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Left Atrial Appendage Closure Periprocedural Imaging

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Cardiac Imaging in Structural Heart Disease Interventions

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Abstract

Percutaneous left atrial appendage closure (LAAC) has become an important tool for stroke prevention in patients with nonvalvular atrial fibrillation (AF). LAAC is an alternative to oral anticoagulation (OAC) and, thus, is a desirable option for patients at high risk for bleeding. In the early days of LAAC, concerns were raised about the procedure’s safety and long-term efficacy. However, operator technique improvements, pre-, and periprocedural imaging advancements, and device development have improved safety and technical success rates. This chapter reviews the periprocedural multimodality imaging in percutaneous LAAC when using the 2 FDA-approved devices, Watchman FLX (Boston Scientific Corporation) and Amulet (St. Jude Medical, Minneapolis, MN).

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Abbreviations

CCTA:

Cardiac computer tomography angiography

DOAC:

Direct oral anticoagulation

IAS:

Interatrial septum

ICE:

Intracardiac echocardiography

LA:

Left atrium

LAAC:

Left atrial appendage closure

LV:

Left ventricle

MPR:

Multiplanar reconstruction

OAC:

Oral anticoagulation

PFO:

Patent foramen ovalis

TEE:

Transoesophageal echocardiography

TTE:

Transthoracic echocardiography

References

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Author information

Authors and Affiliations

  1. Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada

    Mesfer Alfadhel & Jacqueline Saw

Authors
  1. Mesfer Alfadhel
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  2. Jacqueline Saw
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Corresponding author

Correspondence to Jacqueline Saw .

Editor information

Editors and Affiliations

  1. Division of Cardiology, Duke University Medical Center, Durham, NC, USA

    Anita M. Kelsey

  2. Duke University Hospital, Durham, NC, USA

    Sreek Vemulapalli

  3. MedStar Health Research Institute and Georgetown University, Washington, DC, DC, USA

    Anita Sadeghpour

Ethics declarations

Dr. Saw has received unrestricted research grant support (from the Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, National Institutes of Health, University of British Columbia Division of Cardiology, AstraZeneca, Abbott Vascular, St Jude Medical, Boston Scientific, and Servier), salary support (Michael Smith Foundation of Health Research), speaker honoraria (AstraZeneca, Abbott Vascular, Boston Scientific, and Sunovion), consultancy and advisory board honoraria (AstraZeneca, St Jude Medical, Abbott Vascular, Boston Scientific, Baylis, Gore, FEops), and proctorship honoraria (Abbott Vascular, St Jude Medical and Boston Scientific), all outside the submitted work. Dr. Alfadhel has no disclosures.

Chapter Review Questions

Chapter Review Questions

An 80-year-old man with AF rhythm and high risk for internal bleeding, and candidate for percutaneous LAA closure:

  1. 1.

    In the pre-procedural evaluation of the interatrial septum (IAS) by TEE which of the following is INCORRECT?

    1. A.

      In the presence of a large PFO, utilizing PFO to cross the septum is recommended to avoid iatrogenic ASD.

    2. B.

      Presence of a thick or aneurysmal IAS can be challenging for septostomy.

    3. C.

      The optimal location for transseptal puncture for LAA closure is inferior and posterior of IAS.

    4. D.

      The best TEE view during transseptal puncture is bi-caval and short axis views.

    Answer: A

    A PFO should not be used for sheath access as the resulting transseptal angle is not optimal for a coaxial approach to the LAA. Instead, performing a separate transseptal puncture inferoposteriorly is advised to provide a more direct vector orientation to access the LAA, which arises anteriorly and superiorly.

  2. 2.

    The morphology of LAA is described as a short LAA body that branches into several lobes. Which of the following shape is matched this definition:

    1. A.

      Windsock

    2. B.

      Chicken-wing

    3. C.

      Cauliflower

    4. D.

      Cactus

    Answer: C

    The cauliflower morphology has a short LAA body that branches into several lobes.

  3. 3.

    Which TEE views commonly provide the widest diameter of the LAA orifice?

    1. A.

      0°

    2. B.

      45°

    3. C.

      90°

    4. D.

      135°

    Answer: D The short axis of the LAA is typically obtained at 135° imaging plane. This angle usually provides imaging of the widest diameter of the LAA orifice.

  4. 4.

    In the percutaneous LAA closure pre-procedural evaluation by cardiac CT

    1. A.

      LAA dimensions by cardiac CT are larger than LAA dimensions by TEE

    2. B.

      LAA dimensions by cardiac CT are smaller than LAA dimensions by TEE

    3. C.

      LAA dimensions by cardiac CT are comparable to LAA dimensions by TEE

    4. D.

      Cardiac CTA is not recommended for pre-procedural evaluation

    Answer: A

    Many studies have shown that the measurements of LAA dimensions are larger on CTA than TEE. Depth dimensions by 2D-TEE were similarly smaller than 3D TEE, and both were smaller than CTA.

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Alfadhel, M., Saw, J. (2024). Left Atrial Appendage Closure Periprocedural Imaging. In: Kelsey, A.M., Vemulapalli, S., Sadeghpour, A. (eds) Cardiac Imaging in Structural Heart Disease Interventions. Springer, Cham. https://doi.org/10.1007/978-3-031-50740-3_6

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  • DOI: https://doi.org/10.1007/978-3-031-50740-3_6

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-50739-7

  • Online ISBN: 978-3-031-50740-3

  • eBook Packages: MedicineMedicine (R0)

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