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

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Left Atrial Appendage Morphology With The Progression of Atrial Fibrillation

10.21203/rs.3.rs-757374/v2 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Fumi Yokohama ◽

Norihisa Toh ◽

Koji Nakagawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Therapeutic Strategy ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Volume Index ◽

Determining The Indication ◽

Device Size ◽

Laa Closure

Abstract Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 340 patients (mean age: 65 ± 15 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 105), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth, greater LAA lobes, and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (r = 0.37, p < 0.01) and the duration of continuous AF (r = 0.30, p < 0.01), but not with age or the period from the onset of AF. In conclusion, LAA size, which is the determinant for selecting device size of transcatheter LAA closure, was increased with the progression of AF. Our findings have potential implications for therapeutic strategy of transcatheter LAA closure.

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Left Atrial Appendage Morphology With the Progression of Atrial Fibrillation

10.21203/rs.3.rs-757374/v1 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Fumi Yokohama ◽

Norihisa Toh ◽

Koji Nakagawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Therapeutic Strategy ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Volume Index ◽

Determining The Indication ◽

Device Size ◽

Laa Closure

Abstract Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 340 patients (mean age: 65 ± 15 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 105), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth, greater LAA lobes, and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (R = 0.37, P < 0.01) and the duration of continuous AF (R = 0.30, P < 0.01), but not with age or the period from the onset of AF. LAA size, which is the determinant for selecting device size of transcatheter LAA closure, was increased with the progression of AF. Our findings have potential implications for therapeutic strategy of transcatheter LAA closure.

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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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P1433Prevalence and location of residual leaks following percutaneous left atrial appendage occlusion: the importance of 3D transesophageal echocardiography

EP Europace ◽

10.1093/europace/euaa162.158 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

J Lopes ◽

R Teixeira ◽

D Campos ◽

C Saleiro ◽

J Sousa ◽

...

Keyword(s):

Transesophageal Echocardiography ◽

Left Atrial ◽

Left Atrial Appendage ◽

Interventional Cardiology ◽

Atrial Appendage ◽

Posterior Portion ◽

3D Transesophageal Echocardiography ◽

The Impact ◽

Laa Closure

Abstract Background The left atrial appendage (LAA) shape and size are very variable, and incomplete appendage closure or persistent leaks around the device are common following device placement. Limited studies reported the rate of peri-device leaks (PDL) after percutaneous left atrial appendage closure, and the impact of 3D transesophageal echocardiography (3D-TEE) on the detection of those leaks. Aim To describe the rate and location of leaks 1 month after percutaneous closure of the LAA, with and without the use of 3D-TEE. Methods A cohort study of consecutive patients (P) who were submitted to a percutaneous LAA closure with success in one interventional cardiology centre, between May 2010 and October 2018, were included. Clinical and echocardiography data were recorded and analysed. Two groups were created: Group A (GA) included patients until August 2015 submitted to 2D TEE on follow up (N= 48) versus Group B (GB), which was composed of patients submitted to 3D-TEE after August 2015 (N= 76). Results A total of 124 P had an in-hospital admission for LAA closure, with control TEE 1 month after the procedure. Mean age was 73 ± 7 years old, with 62.9% male patients. The procedure was guided by TEE (52%) or intra cardiac echocardiography (ICE) (48%).Transeptal puncture was preferred (95% of the procedures). The most used device was Amulet (62%) vs ACP (23%) and Watchman (15%). In the follow up TEE, 20% of patients had only 1 leak and 2% had 2 leaks. Of the detected leaks,31% were considered minor (< 1 mm), 35% moderate (1-3 mm) and 34% major (> 3 mm). Patients with leaks had a larger LAA diameter (22 ± 4 mm vs. 17 ± 3 mm, P = 0.01). Of the detected leaks, 50% were located in the superior portion of the device, 23% were located in the inferior portion, 8% in the posterior portion and 8% in the lateral portion. In GA the rate of leaks was 14% vs 24.5% in GB, with differences also when specified the size of the leak – minor (GA 2% vs GB 8.8%), moderate (GA 8% vs GB 8.1%) and major (GA 4% vs GB 7.6%). Conclusion The use of 3D echocardiography, 1 month after successful percutaneous LAA closure, augmented the rate of detection of device leaks. It remains to be studied the clinical impact of this finding.

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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.

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A STUDY OF LEFT ATRIAL APPENDAGE FLOW BY DOPPLER TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN PATIENTS WITH ATRIAL SEPTAL DEFECT

Journal of Al-Nahrain University-Science ◽

10.22401/jnus.12.1.08 ◽

2009 ◽

Vol 12 (1) ◽

pp. 52-60

Author(s):

Mawada Mousa Funjan ◽

Keyword(s):

Atrial Septal Defect ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Septal Defect ◽

Left Atrial Appendage ◽

Atrial Appendage

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P3731The improvement in left atrial strain among patients undergoing percutaneous left atrial appendage closure

European Heart Journal ◽

10.1093/eurheartj/ehz745.0585 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

S Ijuin ◽

A Hamadanchi ◽

F Haertel ◽

L Baez ◽

C Schulze ◽

...

Keyword(s):

Atrial Fibrillation ◽

Sinus Rhythm ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Left Atrial Appendage ◽

Lateral Wall ◽

Bleeding Risk ◽

Atrial Appendage ◽

Left Atrial Appendage Closure ◽

Left Atrial Strain

Abstract Background Percutaneous left atrial appendage closure (LAAC) is being established as an alternative option for atrial fibrillation (AF) patients with high bleeding risk. Few studies reported the influence of percutaneous LAAC on left atrial (LA) performance, but most of the studies demonstrated no remarkable changes in their parameters after the procedure. Method The study included 95 patients (age: 75±6.7 years, 67% male) whom underwent percutaneous LAAC in a single center between September 2012 and November 2018. LA strain was evaluated at three different time intervals by transesophageal echocardiography (baseline, 45 days and 180 days after procedure). All data were analyzed using a dedicated. 70 patients had atrial fibrillation whereas 25 were in sinus rhythm. Analysis was performed for peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from segment of lateral wall in mid-esophageal 4 chamber view. The validity of lateral wall left atrial analysis was recently shown by our group. PACS was obtained in patients with sinus rhythm during exams. Results Compared to baseline, PALS was significantly increased after 45 days (12.4±8.4% vs 16.0±10.7%, p=0.001) and remained stable after 180 days (13.8±9.0% vs 17.0±12.4%, p=0.098). Even in only patients with atrial fibrillation during exams, it was increased (10.8±7.7% vs 13.4±7.1%, p=0.012 and 8.5±5.1% vs 13.9±8.1%, p=0.014). Similarly, compared with the baseline, PACS was significantly increased after 45 days and 180 days (5.8±3.9% vs 10.6±7.6%, p=0.001 and 4.5±2.6% vs 7.9±3.1%, p=0.036). The Changes in PALS and PACS Conclusion Our study has demonstrated for the first time the improvement in LA strain following LAAC within 45 days of implantation by transesophageal echocardiography and these values were maintained at least for 6 months. Further appraisal is warranted for confirmation of these preliminary findings.

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