J. Potvin

Transcatheter Left Atrial Appendage Closure Using Intracardiac Echocardiographic Guidance From the Left Atrium

BACKGROUND Most commonly, left atrial appendage (LAA) occlusion procedures are performed using transesophageal echocardiography (TEE) guidance and general anaesthesia. Intracardiac echocardiography (ICE) offers potential advantages over TEE, however, ICE-guided LAA occlusion experience is limited and has been typically performed from a right-sided location where LAA visualization might be suboptimal. We sought to evaluate the efficacy and safety of percutaneous LAA occlusion using ICE guidance performed from the left atrium. METHODS Thirty-seven patients with atrial fibrillation, significant risk for stroke, and long-term contraindication to anticoagulation underwent LAA closure with the Amplatzer Cardiac Plug (St Jude Medical, Inc, St Paul, MN) with mild sedation and ICE guidance. The ICE catheter was introduced in the left atrium through a second transseptal puncture. Patients underwent preprocedural TEE to rule out thrombus and 3-month follow-up TEE to assess occlusion grade. Patient characteristics, procedural data, effectiveness of ICE imaging, quality of occlusion, and complications were prospectively recorded. RESULTS Procedural success was achieved in 36 of 37 patients (97%). Closure was complete or near complete (grade ≥3 according to ICE and angiography) in all cases where the device was released. In all cases, ICE imaging yielded good LAA and surrounding structure visualization and adequate procedural guidance. Three major procedural or in-hospital complications occurred. Median length of stay was 1 day. Follow-up TEE documented the absence of any residual peri-device leak in all but 1 (29 of 30) case. CONCLUSION Initial experience suggests LAA occlusion with the Amplatzer Cardiac Plug using ICE guidance from the left atrium is feasible, reproducible, and safe.

Valve-in-Valve Implantation of a Sapien 3 Transcatheter Heart Valve for Reduction of Paravalvular Regurgitation Despite Optimal Placement of the First Transcatheter Heart Valve

Valve-in-valve implantation is generally successful in reducing paravalvular regurgitation (PVR) in cases in which the first transcatheter heart valve is deployed in a suboptimal location. We describe a case of severe PVR 2 months after implantation of a 26-mm Sapien XT valve (Edwards Lifesciences Inc, Irvine, CA) in the optimal location. Valve-in-valve implantation of a Sapien 3 valve (Edwards Lifesciences Inc), and enough left ventricular outflow tract tissue at the inflow edge the Sapien XT to appose the sealing cuff of the Sapien 3 combined for successful PVR treatment. To our knowledge, this is the first case of PVR reduction with valve-in-valve despite the original valve being appropriately sized and placed.