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.