Discussion:
In this study, we present the outcomes of employing preemptive
balloon-assisted dilation of the interatrial septum to facilitate the
traversal of ICE in the Left Atrium during LAAO. While there have been
isolated case reports describing the occasional utilization of this
approach, our study stands as the first consecutive series that
systematically compares this strategy against the conventional standard
of care11.
Our findings suggest that the routine use of preemptive balloon dilation
of the IAS is correlated with an easier ICE traversal following a single
trans-septal puncture. This approach significantly reduces both the
total time required and the variability in the time needed to
successfully navigate the ICE within the LA (2.9±1.2 minutes compared to
5.2±7.5 minutes).
With the availability of more than one LAAO
device10,12, the choice of device is often made
post-assessment of the Left Atrial Appendage (LAA) during the procedure.
However, opting for a large LAAO access sheath for IAS dilation
necessitates an early decision regarding the device / sheath type before
ICE traversal in the LA. As more LAAO devices gain approval, it becomes
increasingly crucial to defer the device type selection until final
imaging of the LAA can be performed via ICE within the operating suite.
Our proposed approach effectively eliminates the need for unnecessary
utilization of an inappropriate LAAO access sheath, thereby reducing
costs and minimizing the number of device exchanges.
While Intracardiac Echocardiography (ICE) usage is on the rise for LAAO
procedures, a significant majority of these procedures are still
conducted under Transesophageal Echocardiography (TEE) guidance. The key
challenges reported most frequently in the adoption of ICE for LAAO are
the complexities associated with ICE traversal in the LA and obtaining
clear views of the LAA with ICE. Our proposed strategy serves to
expedite the learning curve for ICE traversal within the LA via a single
trans-septal puncture, potentially lowering the barriers to early
adoption of ICE in LAAO procedures.
Furthermore, the 4D ICE technology is increasingly available and being
employed to guide LAAO procedures. However, these catheters typically
possess larger diameters compared to their 2D
counterparts13 14. Our technique may
prove particularly valuable in alleviating the challenges associated
with ICE traversal in the LA when using these larger diameter 4D ICE
catheters.
Finally, it is worth noting that ICE is the preferred modality for
imaging during electrophysiologist (EP)-performed ablation procedures,
enhancing the comfort level of EPs with ICE over Interventional
cardiologists (ICs). However, this technique necessitates the use of
large balloon catheters and other IC techniques. LAAO procedures are
often performed by either EPs or ICs. Our approach highlights a unique
opportunity for collaboration between electrophysiologists and
interventional cardiologists, enabling a cohesive team to perform these
procedures and fostering mutual learning.
Nevertheless, it is essential to acknowledge the limitations of this
study. This research represents a single-center, single-operator
investigation, which may limit the generalizability of the results.
However, it is worth noting that we have reported data on consecutive
patients undergoing LAAO outside of clinical trials. Additionally, we
did not base the utilization of ICE or balloon dilation on any
pre-imaging information.