints, high-risk age of patients was 74.6 ± 11.1 years, and most of them
conditions, or a lack of cooperation. In addition to enhancing (65%) were male. The mean CHA2DS2-VASc score was
6
patient comfort and satisfaction, ICE improves the efficiency 4.6 ± 1.0, and the mean HAS-BLED score was 4.5 ± 0.9
and safety of structural heart procedures. The three- (additional demographic data are provided in Table 1).
4,7
dimensional (3D) ICE-guided procedure enables a single Although pre-procedural imaging was not required, some
operator to complete the procedure, eliminating the need for patients who underwent LAAO procedures under 3D ICE
multiple personnel in the laboratory. 6,8,9 Furthermore, ICE guidance alone were subjected to pre-procedural imaging
guidance reduces the time required by experienced operators using cardiac computed tomography angiography (CTA)
to perform fluoroscopy and improves procedural scheduling to evaluate appendage anatomy and rule out the presence
by using fewer medical specialties. 10-12 of LAA thrombus. We also employed FEops software
The introduction of 3D ICE enhances the capabilities to evaluate appendage anatomy and perform predictive
of ICE guidance in LAAO procedures. Although 3D simulations of the LAAO device in eight of these patients.
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Volume 2 Issue 4 (2024) 2 doi: 10.36922/bh.4018