Left atrial appendage perimeter ostium evaluation by cardiac CT utilizing 3mensio technology for watchman implantation

Abstract Background Left atrial appendage occlusion (LAAO) with Watchman device traditionally relies on accurate left atrial appendage ostium diameter measurement by 2D or 3D transesophageal echocardiogram (TEE). Alternate methods of ostium measurement including area-derived diameter and perimeter-derived diameter using cardiac computed tomography (CT) have been proposed. Methods We performed a retrospective analysis of 92 patients with atrial fibrillation (Afib) who underwent LAAO with WATCHMAN implantation with pre-procedural TEE and CT between May 2015 and December 2018. LAA characteristics including ostial or landing zone perimeter, minimum and maximum diameters were acquired utilizing 3mensio Structural Heart Imaging Program. Proposed device size was estimated utilizing ostium perimeter by CT and compared to the current standard utilizing ostium diameter by 2D-TEE. Both measurements were then compared to actual final device size that satisfying release criteria. Results CT had a very high correlation with the actual implanted device size (Pearson coefficient r=0.94, p<0.001), while TEE based sizing had a lower correlation (Pearson coefficient r=0.66, p<0.001). CT predicted size had a significantly higher agreement compared to standard TEE based sizing (93.4% vs 47.8%), and higher interrater agreement (Cohen's kappa = 0.91 vs Cohen's kappa = 0.32, p<0.001, p<0.001 respectively). Bland-Altman analysis also showed better correlation with CT-based sizing. Procedural complications were 0, and 0 patients had a leak recorded at 45-days post implant. Conclusion CCT LAA perimeter sizing is superior to the current standard TEE based Watchman sizing. Larger, multi-center studies may be necessary to further validate results. FUNDunding Acknowledgement Type of funding sources: None. 3mensio after CT upload

Download Full-text

P3730Left atrial appendage perimeter measurement by cardiac CT is superior to transesophageal echocardiography for Watchman device sizing

European Heart Journal ◽

10.1093/eurheartj/ehz745.0584 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

L Seibolt ◽

D Verma ◽

W Mulroy ◽

A Loli

Keyword(s):

Left Atrial ◽

Cardiac Ct ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Current Standard ◽

Landing Zone ◽

Pearson Coefficient ◽

Watchman Device ◽

Very High ◽

Device Size

Abstract Background Left atrial appendage occlusion with Watchman device traditionally relies on accurate left atrial appendage (LAA) ostium diameter measurement by 2D or 3D transesophageal echocardiogram (TEE). Alternate methods of ostium measurement including area-derived diameter and perimeter-derived diameter using cardiac computed tomography (CT) have been proposed. Purpose We aim to use CT technology with an advanced medical imaging application to measure LAA ostium perimeter for improved pre-procedural device sizing. Methods We performed a retrospective analysis of 92 patients with atrial fibrillation (Afib) who underwent Watchman implantation with pre-procedural TEE and cardiac CT between May 2015 and December 2018. LAA characteristics including ostial or landing zone perimeter, minimum and maximum diameters were acquired utilizing 3mensio Structural Heart Imaging Program. Proposed Watchman device size was estimated utilizing ostium perimeter by CT and compared to the current standard utilizing ostium diameter by 2D-TEE. Both measurements were then compared to actual implanted Watchman device size which met the P.A.S.S. criteria of position, anchor, size and seal. Results Watchman device sizing based on novel LAA landing zone perimeter size by CT had a very high correlation with the actual implanted Watchman size (Pearson coefficient r=0.94, p<0.001). Traditional TEE based Watchman sizing only had a modest correlation with the implanted Watchman size (Pearson coefficient r=0.66, p<0.001). CT predicted Watchman size had a significantly higher agreement compared to current standard TEE based sizing (93.4% vs 47.8%), inter-rater agreement was very high for CT based Watchman sizing compared to current standard TEE based sizing (Cohen's kappa = 0.91 vs Cohen's kappa = 0.32, p<0.001, p<0.001 respectively). Bland-Altman analysis also showed better correlation with CT based sizing compared to TEE (see Figure 1). Figure 1 Conclusion CT LAA perimeter sizing is superior to the current standard TEE based Watchman sizing. Larger, multi-center studies may be necessary to further validate our results.

Download Full-text

Pre-procedural Determination of Device Size in Left Atrial Appendage Occlusion Using Three-dimensional Cardiac Computed Tomography

10.21203/rs.3.rs-795122/v1 ◽

2021 ◽

Author(s):

Iksung Cho ◽

William D. Kim ◽

Oh Hyun Lee ◽

Min Jae Cha ◽

Jiwon Seo ◽

...

Keyword(s):

Computed Tomography ◽

Left Atrial ◽

Cardiac Ct ◽

Left Atrial Appendage ◽

Cardiac Computed Tomography ◽

Three Dimensional ◽

Atrial Appendage ◽

Landing Zone ◽

Left Atrial Appendage Occlusion ◽

Device Size

Abstract Background: The two-dimensional-based LAAO size prediction system using transesophageal echocardiography is limited by the complex structure of the left atrial appendage (LAA). The LAA anatomy can be evaluated more precisely using three-dimensional images from cardiac CT; however, a CT-based sizing method has not been established. We aimed to assess the accuracy of measurements derived from cardiac computed tomography (CT) images for selecting left atrial appendage occlusion (LAAO) devices.Methods: 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.Results: 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.Conclusions: 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.

Download Full-text

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

Scientific Reports ◽

10.1038/s41598-021-03537-9 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Iksung Cho ◽

William D. Kim ◽

Oh Hyun Lee ◽

Min Jae Cha ◽

Jiwon Seo ◽

...

Keyword(s):

Computed Tomography ◽

Left Atrial ◽

Cardiac Ct ◽

Left Atrial Appendage ◽

Cardiac Computed Tomography ◽

Three Dimensional ◽

Atrial Appendage ◽

Landing Zone ◽

Mean Error ◽

Device Size

AbstractThe 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.

Download Full-text

One year outcome and analysis of peri-device leak of left atrial appendage occlusion devices

European Heart Journal ◽

10.1093/eurheartj/ehab724.0579 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

M Mansour ◽

E Harnay ◽

A Al Ayouby ◽

V Mansourati ◽

Y Jobic ◽

...

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Cardiac Computed Tomography ◽

Male Gender ◽

Atrial Appendage ◽

P Value ◽

Cardiac Computed Tomography Angiography ◽

Landing Zone ◽

Left Atrial Appendage Occlusion ◽

Maximal Diameter

Abstract Background The prevalence of peri-device leak (PDL) of left atrial appendage occlusion (LAAO) devices has been previously reported. However, there have been only few data that compared different existing devices. The aim of this study was to assess the incidence of PDL with both devices WATCHMAN® and AMPLAZER Amulet®, and to evaluate the clinical outcome at 12 months. Methods Consecutive patients who underwent LAAO between January 2018 and 2020 were randomly assigned to either WATCHMAN or AMPLATZER Amulet implantation based on a systematic two-week alternation between both devices. LAA measurements were assessed using cardiac computed tomography angiography (CCTA) prior to, and transesophageal echocardiography (TEE) during the procedure. At 8 weeks post-LAAO, patients underwent TEE and/or CCTA to identify the presence of PDL and/or device-related complications. Patients were then followed for 12 months to identify major adverse cardiovascular/embolic events. Results The cohort consisted of 51 patients (25 WATCHMAN, 26 AMPLATZER Amulet; mean age 76±7 years; male gender 76%). Both groups were identically matched for demographics, comorbidities and indication for LAAO. There were 19 patients who had PDL (13 WATCHMAN vs 6 AMPLATZER Amulet, P-value=0.033). Of them, 8 (15%) patients had significant PDL (7 WATCHMAN vs. 1 AMPLATZER Amulet, P-value=0.018). On CCTA, the landing zone maximal diameter of the AMPLATZER Amulet device had the strongest correlation with the final deployed device size (Spearman'rho 0.92, P-value<0.0001). In the multivariate analysis, male gender and device type were independent predictors of any PDL (P-values 0.016 and 0.031, respectively). On a mean follow-up of 12 months, the total number of events was more prevalent in the WATCHMAN group (P-value 0.008), but the incidence of cardio-embolic events reached borderline significance (16% vs. 0%, P-value=0.051). Conclusions Among patients who underwent LAAO, almost 15% had significant PDL with the majority belonging to the WATCHMAN group. Still, larger studies are warranted to evaluate its effectiveness in stroke prevention. FUNDunding Acknowledgement Type of funding sources: None. Table 1 Table 2

Download Full-text

Multimodality Imaging for Optimal Device-size Selection During Percutaneous Left Atrial Appendage Closure in Thai Population

10.21203/rs.3.rs-277441/v1 ◽

2021 ◽

Author(s):

Sakolwat Montrivade ◽

Vorarit Lertsuwunseri ◽

Monravee Tumkosit ◽

Suphot Srimahach

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Landing Zone ◽

Zone Diameter ◽

Size Selection ◽

The Mean ◽

Implanted Device ◽

Device Size ◽

Laa Closure

Abstract Background: Optimal device size selection is crucial for percutaneous left atrial appendage (LAA) closure. Transesophageal echocardiography (TEE) is the standard imaging technique for LAA assessment, however there are discrepancies among different imaging modalities. We aimed to evaluate the agreement between device size and LAA size measured by three methods: multi-detector cardiac computed tomography (MDCT), TEE, and angiography. Methods: Patients who underwent percutaneous LAA closure at King Chulalongkorn Memorial Hospital from 2012 to 2020 were included in this study. MDCT, TEE and angiography were reviewed. LAA ostial diameter, landing zone diameter and maximal depth from each imaging modality was measured and analyzed. Agreement between landing zone diameter and implanted device size was assessed.Results: We reported on 61 consecutive patients who underwent percutaneous LAA closure. The mean age of patients was 74.0 ± 8.4 years. The mean CHA2DS2 score, CHA2DS2-VASc score and HAS-BLED score were 2.8 ± 1.4, 4.6 ± 1.8 and 2.6 ± 1.0, respectively. Device implantation was successful in all patients (100%). Two different LAA closure devices were used: Watchman (n = 43, 70.5%) and Omega (n = 18, 29.5%). Maximum landing zone diameter measured by MDCT scan, TEE and angiography were 23.4 ± 3.9 mm, 22.2 ± 4.8 mm and 22.7 ± 3.5 mm, respectively. MDCT measurement was significantly larger than TEE measurement (p = 0.015) and closer to implanted device size compared with TEE and angiography. The difference between landing zone diameter measured by CT scan and device size was -1.65 ± 2.0 mm compared with -4.8 ± 4.6 mm for TEE and -4.3 ± 3.3 mm for angiography.Conclusion: MDCT sizing of LAA results in larger measurement than TEE. Routine implementation of MDCT sizing may improve procedural success with more accurate device size selection.

Download Full-text

Multimodality Approach for Endovascular Left Atrial Appendage Closure: Head-To-Head Comparison among 2D and 3D Echocardiography, Angiography, and Computer Tomography

Diagnostics ◽

10.3390/diagnostics10121103 ◽

2020 ◽

Vol 10 (12) ◽

pp. 1103

Author(s):

Gianpiero Italiano ◽

Anna Maltagliati ◽

Valentina Mantegazza ◽

Laura Fusini ◽

Maria Elisabetta Mancini ◽

...

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Multimodality Imaging ◽

Imaging Techniques ◽

Cardiac Computed Tomography ◽

Atrial Appendage ◽

Imaging Modalities ◽

Left Atrial Appendage Closure ◽

Landing Zone ◽

2D And 3D

Background: Percutaneous left atrial appendage closure (LAAC) requires accurate pre- and intraprocedural measurements, and multimodality imaging is an essential tool for guiding the procedure. Two-dimensional (2D TOE) and three-dimensional (3D TOE) transoesophageal echocardiography, cardiac computed tomography (CCT), and conventional cardiac angiography (CCA) are commonly used to evaluate left atrial appendage (LAA) size. However, standardized approaches in measurement methods by different imaging modalities are lacking. The aims of the study were to evaluate the LAA dimension and morphology in patients undergoing LAAC and to compare data obtained by different imaging modalities: 2D and 3D TOE, CCT, and CCA. Methods: A total of 200 patients (mean age 70 ± 8 years, 128 males) were examined by different imaging techniques (161 2D TOE, 103 3D TOE, 98 CCT, and 200 CCA). Patients underwent preoperative CCT and intraoperative 2D and 3D TOE and CCA. Results: A significant correlation was found among all measurements obtained by different modalities. In particular, 3D TOE and CCT measurements were highly correlated with an excellent agreement for the landing zone (LZ) dimensions (LZ diameter: r = 0.87; LAA depth: r = 0.91, p < 0.001). Conclusions: Head-to-head comparison among imaging techniques (2D and 3D TOE, CCT, and CCA) showed a good correlation among LZ diameter measurements obtained by different imaging modalities, which is a parameter of paramount importance for the choice of the LAAC device size. LZ diameters and area by 3D TOE had the best correlation with CCT.

Download Full-text

Comparing Measurements of Intracardiac Echocardiography and Other Periprocedural Imaging of the Left Atrial Appendage For Percutaneous Occlusion

10.22541/au.163293403.36120062/v1 ◽

2021 ◽

Author(s):

changjian he ◽

Liu Qian ◽

Ling You ◽

Lianxia Wang ◽

Hongning Yin ◽

...

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Cardiac Computed Tomography ◽

Intracardiac Echocardiography ◽

Atrial Appendage ◽

Cardiac Computed Tomography Angiography ◽

Landing Zone ◽

Left Atrial Appendage Occlusion ◽

Good Comparison ◽

Major Adverse Events

Background: Intracardiac echocardiography (ICE) has recently been used as a safe and feasible imaging to guide left atrial appendage occlusion (LAAO). However, there is no good comparison of the correlation of left atrial appendage (LAA) measurements between ICE, transesophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA) and fluoroscopy. Methods: We compared the correlation between ICE and CCTA, TEE, fluoroscopy on two key LAA measurements of each patient: (1) Lambre measured the landing zone and orifice; (2) Watchman measured the ostium and depth. Results: In this study, the success rate of operation was 100%, and no major adverse events occurred. For Lambre landing zone, mean measurements were 22.5±4.0mm with ICE, 23.5 ±4.5mm CCTA, 22.0±4.5mm TEE, 21.5±4.4mm fluoroscopy (P < 0.001). R values 0.78 ICE/CCTA, 0.85 ICE/TEE, 0.81 ICE / fluoroscopy; For Lambre orifice, mean measurements were 29.1±4.0mm with ICE, 31.0±3.9mm CCTA, 25.6±4.6mm TEE and 28.9±3.9mm fluoroscopy (P < 0.001). R values 0.68 ICE/CCTA, 0.76 ICE/TEE, and 0.75 ICE/fluoroscopy. For Watchman ostium, mean measurements were 22.7±3.2mm with ICE, 23.9±3.2mm CCTA, 21.9±3.1mm TEE, and 21.6±3.0mm fluoroscopy (P<0.001). R values 0.69 ICE/CCTA, 0.85 ICE/TEE, and 0.71 ICE/fluoroscopy; For Watchman depth, mean measurements were 22.1±3.1mm with ICE, 24.8±4.1mm CCTA, 23.7±2.9mm TEE, and 21.1±3.3mm fluoroscopy (P=0.002). R values 0.31 ICE/CCTA, 0.67 ICE/TEE, and 0.41 ICE/fluoroscopy. Conclusion: ICE from LA can be a safe and efficacious imaging option to guide LAAO, and ICE has good correlation with CCTA, TEE and fluoroscopy.

Download Full-text

Into the new dawn or back to the roots!? Is cardiac computed tomography the future for thrombus exclusion in the left atrial appendage?

Journal of Cardiovascular Electrophysiology ◽

10.1111/jce.15054 ◽

2021 ◽

Author(s):

Andreas Metzner ◽

Andreas Rillig ◽

Christoph Sinning

Keyword(s):

Computed Tomography ◽

Left Atrial ◽

Left Atrial Appendage ◽

Cardiac Computed Tomography ◽

Atrial Appendage ◽

The Future

Download Full-text

Safety and effects of volume loading during transesophageal echocardiography in the pre-procedural work-up for left atrial appendage closure

Cardiovascular Ultrasound ◽

10.1186/s12947-020-00230-1 ◽

2021 ◽

Vol 19 (1) ◽

Author(s):

Afonso B. Freitas-Ferraz ◽

Mathieu Bernier ◽

Kim O’Connor ◽

Jonathan Beaudoin ◽

Jean Champagne ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Maximum Diameter ◽

Volume Loading ◽

Fluid Bolus ◽

Work Up ◽

Device Size ◽

Laa Closure

Abstract Background In patients undergoing left atrial appendage (LAA) closure, an accurate sizing of the LAA is key to optimize device sizing, procedural success and reduce complications. Previous studies have shown that intraprocedural volume loading increases LAA dimensions and improves device sizing. However, the safety and effects on LAA and device sizing of administering a fluid bolus during pre-procedural transesophageal echocardiography (TEE) are unknown. The aim of this study was to determine the safety and impact on LAA dimensions and device sizing of an intravenous (IV) fluid bolus administered during TEE in the setting of the pre-procedural work-up for LAA closure. Methods The study included a total of 72 patients who underwent TEE to assess suitability for LAAC and received a 500 ml IV bolus of normal saline. The LAA landing zone (LZ) and depth were measured by TEE before and after volume loading, and these measurements were used to predict the device size implanted during a subsequent percutaneous LAAC procedure. Results There were no complications associated with volume loading. The baseline mean LZ was 19.6 ± 3.6 mm at 90o, and 20.2 ± 4.1 mm at 135o. Following fluid bolus, the maximum diameter increased 1.5 ± 1.0 mm at 90o (p<0.001), and 1.3 ± 1.0 mm at 135o (p<0.001). The baseline mean depth of the LAA was 26.5 ± 5.5 mm at 90o, and 23.9 ± 5.8 mm at 135o. After fluid bolus, the mean depth increased by 1.5 ± 1.8 mm (p<0.001) and 1.6 ± 2.0 (p<0.001), at 90o and 135o, respectively. Sizing based on post-bolus measurements of the LZ significantly improved the agreement with the final device size selection during the procedure in 71.0% of cases (vs. 42.0% with pre-bolus measurements). Conclusions Volume loading during ambulatory TEE as part of the pre-procedural work-up of LAAC is safe and significantly increases LAA dimensions. This strategy may become the new standard, particularly in centers performing LAAC with no TEE guidance, as it improves LAA sizing and more accurately predicts the final device size.

Download Full-text