Wishing all the doctors a Happy Doctors’ Day!
I feel proud and honoured to be a doctor & cardiologist. When I see patients coming in extremely sick and with immediate treatment at any time of the day or night with transcatheter procedures, they recover and go home with smiles on their faces & family members’ faces, all the hardships we as doctors go through is forgotten.
At Kauvery Hospital, the management led by Dr Aravindan ED, and the infrastructure provided including the hybrid cath lab operating room, allow us to undertake complex cardiac procedures safely. On this Doctor’s Day, I wish Dr Aravindan and all our colleagues a happy Doctor’s Day 2024 and thank the family members of all the doctors for their unconditional support.
Intracardiac Echo Guided Left Atrial Appendage Occlusion Under Conscious Sedation
The incidence of embolic stroke is higher in elderly patients (> 65 years) with atrial fibrillation with comorbidities like hypertension, diabetes, heart failure and prior stroke. To reduce the above risk, anticoagulation with warfarin or newer oral anticoagulation (NOAC) is given. Even though this is effective in preventing embolic stroke, major bleeding including cerebral hemorrhage and gastrointestinal bleeding are higher, more so in elderly patients at risk of fall. Anticoagulation is also contraindicated in patients who have already had major bleeding.
In a majority of patients in AF with embolic stroke, the source of embolus is from the left atrial appendage (LAA). By mechanically occluding the LAA with an occluder (LAAO), this risk can be reduced, and anticoagulation can be avoided; henceforth, the associated bleeding can also be avoided. Conventionally, LAAO is done under general anesthesia (GA) and transesophageal echo (TEE) guidance, but in patients with recent stroke, swallowing impairment and other comorbidities, the above will not be possible. The alternative is to consider doing the procedure under conscious sedation with intracardiac echo (ICE) guidance, wherein the ultrasound probe at the tip of a catheter is passed through a blood vessel in the groin (femoral vein) and real-time continuous echo guidance is achieved to close the LAA safely and precisely. This needs expertise and availability.
At Kauvery Hospital, with the availability of the hybrid cath lab operating room with integrated imaging including ICE, and experts with international experience, it is possible to offer this advanced procedure for the benefit of patients with unmet needs. For the first time in India, 5 consecutive patients underwent successful ICE-guided LAAO under conscious sedation at Kauvery Hospital, Alwarpet, Chennai.
Typically, the procedure lasts 30 to 45 minutes in the hybrid cath lab; mild sedation is given and femoral vein access is obtained under local anesthesia. Two punctures are taken on the same side, one for the ICE probe and the other one for LAAO. Real-time ICE guidance is used to gain trans-septal access from the right atrium to the left atrium. Following this, the JR 4 catheter is placed in the left upper pulmonary vein and exchanged for Amplatz super stiff wire. Through the same TSP, the ICE probe is passed to the left atrium and positioned to achieve a real-time continuous image of the LAA. The device sizing is done with ICE and fluoroscopy and upsized by 20 to 30%. The delivery sheath is passed over the stiff wire and a pigtail is kept inside the sheath down. The whole sheath and pigtail are brought down in front of the LAA ostium (the modified deployment technique is used in patients with persistent clots in the LAA). The appropriate size LAAO device is introduced through the sheath and deployed in stages as shown, and the final ICE and fluoroscopy will confirm complete sealing of the LAA ostium, before being released after stability testing.
In conclusion, ICE-guided LAAO under conscious sedation is an advancement in the LAAO procedure with higher safety in these high-risk patients with no other options, in preventing recurrent stroke while avoiding the bleeding risk associated with anticoagulation.
Fig 1. ICE Guided Trans-Septal Puncture
Fig 2. ICE Probe Behind TSP Needle Giving Real-Time Image Guidance
Fig 3. LAA Angio Showing Clot
Fig 4. LAAO in Position with ICE Probe Behind
Dr. R. Anantharaman
Senior Consultant Interventional Cardiologist,
Kauvery Hospital Chennai
