Featured ArticleLeft atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations
Introduction
Atrial fibrillation (AF) is one of the most common arrhythmias, affecting millions of people in the United States each year.1 AF-related stroke is effectively prevented with oral anticoagulation.2 A narrow therapeutic window, risk of bleeding, noncompliance, and the recognition of the left atrial appendage (LAA) as a major site of thrombus formation have led to the development of LAA closure (LAAC) techniques. Randomized trials have validated the Watchman device (Boston Scientific, St Paul, MN) as a viable alternative to oral anticoagulation.3, 4 In these trials, the Watchman device implant procedure was designed to be performed under transesophageal echocardiography (TEE) and fluoroscopy guidance. TEE guidance commonly leads to the need for general anesthesia (GA) and carries additional risks, including esophageal lesions and aspiration, along with patient inconvenience and increased complexity of procedural logistics. Intracardiac echocardiography (ICE) imaging has been used for more than 2 decades in several interventional procedures, including septal defect closure and arrhythmia ablations.5, 6, 7 ICE not only can obviate the need for GA but also can reduce the patient experience to a simple venous puncture without compromising quality of care. Recently, it has been investigated in a few descriptive studies for guidance through LAAC.8, 9, 10, 11 None of these studies compared the use of ICE vs TEE in terms of both procedural outcomes and cost during LAAC using a Watchman device. Additionally, the optimal ICE imaging strategy and views have not been defined. In this study we evaluated the optimal views to image the LAA with ICE during the Watchman procedure and delineated the impact of ICE in procedural parameters as well as hospital finances.
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Study design and patient population
Patients with nonvalvular AF, significant risk of stroke, and a history of bleeding or a contraindication for a long-term anticoagulation referred for LAAC (n = 104) between April 2015 and January 2018 at 3 centers were chosen for a retrospective analysis from an institutional review board–approved registry. Data collection included medical history, procedural reports, and follow-up events. Informed consent was obtained from every patient before the procedure in accordance with the ethical
Defining optimal ICE views
During each case, individual views were systematically evaluated to select a main “working view” for the procedure. After deployment, the Watchman was evaluated by multiple views. The RVOT/pulmonary artery (PA) view was used in every case as a screening view to rule out LAA thrombus before the transseptal puncture. The coronary sinus (CS) view was not used in any case because CS cannulation with the ICE catheter would have required additional instrumentation.
To demonstrate the anatomic basis of
Discussion
The salient results of our study are as follows. (1) Complete imaging of the LAA to guide Watchman device implants can be obtained by ICE using a series of ICE catheter positions. (2) Implant procedure is expedited by the use of ICE, with shorter in-room times, turnaround times, and fluoroscopy times. (3) Implant success is not compromised by ICE. (4) Total costs and hospital charges are similar.
Our study aimed primarily to compare the feasibility and safety of the procedure using ICE vs TEE
Conclusion
ICE is safe, feasible, and comparable in cost to TEE during LAAC with a Watchman device. Moreover, avoiding GA makes ICE a more convenient and less invasive option for high-risk patients.
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Cited by (0)
Funded by the Lois and Carl Davis Centennial Chair, the Charles Burnett III endowment, the Antonio Pacifico fellowship fund, and NHLBI Grant R01HL115003 (MV). Dr Valderrábano has received consulting and speaking honoraria from Biosense Webster and Boston Scientific. Dr Reddy has served as a consultant to manufacturers of the Watchman device (Boston Scientific) and the ICE catheter (Biosense Webster); in addition, he has conflicts with other cardiovascular companies not related to this manuscript. A comprehensive list is given in the Supplemental Appendix.