Left atrial appendage remodeling following percutaneous closure with WATCHMAN 2.5 and FLX: insights from the WATCH-DUAL registry

Abstract Background Percutaneous left atrial appendage closure (LAAC) has emerged as a valid option for prevention of thromboembolic events in patients with non-valvular atrial fibrillation and contraindications for oral anticoagulation. The most recent devices have been created to improve the intervention efficiency and to allow the procedure in a wider range of anatomies. The new-generation Watchman FLX (WMFLX) features a new design but its in vivo performances have not been compared to the previous WATCHMAN 2.5 (WM2.5) prosthesis. Hence, the data regarding conformability, compression and device-related LAA remodeling are scarce. Purpose To compare the anatomical results of WM2.5 and WMFLX implantation and impact on LAA dimensions. Methods This study included LAAC patients from the WATCH-DUAL registry who benefited from a pre- and post-intervention CT scan. The WATCH-DUAL study was a dual center observational study including all the LAAC procedures prospectively collected in local registries from two high-volume centres between November 2017 and December 2020. The LAA and device dimensions were measured in a centralized core lab by 3D CT scan reconstruction methods, focusing on the device landing zone (LZ/defined as the cross section of the appendage that was perpendicular to its axis and connected the circumflex artery to a point 1 to 2 cm inside the LAA). Results This analysis included n=107 patients (n=58 WMFLX, n=49 WM2.5). The patients clinical profiles didn't differ, except for a higher proportion of coronary artery disease in WM2.5 group. The LAA dimensions were comparable between groups. There was a significantly higher proportion of chickenwing shapes in the WMFLX patients. The mean device baseline diameter was in the WMFLX compared to the WM2.5 patients (28.8±0.5 vs. 25.7±0.4 mm, p<0.001). The median delay for CT control was 48 (43–62) days. The LZ area (451 (363–521) vs. 366 (260–459) mm2, p<0.001) and minimal diameter (23.0 (20.7–24.8) vs. 18.7 (15.9–21.8) mm, p<0.001) significantly increased after implantation among patients. The LZ area increase absolute value and percentage were 101 (18–151) mm2 and 28 (4–54) % respectively. The LZ dimensions increase was more pronounced in the WMFLX group: these patients exhibited post LAAC larger LZ area and dimensions compared to the WM2.5 cases. The LAA eccentricity was reduced after implantation: the ratio LZ maximal/LZ minimal diameter significantly decreased for all patients (r=1.28 (1.18–1.40) vs. 1.06 (1.05–1.09), p<0.001). Comparable results were observed in WMFLX and WM2.5 patients. A multivariable regression analysis demonstrated that baseline LAA length, baseline LZ eccentricity and WM FLX use were independent predictors of LAA remodeling/dimensions increase. Conclusion LAA dimensions increased over time at the site of WM prosthesis implantation suggesting a local positive appendage remodeling after procedure. This phenomenon appears to be more pronounced with the WMFLX device. FUNDunding Acknowledgement Type of funding sources: None.

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Abstract 14676: Landmark-based Functional Computed Tomography Reveals Diminished Left Atrial Appendage Contraction During Atrial Fibrillation

Circulation ◽

10.1161/circ.142.suppl_3.14676 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Jonathan H Chung ◽

Gordon Ho ◽

Andrew Schluchter ◽

Francisco Contijoch ◽

Jonathan C Hsu ◽

...

Keyword(s):

Computed Tomography ◽

Atrial Fibrillation ◽

Ejection Fraction ◽

Sinus Rhythm ◽

Ct Scan ◽

Blood Volume ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

History Of

Introduction: The formation of thrombus in the left atrial appendage (LAA) and risk for systemic embolization may result in part from stasis and poor blood volume emptying during atrial fibrillation (AF). Functional 4-dimensional computed tomography (4DCT) is a promising technique to measure LAA ejection fraction and blood volume emptying. Hypothesis: We hypothesize that the LAA ejection fraction measured by 4DCT is decreased during AF compared to sinus rhythm. Methods: 256-slice 4DCT scans obtained in patients for coronary artery imaging or pre-procedurally for AF, VT or SVT ablation procedures were analyzed retrospectively. In each patient, LAA volumes were measured at multiple phases during one cardiac cycle using segmentation software (ITK-SNAP and Osirix MD). LAA ejection fraction was calculated as the difference between minimum and maximum volumes and was analyzed using Wilcoxon rank sum. Results: Out of 54 patients, 37 patients were in sinus rhythm and 17 patients were in AF. Between NSR vs. AF, mean age was 69.1±12.8 vs 73.2±11.5 years (p=0.13), 28% vs 36% female (p=0.54), LVEF was 58±11% vs 60±9% (p=0.95), and echo-derived left atrial volume index was 29.5±6.1 ml/m2 vs 41.7±12.8 ml/m2 (p=0.06). Patients who were in sinus rhythm during their CT scan had a higher LAA ejection fraction than those who were in AF (58±13% vs. 29±9%, p<0.0001). For patients who were in AF during their CT scan, there was no difference in LAA ejection fraction between patients with a history of paroxysmal AF compared to patients with a history of persistent AF (30±10% vs. 28±10%, p=0.75). Conclusions: Analysis of the LAA volumes using functional cardiac CT is a feasible method to quantify blood volume emptying from the LAA. Patients in AF were observed to have significantly decreased LAA ejection fraction and blood volume emptying compared to patients in sinus rhythm. Further studies are needed to determine whether this technique may improve personalized risk stratification for stroke.

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Safety and efficacy of left atrial appendage occlusion guided by CT-scan and intracardiac echocardiography from the left atrium

Archives of Cardiovascular Diseases Supplements ◽

10.1016/j.acvdsp.2018.10.333 ◽

2019 ◽

Vol 11 (1) ◽

pp. 150

Author(s):

T. Pommier ◽

Basile Mouhat ◽

C. Vernay ◽

Yacine Chenna ◽

C. Guenancia ◽

...

Keyword(s):

Ct Scan ◽

Left Atrium ◽

Left Atrial ◽

Left Atrial Appendage ◽

Intracardiac Echocardiography ◽

Atrial Appendage ◽

Safety And Efficacy ◽

Left Atrial Appendage Occlusion

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Use of a Novel Septal Occluder Device for Left Atrial Appendage Closure in Patients With Postsurgical and Postlariat Leaks or Anatomies Unsuitable for Conventional Percutaneous Occlusion

Circulation Cardiovascular Interventions ◽

10.1161/circinterventions.120.009227 ◽

2020 ◽

Vol 13 (10) ◽

Author(s):

Domenico G. Della Rocca ◽

Rodney P. Horton ◽

Nicola Tarantino ◽

Christoffel Johannes Van Niekerk ◽

Chintan Trivedi ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Oral Anticoagulation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Systemic Circulation ◽

Atrial Appendage ◽

Landing Zone ◽

Septal Occluder Device ◽

Occluder Device ◽

Laa Closure

Background: Interventional therapies aiming at excluding the left atrial appendage (LAA) from systemic circulation have been established as a valid alternative to oral anticoagulation in patients at high thromboembolic risk. However, their efficacy on stroke prophylaxis may be compromised owing to incomplete LAA closure. Additionally, the need for an alternative thromboembolic prevention may remain unmet in patients with contraindications to oral anticoagulation whose appendage anatomy is unsuitable for some conventional devices commercially available. We aimed at evaluating the feasibility of LAA closure with the novel Gore Cardioform Septal Occluder in patients with incomplete appendage ligation or anatomic features which do not meet the manufacturer’s requirements for Watchman deployment. Methods: Twenty-one consecutive patients (mean age: 72±6 years; 85.7% males; CHA 2 DS 2 -VASc: 4.5±1.4; HAS-BLED: 3.6±1.0) were included. Transesophageal echocardiography was performed within 2 months to assess for residual LAA patency. Results: Fourteen patients had incomplete LAA closure following surgical (n=6) or Lariat ligation (n=8). In 7 patients with an appendage anatomy unsuitable for Watchman deployment, the mean maximal landing zone size and LAA depth were 14.4±1.3 and 18.6±2.8 mm. Successful Cardioform Septal Occluder deployment was achieved in all patients. No peri-procedural complications were documented. Procedure and fluoroscopy times were 46±13 and 14±5 minutes. Follow-up transesophageal echocardiography after 58±9 days revealed complete LAA closure in all patients. Conclusions: Transcatheter LAA closure via a Cardioform Septal Occluder device might be a valid alternative in patients with residual leaks following failed appendage ligation or whose LAA anatomy does not meet the minimal anatomic criteria to accommodate a Watchman device. Graphic Abstract: A graphic abstract is available for this article.

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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.

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P2467Fusion imaging (Anatomical Intelligence) enables automated left atrial appendage sizing in real-time a single center pilot study

European Heart Journal ◽

10.1093/eurheartj/ehz748.0799 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Afzal ◽

V Veulemans ◽

K Hellhammer ◽

K Piayda ◽

N Nijhof ◽

...

Keyword(s):

Real Time ◽

Left Atrial ◽

Left Atrial Appendage ◽

Fusion Imaging ◽

Atrial Appendage ◽

Patient Specific ◽

Heart Model ◽

Landing Zone ◽

Device Selection ◽

The Mean

Abstract Background and purpose Percutaneous left atrial appendage occlusion (LAAO) depicts an alternative treatment for patients with atrial fibrillation who are deemed for long-term oral anticoagulation therapy. In order to perform a successful LAAO accurate sizing of left atrial appendage (ostium, landing zone and depth) for device selection is essential. Echo-Fluoro fusion imaging in real-time offers with its latest prototype a patient-specific segmented automated 3D heart model and sizing of left atrial appendage (LAA). We therefore aimed to evaluate the automated segmented LAA sizing by comparing to 2D transesophageal (TOE) and MSCT measurements as gold standard. Methods We studied prospectively data of 8 consecutive patients who were admitted to our clinic for left atrial appendage closure. MSCT was performed preprocedural and analyzed with commercially available 3mensio software (Pie medical imaging). 2D TOE measurements and automated segmentation of the LAA and sizing were performed during the procedure by a highly experienced team of periinterventional cardiac imaging specialist and structural heart disease interventionalist who were blinded to the prior MSCT analysis. Dimension of ostium, landing zone (10 mm into the LAA parallel to the ostial plane at the level of the left circumflex for Amplatzer device) and depth (perpendicular to the ostial plane) were obtained in different TOE views according to instructions for use of Amulet Occluder. In order to generate an automated 3 D heart model, a high-quality 3D TOE image of the LAA volume and surrounding structures was acquired. After successful ECG-gated segmentation a 3 D heart model was generated. Automated LAA sizing followed in real-time. All measurements were taken into consideration before device selection. A Kruskal Wallis test was used to compare mean ranks of independent samples. A concordance analysis according to Kendall W was carried out to investigate reliability. Results The mean age of the patients was 82,6±4.15 years and half of the patients were female. All procedures were conducted successfully. The mean values of ostium and landing zone were comparable in TOE, automated sizing and MSCT sizing (ostium: 23,78±2,15 mm vs 25,71±5,25 mm vs 27,35±3,3 mm; (p=0,175); landing zone 22,13±3,18 mm vs 23,57±3,31 mm vs 24,00±3,51 mm; (p=0,377)). Furthermore, a significant concordance between the measurements was shown (ostium W= 0,991; p=0.045, landing zone W=0,835, p=0.014). Conclusion Automated LAA sizing acquired by fusion imaging may be an elegant real-time alternative for precise LAA Occluder device selection and needs to be investigated further.

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Compliance of left atrium with and without left atrium appendage

AJP Heart and Circulatory Physiology ◽

10.1152/ajpheart.1990.259.4.h1006 ◽

1990 ◽

Vol 259 (4) ◽

pp. H1006-H1008 ◽

Cited By ~ 8

Author(s):

C. A. Davis ◽

J. C. Rembert ◽

J. C. Greenfield

Keyword(s):

Left Atrium ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Volume Data ◽

Hemodynamic Function

Compliance of the left atrial chamber was estimated with and without the appendage intact in six isolated canine left atria. Pressure-volume determinations were measured over a range of 5-30 mmHg for the whole left atrium and were repeated with the appendage excluded. The slope of the pressure vs. normalized volume data for the left atrium without the appendage (10.45 +/- 0.87) was significantly greater (P less than 0.01) than with the appendage intact (4.10 +/- 0.72). These data suggest that the left atrial appendage is more compliant than the remaining left atrium. Assuming that this relationship remains in vivo, the left atrial appendage may play an augmented role in maintaining hemodynamic function when filling pressures are elevated.

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Complete Obliteration of the Left Atrial Appendage an Analysis of Epicardial Excision and Novel Pericardial Patch Exclusion

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000281 ◽

2016 ◽

Vol 11 (4) ◽

pp. 282-287 ◽

Cited By ~ 3

Author(s):

Bayan B. Malakouti-Nejad ◽

Eliot J. Winkler ◽

Marjorie I. Johnson ◽

Jorge Catrip ◽

Katie L. Losenno ◽

...

Keyword(s):

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Incomplete Resection ◽

Pericardial Patch ◽

Circumflex Artery ◽

Complete Obliteration ◽

Procedural Success ◽

The Impact ◽

Total Elimination

Objective Conventional epicardial excision is believed to be the most effective method of surgically obliterating the left atrial appendage (LAA), although incomplete resection and residual LAA volume may undermine its effectiveness. We sought to compare the impact of conventional epicardial excision with a novel LAA pericardial patch exclusion on residual LAA volume. Methods We performed LAA obliteration using pericardial patch exclusion, followed by conventional epicardial excision, in 27 cadaveric hearts. After each procedure, residual LAA volume was measured by two different techniques and compared with baseline volume. There was no difference in baseline LAA volume between each procedure. Results Procedural success was achieved in all hearts. Conventional epicardial excision left a residual LAA volume of 0.95 mL (24%), as compared with pericardial patch exclusion, which left a residual volume of 0.17 mL (4%, P = 0.0001). Further analysis of fixed and fresh hearts showed that reduction of LAA volume was more pronounced in the fresh hearts, suggesting effectiveness in live patients. Neither technique resulted in any significant change in the endocardial shape of the LAA orifice or injury to the circumflex artery. Conclusions Conventional epicardial excision of the LAA results in significantly more residual LAA volume, which may have important implications in persistent stroke risk. Pericardial patch exclusion seems to achieve near-total elimination of the LAA and may be a superior surgical option.

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