LAAC with ZERO Fluoroscopy Via ICE Guidance (LAmbre)

Huimin Chu MD.

Arrhythmia Center, Ningbo First Hospital, Ningbo, PRC

Ningbo College of Cardiac Arrhythmia

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.

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）

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

Guidewire and Swartz Sheath in SVC

Geometry

reconstruction of

the left atrium，

LAA, LSPV,

LIPV with

cartosound

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.

Guidewire into LSPV

Delivery swartz sheath into LSPV

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

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

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

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.

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

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

LZ : Pigtail Cath & Water Injection

Note the marker of

Pigtail Cath

Water injection

indicate the tip of the

delivery sheath

Occluder Delivering (LAmbre 22/28mm)

• The “Dual-Rail” sign of the delivery sheath was covered by the folded occluder

Deployment of Umbrella and Cover Disc

Umbrella Deployed Cover Disc Deployed

• Please note the relative distance between umbrella and LCX (yellow arrow)

Axis-X : Color Doppler & Tug Test

• The umbrella was positioned within the landing zone, without obvious peri-device leak

Axis-Y : Color Doppler

Axis-Z : Color Doppler

Occluder Release

No Fluoro! No Contrast!

The TEE follow-up at 45 days indicated good position and no obvious peri-device leak.

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

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

Discussion

• Will ICE guide LAAC become a routine procedure?