Type of Interventions and Procedural Issues
Half of the patients referred for LAAC in our center, had a second cardiac intervention either in a combined strategy or in during a second procedure. These second intervention, whether structural or electrophysiological, were also performed from a venous femoral access. Thus, the combined strategy by using the same venous femoral access can reduce the cumulative risk of vascular complications. Moreover, the same transeptal puncture when required for AF ablation or TEMVR may be used for the LAAC (16). However, the optimal transeptal position may be different for TEMVR and LAAC, and the use of the optimal TEMVR transeptal puncture position should be preferred and used for the LAAC. In our experience, when AF ablation or TEMVR are combined, LAAC is performed last. However, when the other intervention is a flutter ablation or LP implantation, LAAC is performed first.
LAAC can be combined with other interventions requiring arterial access. The transaortic valve replacement (TAVR) is probably the procedure that could lead to a such combined strategies (16). In this approach, TAVR is first performed from an arterial access and LAAC then performed by a venous femoral access.
However, more procedures are now done using conscious sedation. Most TAVR, AF or flutter ablations, and LP implantations are performed without general anesthesia, while LAAC and TEMVR often require TEE guidance and general anesthesia (27, 28). The use of intracardiac echocardiography may obviate the need for general anesthesia (29).