Left Atrial Appendage Occlusion with Intracardiac Echocardiography and
Electroanatomic Mapping
Abstract
Left atrial appendage occlusion (LAAO) has emerged as an important
therapy for patients with atrial fibrillation at risk for stroke who are
not good candidates for long-term oral anticoagulation. Transesophageal
echocardiography (TEE) has an important and foundational role in
preprocedural left atrial appendage assessment, intraprocedural guidance
and device deployment, and post-procedural evaluation in follow-up.
Recent studies have evaluated intracardiac echocardiography (ICE) as a
primary intraprocedural imaging modality without the need for TEE. The
use of ICE offers promise of expedited patient care, reduced procedural
complexity, and reduced costs. Observational reports of ICE for LAAO
highlight significant variability in procedural technique, including but
not limited to ICE catheter placement and position as well as the type
and number of intracardiac views. Integration with concomitant
electroanatomic mapping provides additional information to the operator
regarding the orientation of the ICE catheter to the atrial geometry and
can be used to optimize views and avoid perforation. It also allows for
more precise near-field delineation of transseptal access. This review
characterizes a standardized approach for harnessing ICE based off four
anatomic views (aortic, mitral, left superior pulmonary vein, and
inferior). These views optimize the unique vantage points of left atrial
ICE as opposed to attempting to replicate the transesophageal windows.
The focus on complementary and orthogonal angles allows for more precise
device placement and assessment for device positioning and peri-device
leak.