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

Table 1. Baseline characteristics The patients were scheduled for a follow-up cardiology
appointment at 6 weeks, which included either cardiac
Demographics TEE and 3D ICE CTA or TEE. For Group 1, the preferred imaging strategy
3D ICE at the 6-week follow-up was TEE; however, two patients
(n=7) (n=13) underwent cardiac CTA. Meanwhile, for Group 2, cardiac
Age (years) 77.4±9.0 73.0±12.1 CTA was recommended at follow-up instead of TEE;
Sex, n (%) however, two patients underwent TEE. Follow-up imaging
Male 3 (42.9) 10 (76.9) was either pending or unavailable for two patients (one
Female 4 (57.1) 3 (23.1) from each group).
Race, n (%) 2.1. Procedural steps for LAAO under the guidance
White 3 (42.9) 7 (53.8) of Nuvision 4D ICE probe
Black or African American 0 (0.0) 5 (38.5) 2.1.1. Insertion into the RA
Asian 2 (28.6) 1 (7.7)
Other 2 (28.6) 0 (0.0) a. Obtain USG-guided common femoral vein access
Smoking status, n (%) using a micropuncture needle
b. Insert a 12F 30-cm Cook sheath into the inferior vena
Current 0 (0.0) 0 (0.0) cava (IVC), ensuring that the 0.035′′ wire remains in
Former 4 (57.1) 4 (30.8) place for facilitating “fluro-map” easy navigation into
Never 3 (42.9) 8 (61.5) the RA (Figure 1A)
Unknown 0 (0.0) 1 (7.7) c. Advance the ICE probe to the RA by rotating the
Other risk factors entire probe clockwise or counterclockwise, ensuring
CHA DS -VASc score 5.1±1.1 4.3±0.9 that the IVC remains visible on top of the image
2
2
throughout the procedure
HAS-BLED score 4.7±1.1 4.4±0.9 d. It may be necessary to apply a slight anterior inclination
CHF (%) 2 (28.6) 6 (46.2) to the deflection knob to remain in the IVC, especially
Hypertension (%) 6 (85.7) 13 (100) if entering from the left side and before entering the RA.
Diabetes mellitus (%) 3 (42.9) 7 (53.8) This is performed to prevent entering the hepatic veins
History of stroke/TIA/SE (%) 4 (57.1) 5 (38.5) and avoid the Eustachian ridge at the IVC/RA junction
Vascular disease (%) 3 (42.9) 1 (7.7) e. Upon reaching the mid-RA (facing the tricuspid valve
Abnormal renal function (%) 1 (14.3) 5 (38.5) [TV]), return to the home view.
Medication usage predisposing to bleeding (%) 6 (85.7) 9 (69.2) 2.1.2. ICE views in mid-RA
Alcohol (%) 0 (0.0) 1 (7.7) a. The following structures can be visualized by
Notes: CHA2DS2-VASc is the tool to estimate the annual risk of performing a gradual clockwise rotation of the probe.
stroke in atrial fibrillation patients and includes CHF, hypertension, Alternatively, this can be accomplished by gradually
age, diabetes mellitus, history of stroke or TIA, vascular disease
and sex; HAS-BLED is a tool to estimate annual risk of bleeding in rotating the tip rotation knob
atrial fibrillation patients taking oral anticoagulants and includes b. Home view with the right atrium (RA), TV, and right
hypertension, abnormal renal/liver function, stroke, bleeding history or ventricle (RV) in view (Figure 2A)
predisposition, labile INR, older age (>65 years) and drugs/alcohol use c. TV, coronary sinus, pulmonic valve, aortic valve
concomitantly. d. Mitral valve (MV), LAA (Figure 2B)
Abbreviations: TEE: Transesophageal echocardiography;
3D ICE: Three-dimensional intracardiac echocardiography; e. Interatrial septum (IAS)
TIA: Transient ischemic attack; SE: Systemic thromboembolism. f. Left upper and lower pulmonary veins (PVs) (Figure 2C)
g. Once past the esophagus and descending aorta, the
Watchman FLX was used for LAA occlusion in all cases. right upper and lower PVs can be visualized. It may be
Notably, four patients in the 3D ICE Group 2 had no pre- necessary to slightly advance the probe to visualize the
procedural imaging data available. Table 2 provides a upper right PV (Figure 2D)
summary of the minimalistic approach to LAAO, which is h. Return to the neutral home view
conducted at our center using a 4D Nuvision ICE catheter 2.1.3. ICE views in RV
(Biosense Webster).
a. Lower the probe into the RA
All patients underwent post-procedural echocardiography b. While maintaining the TV in view, apply an anterior
either the same day or the following day before discharge. tilt (clockwise rotation of the deflection knob) until

Volume 2 Issue 4 (2024) 3 doi: 10.36922/bh.4018