Left Atrial Appendage Occlusion Simulation: Initial Experience at the Montreal Heart Institute

In this interview, we speak with Blandine Mondesert, MD, an electrophysiologist at Montreal Heart Institute, about her experience in a recent case in which simulation-based planning was used to rehearse a full left atrial appendage occlusion (LAAO) procedure.

Tell us about your center at the Montreal Heart Institute.

Montreal Heart Institute is one of the biggest centers in Canada involved in research and new technologies. We have more than 50 cardiologists at the Montreal Heart Institute and more than 12 cardiac surgeons. In 2009, we were the first center in Canada to perform LAAO, along with interventional cardiologist Dr Reda Ibrahim.

How many LAAO procedures are performed monthly at your institution?

Since 2009, we have performed approximately 4 to 5 LAAOs per month. We have one day dedicated to those procedures every month. That comes out to about 50 cases per year, which is significant. The main indication for LAAO is a high risk of stroke in patients with a contraindication to anticoagulant therapy. As the procedure is now more well-known and routinely performed, we have had more referrals in our area, so our numbers have continued to increase in the last few years.

What interests you about using simulation training as a tool in cardiology-related procedures?

There are 2 very important benefits of simulation. The first benefit is that simulation is hugely helpful with training. As with any new technology, we want our fellows to be properly trained before using any technology in human patients. The other important aspect about simulation is that it is helpful when preparing for difficult cases. Performing a simulation of the procedure ahead of the actual case allows for better preparation about the specificity of the case and awareness of complex anatomy.

Tell us about the recent LAAO procedure simulation at the Montreal Heart Institute.

First, a three-dimensional (3D) printed replica based on a computed tomography (CT) scan of the patient’s heart was created 2-3 days before the procedure. Using the CT scan, a reconstruction was done, along with use of the FEops HEARTguide (FEops nv), to help us predict the best size and placement of the device. We then had a reconstruction of a 3D printed heart to use for the simulation. The day before the procedure, we rehearsed the full LAAO procedure in the operating room (OR) using the Left Atrial Appendage Closure System (Biomodex) simulator. The following day, we performed the real procedure on the patient, which went smoothly. We found it was helpful to have already performed the simulated procedure beforehand to be prepared for what we might face during the procedure.

Who were the specialists involved in this case?

In this case, as in most of the LAAO cases performed at the Montreal Heart Institute, there are always 2 operators, including the interventional cardiologist (Dr Ibrahim) and the electrophysiologist (myself). Dr Walid Ben Ali, cardiac surgeon, is also involved in simulations.

We also have a cardiologist who is specialized in echocardiography on hand during the procedure to perform the transesophageal echocardiogram. In addition, there is an anesthesiologist available since we are doing the procedure with the patient under general anesthesia, as well as a respiratory therapist. Nurses are also involved in cases to help us during the procedure. These procedures are also sometimes performed under conscious sedation; in those instances, we use intracardiac echocardiography.

In what other ways are case-specific rehearsals of novel technologies being used at the Montreal Heart Institute? Are simulations of other electrophysiology (EP)-specific procedures planned?

The Montreal Heart Institute has partnered with Biomodex to develop new technologies in simulation, including in cardiac EP procedures. In interventional cardiology procedures, there are huge developments in percutaneous aortic valve, mitral valve, and tricuspid valve replacements. In EP, we are planning to develop physician training and simulation for leadless pacemaker implantation. The main consideration in developing that kind of simulation, especially for valve replacement and leadless pacemaker implantation procedures, is practicing on a beating heart.

What is significant about LAAO simulation?

This was the first rehearsal that we performed on a patient before the actual procedure. It helped us determine how and where to do the transseptal puncture at the time of the procedure to correctly deploy the device. The angle of the transseptal puncture is very important in LAAO, and when the device is deployed, it is crucial to have the best alignment. I believe all these elements help improve patient care.

What are the advantages and limitations of simulation modalities?

The main advantage is in training new fellows and physicians on emerging technologies. It is important to have the best training possible, and simulation is a good tool for this. Simulation is also helpful for preparing for difficult cases. The limitation so far is that we are working on developing a better beating heart model. For current simulations of valve replacement or leadless pacemaker implantation, it can also sometimes be difficult to view all of the structure around the valve or determine ventricular trabeculations; we are working to improve on that in the next few months.

What other initiatives and research is the Montreal Heart Institute currently involved in?

Regarding new technologies in the EP field, the Montreal Heart Institute is involved with leadless pacing developments and use of the extravascular implantable cardioverter-defibrillator. We are also going to be part of a study on dual-chamber leadless pacemaker implantation.

I am proud to be a part of the Montreal Heart Institute, which is involved in the development of so many cutting-edge tools for cardiac care. 

Disclosures: The author has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Mondesert reports consulting fees from Abbott, Boston Scientific, and Medtronic; payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Boston Scientific and Medtronic; and participation on a data safety monitoring board or advisory board from Biotronik and Medtronic.