Use of intracardiac echocardiography to guide implantation of a left atrial appendage occlusion device (PLAATO)

Background

Over 90% of thrombi in atrial fibrillation (AF) originate from the left atrial appendage (LAA). Patients with contraindications to anticoagulation are potential candidates for LAA occlusion using the Percutaneous Left Atrial Appendage Transcatheter Occlusion system (PLAATO, ev3 Inc., Plymouth, MN). Transesophageal echocardiography (TEE) is typically used to guide implantation.

Objective

This study sought to examine the utility of intracardiac echocardiography (ICE) in providing adequate imaging guidance as an alternative to TEE during PLAATO implantation.

Methods

The study group consisted of 10 patients who underwent PLAATO implantation with simultaneous TEE and ICE imaging guidance. ICE was used to perform the following tasks typically fulfilled by TEE: (1) verification of the absence of LAA thrombus, (2) identification of the LAA ostial dimension for device sizing, (3) guidance of transseptal puncture, (4) verification of the delivery sheath position, and (5) confirmation of location and stability of device before its irrecoverable release. The ability of ICE to perform these tasks was assessed from three separate positions: the standard right atrial (RA) position, within the coronary sinus (CS), and the right ventricular outflow tract.

Results

ICE imaging of the LAA was optimal from within the CS, although imaging from the proximal pulmonary artery provided better visualization of the distal LAA in cross-section. The LAA dimensions, confirmation of the absence of LAA thrombus, proper positioning of the delivery sheath, verification of location and stability of the device obtained by ICE were consistent with findings from TEE.

Conclusion

Using nonconventional imaging planes, ICE imaging was able to perform the intraprocedural functions provided by TEE during implantation of the PLAATO left atrial appendage occlusion device.

Keywords: Atrial fibrillation, Intracardiac echocardiography, Left atrial appendage occlusion, Transesophageal echocardiography