The role of echocardiography in percutaneous left atrial appendage occlusion

Abstract

Percutaneous device closure of the left atrial appendage (LAA) has been introduced in the last decade as a minimally invasive alternative treatment to long-term anticoagulation to reduce the risk of thrombo-embolism in patients with atrial fibrillation. Echocardiography is an essential tool at all stages of the procedure. Pre-procedural echocardiography is used to screen suitable candidates and to define LAA morphology and dimension; peri-procedural transoesophageal or intracardiac echocardiography has a major role in guiding, delivery, and deployment of the device, for screening of procedural complications and for assessing procedural success; and post-procedural echocardiography is important in the surveillance and monitoring of long-term outcome. This article aims to outline the role of echocardiography at each stage of LAA occlusion.

Transcatheter Left Atrial Appendage Closure Using Intracardiac Echocardiographic Guidance From the Left Atrium

“…Procedural success was defined as the release of a stable occlusion device at the intended site with adequate occlusion of the LAA without impingement on surrounding cardiac structures. Based on a previous publication, 15 quality of occlusion was assessed using angiography (on a scale of 1 to 4, severe to no leak), intraprocedural ICE and 3-month follow-up TEE (on a scale of 1 to 5, severe to no leak). Occlusion was deemed satisfactory when graded 3 or 4 using angiography and 4 or 5 using echocardiography.…”

Left Atrial Appendage Exclusion for Atrial Fibrillation

“…In addition, an important unknown is how to determine when the appendage is adequately closed, and whether the definition should be anatomical, electrical or functional 7, 10 and whether transesophageal or intracardiac echocardiography, CT or MRI is the optimal imaging study. 140,141,166,[173][174][175][176] All closure devices and techniques will leave a small "beak" where tissues are approximated or adjacent to a device; whether these impact stroke prevention is not known. Additionally, accessory lobes, pectinate muscles or other structures may exist proximal to a device or closure; their impact is uncertain.…”

Monitoring and guiding cardiac interventions and surgery

“…Consequently, it has been demonstrated to be particularly useful in guiding transcatheter LAA occlusion as it provides accurate visualization and assessment of both the interatrial septum and the LAA [1] [68][78] [79]. RT3D TEE has also been shown to provide accurate quantitative analysis of LAA anatomy including the number of lobes which is crucial for patient selection and appropriate occluder placement [80] [81]. Device sizing requires careful measurement of the appendage dimensions.…”