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• W2911850489 abstract "Atrial fibrillation is the most common arrhythmia and it is associated with a significant risk of embolic stroke due to clot formation, arising predominantly from the left atrial appendage. Major gastro-intestinal bleeding and haemorrhagic stroke are side-effects of oral anticoagulation, and, lifestyle, intolerance or interfering medication/comorbidities may limit the use of warfarin or novel anticoagulants. For these patients, transcatheter left atrial appendage occlusion (LAAO) is a therapeutic alternative. As with many structural heart procedures, fluoroscopy and transoesophageal echocardiography (TOE) are used for procedural guidance. Transoesophageal echocardiography is employed to determine the optimal position of the trans-septal puncture, to prevent atrial perforation by the wire and to guide and confirm the position of the LAAO device. Therefore, TOE is necessary throughout the procedure with the patient placed in a prone position. At present, general anaesthesia with tracheal intubation is widely used to secure the airway and to prevent aspiration. Nevertheless, there is a tendency toward minimalism in TOE-guided procedures with deep sedation only 1. Respiratory distress is a well-known complication of deep sedation. Significant hypoxaemia was reported in 18% of patients sedated for TOE examination, primarily in patients with mitral valve disease or heart failure 2. Furthermore, it has been shown that sedatives (e.g. propofol) impair the swallowing process at clinically-relevant doses. This risk for aspiration might be further aggravated by the TOE probe, especially with the patient in the supine position when saliva and other fluids cannot drain out of the mouth. For good reason, it is recommended to perform TOE in the left lateral decubitus position, which provides some protection from aspiration 3. We have developed a technique that avoids tracheal intubation or deep sedation with an unsecured airway during short LAAO procedures, involving the use of a Gastro-Laryngeal Tube (G-LT)® (VBM, Sulz, Germany). The feasibility of supraglottic airway device (SAD) use during TOE has been previously described 4. However, as the echo probe is positioned behind the SAD and also repositioned frequently during the procedure, displacement of the mask may be a complication of this technique. Furthermore, the stimulus induced by these movements may result in adverse patient reactions. The G-LT is a re-useable SAD. This device was initially invented for, and used in, complex gastro-intestinal procedures, either for sedation or general anaesthesia 5. At the moment only one size is available. The composition of the G-LT is similar to established laryngeal tubes; however, a working oesophageal channel is incorporated enabling passage of devices up to 13.8 mm outer diameter. During insertion, this working channel is occluded by an inflatable obturator (Fig. 6a and b). Our experience has shown that a 3D-TOE probe (Philips ×7-2t, Philips Medical Systems Nederland B.V., Best, the Netherlands) can also be placed easily through the device lumen (Fig. 6a and c). From our point of view, there are several advantages to this device. First, the position of the G-LT is securely maintained during repositioning of the TOE probe. Secondly, as the probe is enclosed within the oesophageal lumen by the G-LT, there is reduced stimulus to the patient during advancement and retraction (Fig. 6d). Therefore, sedation with spontaneous respiration can be comfortably achieved while maintaining a patent airway and affording a degree of protection from aspiration. To date, we have used the G-LT in a series of 15 patients undergoing LAAO. In one patient, a correct and sealed placement of the G-LT was not possible and tracheal intubation was employed instead. In our experience, the position of the G-LT was in fact improved after the insertion of the TOE probe, due to a stabilising effect. The primary disadvantage of the G-LT is that there is only one size available. In small patients or patients with reduced mouth opening, insertion and correct placement may be challenging. Transoesophageal echocardiography was possible in all patients. Due to the borderline fit of the TOE probe within the working channel, extraction of the probe should be performed carefully in order to prevent unintended dislodgement of the G-LT. Overall, the G-LT appears to be a feasible alternative to tracheal intubation in selected patients undergoing short TOE-guided procedures." @default.
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• W2911850489 date "2019-02-08" @default.
• W2911850489 modified "2023-09-27" @default.
• W2911850489 title "Supraglottic airway device use for transoesophageal echocardiography during left atrial appendage occlusion" @default.
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• W2911850489 doi "https://doi.org/10.1111/anae.14597" @default.
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