Elsevier

Heart Rhythm

Volume 16, Issue 3, March 2019, Pages 334-342
Heart Rhythm

Featured Article
Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations

https://doi.org/10.1016/j.hrthm.2018.12.013Get rights and content

Background

Imaging guidance for left atrial appendage (LAA) closure (LAAC) conventionally consists of transesophageal echocardiography (TEE) and fluoroscopy under general anesthesia (GA). Intracardiac echocardiography (ICE) can eliminate the need for GA, expedite procedural logistics, and reduce the patient experience to a simple venous puncture.

Objective

The purpose of this study was to define optimal ICE views and compare procedural parameters and cost of ICE vs TEE during LAAC with the Watchman device.

Methods

Optimal ICE views of the LAA for Watchman implant were delineated using Carto-Sound and 3-dimensional rendition of the LAA in 6 patients. Procedural and financial parameters of 104 consecutive patients with standard indications for LAAC undergoing Watchman implant using ICE guidance through a single transseptal puncture (n = 53 [51%]) were compared with those of TEE-guided implants (n = 51 [49%]) in 3 centers.

Results

Clinical characteristics were similar between the 2 groups. Total in-room, turnaround, and fluoroscopy times all were shorter using ICE (P <.05) under local anesthesia compared to the TEE group. Implant success was 100% in both groups without peri-device leaks or procedural complications. Follow-up TEE showed no significant peri-device leak in both groups. Total hospital charges for ICE with local anesthesia vs TEE were similar, as were total hospital direct and indirect costs. Professional fees were significantly lower with ICE and local anesthesia than with TEE because the charge of anesthesia staff was avoided.

Conclusion

ICE-guided Watchman implant is safe, feasible, and comparable in cost to TEE during LAAC with a Watchman device but avoids GA and expedites procedure turnaround.

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.

Section snippets

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.

References (19)

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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.

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