A comparative study of different imaging modalities for successful percutaneous left atrial appendage closure

Abstract

ObjectivesAccurate sizing of the left atrial appendage (LAA) is essential when performing percutaneous LAA closure. This study aimed to compare different LAA imaging modalities and sizing methods in order to obtain successful LAA closure.BackgroundPercutaneous LAA closure is an increasingly used treatment strategy to prevent stroke in patients with atrial fibrillation. LAA sizing has typically been done by 2D-transoesophageal echocardiography (TEE).MethodsPatients who had a preprocedural TEE and preprocedural and postprocedural multislice CT (MSCT) were identified. Preprocedural measurements of LAA ostia and landing zones by 2D-TEE, MSCT and angiography were collected and analysed for those patients with successful LAA closure - i.e. with no contrast leakage at 3-month follow-up MSCT.ResultsThe study population (n=67) had a mean CHA2DS2-VASc score of 3.0 and HAS-BLED score of 2.7. Fifty-eight patients (87%) were identified to have successful LAA closure. Based on MSCT, 48 LAA sizings (83%) resulted in a correct LAA closure device size selection, whereas with 2D-TEE sizing, only 33 measurements (57%) would have resulted in a correct device size selection (p<0.01). Using adapted Bland-Altman method, MSCT-based perimeter-derived mean diameter was shown to be the best parameter to guide LAA device size selection for ‘closed-end’ devices (Amulet, WatchmanFLX), whereas the maximal diameter was the best parameter for the ‘open-end’ Watchman device.ConclusionsPreprocedural MSCT-based LAA closure device size selection proves to be a more accurate method than conventional 2D-TEE-based sizing. Depending on the LAA closure device design, perimeter-derived mean diameter or maximal diameter could be the better sizing method.

Usable implantation depth for watchman left atrial appendage occlusion is greater with appendage angiography than transesophageal echocardiography

“…Our findings are consistent with previous comparisons of CT angiography to TEE for measuring LAA size, and provide further evidence that TEE has limitations in providing accurate size measurements . For the most part, TEE does allow acceptable sizing in terms of LAA ostial diameter and depth for successful completion of LAA occlusion.…”

“…Transesophageal echocardiography (TEE) is currently employed as the standard for procedural measurement of the LAA ostial diameter and depth in the two‐dimensional (2D) omniplane views of 0°, 45°, 90°, and 135°. Studies comparing TEE sizing of the LAA with computed tomography (CT) imaging have shown more accurate LAA ostial diameter and depth with CT compared to TEE . However, routine use of CT is not commonly performed commercially due to lack of formal vendor recommendation, and is not feasible for every case at every institution due to workflow, cost, reimbursement, and the need for intravenous contrast.…”

“…Studies comparing TEE sizing of the LAA with computed tomography (CT) imaging have shown more accurate LAA ostial diameter and depth with CT compared to TEE. [7][8][9][10] However, routine use of CT is not commonly performed commercially due to lack of formal vendor recommendation, and is not feasible for every case at every institution due to workflow, cost, reimbursement, and the need for intravenous contrast. TEE therefore remains the most commonly used modality for LAA size assessment for the Watchman implantation.…”

Comparison of transesophageal and intracardiac echocardiography in guiding percutaneous left atrial appendage closure with an Amplatzer Amulet device

“…The most important possible complications are those associated with right heart catheterization such as pulmonary embolism, pericardial tamponade, but also bleeding from the puncture site, and vascular complications. Moreover, the mono-plane images may limit the usefulness of ICE in left atrial appendage occluder sizing [4].…”

“…Also TOE remains the gold standard for exclusion of thromboembolic material within the left atrium and in its appendage [2,3]. Nevertheless, some authors emphasize the advantages of computed tomography or cardiac magnetic resonance for exploration of the anatomy of the left atrial appendage and for the precise measurement of its dimensions [4,5]. Thus the debate on the optimal imaging strategy for the pre-procedural visualization of the left atrium is still open.…”