Left Atrial Appendage Closure Guided by Integrated Echocardiography and Fluoroscopy Imaging Reduces Radiation Exposure

Abstract

Aims: To investigate whether percutaneous left atrial appendage (LAA) closure guided by automated real-time integration of 2D-/3D-transesophageal echocardiography (TEE) and fluoroscopy imaging results in decreased radiation exposure.

Methods and results: In this open-label single-center study LAA closure (AmplatzerTM Cardiac Plug) was performed in 34 consecutive patients (8 women; 73.1±8.5 years) with (n = 17, EN+) or without (n = 17, EN-) integrated echocardiography/fluoroscopy imaging guidance (EchoNavigator® [EN]; Philips Healthcare). There were no significant differences in baseline characteristics between both groups. Successful LAA closure was documented in all patients. Radiation dose was reduced in the EN+ group about 52% (EN+: 48.5±30.7 vs. EN-: 93.9±64.4 Gy/cm2; p = 0.01). Corresponding to the radiation dose fluoroscopy time was reduced (EN+: 16.7±7 vs. EN-: 24.0±11.4 min; p = 0.035). These advantages were not at the cost of increased procedure time (89.6±28.8 vs. 90.1±30.2 min; p = 0.96) or periprocedural complications. Contrast media amount was comparable between both groups (172.3±92.7 vs. 197.5±127.8 ml; p = 0.53). During short-term follow-up of at least 3 months (mean: 8.1±5.9 months) no device-related events occurred.

Conclusions: Automated real-time integration of echocardiography and fluoroscopy can be incorporated into procedural work-flow of percutaneous left atrial appendage closure without prolonging procedure time. This approach results in a relevant reduction of radiation exposure.

Trial registration: ClinicalTrials.gov NCT01262508.

Conflict of interest statement

Competing Interests: This study was funded in part by Biotronik. JB receives honoraria for lectures from Philips Healthcare. TZ receives honoraria for lectures from St. Jude Medical. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials.

Figures

Fig 1. CONSORT flow chart.

Fig 2. Overview of integrated echocardiography and fluoroscopy imaging.

The image acquisition angles during transseptal puncture are depicted in the lower right corner of each image. A+B) Concordant views of TEE and fluoroscopy images. C) In the “Free view” echocardiographic images can be rotated and zoomed independently from the echocardiographer by using a tableside control. D) Conventional echocardiographic view using the x-plane mode for identification of the preferred transseptal puncture site (Septum, blue). Sheath with transseptal needle; Pigtail cath. = pigtail catheter; RV cath. = catheter in the right ventricle.

Fig 3. Visualization of the LAA and surrounding structures preceding occluder positioning.

The LAA orifice (red), the crista (yellow), and the septum (blue) are marked by landmark setting. A) 2D-TEE image in the same anatomical alignment as the C-arm. B) Outlines of 2D-TEE (pink lines) are fused with the fluoroscopy image. C+D) 2D-TEE with anatomical landmarks depicted in different angles. Note the sheath in close proximity to the left superior pulmonary vein as supported by the matching landmarks in different views. RV cath. = catheter in the right ventricle.

Fig 4. Evaluation of adequate device position and stability by using 3D-TEE and fluoroscopy.

After LAA occluder release correct positioning is verified simultaneously by rotation and zoom of the 3D-TEE image and angiography. The LAA occluder is shown in the 3D-TEE “Free view” (A) by using the tableside control and the fluoroscopy (B) demonstrating the relationship to surrounding structures (LCX, crista). Note the relatively large crista which could not be fully covered by the disc of the LAA occluder, while contrast agent injection demonstrated good LAA sealing.