scholarly journals Left atrial appendage closure in the presence of thrombus: incidence, technique and outcomes

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
A Fontenla Cerezuela ◽  
I Gomez-Blazquez ◽  
C Corros ◽  
D Rodriguez ◽  
L Borrego-Bernabe ◽  
...  
Keyword(s):  
Left Atrial ◽  
Left Atrial Appendage ◽  
High Volume ◽  
Atrial Appendage ◽  
Landing Zone ◽  
Funding Sources ◽  
High Volume Center ◽  
Occlusion Technique ◽  
Protection Devices ◽  
Clinical Conditions

Abstract Funding Acknowledgements Type of funding sources: None. Background Patients with left atrial appendage (LAA) thrombus are excluded for LAA occlusion (LAAO) in clinical trials. However, some of them may require this therapy due to repeated thromboembolisms despite accurate anticoagulation.  Aim The aim of the study is to describe the prevalence of LAA thrombosis in patients submitted for LAAO in a high-volume center of LAAO procedures, explaining the employed technique and results in this scenario. Methods Single-center retrospective analysis including all consecutive patients referred for LAAO. Results LAA thrombus was detected by TEE in 8/76 patients referred for LAAO (10.5%). Five of them underwent LAAO despite the presence of thrombus due to clinical conditions. All the procedures were successfully performed with  Amulet devices (Table). The following preventive measures were putting in place during the implants: avoidance of contrast injection into the LAA during the procedure (non-touch technique), TEE measure for device size election; and TEE device deployment guidance with special care to the the sheath orientation and depth enabling a slow and single implant of the device partially released in the LAA before complete implantation at the entrance of the LAA (Figure. A&B: Large LAA thrombus partially occupying the landing zone. C: Thrombus sealed by LAAO device. D&E: Non-touch technique: echo-guided progressive deployment of the LAAO device without thrombus shifting). No cerebral protection devices were used. TEE performed one month after the procedure ruled out the presence of residual thrombi or leaks in all cases. There were no events after a median follow-up of 17.1 months (range: 32.3-1.1) Conclusion LAAO in patient with LAA thrombus can be effectively and safely performed, in high-volume centers  and with an accurate technique, under accurate TEE guidance. Abstract Figure. LAA thrombus and occlusion technique

Interventional closure of the left atrial appendage for stroke prevention - experience from a high volume center

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. P2188-P2188
Author(s):  
Y. Matsuo ◽  
S. Moebius-Winkler ◽  
M. Sandri ◽  
N. Mangner ◽  
N. Majunke ◽  
...  
Keyword(s):  
Stroke Prevention ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
High Volume ◽  
Atrial Appendage ◽  
Interventional Closure ◽  
High Volume Center

scholarly journals Left atrial appendage closure for stroke prevention - long term results from high volume center

2013 ◽  
Vol 34 (suppl 1) ◽  
pp. P407-P407
Author(s):  
Y. Matsuo ◽  
S. Moebius-Winkler ◽  
M. Sandri ◽  
N. Mangner ◽  
N. Majunke ◽  
...  
Keyword(s):  
Stroke Prevention ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
High Volume ◽  
Atrial Appendage ◽  
Long Term Results ◽  
Left Atrial Appendage Closure ◽  
High Volume Center

scholarly journals 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

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.

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

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.

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

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.

Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience

2018 ◽  
Vol 107 (12) ◽  
pp. 1139-1147 ◽  
Author(s):  
Thomas Fink ◽  
Michael Schlüter ◽  
Roland Richard Tilz ◽  
Christian-Hendrik Heeger ◽  
Christine Lemes ◽  
...  
Keyword(s):  
Left Atrial ◽  
Second Generation ◽  
Left Atrial Appendage ◽  
High Volume ◽  
Atrial Appendage ◽  
Long Term Outcomes

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

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
K Mahmoudi ◽  
R Galea ◽  
S Elhadad ◽  
L Z Rezine ◽  
F Sebag ◽  
...  
Keyword(s):  
Ct Scan ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Atrial Appendage ◽  
Post Intervention ◽  
Circumflex Artery ◽  
Landing Zone ◽  
Reconstruction Methods ◽  
Minimal Diameter

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&lt;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&lt;0.001) and minimal diameter (23.0 (20.7–24.8) vs. 18.7 (15.9–21.8) mm, p&lt;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&lt;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.

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

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.

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

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&lt;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

Abstract 17421: Use of a Novel Septal Occluder Device for Left Atrial Appendage Closure in Patients With Post-Surgical and Post-Lariat Leaks or Anatomies Unsuitable for Conventional Percutaneous Occlusion

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Domenico G Della Rocca ◽  
Rodney Horton ◽  
Nicola Tarantino ◽  
Luigi Di Biase ◽  
Carola Gianni ◽  
...  
Keyword(s):  
Left Atrial ◽  
Left Atrial Appendage ◽  
Systemic Circulation ◽  
Atrial Appendage ◽  
Landing Zone ◽  
Septal Occluder Device ◽  
Watchman Device ◽  
Occluder Device ◽  
Procedural Complications ◽  
Laa Closure

Introduction: Interventional therapies aiming at excluding the left atrial appendage (LAA) from systemic circulation have been established as a valid alternative to oral anticoagulation (OAC) in patients at high thromboembolic (TE) risk. However, their efficacy on stroke prophylaxis may be compromised owing to incomplete LAA closure. Additionally, the need for an alternative TE prevention may remain unmet in patients with contraindications to OAC whose appendage anatomy is unsuitable for some conventional devices commercially available. Hypothesis: We aimed at evaluating the feasibility of LAA closure with the novel Gore® Cardioform Septal Occluder (CSO) in patients with incomplete appendage ligation or anatomical 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. Trans-esophageal echocardiography (TEE) 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±1.3mm and 18.6±2.8mm. Successful CSO deployment was achieved in all patients. No peri-procedural complications were documented.Procedure and fluoroscopy times were 46±13min and 14±5min. Follow-up TEE after 58±9 days revealed complete LAA closure in all patients. Conclusions: Transcatheter LAA closure via a CSO device might be a valid alternative in patients with residual leaks following failed appendage ligation or whose LAA anatomy does not meet the minimal anatomical criteria to accommodate a Watchman device.

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