Comparison of fluoroscopy and transesophageal echocardiogram for intra-procedure device surveillance assessment during implantation of Watchman
Graphical abstract
Introduction
Atrial fibrillation (AF) has been shown to increase individual embolic strokes risk by five-fold, mainly because of thrombus formation in the left atrial appendage (LAA) [[1], [2], [3]]. Left atrial appendage occlusion (LAAO), nowadays universally performed for stroke prevention in non-valvular AF patients, is recommended according to 2019 AHA/ACC guidelines (IIb) especially for those at high risk of stroke with contraindications for long-term oral anticoagulation [4].
To ensure successful device implantation in LAAO, evaluation of intra-procedural device surveillance is important. Occluder stability is largely associated with desirable position and anchoring while adequate device compression and accurate measurements of peri-device leak can further help assess implant outcomes. TEE accompanied by fluoroscopy is nowadays the recommended conventional imaging modality to guide and assess LAAO [[5], [6], [7], [8]]. On the other hand, the use of TEE throughout the procedure requires a dedicated anesthetic team and is limited by gastrointestinal disease, stomatology disease and risks of esophageal injury, which leads to increasing procedural burden and complexity. In the present study, we systematically compared fluoroscopic assessment of device position, stability and residual leak to the established TEE-based approach. Furthermore, the feasibility and safety of intra-procedural guidance with fluoroscopy alone was tentatively explored in clinical practice.
Section snippets
Methods
A total of 208 consecutive patients who were referred to Zhongshan Hospital, Fudan University for LAAO using the WATCHMAN™ device (Boston Scientific, Marlborough, MA, USA) were studied. All patients had non-valvular AF at high-risk for stroke (CHA2DS2 ≥ 2) and relative or absolute contraindications for long-term oral anticoagulation (OAC). The study included both retrospective and prospective analysis. In 101 patients, LAAO procedure was performed under general anesthesia guided by TEE and
Results
This study enrolled 101 patients (59 male, mean age of 68.16 ± 7.82) in the retrospective cohort and 107 patients (70 male, mean age of 66.28 ± 10.03) in the prospective group. Baseline characteristics of the retrospective and prospective cohorts are described in Table 1 and no statistically significant differences in gender, age, incidence of hypertension, diabetes, stroke and major bleeding were found. The CHA2DS2-VASc and HAS-BLED scores were also similar between two cohorts (3.74 ± 1.38 vs
Discussion
In our study comparing the utility of TEE and fluoroscopy for intra-procedural device surveillance, fluoroscopy was comparable for assessing device position, stability and detecting residual leakage. The derived fluoroscopic assessment was applied in a prospective study in which LAAO procedure was performed with fluoroscopy-only guidance. Perioperative and follow-up clinical outcomes in the prospective cohorts further confirmed the feasibility and safety of fluoroscopy alone during LAAO in a
Conclusion
LAAO performed by experienced operators in large volume centers is feasible under fluoroscopy guidance. However, there is a trend in favor of TEE for a greater safety of the procedure, allowing to achieve a more complete seal of the appendage. This minimalistic approach could be proposed among patients with strong contra-indications for general anesthesia and/or transesophageal echocardiography.
Funding
This work was supported by the National Natural Science Foundation of China [grant numbers 81771837], Shanghai Committee of Science and Technology [grant numbers 17411962400].
Declaration of Competing Interest
The authors declare that they have no conflict of interest.
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Contribute equally to the work.