Anatomical structures can differ greatly from patient to patient, thus a “multi-imaging” methodology is recommended. This section will guide the operator through different structures in the heart in a step-by-step manner, including the main ICE views utilized for LAA closure procedure. The basic assumptions here are that the projections are taken from a femoral approach, which can be considered standard in percutaneous LAA closure. Although, very few operators prefer to introduce the ICE catheter through the jugular or subclavian veins; both of which can provide good vascular access, but they increase the invasiveness of the procedure. The operator is also standing at the right side of the table, with the patient’s head to the left. All ICE catheters currently available on the market will fit in an 8.5–9.5 Fr venous sheath introducer (long or short).

The catheter should be inserted in a neutral position (straight) and advanced with small movements from the left femoral venous access. It is advisable to advance the catheter into the inferior vena cava under fluoroscopic guidance, which can be achieved by gentle flexion of the catheter at the level of the iliac vein. The catheter is then advanced and the liver images will soon appear (Fig. 7.1). Take the opportunity with small advancement and withdrawal movements to center the image and adjust the depth of the window.

After visualization of the liver, the catheter is advanced slightly into the right atrium (RA). This long axis image of the RA, tricuspid valve (TV) and right ventricle (RV) is the starting view before any further manipulation of the catheter (Fig. 7.2). Note that the catheter is still in neutral position with no steering on the handle’s control knobs. It is useful to return to this “start view” if the operator loses the image bearings during the procedure.

From the “start view” with the catheter still in neutral position, the shaft is then rotated slightly clockwise (towards patient’s left). From this view, a long axis image of the aortic valve, aortic root, left ventricular (LV) outflow, pulmonary valve and part of the LA are visualized (Fig. 7.3).

From the previous view (aorta and pulmonary artery), a subtle rotation clockwise (towards patient’s left) will bring the fossa ovalis into view (Fig. 7.4). Small “back and forth” movements can be made to center the structure. The head of the catheter must be steered back and right, to improve the plane of visualization. Also the depth of field must be adjusted to get a full view of the inter-atrial septum (Fig. 7.5). This view is very useful to monitor and perform a safe and effective transseptal puncture.

This section is dedicated to the ICE views that are useful for performing transseptal puncture. The aim of this procedural step is to get a safe and effective transseptal puncture in the inferior–posterior portion of the fossa ovalis. Starting with the ICE probe in the center of the RA as described in the section above, a cranio-caudal view of the fossa ovalis is seen (Fig. 7.6). We suggest that this view is maintained during the transseptal apparatus withdrawal from the superior vena cava to the right atrium, and then to the fossa ovalis. This ICE view confirms if the transseptal apparatus is tenting on the fossa ovalis and at which level in the vertical direction (see Fig. 7.6 following the vertical blue line across the fossa ovalis, and also Fig. 7.5). From this view, tenting of the fossa ovalis inferiorly is well seen. Following this step, the anteroposterior position of the dilator should be visualized, which can be achieved in two ways: (1) further clockwise rotation which moves the plane of imaging more posteriorly to explore the posterior part of the fossa ovalis, or (2) keeping the dilator stable in this position but move the ICE probe to the “para-coronary sinus view” (see below). These two ICE views reveal if the tenting is in the anterior or posterior fossa ovalis (see Fig. 7.6 following the horizontal red line on the fossa ovalis). To achieve a more posterior position, the catheter should be rotated clockwise. It is suggested that the needle is advanced in the anteroposterior fluoroscopy view and the puncture performed under both fluoroscopic and ICE guidance.

From the septum visualization, move the catheter slowly clockwise. An image of the mitral valve (MV) is obtained. At this point, slightly roll the shaft clockwise and then adjust the anterior/posterior knob to get a visualization of the LAA (Fig. 7.7). This view can be used to evaluate LAA morphology and dimensions. It is also of great use to monitor the occluder device placement.

Advancing the probe inside the CS usually provides excellent LAA images (Fig. 7.8). Unfortunately, to get to the CS with the ICE catheter can be quite complex, requiring a lot of manipulation and can potentially be dangerous. A recommended safer way would be to advance a sheath into the CS first, before advancing the ICE catheter. For instance, a multipurpose catheter can be used to cannulate the CS cannulation, followed by advancing an exchange length Amplatzer Extrastiff Wire (AGA Medical Corporation, Plymouth, MN) into the CS. An 11 Fr Mullins sheath can then be advanced into the CS. The ICE catheter can then be advanced through the Mullins sheath into the CS without any steering. The sheath should be carefully flushed with saline before advancing the probe. From this position gently rotate the shaft to center the LAA image. Good images can be obtained by also keeping the ICE probe inside the introducer.

This is a previously undescribed view that provides similar images to those obtained by advancing the probe inside the CS, in a simpler and safer way. From the “start view”, with the catheter in neutral position, rotate the shaft gently counterclockwise (towards patient’s right). Target the typical trabeculated tissue of this structure. Then steer the catheter all the way posteriorly. From this position, a good projection of the LAA can be obtained (Fig. 7.9). Note that the tip of the catheter lies just below the coronary sinus ostium.