Percutaneous closure of the left atrial appendage (LAA) is a procedure increasingly performed in patients with atrial fibrillation at high risk of stroke and with contraindications to long-term oral anticoagulation therapy.1 The procedure involves transatrial septal puncture, angiography of the left appendage, and positioning of an occluding device. The patient must be immobile during all these phases, as a sudden movement can increase the risk of significant complications, including atrial perforation and pericardial tamponade.2 To keep patients immobile and allow a prolonged three-dimensional transesophageal echocardiography (3D-TEE) examination, percutaneous LAA is usually performed under general anesthesia.

The risk of general anesthesia in the elderly is associated not only with challenges of airway control, potential for residual neuromuscular block, and an increased risk of perioperative pulmonary complications3,4 but also with the risk of cognitive decline.5 Furthermore, general anesthesia may increase costs and reduce the number of procedures that can be performed daily.6

Continuous TEE is an essential tool to help the interventional cardiologist perform the procedure, and it allows for the administration of lower doses of contrast medium and an overall lower exposure to radiation for the patient and the operating team. Nevertheless, it can be challenging for the patient to tolerate what can be a protracted TEE examination.

Herein, we present a case series of three patients who underwent percutaneous LAA closure under continuous TEE and deep sedation. The procedure was facilitated with the use of a new noninvasive ventilation mask that can be placed around the TEE probe.

Case series

With San Raffaele Scientific Institute Ethical Committee approval (Milan; protocol no. VP/50ER/mm) and patients’ written consent, three elderly patients (80, 76, and 74 yr) underwent percutaneous LAA closure under continuous 3D-TEE guidance (Vivid E9; GE Medical Systems, Milwaukee, WI, USA). Monitoring included electrocardiography, invasive blood pressure monitoring, capnography, and pulse oximetry. Sedation was performed with midazolam (2 mg), continuous infusions of propofol (40-60 mg·hr−1 and remifentanil (0.025-0.05 µg·kg−1·min−1). Each patient’s sedation level was evaluated by means of the Observer’s Assessment of Alertness/Sedation (OAA/S) scale7 which ranges from 0-5, where 0 = the patient does not respond to squeezing the trapezius, and 5 = the patient responds readily to name spoken in normal tone. Once the patient’s OAA/S score was 1, the TEE probe was inserted. Thereafter, the Janus mask (Biomedical Srl; Florence, Italy) (Fig. 1A and B) was placed on the patient’s face around the probe without the necessity of removing the device.8 The patient’s spontaneous ventilation was assisted with pressure support of 12-16 cm H2O and a positive end-expiratory pressure of 7 cm H2O with an F i O2 = 0.3. Oxygen saturation during the procedures was 94-98%, and arterial partial pressure of carbon dioxide ranged from 34.0-44.9 mmHg.

Fig. 1
figure 1

The Janus mask for noninvasive ventilation in its closed (A) and open (B) appearance

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The procedures lasted 75-90 min and were uneventful, and the operators rated the procedural conditions as excellent (5 on a scale of 1-5). The OAA/S scale remained at 1 throughout the procedures and reached 5 from one to three minutes after sedation was discontinued. Patients tolerated the mask favourably and did not recall the procedure. Furthermore, all patients assessed their pain at zero on the numeric rating scale both during and after the procedure. One of the three echocardiography teams complained of excessive image attrition due to difficulties in moving the TEE probe. In particular, they experienced difficulty in introducing the TEE probe into the patient’s mouth due to suboptimal gliding of the probe through the flexible sheets of the mask’s central port, which are designed to limit airway leakage around the probe.

Discussion

We present a small case series of patients undergoing LAA closure with continuous 3D-TEE performed without general anesthesia. To perform such an interventional procedure, the patient must remain immobile throughout the entire procedure.2 For this reason, as well as the need for continuous and prolonged TEE, LAA closure is mainly performed under general anesthesia, which itself is burdened by an increased risk of pulmonary complications.4,9 The possibility of substituting general anesthesia with sedation while keeping the patient spontaneously breathing is debatable. Deep sedation is associated with an increased risk of upper airway collapse,10 and assisting the patient’s breathing with is recommended. The Janus mask has several advantages. For example, the mask can be placed on the patient’s face and tested before induction of sedation as a normal mask for non-invasive ventilation. The mask has a hole that allows TEE examination during non-invasive ventilation, and it can be opened (and closed) around the endoscopic probe, facilitating insertion of the TEE probe into the patient’s mouth (video; available as Electronic Supplementary Material). The mask can also be used in an emergency or unplanned situation (even if this was not the case in our case series) (Fig. 2A, B, and C, Fig. 3).

Fig. 2
figure 2

The Janus mask: open on a patient’s face with a transesophageal echocardiography probe inserted in his mouth (A), during its closure (B), and closed around the probe (C)

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Fig. 3
figure 3

Transesophageal echocardiography performed during noninvasive ventilation

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The possibility to perform LAA closure without general anesthesia has many advantages; for example, it allows less operating room utilization and obviates the potential side effects of general anesthesia, particularly in the elderly. It is reasonable to anticipate that cardiology (e.g., transfemoral aortic valve implantation and mitral valve repair), gastroenterology, and thoracic/pulmonology11 procedures could be managed in a similar way to avoid general anesthesia. In cardiology procedures, this would minimize the administration of contrast medium.