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Hagendorff A, Stöbe S, Helfen A, Knebel F, Altiok E, Beckmann S, Bekfani T, Binder T, Ewers A, Hamadanchi A, Freyhaus HT, Groscheck T, Haghi D, Knierim J, Kruck S, Lenk K, Merke N, Pfeiffer D, Dorta ER, Ruf T, Sinning C, Wunderlich NC, Brandt R, Ewen S. Echocardiographic assessment of left atrial appendage morphology and function-an expert proposal by the German Working Group of Cardiovascular Ultrasound. Clin Res Cardiol 2024:10.1007/s00392-024-02492-5. [PMID: 39196343 DOI: 10.1007/s00392-024-02492-5] [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: 06/04/2024] [Accepted: 07/04/2024] [Indexed: 08/29/2024]
Abstract
The left atrial appendage is a blind ending cardiac structure prone to blood stasis due to its morphology. This structure is a preferred region of thrombogenesis in relation to reduced myocardial contractility of the atrial wall. Blood stasis occurs primarily in low flow conditions. One of the tasks of echocardiography is the analysis of morphology and function of the left atrial appendage. The detection of thrombi by echocardiography is difficult and must be carried out thoroughly and carefully to avoid potential complications-especially in the context of rhythm control. The assessment of thromboembolic risk, especially in patients with unknown and presumed atrial fibrillation is a second challenge by characterizing atrial function and flow conditions in the left atrial appendage. Thus, this proposal focuses on the obvious problems of echocardiography when assessing left atrial appendage and the role of this method in planning a potential interventional closure of left atrial appendage.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany.
| | - Stephan Stöbe
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Andreas Helfen
- Department of Kardiologie, Katholische St. Paulus Gesellschaft, St.-Marien-Hospital Lünen, Lünen, Germany
| | - Fabian Knebel
- Department of Internal Medicine II, Cardiology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Ertunc Altiok
- Department of Cardiology, Angiology, and Intensive Medicine, University Hospital Aachen, Aachen, Germany
| | - Stephan Beckmann
- Privatpraxis Kardiologie, Beckmann Ehlers Und Partner, Berlin-Grunewald, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Thomas Binder
- Department of Cardiology, University Hospital AKH, Vienna, Austria
| | - Aydan Ewers
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Ali Hamadanchi
- Department of Cardiology, University of Jena, Jena, Germany
| | - Henrik Ten Freyhaus
- Department of Internal Medicine III, Cardiology, University of Cologne, Cologne, Germany
| | - Thomas Groscheck
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Dariush Haghi
- Kardiologische Praxisklinik Ludwigshafen-Akademische Lehrpraxis of the University of Mannheim, Ludwigshafen, Germany
| | - Jan Knierim
- Department of Internal Medicine and Cardiology, Paulinenkrankenhaus Berlin, Berlin, Germany
| | - Sebastian Kruck
- Praxis Für Kardiologie Cardio Centrum Ludwigsburg, Ludwigsburg, Germany
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Charité Berlin, Berlin, Germany
| | | | - Elena Romero Dorta
- Department of Cardiology, Angiology and Intensive Care Medicine, University of Berlin, Deutsches Herzzentrum Charité Berlin, Campus Mitte, Berlin, Germany
| | - Tobias Ruf
- Department of Cardiology, Center of Cardiology, Heart Valve Center, University Medical Center Mainz, University of Mainz, Mainz, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart and Vascular Center Hamburg, German Centre of Cardiovascular Research (DZHK), Hamburg, Germany
| | | | - Roland Brandt
- Department of Cardiology, Kerckhoff Klinik GmbH, Bad Nauheim, Germany
| | - Sebastian Ewen
- Department Cardiology and Intensive Care Medicine, Schwarzwald-Baar Klinik, Villingen-Schwenningen, Germany
- University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
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2
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Moras E, Gandhi K, Yakkali S, Frishman WH, Aronow WS. Left Atrial Appendage Occlusion as a Strategy for Reducing Stroke Risk in Nonvalvular Atrial Fibrillation. Cardiol Rev 2024:00045415-990000000-00304. [PMID: 39078133 DOI: 10.1097/crd.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
Nonvalvular atrial fibrillation (AF) is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Stroke prevention is a crucial aspect of management, considering the increasing AF population and the associated morbidity and mortality. The left atrial appendage (LAA) has been identified as a predominant source of AF-associated thrombus and stroke, with at least 90% of the thrombi originating from this anatomical structure. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. In addition, these medications also require strict compliance for efficacy and have high failure rates in higher-risk patients. LAA occlusion (LAAO) has emerged as an alternative strategy for stroke prevention with encompassing various percutaneous and surgical techniques. Randomized controlled trials evaluating this intervention have shown promising results in stroke reduction replacing anticoagulation therapy. In this review, we aim to provide a comprehensive overview on the anatomy of the LAA and its role in thrombus formation, the emergence of various LAAO techniques and devices, and provide evidence on the role of LAAO in the reduction of stroke risk among patients with nonvalvular AF.
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Affiliation(s)
- Errol Moras
- From the Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Kruti Gandhi
- From the Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shreyas Yakkali
- Department of Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, New York, NY
| | | | - Wilbert S Aronow
- Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
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Farooqi P, Yaqobi A, Mia Khail B, Niño Medina JA, Obaid Ullah Z, Saeed A, Alamy H, Farooqi SA, Azizi N, Duarte LE, Ghani T, Aminpoor H. Left Atrial Septal Pouch (LASP) and Cryptogenic Stroke: A Narrative Review. Cureus 2024; 16:e64245. [PMID: 39130916 PMCID: PMC11313746 DOI: 10.7759/cureus.64245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2024] [Indexed: 08/13/2024] Open
Abstract
Over 20% of ischemic strokes are cardioembolic strokes, necessitating research into thrombus formation locations, particularly the left atrial appendage (LAA). The left atrial septal pouch (LASP), which is linked to thrombus development and stasis, has drawn attention recently as a possible thromboembolic location, especially in atrial fibrillation (AF). The primary aim of this review is to explore LASP's role in cryptogenic strokes and to discuss the methods used to assess LAA anatomy. Imaging modalities such as cardiac computed tomography (CT) and transesophageal echocardiography (TEE) are crucial for diagnosing and characterizing LASP. LASP, found in about one-third of individuals, provides an additional site for thrombus development in the left atrium. The potential clinical implications of LASP-related thromboembolic events include the need for targeted therapeutic strategies, such as anticoagulant medication and, in some cases, consideration of LASP closure to prevent recurrent strokes. Further investigation is required to elucidate LASP's involvement in thromboembolic events and to guide stroke prevention in at-risk patients.
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Affiliation(s)
- Palwasha Farooqi
- Internal Medicine, Kabul University of Medical Sciences, Kabul, AFG
| | - Adila Yaqobi
- Pediatric Medicine, Kabul University of Medical Sciences, Kabul, AFG
| | | | - Jose A Niño Medina
- Law and Political Sciences/Health Sciences, University of Carabobo, Valencia, VEN
| | | | - Abed Saeed
- Cardiovascular Medicine, Ali Abad Teaching Hospital, Kabul, AFG
| | - Haroon Alamy
- Internal Medicine, Armed Forces Academy of Medical Sciences, Kabul, AFG
| | - Syed Ahmad Farooqi
- Internal Medicine, Liaquat University of Medical and Health Sciences, Jamshoro, PAK
| | - Najim Azizi
- Surgery, Herat Regional Hospital, Herat, AFG
| | | | - Torgot Ghani
- Internal Medicine, Wazir Mohammad Akbar Khan Hospital, Kabul, AFG
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Heidari H, Kanschik D, Maier O, Wolff G, Brockmeyer M, Masyuk M, Bruno RR, Polzin A, Erkens R, Antoch G, Reinartz SD, Werner N, Kelm M, Zeus T, Afzal S, Jung C. A comparison of conventional and advanced 3D imaging techniques for percutaneous left atrial appendage closure. Front Cardiovasc Med 2024; 11:1328906. [PMID: 38596690 PMCID: PMC11002144 DOI: 10.3389/fcvm.2024.1328906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/15/2024] [Indexed: 04/11/2024] Open
Abstract
Background Understanding complex cardiac anatomy is essential for percutaneous left atrial appendage (LAA) closure. Conventional multi-slice computed tomography (MSCT) and transesophageal echocardiography (TEE) are now supported by advanced 3D printing and virtual reality (VR) techniques for three-dimensional visualization of volumetric data sets. This study aimed to investigate their added value for LAA closure procedures. Methods Ten patients scheduled for interventional LAA closure were evaluated with MSCT and TEE. Patient-specific 3D printings and VR models were fabricated based on MSCT data. Ten cardiologists then comparatively assessed LAA anatomy and its procedure relevant surrounding structures with all four imaging modalities and rated their procedural utility on a 5-point Likert scale questionnaire (from 1 = strongly agree to 5 = strongly disagree). Results Device sizing was rated highest in MSCT (MSCT: 1.9 ± 0.8; TEE: 2.6 ± 0.9; 3D printing: 2.5 ± 1.0; VR: 2.5 ± 1.1; p < 0.01); TEE, VR, and 3D printing were superior in the visualization of the Fossa ovalis compared to MSCT (MSCT: 3.3 ± 1.4; TEE: 2.2 ± 1.3; 3D printing: 2.2 ± 1.4; VR: 1.9 ± 1.3; all p < 0.01). The major strength of VR and 3D printing techniques was a superior depth perception (VR: 1.6 ± 0.5; 3D printing: 1.8 ± 0.4; TEE: 2.9 ± 0.7; MSCT: 2.6 ± 0.8; p < 0.01). The visualization of extracardiac structures was rated less accurate in TEE than MSCT (TEE: 2.6 ± 0.9; MSCT: 1.9 ± 0.8, p < 0.01). However, 3D printing and VR insufficiently visualized extracardiac structures in the present study. Conclusion A true 3D visualization in VR or 3D printing provides an additional value in the evaluation of the LAA for the planning of percutaneous closure. In particular, the superior perception of depth was seen as a strength of a 3D visualization. This may contribute to a better overall understanding of the anatomy. Clinical studies are needed to evaluate whether a more comprehensive understanding through advanced multimodal imaging of patient-specific anatomy using VR may translate into improved procedural outcomes.
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Affiliation(s)
- Houtan Heidari
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Dominika Kanschik
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Oliver Maier
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Maximilian Brockmeyer
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Maryna Masyuk
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Ralf Erkens
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Sebastian Daniel Reinartz
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Düsseldorf, Germany
| | - Nikos Werner
- Department of Cardiology, Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
- CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
| | - Shazia Afzal
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
- Department of Cardiology, Heartcenter Trier, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University, Medical Faculty, Düsseldorf, Germany
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Ono S, Maruo T, Kubo S, Kadota K. Validation study of new left atrial appendage closure device measurement by two-dimensional and three-dimensional transesophageal echocardiography. J Echocardiogr 2024; 22:16-24. [PMID: 37644318 DOI: 10.1007/s12574-023-00619-7] [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] [Received: 01/24/2023] [Revised: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND In left atrial appendage closure using WATCHMAN FLX, accurate device measurement by transesophageal echocardiography (TEE) is important. We aimed to experimentally validate appropriate methods of device measurement with two-dimensional (2D) and three-dimensional (3D) TEE compared with actual size. METHODS We prepared a full range of device sizes (20, 24, 27, 31, 35 mm), each with five different compression rates. Each device was measured by 2D and 3D TEE at depths of 2, 4, and 6 cm in vitro using inner, outer, and middle line methods. We compared the difference between the actual size by caliper and measurements at each compression rate and depth by the three methods in 2D and 3D TEE. RESULTS A total of 450 patterns of measurements were analyzed. The differences using the middle line method were much less than those using the inner and outer line methods in 2D and 3D TEE (2D TEE: 0.45 ± 0.36 vs. 2.55 ± 0.99 vs. 2.59 ± 0.72 mm, p < 0.01; 3D TEE: 0.34 ± 0.27 vs. 2.38 ± 0.69 vs. 1.86 ± 0.77 mm, p < 0.01). Moreover, the differences in measurements by 3D TEE were more accurate than those of 2D TEE in the inner (2.47 ± 1.86 vs. 1.86 ± 0.77 mm, p < 0.01) and middle (0.58 ± 0.37 vs. 0.34 ± 0.27 mm, p < 0.01) line methods. CONCLUSIONS Middle line method by 3D TEE is the most reliable approach for device measurement at left atrial appendage closure using WATCHMAN FLX device.
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Affiliation(s)
- Sachiyo Ono
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan.
| | - Takeshi Maruo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
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Pan YQ, Jin LS, Qian S, Jiang T, Wang ZN, Chen YL, Qiu YX, Wu YH, Fu JY, Li L, Lin YN, Li YC. Twice-daily rivaroxaban after percutaneous left atrial appendage closure for atrial fibrillation. Front Pharmacol 2024; 15:1344828. [PMID: 38455964 PMCID: PMC10917903 DOI: 10.3389/fphar.2024.1344828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 02/02/2024] [Indexed: 03/09/2024] Open
Abstract
Background and aim: Rivaroxaban is an emerging oral anticoagulant for postoperative anticoagulation after percutaneous left atrial appendage closure (LAAC). Because a once-daily dosing regimen of rivaroxaban causes fluctuations in the drug plasma concentration, we studied the feasibility and safety of twice-daily rivaroxaban as a postoperative anticoagulation regimen for patients with atrial fibrillation (AF) undergoing LAAC. Methods: This study involved patients with AF who underwent LAAC and took rivaroxaban postoperatively. A total of 326 patients who received a standard total dose (15 or 20 mg) of rivaroxaban based on their creatinine clearance rate were divided into the twice-daily (BID) rivaroxaban group (n = 208) and once-daily (QD) rivaroxaban group (n = 118) according to their anticoagulation strategy. Transesophageal echocardiography was recommended at 3-6 months postoperatively to check for device-related thrombosis (DRT). Clinical outcomes were evaluated during postoperative anticoagulation. Results: The median CHA2DS2-VASc score (4 [3, 5] vs. 4 [3, 5], p = 0.28) and HAS-BLED score (2 [2, 3] vs. 2 [2, 3], p = 0.48) were not significantly different between the groups. During the anticoagulation period (4.1 ± 0.7 vs. 4.1 ± 0.9 months, p = 0.58), 148 (71.2%) patients in the BID group and 75 (63.6%) in the QD group underwent follow-up transesophageal echocardiography. There were no statistically significant differences between the two groups in terms of DRT (1.4% vs. 2.7%, p = 0.60), minor bleeding (8.2% vs. 11.0%, p = 0.39), thromboembolic events (1.0% vs. 0.8%, p = 1.00), major bleeding (0.5% vs. 0.8%, p = 1.00), or death. Conclusion: A short course of twice-daily rivaroxaban following LAAC is a feasible alternative regimen with a low rate of major bleeding events, DRT, and thromboembolic events for patients with AF.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Yue-Chun Li
- Department of Cardiology, Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China
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7
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Krishan S, Hashim L, Javed L, Gomez-Perez J, Muhammad R, Gondal J, Sacco J, Clifton S, Khattab M, Munir MB, DeSimone CV, Deshmukh A, Stavrakis S, Asad ZUA. Comparison of intracardiac echocardiography with transesophageal echocardiography for left atrial appendage occlusion: an updated systematic review and meta-analysis. J Interv Card Electrophysiol 2023; 66:1337-1340. [PMID: 37074511 DOI: 10.1007/s10840-023-01547-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Satyam Krishan
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Laila Hashim
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Laraib Javed
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Janeth Gomez-Perez
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Rohaan Muhammad
- Oklahoma State University College of Osteopathic Medicine, Tulsa, OK, USA
| | - Jalal Gondal
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - John Sacco
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Shari Clifton
- Robert M. Bird Health Sciences Library, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Mohamad Khattab
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Muhammad Bilal Munir
- Department of Cardiovascular Medicine, Section of Electrophysiology, University of California Davis, Davis, CA, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Stavros Stavrakis
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA
| | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, 800 Stanton L. Young Blvd, AAT 5400, Oklahoma City, OK, 73104, USA.
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Fernandes R, Torres HR, Oliveira B, Azevedo J, Fan K, Lee AP, Vilaca JL, Morais P. Deep learning networks in the segmentation of the left atrial appendage in 2D ultrasound: A comparative analysis. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083227 DOI: 10.1109/embc40787.2023.10340937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Left atrial appendage (LAA) is the major source of thromboembolism in patients with non-valvular atrial fibrillation. Currently, LAA occlusion can be offered as a treatment for these patients, obstructing the LAA through a percutaneously delivered device. Nevertheless, correct device sizing is a complex task, requiring manual analysis of medical images. This approach is sub-optimal, time-demanding, and highly variable between experts. Different solutions were proposed to improve intervention planning, but, no efficient solution is available to 2D ultrasound, which is the most used imaging modality for intervention planning and guidance. In this work, we studied the performance of recently proposed deep learning methods when applied for the LAA segmentation in 2D ultrasound. For that, it was created a 2D ultrasound database. Then, the performance of different deep learning methods, namely Unet, UnetR, AttUnet, TransAttUnet was assessed. All networks were compared using seven metrics: i) Dice coefficient; ii) Accuracy iii) Recall; iv) Specificity; v) Precision; vi) Hausdorff distance and vii) Average distance error. Overall, the results demonstrate the efficiency of AttUnet and TransAttUnet with dice scores of 88.62% and 89.28%, and accuracy of 88.25% and 86.30%, respectively. The current results demonstrate the feasibility of deep learning methods for LAA segmentation in 2D ultrasound.Clinical relevance- Our results proved the clinical potential of deep neural networks for the LAA anatomical analysis.
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Wollborn J, Schuler A, Sheu RD, Shook DC, Nyman CB. Real-Time Multiplanar Reconstruction Imaging Using 3-Dimensional Transesophageal Echocardiography in Structural Heart Interventions. J Cardiothorac Vasc Anesth 2023; 37:570-581. [PMID: 36517335 DOI: 10.1053/j.jvca.2022.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/04/2022] [Accepted: 11/07/2022] [Indexed: 11/15/2022]
Abstract
The complexity of structural heart interventions has led to a demand for sophisticated periprocedural imaging guidance. Although traditional 2-dimensional (2D) transesophageal techniques are used widely, new-generation 3D ultrasound probes enable high temporal and spatial resolution. Multiplanar reconstruction of acquired 3D datasets has gained considerable momentum for precise imaging and to increase the validity of measurements. Previously, this technique was used after the acquisition of suitable 3D datasets. Recent advances in technology have enabled the use of live mode for multiplanar reconstruction across different ultrasound vendor platforms. The use of live multiplanar reconstruction can enhance the precision in real-time imaging, enable simultaneous visualization of structures of interest in multiple planes, reduce the need for probe manipulation, and thereby contribute to the success of the procedures. In this narrative review, the authors describe the rationale and utility for 3D transesophageal live multiplanar reconstruction, and outline its use for the structural heart interventions of mitral and tricuspid valve edge-to-edge repair, left atrial appendage occlusion, and the Lampoon procedure. A 3D transesophageal echocardiogram with live-multiplanar reconstruction has the potential to advance guidance of these complex interventions.
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Affiliation(s)
- Jakob Wollborn
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - Andreas Schuler
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Richard D Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Douglas C Shook
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Charles B Nyman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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10
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Sheng J, Yang Z, Xu M, Meng J, Gong M, Miao Y. A prediction model based on functional mitral regurgitation for the recurrence of paroxysmal atrial fibrillation (PAF) after post-circular pulmonary vein radiofrequency ablation (CPVA). Echocardiography 2022; 39:1501-1511. [PMID: 36376256 PMCID: PMC10098807 DOI: 10.1111/echo.15479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/19/2022] [Accepted: 10/08/2022] [Indexed: 11/16/2022] Open
Abstract
AIM To construct a prediction model based on functional mitral regurgitation (FMR) in patients with paroxysmal atrial fibrillation (PAF) to predict atrial fibrillation recurrence after the post-circular pulmonary vein radiofrequency ablation (CPVA). METHODS We retrospectively analyzed 289 patients with PAF who underwent CPVA for the first time. The patients were randomly divided into modeling group and verification group at the ratio of 75:25. In the modeling group, the multivariate logistic regression was used to analyze and construct a prediction model for post-CPVA recurrence in PAF patients, which was then validated in the verification group. RESULTS (1) After 3-6 months of follow-up, the patients were divided into sinus rhythm group (252 cases) and recurrence group (24 cases); (2) In the modeling group, the age, left atrial diameter (LAD), and the degree of MR (mild, moderate, severe) were higher in recurrence group than that of the sinus rhythm group, and the left atrial appendage emptying velocity (LAAV) was lower in recurrence group (all p < .05). (3) A model for predicting the recurrence of PAF after radiofrequency ablation was constructed in the modeling group. The equation was: Logit(P) = -3.253 + .092 × age + 1.263 × mild MR + 2.325 × moderate MR + 5.111 × severe MR -.113 × LAAV. The area under the curve (AUC) of the model was .889 in modeling group and .866 in verification group, and the difference was not statistically significant (p > .05). CONCLUSION The prediction model of atrial fibrillation (AF) recurrence after CPVA in PAF patients has good predictive efficacy, specificity, and accuracy.
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Affiliation(s)
- Jingyu Sheng
- Department of Electrocardiography, Wujin Hospital Affiliated with Jiangsu University, The Wujin Clinical college of Xuzhou Medical University, Changzhou, China.,Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
| | - Zhenni Yang
- Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
| | - Min Xu
- Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
| | - Jun Meng
- Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
| | - Mingxia Gong
- Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
| | - Yuxia Miao
- Department of Cardiovascular Division, The Third Affiliated Hospital of Soochow University, Chang Zhou, China
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11
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Sun A, Ren S, Xiao Y, Chen Y, Wang N, Li C, Tan X, Pan Y, Sun F, Ren W. Real-time 3D echocardiographic transilluminated imaging combined with artificially intelligent left atrial appendage measurement for atrial fibrillation interventional procedures. Front Physiol 2022; 13:1043551. [PMID: 36439257 PMCID: PMC9681832 DOI: 10.3389/fphys.2022.1043551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/27/2022] [Indexed: 11/10/2022] Open
Abstract
Aims: This study investigated the feasibility and accuracy of real-time three-dimensional (3D) echocardiographic transilluminated imaging (TrueVue Glass) in left atrial appendage (LAA) anatomical morphology and artificial intelligence (AI)-assisted 3D automated LAA measurement (3D Auto LAA) software in the preoperative evaluation of LAA occlusion (LAAO) in patients with atrial fibrillation (AF). Method and results: Thirty-seven patients with AF were selected. Two-dimensional (2D) and real-time 3D transesophageal echocardiography (RT3D-TEE) were performed preoperatively, using conventional 3D, the new 3D TrueVue Glass mode, and cardiac computed tomography angiography (CCTA) to assess and type the morphology of LAA. Physiological parameters were measured using traditional 2D and 3D manual (3D Manual LAA), 3D Auto LAA, and CCTA. TrueVue Glass for LAA outer contour display was compared with CCTA. Comparisons were based on correlation and consistency in measuring the maximum diameter (LZ max), minimum diameter (LZ min), area (LZ area), and circumference (LZ cir) of LAA landing zone (LZ). Times and variabilities were compared. The concordance rate for external shape of LAA was 97.14% between TrueVue Glass and CCTA. 3D Auto LAA and 3D Manual LAA have a stronger correlation and higher consistency in all parameters. 3D Auto LAA showed higher intra- and interobserver reproducibility and allowed quicker analysis (p < 0.05). LAAO was performed in 35 patients (94.59%), and none of which had serious adverse events. Conclusion: TrueVue Glass is the first non-invasive and radiation-free visualization of the overall external contour of LAA and its adjacent structures. 3D Auto LAA simplifies the measurement, making the preoperative assessment more efficient and convenient while ensuring the accuracy and reproducibility. A combination of the two is feasible for accurate and rapid assessment of LAA anatomy and physiology in AF patients and has practical application in LAAO.
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Affiliation(s)
- Aijiao Sun
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Sihua Ren
- Department of Radiology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Yangjie Xiao
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yixin Chen
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Nan Wang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Chendi Li
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xueying Tan
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yilong Pan
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Feifei Sun
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Feifei Sun,
| | - Weidong Ren
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
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12
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Branzoli S, Guarracini F, Marini M, D’Onghia G, Catanzariti D, Merola E, Annicchiarico L, Casagranda G, Stegagno C, Fantinel M, La Meir M. Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective. J Clin Med 2022; 11:6492. [PMID: 36362719 PMCID: PMC9656641 DOI: 10.3390/jcm11216492] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. METHODS Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. RESULTS Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. CONCLUSION Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.
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Affiliation(s)
- Stefano Branzoli
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
- Cardiac Surgery Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Massimiliano Marini
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
- Heart Rhythm Management Centre, UZ Brussel, 1050 Brussel, Belgium
| | - Giovanni D’Onghia
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Elettra Merola
- Gastroenterology Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | | | - Chiara Stegagno
- Neurology Rehabilitation Unit, Eremo Hospital, 38122 Trento, Italy
| | - Mauro Fantinel
- Cardiology Unit, Santa Maria Hospital, 32032 Feltre, Italy
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
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13
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Ortiz-Leon XA, Posada-Martinez EL, Bregasi A, Chen W, Crandall I, Pereira J, Faridi KF, Akar JG, Lin BA, McNamara RL, Freeman JV, Curtis J, Arias-Godinez JA, Sugeng L. Changes in left atrial appendage orifice following percutaneous left atrial appendage closure using three-dimensional echocardiography. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1361-1369. [PMID: 35064846 DOI: 10.1007/s10554-022-02525-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 01/07/2022] [Indexed: 11/25/2022]
Abstract
Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. We included 50 patients who underwent percutaneous LAA occlusion with the Watchman device and had acceptable three-dimensional transesophageal echocardiography images of LAA pre- and post-device placement. We measured offline the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Patients were elderly (mean age 76 ± 8 years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1 ± 3.2 vs. post-device 21.5 ± 3.4 mm, p < 0.001), diameter 2 (20.6 ± 3.9 vs. 22.1 ± 3.6 mm, p < 0.001), minimum diameter (17.6 ± 3.1 vs. 21.3 ± 3.4 mm, p < 0.001), maximum diameter (21.5 ± 3.9 vs. 22.4 ± 3.6 mm, p = 0.022), circumference (63.6 ± 10.7 vs. 69.6 ± 10.5 mm, p < 0.001), and area (3.1 ± 1.1 vs. 3.9 ± 1.2 cm2, p < 0.001). Eccentricity index decreased after procedure (1.23 ± 0.16 vs. 1.06 ± 0.06, p < 0.001). LUPV peak S and D velocities did not show a significant difference (0.29 ± 0.15 vs. 0.30 ± 0.14 cm/s, p = 0.637; and 0.47 ± 0.19 vs. 0.48 ± 0.20 cm/s, p = 0.549; respectively). LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.
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Affiliation(s)
- Xochitl A Ortiz-Leon
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
- Laboratory of Echocardiography, National Institute of Cardiology, Juan Badiano 1, Belisario Domínguez Secc. 16, 14080, Mexico City, Mexico
| | - Edith L Posada-Martinez
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
- Laboratory of Echocardiography, National Institute of Cardiology, Juan Badiano 1, Belisario Domínguez Secc. 16, 14080, Mexico City, Mexico
| | - Alda Bregasi
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
- Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 322, Los Angeles, CA, 90033, USA
| | - Wanwen Chen
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Ian Crandall
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Jason Pereira
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Kamil F Faridi
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Joseph G Akar
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Ben A Lin
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
- Keck School of Medicine, University of Southern California, 1510 San Pablo St., Suite 322, Los Angeles, CA, 90033, USA
| | - Robert L McNamara
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - James V Freeman
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Jeptha Curtis
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA
| | - Jose A Arias-Godinez
- Laboratory of Echocardiography, National Institute of Cardiology, Juan Badiano 1, Belisario Domínguez Secc. 16, 14080, Mexico City, Mexico
| | - Lissa Sugeng
- Laboratory of Echocardiography, Yale New Haven Hospital, Cardiovascular Division, Yale School of Medicine, 20 York Street, New Haven, CT, 06510, USA.
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14
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Implantation of Watchman FLX for Patients with Difficult Left Atrial Appendage Anatomy: A Case-Based Discussion. Curr Probl Cardiol 2022; 47:101266. [DOI: 10.1016/j.cpcardiol.2022.101266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 05/23/2022] [Indexed: 11/03/2022]
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15
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Fukutomi M, Fuchs A, Bieliauskas G, Wong I, Kofoed KF, Sondergaard L, De Backer O. Computed tomography-based selection of transseptal puncture site for percutaneous left atrial appendage closure. EUROINTERVENTION 2022; 17:e1435-e1444. [PMID: 34483092 PMCID: PMC9900448 DOI: 10.4244/eij-d-21-00555] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND An inferoposterior transseptal puncture (TSP) is generally recommended for percutaneous left atrial appendage (LAA) closure. However, the LAA is a highly variable anatomical structure. This may have an impact on the preferred TSP site. AIMS This study aimed to determine the optimal TSP site for percutaneous LAA closure in different LAA morphologies. METHODS In this prospective study, 182 patients undergoing percutaneous LAA closure were included. The spatial relationship of the LAA to the fossa ovalis and its consequence for TSP was assessed at preprocedural cardiac computed tomography (CCT). RESULTS Based on CCT analysis, it was predicted that coaxial alignment between the delivery sheath and the LAA would be obtained by an inferoposterior, inferocentral, or inferoanterior TSP in 75%, 16% and 8% of cases, respectively. This was also confirmed by procedural LAA angiogram in 175 cases (96%) with <30° angle between the delivery sheath and the LAA central axis. Multivariate logistic regression analysis identified reverse chicken wing LAA (odds ratio [OR] 6.36 [1.85-29.3]; p=0.005) and posterior bending of the proximal LAA (OR 17.2 [3.3-96.2]; p<0.001) as independent predictors of a central or anterior TSP - this to increase the chance of obtaining coaxial alignment between the delivery sheath and the LAA. CONCLUSIONS An inferoposterior TSP is recommended in the majority of percutaneous LAA closure procedures in order to obtain coaxial alignment between the delivery sheath and the LAA. An inferior but more central/anterior TSP should be recommended in case of a reverse chicken wing LAA or posterior bending of the proximal LAA, which occurs in 20-25% of cases.
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Affiliation(s)
- Motoki Fukutomi
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Fuchs
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gintautas Bieliauskas
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ivan Wong
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Klaus Fuglsang Kofoed
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Sondergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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16
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Huang H, Chen L, Liu J, Wang W, Cao Y, Yuan B, Tao E, Fang Q, Tang L, Wang F, Wan L. Clinical application of percutaneous left atrial appendage occlusion guided only by transesophageal echocardiography without fluoroscopy and angiography in the patients with nonvalvular atrial fibrillation. J Card Surg 2022; 37:1479-1485. [PMID: 35355334 DOI: 10.1111/jocs.16463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/05/2022] [Accepted: 02/21/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM The objective of this study was to understand the clinical efficacy and application of the percutaneous left atrial appendage occlusion (PLAAO) guided only by the transesophageal echocardiography (TEE) in patients with nonvalvular atrial fibrillation (NVAF), without using the fluoroscopy and angiography. METHODS During the time period of this study from June 2020 to June 2021, 32 patients underwent PLAAO and all underwent a TEE guided approach. The anatomical features of the left atrial appendage (LAA) were evaluated and observed by TEE before and during the procedure. LAA occluder device was selected for the appropriate size. Intraoperative TEE guided and monitored the process of PLAAO in real-time, and also evaluated the stability and tightness of the occluder device, following monitored postoperative complications. RESULTS The PLAAO procedure was successful in all the patients. No serious complications like dislocation of the occluder and embolism were seen. Postoperative TEE demonstrated that the PLAAO occluder devices were in a good position without residual shunting. CONCLUSIONS PLAAO only guided by TEE may become a safe and reliable surgical procedure, which can protect surgeons and patients from radiation, and can gradually become a novel surgical method of PLAAO with the practical application value.
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Affiliation(s)
- Huang Huang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Li Chen
- Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Department of Ultrasound Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Jichun Liu
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Wenjun Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yuanping Cao
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Bin Yuan
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ende Tao
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Qiao Fang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Liang Tang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Fudong Wang
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Li Wan
- Department of Cardiac Surgery, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.,Human Genetic Resources Center, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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17
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Kim WD, Cho I, Kim YD, Cha MJ, Kim SW, Choi Y, Shin SY. Improving Left Atrial Appendage Occlusion Device Size Determination by Three-Dimensional Printing-Based Preprocedural Simulation. Front Cardiovasc Med 2022; 9:830062. [PMID: 35252401 PMCID: PMC8889006 DOI: 10.3389/fcvm.2022.830062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 01/18/2022] [Indexed: 01/01/2023] Open
Abstract
Background The two-dimensional (2D)-based left atrial appendage (LAA) occluder (LAAO) size determination by using transesophageal echocardiography (TEE) is limited by the structural complexity and wide anatomical variation of the LAA. Objective This study aimed to assess the accuracy of the LAAO size determination by implantation simulation by using a three-dimensional (3D)-printed model compared with the conventional method based on TEE. Methods We retrospectively reviewed patients with anatomically and physiologically properly implanted the Amplatzer Cardiac Plug and Amulet LAAO devices between January 2014 and December 2018 by using the final size of the implanted devices as a standard for size prediction accuracy. The use of 3D-printed model simulations in device sizing was compared with the conventional TEE-based method. Results A total of 28 cases with the percutaneous LAA occlusion were reviewed. There was a minimal difference [−0.11 mm; 95% CI (−0.93, 0.72 mm); P = 0.359] between CT-based reconstructed 3D images and 3D-printed left atrium (LA) models. Device size prediction based on TEE measurements showed poor agreement (32.1%), with a mean difference of 2.3 ± 3.2 mm [95% CI (−4.4, 9.0)]. The LAAO sizing by implantation simulation with 3D-printed models showed excellent correlation with the actually implanted LAAO size (r = 0.927; bias = 0.7 ± 2.5). The agreement between the 3D-printed and the implanted size was 67.9%, with a mean difference of 0.6 mm [95% CI (−1.9, 3.2)]. Conclusion The use of 3D-printed LA models in the LAAO size determination showed improvement in comparison with conventional 2D TEE method.
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Affiliation(s)
- William D. Kim
- College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Iksung Cho
- Division of Cardiology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Doo Kim
- Department of Mechanical Engineering, Graduate School, Chung-Ang University, Seoul, South Korea
| | - Min Jae Cha
- Department of Radiology, Chung-Ang University Hospital, Seoul, South Korea
| | - Sang-Wook Kim
- Division of Cardiology, Chung-Ang University Hospital, Seoul, South Korea
- Heart Research Institute, Chung-Ang University Hospital, Seoul, South Korea
| | - Young Choi
- Department of Mechanical Engineering, Graduate School, Chung-Ang University, Seoul, South Korea
| | - Seung Yong Shin
- Division of Cardiology, Chung-Ang University Hospital, Seoul, South Korea
- *Correspondence: Seung Yong Shin
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18
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Pasquali M, Fusini L, Italiano G, Maltagliati A, Tamborini G, Penso M, Andreini D, Redaelli A, Pappalardo O, Pepi M. Feasibility study of a mixed reality tool for real 3D visualization and planning of left atrial appendage occlusion. J Cardiovasc Comput Tomogr 2022; 16:460-462. [DOI: 10.1016/j.jcct.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/21/2022] [Accepted: 02/22/2022] [Indexed: 10/19/2022]
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19
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Burkule N, Bansal M, Govind S, Alagesan R, Ponde C, Parashar S. Corrected and Republished: Indian Academy of Echocardiography Guidelines for Performance of Transesophageal Echocardiography in Adults. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2022. [DOI: 10.4103/jiae.jiae_54_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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20
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Hahn RT, Saric M, Faletra FF, Garg R, Gillam LD, Horton K, Khalique OK, Little SH, Mackensen GB, Oh J, Quader N, Safi L, Scalia GM, Lang RM. Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography. J Am Soc Echocardiogr 2022; 35:1-76. [PMID: 34280494 DOI: 10.1016/j.echo.2021.07.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Rebecca T Hahn
- Columbia University Irving College of Medicine, New York, New York
| | - Muhamed Saric
- New York University Langone Health, New York, New York
| | | | - Ruchira Garg
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Omar K Khalique
- Columbia University Irving College of Medicine, New York, New York
| | - Stephen H Little
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | | - Jae Oh
- Mayo Clinic, Rochester, Minnesota
| | | | - Lucy Safi
- Hackensack University Medical Center, Hackensack, New Jersey
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21
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Pre-procedural determination of device size in left atrial appendage occlusion using three-dimensional cardiac computed tomography. Sci Rep 2021; 11:24107. [PMID: 34916575 PMCID: PMC8677741 DOI: 10.1038/s41598-021-03537-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 12/06/2021] [Indexed: 12/31/2022] Open
Abstract
The 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.
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Limite LR, Radinovic A, Cianfanelli L, Altizio S, Peretto G, Frontera A, D'Angelo G, Baratto F, Marzi A, Ancona F, Ingallina G, Capogrosso C, Stella S, Melillo F, Agricola E, Della Bella P, Mazzone P. Outcome of left atrial appendage closure using cerebral protection system for thrombosis: no patient left behind. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 45:23-34. [PMID: 34841552 DOI: 10.1111/pace.14398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 08/26/2021] [Accepted: 10/31/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) thrombosis increases the risk of stroke and its management has to be assessed. The aim of the present study is to evaluate short and long-term safety and efficacy of a standardized approach of percutaneous LAA closure (LAAC) routinely using a cerebral protection device (CPD) in patients with LAA thrombosis or sludge (LAAT). METHODS We prospectively enrolled 14 consecutive patients with atrial fibrillation complicated by LAAT presenting in a high-volume tertiary center. In seven patients (50%) LAAT was found after anticoagulant withdrawal for severe bleedings and in the remaining half LAAT was found despite appropriate anticoagulant therapy. All patients were treated with a standardized interventional approach of LAAC routinely using a CPD and guided by transoesophageal echocardiography. RESULTS Mean age was 68 ± 14 years and nine patients (64%) were male. Mean CHA2 DS2 -VASc and HAS-BLED scores were 3.3 ± 1.6 and 2.3 ± 1.1, respectively. Six patients (42.8%) presented organized thrombi while eight LAA sludge (57.1%). In 13 patients (92.8%) CPD was positioned through a right radial arterial access. Procedural success was achieved in all patients. In one patient we assisted to embolization of the thrombus during deployment of the device in the absence of neurological consequences. During a mean follow up of 426 ± 307 days, one patient died for non-cardiac cause while no embolic event or major bleeding were reported. CONCLUSION In an unselected cohort, LAAC with the systematic use of CPD was a feasible, safe and effective therapeutic option for LAAT both acutely and after long-term follow-up.
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Affiliation(s)
- Luca Rosario Limite
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Radinovic
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Rehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Savino Altizio
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Peretto
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Frontera
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe D'Angelo
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Baratto
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandra Marzi
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Ancona
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giacomo Ingallina
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristina Capogrosso
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefano Stella
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Melillo
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Eustachio Agricola
- Unit of Cardiovascular Imaging, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Della Bella
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Patrizio Mazzone
- Department of Arrhythmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Hagendorff A, Helfen A, Flachskampf FA, Ewen S, Kruck S, La Rosée K, Knierim J, Voigt JU, Kreidel F, Fehske W, Brandt R, Zahn R, Knebel F. Manual zur Indikation und Durchführung spezieller echokardiographischer Anwendungen. DER KARDIOLOGE 2021. [PMCID: PMC8521495 DOI: 10.1007/s12181-021-00509-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Das zweite Manual zur Indikation und Durchführung der Echokardiographie bezieht sich auf spezifische Anwendungen der Echokardiographie und besondere Fragestellungen bei speziellen Patientengruppen. Dabei stehen v. a. praktische Aspekte im Vordergrund. Methodisch etabliert sind die transösophageale Echokardiographie, die Stressechokardiographie und die Kontrastechokardiographie. Bei nahezu allen echokardiographischen Untersuchungen spielen aktuell 3‑D-Echokardiographie und Deformationsbildgebung eine Rolle. Das gesamte Spektrum der echokardiographischen Möglichkeiten wird derzeit in Notfall- und Intensivmedizin, bei der Überwachung und Führung von Katheterinterventionen, bei strukturellen Herzerkrankungen, bei herzchirurgischen Operationen, bei der Nachsorge von kardialen Unterstützungssystemen, bei kongenitalen Vitien im Erwachsenenalter und bei der Versorgung von hochinfektiösen Patienten in Pandemiezeiten angewandt. Die diagnostischen Fortschritte der konventionellen und modernen echokardiographischen Anwendungen stehen im Fokus dieses Manuals. Die 3‑D-Echokardiographie zur Charakterisierung der kardialen Morphologie und die Deformationsbildgebung zur Objektivierung der kardialen Funktion sind bei vielen Indikationen im klinischen Alltag etabliert. Die Stressechokardiographie zur Ischämie‑, Vitalitäts- und Vitiendiagnostik, die Bestimmung der koronaren Flussreserve und die Kontrastechokardiographie bei der linksventrikulären Wandbewegungsanalyse und kardialen Tumordetektion finden zunehmend klinische Anwendung. Wie für die konventionelle Echokardiographie im ersten Manual der Echokardiographie 2009 beschrieben, erfordert der Einsatz moderner echokardiographischer Verfahren die standardisierte Dokumentation und Akquisition bestimmter Bildsequenzen bei optimierter Geräteeinstellung, da korrekte und reproduzierbare Auswertungen nur bei guter Bildqualität möglich sind.
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Affiliation(s)
- Andreas Hagendorff
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103 Leipzig, Deutschland
| | - Andreas Helfen
- Medizinische Klinik I, Katholisches Klinikum Lünen Werne GmbH St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Frank A. Flachskampf
- Department of Medical Sciences, Universität Uppsala, und Klinisk fysiologi och kardiologi, Uppsala University Hospital, Uppsala, Schweden
| | - Sebastian Ewen
- Klinik für Innere Medizin III – Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Deutschland
| | - Sebastian Kruck
- Cardio Centrum Ludwigsburg Bietigheim, Ludwigsburg, Deutschland
| | - Karl La Rosée
- Gemeinschaftspraxis Dr. La Rosée & Prof. Dr. Müller, Bonn, Deutschland
| | - Jan Knierim
- Klinik für Herz‑, Thorax- und Gefäßchirurgie, Deutsches Herzzentrum Berlin, Berlin, Deutschland
| | - Jens-Uwe Voigt
- Department of Cardiovascular Diseases, University Hospital Gasthuisberg und Department of Cardiovascular Sciences, Cath. University Leuven, Leuven, Belgien
| | - Felix Kreidel
- Zentrum für Kardiologie, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Wolfgang Fehske
- Klinik III für Innere Medizin, Universitätsklinikum Köln – Herzzentrum, Universität zu Köln, Köln, Deutschland
| | - Roland Brandt
- Abteilung für Kardiologie, Kerckhoff Klinik GmbH, Bad Nauheim, Deutschland
| | - Ralf Zahn
- Medizinische Klinik B – Abteilung für Kardiologie, Klinikum der Stadt Ludwigshafen gGmbH, Ludwigshafen am Rhein, Deutschland
- Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Deutschland
| | - Fabian Knebel
- Medizinische Klinik mit Schwerpunkt Kardiologie und Angiologie, Charité – Universitätsmedizin Berlin, Campus Mitte, Berlin, Deutschland
- Sana Klinikum Lichtenberg, Berlin, Deutschland
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Bertolini M, Rossoni M, Colombo G. Operative Workflow from CT to 3D Printing of the Heart: Opportunities and Challenges. Bioengineering (Basel) 2021; 8:bioengineering8100130. [PMID: 34677203 PMCID: PMC8533410 DOI: 10.3390/bioengineering8100130] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/07/2021] [Accepted: 09/17/2021] [Indexed: 01/25/2023] Open
Abstract
Medical images do not provide a natural visualization of 3D anatomical structures, while 3D digital models are able to solve this problem. Interesting applications based on these models can be found in the cardiovascular field. The generation of a good-quality anatomical model of the heart is one of the most complex tasks in this context. Its 3D representation has the potential to provide detailed spatial information concerning the heart’s structure, also offering the opportunity for further investigations if combined with additive manufacturing. When investigated, the adaption of printed models turned out to be beneficial in complex surgical procedure planning, for training, education and medical communication. In this paper, we will illustrate the difficulties that may be encountered in the workflow from a stack of Computed Tomography (CT) to the hand-held printed heart model. An important goal will consist in the realization of a heart model that can take into account real wall thickness variability. Stereolithography printing technology will be exploited with a commercial rigid resin. A flexible material will be tested too, but results will not be so satisfactory. As a preliminary validation of this kind of approach, print accuracy will be evaluated by directly comparing 3D scanner acquisitions to the original Standard Tessellation Language (STL) files.
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Kemi Y, Yamashita E, Fujiwara T, Kario K, Sasaki T, Minami K, Miki Y, Goto K, Take Y, Nakamura K, Naito S. The prevalence and characteristics of candidates for percutaneous left atrial appendage occlusion using a WATCHMAN device among patients who underwent atrial fibrillation ablation in a Japanese population. J Echocardiogr 2021; 19:243-249. [PMID: 34296416 DOI: 10.1007/s12574-021-00538-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 06/22/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) using a WATCHMAN device could be a treatment option for patients with non-valvular atrial fibrillation (AF) with thromboembolic and bleeding risk. We sought to determine the prevalence and characteristics of patients with AF ablation who are potential candidates for WATCHMAN implantation in a Japanese population. METHODS We enrolled 2443 consecutive patients who had previously undergone AF ablation and transesophageal echocardiography (TEE). We assessed their clinical characteristics and measured their LAA orifice diameter and depth retrospectively using the obtained TEE images. We defined patients who met both anatomical criteria (LAA orifice max diameter: 17-31 mm and LAA max depth > LAA orifice max diameter) and clinical criteria (CHA2DS2-VASc score ≥ 2 and HAS-BLED score ≥ 3) as LAAO candidates. RESULTS Among the 2443 enrolled patients, 361 (15%) met the clinical criteria, and 1928 (79%) met the anatomical criteria. Thus 12% (293/2443) of the total patient group met the criteria of LAAO candidates. LAAO candidates showed larger left atrial (LA) volume (77.6 ± 30.1 vs. 67.7 ± 29.1 mL, P < 0.001), larger LAA orifice diameter (22.5 ± 3.2 vs. 22.0 ± 4.3 mm, P = 0.026), and larger LAA depth (28.9 ± 4.6 vs. 27.0 ± 4.8 mm, P < 0.001). LAAO candidates made up only 23% of patients with CHA2DS2-VASc score ≥ 2 (N = 1295), whereas 78% of patients with a HAS-BLED score ≥ 3 (N = 378) were LAAO candidates. CONCLUSION Twelve percent of patients who underwent AF ablation were potential candidates for LAAO using a WATCHMAN device in this Japanese population. It is imperative to evaluate bleeding risk when considering the indications for LAAO.
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Affiliation(s)
- Yuta Kemi
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan. .,Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
| | - Eiji Yamashita
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan.,Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Takeshi Fujiwara
- Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Kazuomi Kario
- Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Takehito Sasaki
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Kentaro Minami
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Yuko Miki
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Koji Goto
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Yutaka Take
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Kohki Nakamura
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
| | - Shigeto Naito
- Gunma Prefectural Cardiovascular Center, 3-12 Kameizumi, Maebashi, Gunma, 371-0004, Japan
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Cimmino G, Loffredo FS, Gallinoro E, Prozzo D, Fabiani D, Cante L, Salerno G, Cappelli Bigazzi M, Golino P. Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:444. [PMID: 34063719 PMCID: PMC8147783 DOI: 10.3390/medicina57050444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.
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Affiliation(s)
- Giovanni Cimmino
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Francesco S. Loffredo
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
- Molecular Cardiology, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
| | - Emanuele Gallinoro
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
| | - Dario Prozzo
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
| | - Dario Fabiani
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Luigi Cante
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Gemma Salerno
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | | | - Paolo Golino
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
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Rajiah P, Alkhouli M, Thaden J, Foley T, Williamson E, Ranganath P. Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices. Radiographics 2021; 41:680-698. [PMID: 33939541 DOI: 10.1148/rg.2021200136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Mohamad Alkhouli
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Jeremy Thaden
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Thomas Foley
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Eric Williamson
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Praveen Ranganath
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
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Burkule N, Bansal M, Govind S, Alagesan R, Ponde C, Parashar S. Indian Academy of Echocardiography Guidelines for Performance of Transesophageal Echocardiography in Adults. JOURNAL OF THE INDIAN ACADEMY OF ECHOCARDIOGRAPHY & CARDIOVASCULAR IMAGING 2021. [DOI: 10.4103/jiae.jiae_39_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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29
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Italiano G, Maltagliati A, Mantegazza V, Fusini L, Mancini ME, Gasperetti A, Brusoni D, Susini F, Formenti A, Pontone G, Fassini G, Tondo C, Pepi M. Multimodality Approach for Endovascular Left Atrial Appendage Closure: Head-To-Head Comparison among 2D and 3D Echocardiography, Angiography, and Computer Tomography. Diagnostics (Basel) 2020; 10:diagnostics10121103. [PMID: 33348561 PMCID: PMC7766723 DOI: 10.3390/diagnostics10121103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gianpiero Italiano
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
- Correspondence: ; Tel.: +39-0258002159; Fax: +39-0258002287
| | - Anna Maltagliati
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Valentina Mantegazza
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Laura Fusini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Maria Elisabetta Mancini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Alessio Gasperetti
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Denise Brusoni
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Francesca Susini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Alberto Formenti
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Gaetano Fassini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
| | - Claudio Tondo
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
- Department of Cardiovascular Sciences and Community Health, University of Milan, 20138 Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, 20138 Milan, Italy; (A.M.); (V.M.); (L.F.); (M.E.M.); (A.G.); (D.B.); (F.S.); (A.F.); (G.P.); (G.F.); (C.T.); (M.P.)
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Cruz-González I, Korsholm K, Trejo-Velasco B, Thambo JB, Mazzone P, Rioufol G, Grygier M, Möbius-Winkler S, Betts T, Meincke F, Sandri M, Schmidt B, Schmitz T, Nielsen-Kudsk JE. Procedural and Short-Term Results With the New Watchman FLX Left Atrial Appendage Occlusion Device. JACC Cardiovasc Interv 2020; 13:2732-2741. [DOI: 10.1016/j.jcin.2020.06.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/04/2020] [Accepted: 06/30/2020] [Indexed: 01/01/2023]
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Kong D, Jiang Y, Zhang X, Jin Q, Dong L, Zhou D, Shu X, Pan C. Reference value of perimeter-derived diameter assessed by three-dimensional transesophageal echocardiography in left atrial appendage occluder size selection. Echocardiography 2020; 37:1828-1837. [PMID: 33007129 DOI: 10.1111/echo.14705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/24/2020] [Accepted: 04/29/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The aim of this study was to investigate the utility of perimeter-derived diameter (PDD) measured by three-dimensional (3D) transesophageal echocardiography (TEE) in predicting the size of left atrial appendage (LAA) occluder. METHODS AND RESULTS Left atrial appendage landing zone diameter (LZD) was measured by two-dimensional (2D) TEE, 3DTEE, and digital subtraction angiography (DSA) as LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD, LZD-DSAmax, respectively, before and during transcatheter LAA closure with Watchman devices in 100 patients. A difference of one or more device size intervals between the predicted size and the size actually implanted was defined as mismatching. Seventy-eight patients were followed up by TEE to obtain occluder compression ratio. The correlation between LZD and the final implanted occluder size was 0.559, 0.641, 0.754, 0.760, 0.782, and 0.848 for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively (P < .001). Matching ratio between the size predicted by retrospective measurements of LZD and the device size actually implanted was 65%, 57%, 66%, 63%, 70%, and 83% for LZD-2Dmax, LZD-2Dmean, LZD-3Dmax, LZD-3Dmean, LZD-PDD and LZD-DSAmax, respectively. There was no significant difference in LZD value, matching ratio, and compression ratio between the patients with eccentric and noneccentric LAA landing zone (P > .05). Compression ratio of the mismatching subjects was higher than that in the matching subjects when evaluated by LZD-2Dmean, LZD-3Dmean, and LZD-PDD (P < .05). CONCLUSIONS Landing zone diameter derived from LAA perimeter measured by preprocedure 3DTEE showed reference value for LAA occluder size selection, providing superior correlation and matching ratio with the final implanted size and indicating the adjustment of oversizing.
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Affiliation(s)
- Dehong Kong
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
| | - Yingying Jiang
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xiaochun Zhang
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Qinchun Jin
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Lili Dong
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
| | - Daxin Zhou
- Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Xianhong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cuizhen Pan
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China.,Shanghai Institute of Cardiovascular Diseases, Shanghai, China.,Shanghai Institute of Medical Imaging, Shanghai, China
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Microtransesophageal Echocardiographic Guidance during Percutaneous Interatrial Septal Closure without General Anaesthesia. J Interv Cardiol 2020; 2020:1462140. [PMID: 32982607 PMCID: PMC7492935 DOI: 10.1155/2020/1462140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 07/30/2020] [Accepted: 08/31/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To study the safety and efficacy of microtransesophageal echocardiography (micro-TEE) and TEE during percutaneous atrial septal defect (ASD) and patent foramen ovale (PFO) closure. Background TEE has proven to be safe during ASD and PFO closure under general anaesthesia. Micro-TEE makes it possible to perform these procedures under local anaesthesia. We are the first to describe the safety and efficacy of micro-TEE for percutaneous closure. Methods All consecutive patients who underwent ASD and PFO closure between 2013 and 2018 were included. The periprocedural complications were registered. Residual shunts were diagnosed using transthoracic contrast echocardiography (TTCE). All data were compared between the use of TEE or micro-TEE within the ASD and PFO groups separately. Results In total, 82 patients underwent ASD closure, 46 patients (49.1 ± 15.0 years) with TEE and 36 patients (47.8 ± 12.1 years) using micro-TEE guidance. Median device diameter was, respectively, 26 mm (range 10–40 mm) and 27 mm (range 10–35 mm). PFO closure was performed in 120 patients, 55 patients (48.6 ± 9.2 years, median device diameter 25 mm, range 23–35 mm) with TEE and 65 patients (mean age 51.0 ± 11.8 years, median device diameter 27 mm, range 23–35 mm) using micro-TEE. There were no major periprocedural complications, especially no device embolizations within all groups. Six months after closure, there was no significant difference in left-to-right shunt after ASD closure and no significant difference in right-to-left shunt after PFO closure using TEE or micro-TEE. Conclusion Micro-TEE guidance without general anaesthesia during percutaneous ASD and PFO closure is as safe as TEE, without a significant difference in the residual shunt rate after closure.
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Gitsioudis G, Marwan M, Schneider S, Schmermund A, Korosoglou G, Hausleiter J, Schroeder S, Rixe J, Leber A, Bruder O, Katus HA, Senges J, Achenbach S. A systematic report on non-coronary cardiac CTA in 1097 patients from the German cardiac CT registry. Eur J Radiol 2020; 130:109136. [DOI: 10.1016/j.ejrad.2020.109136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/09/2020] [Accepted: 06/15/2020] [Indexed: 12/31/2022]
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Shee V, He L, Liu S, Huang X, Chen Y, Xie L, Deng X, Peng J. Personalized Fluoroscopic Angles in Watchman™ Left Atrial Appendage Closure Landing Zone Assessment: A Three-Dimensional Printed Simulation Study. Cureus 2020; 12:e8783. [PMID: 32724734 PMCID: PMC7381882 DOI: 10.7759/cureus.8783] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Background Atrial fibrillation causes ischemic stroke when thrombi dislodge from a cardiac outpouching, the left atrial appendage (LAA), and embolize to the brain. LAA occlusion with the Watchman™ device (Boston Scientific Corporation, MA, USA), which prevents stroke, requires accurate LAA measurements for device sizing. We explore whether standard fluoroscopic LAA measurements improve when obtained at CT-derived viewing angles personalized to LAA anatomy while concurrently referring to three-dimensional (3D) CT. Methods Left atrial 3D reconstructions created from contrast CT (n=28) were analysed to identify personalized viewing angles wherein LAA dimensions (LAA maximum landing zone diameter and LAA length) were best observed. The 3D-CT reconstructions were then 3D printed with stands. Fluoroscopy of anatomically oriented models in the catheter lab simulated LAA angiography. Fluoroscopic images were acquired at standard (caudal 20˚/right anterior oblique 30˚) and personalized viewing angles. Repeated measurements of LAA dimensions were taken from CT (Control), fluoroscopy at standard angles (Standard), personalized angles (Blinded), and personalized angles while concurrently referring to 3D CT (Referred). Results Control measurements correlated and agreed better with Referred and Blinded measurements than with Standard measurements (diameter correlation and agreement: Control/Standard r=.554, limits of agreement [LOAs]=6.83/-5.91; Control/Blinded r=.641, LOA =5.67/-5.54; Control/Referred r=.741, LOA=4.69/-4.14; length correlation and agreement: Control/Standard rs=.829, LOA=9.61/-3.02; Control/Blinded rs=0.789, LOA=7.13/-4.94; Control/Referred rs=.907, LOA=4.84/-4.13). Personalized angles resulted in hypothetical device size predictions more consistent with Control (device size correlation: Control/Standard rs=.698, Control/Blinded rs=.731, Control/Referred rs=.893, P<0.001). False ineligibility rates were Standard=6/28, Blinded=6/28, and Referred=2/28. Conclusion This simulation suggests that personalized fluoroscopic viewing angles with in-procedural reference to 3D CT may improve the accuracy of LAA maximum landing zone diameter and length measurements at the Watchman landing zone. This improvement may result in more consistent device size selection and procedural eligibility assessment. Further clinical research on these interventions is merited.
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Affiliation(s)
- Vikram Shee
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Liwei He
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Shenrong Liu
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Xingfu Huang
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Yanyu Chen
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Liangzhen Xie
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Xiaojiang Deng
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
| | - Jian Peng
- Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, CHN
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Left Atrial Appendage Mechanical Exclusion: Procedural Planning Using Cardiovascular Computed Tomographic Angiography. J Thorac Imaging 2020; 35:W107-W118. [PMID: 32235186 DOI: 10.1097/rti.0000000000000504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Left atrial appendage (LAA) mechanical exclusion is being investigated for nonpharmacologic stroke risk reduction in selected patients with atrial fibrillation. There are multiple potential approaches in various stages of development and clinical application, each of which depends on specific cardiothoracic anatomic characteristics for optimal performance. Multiple imaging modalities can be utilized for application of this technology, with transesophageal echocardiography used for intraprocedural guidance. Cardiovascular computed tomographic angiography can act as a virtual patient avatar, allowing for the assessment of cardiac structures in the context of surrounding cardiac, coronary vascular, thoracic vascular, and visceral and skeletal anatomy, aiding preprocedural decision-making, planning, and follow-up. Although transesophageal echocardiography is used for intraprocedural guidance, computed tomographic angiography may be a useful adjunct for preprocedure assessment of LAA sizing and anatomic obstacles or contraindications to deployment, aiding in the assessment of optimal approaches. Potential approaches to LAA exclusion include endovascular occlusion, epicardial ligation, primary minimally invasive intercostal thoracotomy with thoracoscopic LAA ligation or appendectomy, and minimally invasive or open closure as part of cardiothoracic surgery for other indications. The goals of these procedures are complete isolation or exclusion of the entire appendage without leaving a residual appendage stump or residual flow with avoidance of acute or chronic damage to surrounding cardiovascular structures. The cardiovascular imager plays an important role in the preprocedural and postprocedural assessment of the patient undergoing LAA exclusion.
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Voskoboinik A, Lee RJ. Anatomic Considerations for Epicardial and Endocardial Left Atrial Appendage Closure. Card Electrophysiol Clin 2019; 12:39-45. [PMID: 32067646 DOI: 10.1016/j.ccep.2019.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Left atrial appendage closure is an increasingly used means of achieving thromboprophylaxis in atrial fibrillation, particularly in patients with contraindications to anticoagulation. Left atrial appendage anatomy is highly variable, and preprocedural imaging is critical to choosing the correct device and approach for left atrial appendage closure. This article reviews the common endocardial and epicardial closure systems, including anatomic considerations, advantages and disadvantages, as well as complications to be avoided.
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Affiliation(s)
- Aleksandr Voskoboinik
- Department of Electrophysiology, University of California San Francisco, 500 Parnassus Ave., MU-East Fourth Floor, San Francisco, CA 94143, USA
| | - Randall J Lee
- Department of Electrophysiology, University of California San Francisco, 500 Parnassus Ave., MU-East Fourth Floor, San Francisco, CA 94143, USA.
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Pathan F, Hecht H, Narula J, Marwick TH. Roles of Transesophageal Echocardiography and Cardiac Computed Tomography for Evaluation of Left Atrial Thrombus and Associated Pathology: A Review and Critical Analysis. JACC Cardiovasc Imaging 2019; 11:616-627. [PMID: 29622180 DOI: 10.1016/j.jcmg.2017.12.019] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/21/2017] [Indexed: 01/23/2023]
Abstract
Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making.
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Affiliation(s)
- Faraz Pathan
- Menzies Institute for Medical Research, Hobart, Australia
| | - Harvey Hecht
- Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Jagat Narula
- Icahn School of Medicine at Mount Sinai, New York, New York
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Fan Y, Wong RHL, Lee APW. Three-dimensional printing in structural heart disease and intervention. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:579. [PMID: 31807560 DOI: 10.21037/atm.2019.09.73] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Three-dimensional (3D) printing refers to the process by which physical objects are built by depositing materials in layers based on a specific digital design. It was initially used in manufacture industry. Inspired by the technology, clinicians have recently attempted to integrate 3D printing into medical applications. One of the medical specialties that has recently made such attempt is cardiology, especially in the field of structural heart disease (SHD). SHD refers to a group of non-coronary cardiovascular disorders and related interventions. Obvious examples are aortic stenosis, mitral regurgitation, atrial septal defect, and known or potential left atrial appendage (LAA) clots. In the last decade, cardiologists have witnessed a dramatic increase in the types and complexity of catheter-based interventions for SHD. Current imaging modalities have important limitations in accurate delineation of cardiac anatomies necessary for SHD interventions. Application of 3D printing in SHD interventional planning enables tangible appreciation of cardiac anatomy and allows in vitro interventional device testing. 3D printing is used in diagnostic workup, guidance of treatment strategies, and procedural simulation, facilitating hemodynamic research, enhancing interventional training, and promoting patient-clinician communication. In this review, we attempt to define the concept, technique, and work flow of 3D printing in SHD and its interventions, highlighting the reported clinical benefits and unsolved issues, as well as exploring future developments in this field.
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Affiliation(s)
- Yiting Fan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Randolph H L Wong
- Division of Cardiothoracic Surgery, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Ramchand J, Harb SC, Miyasaka R, Kanj M, Saliba W, Jaber WA. Imaging for Percutaneous Left Atrial Appendage Closure: A Contemporary Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1643957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Jay Ramchand
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C. Harb
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid Saliba
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wael A. Jaber
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Doherty JU, Kort S, Mehran R, Schoenhagen P, Soman P. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2019 Appropriate Use Criteria for Multimodality Imaging in the Assessment of Cardiac Structure and Function in Nonvalvular Heart Disease : A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and the Society of Thoracic Surgeons. J Nucl Cardiol 2019; 26:1392-1413. [PMID: 31250324 DOI: 10.1007/s12350-019-01751-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
This document is the second of 2 companion appropriate use criteria (AUC) documents developed by the American College of Cardiology, American Association for Thoracic Surgery, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. The first document (J Am Coll Cardiol 2017;70:1647-1672) addresses the evaluation and use of multimodality imaging in the diagnosis and management of valvular heart disease, whereas this document addresses this topic with regard to structural (nonvalvular) heart disease. While dealing with different subjects, the 2 documents do share a common structure and feature some clinical overlap. The goal of the companion AUC documents is to provide a comprehensive resource for multimodality imaging in the context of structural and valvular heart disease, encompassing multiple imaging modalities.Using standardized methodology, the clinical scenarios (indications) were developed by a diverse writing group to represent patient presentations encountered in everyday practice and included common applications and anticipated uses. Where appropriate, the scenarios were developed on the basis of the most current American College of Cardiology/American Heart Association Clinical Practice Guidelines.A separate, independent rating panel scored the 102 clinical scenarios in this document on a scale of 1 to 9. Scores of 7 to 9 indicate that a modality is considered appropriate for the clinical scenario presented. Midrange scores of 4 to 6 indicate that a modality may be appropriate for the clinical scenario, and scores of 1 to 3 indicate that a modality is considered rarely appropriate for the clinical scenario.The primary objective of the AUC is to provide a framework for the assessment of these scenarios by practices that will improve and standardize physician decision making. AUC publications reflect an ongoing effort by the American College of Cardiology to critically and systematically create, review, and categorize clinical situations in which diagnostic tests and procedures are utilized by physicians caring for patients with cardiovascular diseases. The process is based on the current understanding of the technical capabilities of the imaging modalities examined.
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Affiliation(s)
| | - Smadar Kort
- American Society of Echocardiography, Morrisville, NC, USA
| | - Roxana Mehran
- Society for Cardiovascular Angiography and Interventions, Washington, DC, USA
| | | | - Prem Soman
- American Society of Nuclear Cardiology, Bethesda, MD, USA
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Smietana J, Plitt A, Halperin JL. Thromboembolism in the Absence of Atrial Fibrillation. Am J Cardiol 2019; 124:303-311. [PMID: 31060729 DOI: 10.1016/j.amjcard.2019.04.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 03/30/2019] [Accepted: 04/04/2019] [Indexed: 11/15/2022]
Abstract
Atrial fibrillation (AF) is associated with thrombus formation in the left atrial appendage and systemic embolic events including ischemic stroke. Cardiogenic thromboembolism can also occur in the absence of clinical AF as a result of various pathological conditions affecting the endocardium. The inconsistent temporal relation between AF and ischemic events has stimulated exploration for factors other than clinical AF that contribute to thromboembolism. These include subclinical AF, a thrombogenic atrial cardiomyopathy, and left atrial appendage dysfunction and embolism from other sources. In conclusion, thromboembolism during normal sinus rhythm is likely multifactorial, involving intertwined pathologic processes. Patients at risk, if accurately identified, could theoretically benefit from anticoagulation.
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Affiliation(s)
- Jeffrey Smietana
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Anna Plitt
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York
| | - Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York.
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Altszuler D, Vainrib AF, Bamira DG, Benenstein RJ, Aizer A, Chinitz LA, Saric M. Left Atrial Occlusion Device Implantation: the Role of the Echocardiographer. Curr Cardiol Rep 2019; 21:66. [PMID: 31183616 DOI: 10.1007/s11886-019-1151-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE OF REVIEW Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. For patients with atrial fibrillation who are unable to tolerate systemic anticoagulation, left atrial appendage (LAA) occlusion has been shown to mitigate stroke risk. In this article, we describe the vital role of the echocardiographer in intraprocedural guidance of percutaneous LAA occlusion procedures as well as in the pre- and post-procedure assessment of these patients. RECENT FINDINGS A few percutaneously delivered devices for LAA exclusion from the systemic circulation are available in contemporary practice. These devices employ an either exclusive endocardial LAA occlusion approach, such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both an endocardial and pericardial (epicardial) approach such as the Lariat procedure (SentreHEART, Palo Alto, CA). Two- and three-dimension transesophageal echocardiography is critical for patient selection, procedure planning, procedural guidance, and ensuring satisfactory immediate as well as long-term LAA occlusion/exclusion efficacy. This review will provide an overview of the role of the echocardiographer in all aspects of LAA occlusion/exclusion procedures for the most commonly used commercially available devices in current practice.
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Affiliation(s)
- David Altszuler
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Alan F Vainrib
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Daniel G Bamira
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Ricardo J Benenstein
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA
| | - Muhamed Saric
- Leon H. Charney Division of Cardiology, New York University Langone Health, New York, NY, USA.
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Ecocardiografía transesófagica mínimamente invasiva con microsonda de última generación para el cierre percutáneo de la orejuela izquierda. Experiencia inicial. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Left Atrial Appendage Occlusion: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 33:1753-1765. [DOI: 10.1053/j.jvca.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/21/2022]
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Jia D, Zhou Q, Song HN, Zhang L, Chen JL, Liu Y, Kong B, He FZ, Wang YJ, Yang YT. The value of the left atrial appendage orifice perimeter of 3D model based on 3D TEE data in the choice of device size of LAmbre™ occluder. Int J Cardiovasc Imaging 2019; 35:1841-1851. [PMID: 31134413 DOI: 10.1007/s10554-019-01627-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/13/2019] [Indexed: 11/28/2022]
Abstract
Preoperative optimal selection of the occluder size is crucial in percutaneous left atrial appendage (LAA) occlusion, and the maximal width of the LAA orifice is the main reference index, however it can not fully meet the practical operation requirements. We retrospectively analyzed three-dimensional (3D) transesophageal echocardiography (TEE) and computed tomography (CT) imaging dataset of the 41 patients who underwent LAA occlusion with LAmbre™ system. The LAA orifice parameters were overall evaluated to determine their role in device size selection. Eight LAA 3D models of the four cases who had been replaced their device during the procedure based on TEE and CT were printed out to verify the optimal parameter decision strategy. There was a significant concordance of the results between 3D TEE and CT in the LAA orifice evaluation. The correlations between the perimeter and maximal width measurements by 3D TEE and the closure disk of the device were stronger than that between the area measurements and the closure disk (r = 0.93, 0.95, 0.86, respectively and p < 0.001 all), and the result was similar to that by CT (r = 0.92, 0.93, 0.84, respectively and p < 0.001 all). The ratios of the maximal width to the minimal width of the four cases were all > 1.4, however the rest 37 cases were all ≤ 1.4. Based on the comprehensive assessment of the LAA orifice perimeter and maximal width of the 3D printed models, the experiments were all succeed just for one try. The LAA orifice perimeter of 3D printed model based on 3D TEE may help in choosing the optimal device size of LAmbre™, especially for the LAA with flater ostial shape.
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Affiliation(s)
- Dan Jia
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China.
| | - Hong-Ning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lan Zhang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jin-Ling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yu Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bin Kong
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fa-Zhi He
- Computer Science and Technology School, Wuhan University, Wuhan, China
| | - Yi-Jia Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuan-Ting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
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Morais P, Vilaca JL, Queiros S, De Meester P, Budts W, Tavares JMRS, D'Hooge J. Semiautomatic Estimation of Device Size for Left Atrial Appendage Occlusion in 3-D TEE Images. IEEE TRANSACTIONS ON ULTRASONICS, FERROELECTRICS, AND FREQUENCY CONTROL 2019; 66:922-929. [PMID: 30869614 DOI: 10.1109/tuffc.2019.2903886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Left atrial appendage (LAA) occlusion is used to reduce the risk of thromboembolism in patients with nonvalvular atrial fibrillation by obstructing the LAA through a percutaneously delivered device. Nonetheless, correct device sizing is complex, requiring the manual estimation of different measurements in preprocedural/periprocedural images, which is tedious and time-consuming and with high interobserver and intraobserver variability. In this paper, a semiautomatic solution to estimate the required relevant clinical measurements is described. This solution starts with the 3-D segmentation of the LAA in 3-D transesophageal echocardiographic images, using a constant blind-ended model initialized through a manually defined spline. Then, the segmented LAA surface is aligned with a set of templates, i.e., 3-D surfaces plus relevant measurement planes (manually defined by one observer), transferring the latter to the unknown situation. Specifically, the alignment is performed in three consecutive steps, namely: 1) rigid alignment using the LAA clipping plane position; 2) orientation compensation using the circumflex artery location; and 3) anatomical refinement through a weighted iterative closest point algorithm. The novel solution was evaluated in a clinical database with 20 volumetric TEE images. Two experiments were set up to assess: 1) the sensitivity of the model's parameters and 2) the accuracy of the proposed solution for the estimation of the clinical measurements. Measurement levels manually identified by two observers were used as ground truth. The proposed solution obtained results comparable to the interobserver variability, presenting narrower limits of agreement for all measurements. Moreover, this solution proved to be fast, taking nearly 40 s (manual analysis took 3 min) to estimate the relevant measurements while being robust to the variation of the model's parameters. Overall, the proposed solution showed its potential for fast and robust estimation of the clinical measurements for occluding device selection, proving its added value for clinical practice.
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A Pilot Study for Left Atrial Appendage Occlusion Guided by 3-Dimensional Rotational Angiography Alone. JACC Cardiovasc Interv 2019; 11:223-224. [PMID: 29348017 DOI: 10.1016/j.jcin.2017.08.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Accepted: 08/29/2017] [Indexed: 11/23/2022]
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Fan Y, Yang F, Cheung GSH, Chan AKY, Wang DD, Lam YY, Chow MCK, Leong MCW, Kam KKH, So KCY, Tse G, Qiao Z, He B, Kwok KW, Lee APW. Device Sizing Guided by Echocardiography-Based Three-Dimensional Printing Is Associated with Superior Outcome after Percutaneous Left Atrial Appendage Occlusion. J Am Soc Echocardiogr 2019; 32:708-719.e1. [PMID: 30948144 DOI: 10.1016/j.echo.2019.02.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) occlusion is an alternative to anticoagulation for stroke prevention in patients with atrial fibrillation. Accurate device sizing is crucial for optimal outcome. Patient-specific LAA models can be created using three-dimensional (3D) printing from 3D transesophageal echocardiographic (TEE) images, allowing in vitro model testing for device selection. The aims of this study were to assess the association of model-based device selection with procedural safety and efficacy and to determine if preprocedural model testing leads to superior outcomes. METHODS In 72 patients who underwent imaging-guided LAA occlusion, 3D models of the LAA were created from 3D TEE data sets retrospectively (retrospective cohort). The optimal device determined by in vitro model testing was compared with the actual device used. Associations of model-match and model-mismatch device sizing with outcomes were analyzed. In another 32 patients, device selection was prospectively guided by 3D models in adjunct to imaging (prospective cohort). The impact of model-based sizing on outcomes was assessed by comparing the two cohorts. RESULTS Patients in the retrospective cohort with model-mismatch sizing had longer procedure times, more implantation failures, more devices used per procedure, more procedural complications, more peridevice leak, more device thrombus, and higher cumulative incidence rates of ischemic stroke and cardiovascular or unexplained death (P < .05 for all) over 3.0 ± 2.3 years after LAA occlusion. Compared with the retrospective imaging-guided cohort, the prospective model-guided patients achieved higher implantation success and shorter procedural times (P < .05) without complications. Clinical device compression (r = 0.92) and protrusion (r = 0.95) agreed highly with model testing (P < .0001). Predictors for sizing mismatch were nonwindsock morphology (odds ratio, 4.7) and prominent LAA trabeculations (odds ratio, 7.1). CONCLUSIONS In patients undergoing LAA occlusion, device size selection in agreement with 3D-printed model-based sizing is associated with improved safety and efficacy. Preprocedural device sizing with 3D models in adjunct to imaging guidance may lead to superior outcomes.
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Affiliation(s)
- Yiting Fan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Fan Yang
- Division of Cardiology, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Gary Shing-Him Cheung
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anna Kin-Yin Chan
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Dee Dee Wang
- Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Yat-Yin Lam
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Marco Chun-Kit Chow
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong SAR, China
| | | | - Kevin Ka-Ho Kam
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Kent Chak-Yu So
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Tse
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Zhiqing Qiao
- Division of Cardiology, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ben He
- Division of Cardiology, Renji Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ka-Wai Kwok
- Department of Mechanical Engineering, The University of Hong Kong, Hong Kong SAR, China
| | - Alex Pui-Wai Lee
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China.
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Poulin MF, Mohamedali B, Kavinsky CJ, Krishnan K. Left atrial appendage occlusion using a Watchman device in a transplanted heart with biatrial anastomosis. Catheter Cardiovasc Interv 2019; 93:758-760. [PMID: 30549242 DOI: 10.1002/ccd.28027] [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: 10/24/2018] [Revised: 11/28/2018] [Accepted: 12/02/2018] [Indexed: 11/09/2022]
Abstract
A percutaneous left atrial appendage (LAA) occlusion using a Watchman device was performed in a patient with prior biatrial anastomosis orthotopic heart transplant (OHT). Due to the anatomical changes following biatrial anastomosis, transesophageal echocardiography (TEE) imaging and transseptal puncture become technically challenging. We describe how the standard LAA views on TEE were obtained for device sizing, and how the transseptal puncture was modified to cross the scarred septum. This case demonstrates that LAA occlusion using a Watchman device in biatrial anastomosis OHT is safe and can successfully be done.
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Affiliation(s)
- Marie-France Poulin
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Burhan Mohamedali
- Cardiovascular Institute of San Diego, 765 Medical Center, Chula Vista, California
| | - Clifford J Kavinsky
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kousik Krishnan
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois
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Moussa Pacha H, Al-khadra Y, Soud M, Darmoch F, Moussa Pacha A, Alraies MC. Percutaneous devices for left atrial appendage occlusion: A contemporary review. World J Cardiol 2019; 11:57-70. [PMID: 30820276 PMCID: PMC6391622 DOI: 10.4330/wjc.v11.i2.57] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/12/2018] [Accepted: 12/17/2018] [Indexed: 02/06/2023] Open
Abstract
Patient with atrial fibrillation (AF) are at risk of developing stroke with the left atrial appendage (LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF, some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion (LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device. Watchman is the most common and only Food and Drug Administration (FDA) approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.
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Affiliation(s)
| | - Yasser Al-khadra
- Cleveland Clinic, Medicine Institute, Cleveland, OH 44195, United States
| | - Mohamad Soud
- MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Fahed Darmoch
- Beth Israel Deaconess Medical center/Harvard Medical School, Boston, MA 02215, United States
| | | | - M Chadi Alraies
- Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, MI 48201, United States
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