laac with zero fluoroscopy via ice guidance (lambre)
TRANSCRIPT
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LAAC with ZERO Fluoroscopy Via ICE Guidance (LAmbre)
Huimin Chu MD.
Arrhythmia Center, Ningbo First Hospital, Ningbo, PRC
Ningbo College of Cardiac Arrhythmia
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Traditionally, we can’t do LAAC without…
• General Anesthesia and TEE seemed to be necessary…
• But, the experience of General Anesthesia and TEE are extremely painful…,Many patients refuse the procedure when hearing about General Anesthesia.
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Limitations of TEE guidance
• Esophagus (columned structure) limited project view • Limited room for TEE probe manipulations • Difficult to measure the compression ratio (135°,right video)
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Case
Female, 77 yo, palpitation for 2 years, diagnosed as PeAF
Previous stroke , EFpHF, HTN
Intolerant to TEE exam & General Anesthesia
Carotid atherosclerosis
Anticoagulation with Dabigatran
CHA2DS2-VASc score 8 ; HAS-BLED score 3
AO: 34mm LVDd:44mm IVS:11mm LVEF:72%
LA:34mm LVDs:26mm LVPW:9mm LVFS:22%
Angle Ostium Depth
0° 19mm 32mm
45° 18mm 29mm
90° 16mm 29mm
135° 16mm 27mm
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Guidewire and Swartz Sheath in SVC
Geometry
reconstruction of
the left atrium,
LAA, LSPV,
LIPV with
cartosound
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Transspetal Puncture
Tenting sign, indicating the TSP site
The puncture site should be as inferior as possible, but not to much.
The thick atrial muscle at the extreme inferior site could be obstacle from ICE probe advancing into LA.
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Guidewire into LSPV
Delivery swartz sheath into LSPV
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ICE probe accessed into LA
ICE probe could accessed into the LA through the dilated channel.
AP or LAO plus LL views are frequently used for demonstrating the access with the assistance of the electroanatomic
mapping system
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ICE Assessment Criteria : Inspiration from Magic Cube
ICE probe could be advanced into LA and the anatomic features of the
LAA could be assessed from triple axises covering six views
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Assessment Criteria of LOVE : 3Axises 6Views
• Anatomic feature of LAA could
be assessed from triple axises
covering six views (Ant. / Pos./
Right/ Left/ Inf./ Sup.)
• Recommended Positions
• Axis-X: LPVs / LA pos. wall
• Axis-Y: RPV Ostium / LA roof
• Axis-Z: LA bottom / MA
LPVs view
RPVO view
LLA view
X
Y
Z
A
P
L R
S
I
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3Axises 6Views: Axis-X
LSPV
ICE: P + L curve
O: 19mm; LZ: 17mm
ICE probe was kept in the LSPV with a little P curve and the fan was adjusted to show the maximum
diameter of the LAA ostium.
As measured from the optimal fan, the ostium was 19mm and the landing zone diameter was 17.
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3Axises 6Views: Axis-Y
RPV Ostium
ICE: greater P curve
O: 18mm; LZ: 16mm
Demonstrated from the right PV ostium to the left.
The ostium and landing zone in this view were 18mm and 16mm
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3Axises 6Views: Axis-Z
Lower LA/MA ostium
ICE: A + turnover + P
O: 21mm; LZ: 13mm
From the lower LA or the MA ostium to the appendage
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LZ : Pigtail Cath & Water Injection
Note the marker of
Pigtail Cath
Water injection
indicate the tip of the
delivery sheath
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Occluder Delivering (LAmbre 22/28mm)
• The “Dual-Rail” sign of the delivery sheath was covered by the folded occluder
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Deployment of Umbrella and Cover Disc
Umbrella Deployed Cover Disc Deployed
• Please note the relative distance between umbrella and LCX (yellow arrow)
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Axis-X : Color Doppler & Tug Test
• The umbrella was positioned within the landing zone, without obvious peri-device leak
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Axis-Y : Color Doppler
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Axis-Z : Color Doppler
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Occluder Release
No Fluoro! No Contrast!
The TEE follow-up at 45 days indicated good position and no obvious peri-device leak.
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52 Cases ICE-guided LAAC in 552 LAAC cases
Ningbo First Hospital
Zero-fluoro Cases Low-fluoro Cases
7
45
ICE-guided LAAC in Ningbo First Hospital
Previous stroke/TIA 33(63.5%)
Bleeding history 3(5.8%)
CHA2DS2-VASc score 4.7±1.6
HAS-BLED score 3.0±0.8
Devices
Watchman 26(50%)
ACP 10(19.2%)
LAmbre 16(30.8%)
Deployments 1.3±0.7
Acute peri-device leak 0.1±0.6mm
Procedural time 79.3±24.5min
Fluoroscopic time 5.9±4.8min
Fluoroscopic exposure 99.4±115.6mGy
Contrast consumption 65.0±55.3ml
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Take Home Message
• ICE is more than an alternative of TEE in LAAC procedure with many advantages - Avoidance of injuries caused by intubation and GA
- First-time detection of complications
- Independent of echo/anesthesia staff and lower technical fees
- Lower or even ZERO fluoroscopic exposure and contrast usage
- Higher procedural efficacy and efficiency
• There are still some limitations - Invasive access
- Learning curve
- No 3-d imaging yet
- Financial concern of the probe
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Discussion
• Will ICE guide LAAC become a routine procedure?