Pre-procedural determination of device size in left atrial appendage occlusion using three-dimensional cardiac computed tomography

Abstract

The complex structure of the left atrial appendage (LAA) brings limitations to the two-dimensional-based LAA occlusion (LAAO) size prediction system using transesophageal echocardiography. The LAA anatomy can be evaluated more precisely using three-dimensional images from cardiac computed tomography (CT); however, there is lack of data regarding which parameter to choose from CT-based images during pre-procedural planning of LAAO. We aimed to assess the accuracy of measurements derived from cardiac CT images for selecting LAAO devices. We retrospectively reviewed 62 patients with Amplatzer Cardiac Plug and Amulet LAAO devices who underwent implantation from 2017 to 2020. The minimal, maximal, average, area-derived, and perimeter-derived diameters of the LAA landing zone were measured using CT-based images. Predicted device sizes using sizing charts were compared with actual successfully implanted device sizes. The mean size of implanted devices was 27.1 ± 3.7 mm. The perimeter-derived diameter predicted device size most accurately (mean error = − 0.8 ± 2.4 mm). All other parameters showed significantly larger error (mean error; minimal diameter = − 4.9 ± 3.3 mm, maximal diameter = 1.0 ± 2.9 mm, average diameter = − 1.6 ± 2.6 mm, area-derived diameter = − 2.0 ± 2.6 mm) than the perimeter-derived diameter (all p for difference < 0.05). The error for other parameters were larger in cases with more eccentrically-shaped landing zones, while the perimeter-derived diameter had minor error regardless of eccentricity. When oversizing was used, all parameters showed significant disagreement. The perimeter-derived diameter on cardiac CT images provided the most accurate estimation of LAAO device size regardless of landing zone eccentricity. Oversizing was unnecessary when using cardiac CT to predict an accurate LAAO size.

Morphological changes in the orifices of the left atrial appendage and left atrium in patients with atrial fibrillation

“…In addition, LAA anatomic parameters varied between males and females. As 3D cardiac CT is a vital tool to effectively evaluate the LAA size, these parameters may be potentially useful in guiding clinicians to choose devices properly ( 15 ).…”

The CT derived angle between the transseptal puncture site and the left atrial appendage as a predictor for complex interventional occlusion procedures

“…Pre‐procedural CCT scanning is increasingly utilized and recognized as a powerful tool in the planning of LAA closure, as it allows additional insights into patient‐specific anatomy 5,21 . Several studies have underlined the importance to obtain the most accurate LAA dimensions through multi‐modal imaging (2D‐TEE, 3D‐TEE, fluoroscopy, CCT, fusion imaging) to prevent device recaptures, intra‐procedural device changes and prolonged procedure duration resulting in higher doses of contrast dye and radiation 22–24 …”

“…5,21 Several studies have underlined the importance to obtain the most accurate LAA dimensions through multi-modal imaging (2D-TEE, 3D-TEE, fluoroscopy, CCT, fusion imaging) to prevent device recaptures, intraprocedural device changes and prolonged procedure duration resulting in higher doses of contrast dye and radiation. [22][23][24] Apart from the difficulties that stem from the anatomical variance of the LAA, the transseptal puncture is another step prone to complications during the procedure. In this context, successful coaxial device deployment depends on the ability to position the delivery sheath with sufficient depth into the LAA, with the long axis of the LAA oriented anteriorly and the plane of the LAA ostium perpendicular to that axis, this is accomplished with a posterior-anterior trajectory of the sheath.…”

Improving Left Atrial Appendage Occlusion Device Size Determination by Three-Dimensional Printing-Based Preprocedural Simulation

“…Fourth, there was a lack of comparison with CT-based sizing and TEE or 3D printing-based sizing methods. Cardiac CT images allow accurate evaluation of the LAA anatomy ( 34 ) and as 3D printing is based on reconstructed CT images, it would be an important matter to include CT-based sizing methods for comparison in future studies. Last, the relatively small sample size should also be taken into consideration in this study.…”