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Korsholm K, Iriart X, Saw J, Wang DD, Berti S, Galea R, Freixa X, Arzamendi D, De Backer O, Kramer A, Cademartiri F, Cochet H, Odenstedt J, Aminian A, Räber L, Cruz-Gonzalez I, Garot P, Jensen JM, Alkhouli M, Nielsen-Kudsk JE. Position Statement on Cardiac Computed Tomography Following Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2024; 17:1747-1764. [PMID: 39142755 DOI: 10.1016/j.jcin.2024.04.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 04/10/2024] [Accepted: 04/26/2024] [Indexed: 08/16/2024]
Abstract
Left atrial appendage occlusion (LAAO) is rapidly growing as valid stroke prevention therapy in atrial fibrillation. Cardiac imaging plays an instrumental role in preprocedural planning, procedural execution, and postprocedural follow-up. Recently, cardiac computed tomography (CCT) has made significant advancements, resulting in increasing use both preprocedurally and in outpatient follow-up. It provides a noninvasive, high-resolution alternative to the current standard, transesophageal echocardiography, and may display advantages in both the detection and characterization of device-specific complications, such as peridevice leak and device-related thrombosis. The implementation of CCT in the follow-up after LAAO has identified new findings such as hypoattenuated thickening on the atrial device surface and left atrial appendage contrast patency, which are not readily assessable on transesophageal echocardiography. Currently, there is a lack of standardization for acquisition and interpretation of images and consensus on definitions of essential findings on CCT in the postprocedural phase. This paper intends to provide a practical and standardized approach to both acquisition and interpretation of CCT after LAAO based on a comprehensive review of the literature and expert consensus among European and North American interventional and imaging specialists.
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Affiliation(s)
| | - Xavier Iriart
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Dee Dee Wang
- Henry Ford Health System, Detroit, Michigan, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Roberto Galea
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Hubert Cochet
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Adel Aminian
- Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium
| | - Lorenz Räber
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
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Shoji T, Sato Y, Togashi D, Kuwata S, Izumo M, Harada T, Akashi YJ. ST-Segment Elevation During Percutaneous Left Atrial Appendage Closure. JACC Case Rep 2024; 29:102216. [PMID: 38379648 PMCID: PMC10874982 DOI: 10.1016/j.jaccas.2023.102216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 12/21/2023] [Indexed: 02/22/2024]
Abstract
A 70-year-old patient with paroxysmal atrial fibrillation underwent left atrial appendage closure. The patient experienced transient hypotension during device implantation. The procedure was abandoned because of ST-T-wave changes on electrocardiography and elevated coronary flow velocity on transesophageal echocardiography, which indicated that the device caused coronary artery compression.
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Affiliation(s)
- Tatsuro Shoji
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yukio Sato
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Daisuke Togashi
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Shingo Kuwata
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Tomoo Harada
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Yoshihiro J. Akashi
- Department of Cardiology, St. Marianna University School of Medicine, Kanagawa, Japan
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Malhotra P. Use of Computed Tomography for Left Atrial Appendage Occlusion Procedure Planning and Post-Procedure Assessment. Interv Cardiol Clin 2024; 13:19-28. [PMID: 37980064 DOI: 10.1016/j.iccl.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an alternative to systemic anticoagulation in patients with non-valvular atrial fibrillation with increased risk for thromboembolic events. Pre- and post-procedural imaging is essential for technical success, allowing practitioners to identify contraindications, select appropriate devices, and recognize procedural complications. Although transesophageal echocardiography has traditionally served as the preeminent imaging modality in LAAO, cardiac computed tomography imaging has emerged as a noninvasive surrogate given its excellent isotropic spatial resolution, multiplanar reconstruction capability, rapid temporal resolution, and large field of view.
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Affiliation(s)
- Pankaj Malhotra
- Department of Imaging, Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Taper M335, Los Angeles, CA 90048, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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Incomplete neo-endothelialization of left atrial appendage closure devices is frequent after 6 months: a pilot imaging study. Int J Cardiovasc Imaging 2021; 37:2291-2298. [PMID: 33675009 DOI: 10.1007/s10554-021-02192-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/10/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE To bridge neo-endothelialization (NE) of implanted left atrial appendage closure (LAA/LAAC) devices, dual antiplatelet therapy is prescribed. Cardiac computed tomography angiography (cCTA) has been proposed for the evaluation of interventional LAAC. This prospective longitudinal observational study applied a standardized imaging protocol to detect progression of NE of LAAC devices 6 months after implantation. METHODS Consecutive cCTA datasets of patients six months after LAAC were acquired and the standardized multi-planar reconstruction LAA occluder view for post-implantation evaluation (LOVE) algorithm was used. Residual flow of contrast agent inside the LAA without a peri-device leak (PDL) was defined as incomplete neo-endothelialization. Absence of residual flow was defined as complete neo-endothelialization. Since PDL allows residual flow in the LAA, irrespective of neoendothelialization, PDL were excluded from this study. Diabetes mellitus, liver disease, body-mass-index, age, device sizes and type will be assessed as predictors for incomplete NE. RESULTS 53 consecutive patients were recruited for cCTA imaging. 36 (68%) showed no PDL and were included in the study (median age 77 years, 19% female). At median follow-up of 6 months (median 180 days, IQR 178-180), 44% of patients showed complete NE compared to 56% with NE still incomplete. Age, BMI, device type and size as well as prevalence of diabetes mellitus and liver disease did not show significant correlation with the completeness of NE. CONCLUSION This pilot study showed that neo-endothelialization is still incomplete in a majority of patients at mid-term follow-up of 6 months after successful LAAC therapy. Further investigation on the consequences of incomplete endothelialization is needed to guide antiplatelet therapy schedules.
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Kuzmin B, Staack T, Wippermann J, Wacker M. Left atrial appendage occlusion device causing coronary obstruction: A word of caution. J Card Surg 2020; 36:723-725. [PMID: 33331003 DOI: 10.1111/jocs.15222] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/28/2022]
Abstract
Closure of the left atrial appendage is a common procedure for patients with atrial fibrillation undergoing cardiac surgery. The technique of left atrial appendage occlusion (LAAO) by an extracardiac clip (AtriClip) is established as a reliable method. Acute coronary obstruction of the circumflex artery has already been described after minimally invasive LAAO. Here, we report a case of delayed circumflex artery obstruction after open-heart surgery. A patient who had mitral and tricuspid valve surgery in combination with AtriClip implantation suffered from myocardial infarction 24 h after clip implantation. Cardiac catheterization showed that the circumflex artery was obstructed on the level of the AtriClip device. The stenosis was treated by percutaneous coronary intervention with stent implantation. In conclusion, the surgeon should consider placing the AtriClip device slightly far away from the base of the left atrial appendage to avoid coronary obstruction.
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Affiliation(s)
- Boris Kuzmin
- Department of Cardiothoracic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Thorsten Staack
- Department of Cardiothoracic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Jens Wippermann
- Department of Cardiothoracic Surgery, Otto-von-Guericke University, Magdeburg, Germany
| | - Max Wacker
- Department of Cardiothoracic Surgery, Otto-von-Guericke University, Magdeburg, Germany
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Pracoń R, De Backer O, Konka M, Kępka C, Kruk M, Trochimiuk P, Dębski M, Dzielińska Z, Søndergaard L, Demkow M. Imaging risk features for device related pulmonary artery injury after left atrial appendage closure with Amplatzer™ Amulet™ device. Catheter Cardiovasc Interv 2020; 98:E420-E426. [PMID: 33220011 DOI: 10.1002/ccd.29393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/23/2020] [Accepted: 11/08/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC). BACKGROUND Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC. METHODS In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected. RESULTS In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (<1.5 mm) for the stabilizing wires to cause risk for DR-PAI, configuration called ''cuddling lobe orientation''. On CT measurements middle lobe-PA distance was 4.7 mm (IQR = 2.7-9.5), with close proximity in 4 (4%) patients, and distal lobe-PA distance was 3.2 mm (IQR = 1.8-7.2 mm), with close proximity in 17 (17%) patients. Stabilizing wires were pointing toward PA in 47 patients (47%) with median wire-to-PA distance 5.7 mm (IQR = 3.6-8.5 mm). ''Cuddling'' was found in 2 (2%) patients and resulted in shorter wires-to-PA distance vs no ''cuddling'' group (2.3 vs 5.8 mm p <.01). At 2.9 ± 1.0 yrs of follow-up, the two patients with ''cuddling lobe orientation'' on post-LAAC CT scan developed late cardiac tamponades (p <.001). One of those required surgery, which confirmed DR-PAI. CONCLUSIONS ''Cuddling lobe orientation'' of Amulet device with the PA was associated with short wires-to-PA distance and late pericardial effusions, including DR-PAI. Hence, such device-to-PA configuration should be avoided.
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Affiliation(s)
- Radosław Pracoń
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Ole De Backer
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marek Konka
- Congenital Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Cezary Kępka
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Kruk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Trochimiuk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Dębski
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Zofia Dzielińska
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Lars Søndergaard
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
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Kalra DK. Cardiac CT: A Sine Qua Non for Structural Heart Interventions. Cardiology 2020; 145:663-665. [PMID: 32829334 DOI: 10.1159/000509466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Dinesh K Kalra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA,
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Sharma SP, Murtaza G, Madoukh B, Atkins D, Nydegger C, Jeffery C, Bommana S, Wang E, Gopinathannair R, Saw J, Natale A, Lakkireddy D. Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices. J Atr Fibrillation 2020; 12:2256. [PMID: 32002118 DOI: 10.4022/jafib.2256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/14/2019] [Accepted: 07/26/2019] [Indexed: 11/10/2022]
Abstract
Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.
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Affiliation(s)
| | - Ghulam Murtaza
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Bader Madoukh
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Donita Atkins
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Cherie Nydegger
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Courtney Jeffery
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Sudha Bommana
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Edward Wang
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Jacqueline Saw
- Vancouver General Hospital, 2775 Laurel St, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
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Lindner S, Behnes M, Wenke A, Sartorius B, Dieker W, Ansari U, Akin M, Bertsch T, Mashayekhi K, Vogler N, Haubenreisser H, Schoenberg SO, Borggrefe M, Akin I. Relation of left atrial appendage closure devices to topographic neighboring structures using standardized imaging by cardiac computed tomography angiography. Clin Cardiol 2018; 42:264-269. [PMID: 30548264 PMCID: PMC6712306 DOI: 10.1002/clc.23136] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/24/2018] [Accepted: 12/10/2018] [Indexed: 11/29/2022] Open
Abstract
Background Although left atrial appendage (LAA) anatomy and topographic relations are well understood, little is known about the impairment of neighboring structures (NBS) by an implanted left atrial appendage closure (LAAC) device. This prospective longitudinal observational study for the first time describes distances of implanted LAA closure (LAAC) devices to NBS using a standardized imaging protocol of cardiac computed tomography angiography (cCTA). Hypothesis cCTA imaging is an eligible tool for post‐implantation evaluation of LAAC devices and their relation to neighboring structures. Methods cCTA data sets of consecutive patients 6 months after successful LAAC were acquired on a third generation dual‐source CT system and reconstructed with a slice thickness of 0.5 mm. The standardized multi‐planar reconstruction LAA occluder view for post‐implantation evaluation (LOVE) algorithm was used to measure the distances to NBS in relation to LAA morphology and implanted LAAC devices. Results A total of 48 patients (median age 80 years, 25% female) were included. Left upper pulmonary vein and circumflex artery were generally closest to occlusion devices (median 2.9 and 2.8 mm, respectively). AMPLATZER AMULET devices were closer to the mitral valve annulus than WATCHMAN devices (6.6 mm (inter quartile range [IQR] 4.9‐8.6) vs 10.9 mm (IQR 7.4‐14.0), P = 0.001). Distances to the left upper pulmonary vein were affected by LAA morphology, with cauliflower type having the closest proximity (1.7 mm [IQR 1.0‐3.4], P = 0.048). Conclusion A standardized cCTA imaging protocol is an eligible tool to accurately measure distances to NBS. Left upper pulmonary vein and circumflex artery are closest to LAAC devices and could thus be most prone to impairment.
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Affiliation(s)
- Simon Lindner
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Annika Wenke
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Wulf Dieker
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Uzair Ansari
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Kambis Mashayekhi
- Clinic for Cardiology and Angiology II, University Center Freiburg Bad Krozingen, University of Freiburg, Bad Krozingen, Germany
| | - Nils Vogler
- Institute of Clinical Radiology, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research), Mannheim, Germany
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