A device-related fistula between coronary artery and left atrial appendage following left atrial appendage closure: Case presentation

INTRODUCTION

Left atrial appendage (LAA) closure (LAAC) is considered a viable alternative to anticoagulation therapy for stroke prevention in nonvalvular atrial fibrillation, we report a case with a less common shunt resulting from a device-related coronary artery-appendage fistula (CAAF) following LAAC.

METHODS AND RESULTS

A 67-year-old male with a history of LAAC was referred to our emergency room with recurrent chest pain and palpitations and was diagnosed with ischemic angina pectoris. Subsequent coronary angiography (CAG) revealed 70% in-stent restenosis and an abnormal shunt of contrast originating from the left circumflex artery (LCA) to the LAA tip which did not exist before. The restenosis was successfully dilated using a drug-coated balloon, the procedure was safely completed without pericardial effusion. The patient had been implanted with a LAmbre occluder (Lifetech Scientific Corp.) in the previous LAAC procedure. This occluder had a lobe-disk design, and the distal umbrella was not fully opened after release, particularly in the lower portion. This could make the hooks embedded on the umbrella contact the LAA wall more tightly, possibly resulting in microperforation and coincidental impingement of the LCA. The epicardial adipose and hyperplastic tissue then chronically wrapped the perforated site, prevented blood outflow into the epicardium, and ultimately formed a CAAF.

CONCLUSION

CAAF is a rare complication after LAAC but may be underestimated, especially for lobe-disk designed occluders. Therefore, CAG is perhaps necessary to detect this complication.

Increased hemoglobin A1c level associates with low left atrial appendage flow velocity in patients of atrial fibrillation

BACKGROUND AND AIMS

High hemoglobin A1c (HbAlc) level is associated with increased cardiovascular disease risk and thromboembolic events [1]. The study sought to explored the association between HbAlc and left atrial appendage flow velocity (LAAV) among non-valvular atrial fibrillation (AF) patients.

METHODS AND RESULTS

A total of 249 consecutive non-valvular AF patients who underwent transesophageal echocardiography (TEE) were divided into two subgroups according to the median of LAAV level (<45 cm/s, ≥45 cm/s). Blood samples and other baseline clinical data of all patients were collected and analyzed. The low LAAV group included 126 patients and the high LAAV group included 123 patients. Patients in the low LAAV group were older and had a higher percentage of persistent AF, chronic heart failure, and higher CHA2DS2-VASc score (P < 0.05). HbAlc level in the low LAAV group was significantly higher than the high LAAV group [6.1 (5.7-6.5)% vs 5.9 (5.6-6.2)%, P = 0.010]. The low LAAV group had larger left atrial diameter (LAD), left atrial area (LAA), higher left atrial pressure (LAP), and lower left ventricular ejection fraction (LVEF) (P < 0.05). Spearman rank correlation analysis showed that the HbAlc level was negatively correlated with LAAV (r = -0.211, P = 0.001). Multivariate analysis indicated that female gender (OR = 2.233, 95% CI 1.110-4.492, P = 0.024), persistent AF (OR = 6.610, 95% CI 3.109-14.052, P < 0.001), and HbAlc (OR = 1.903, 95% CI 1.092-3.317, P = 0.023) were independent factors that associated with low LAAV in AF patients.

CONCLUSION

Increased HbAlc level is associated with decreased LAAV and may reflect a low contractile function of the left atrial appendage.

Comparison of the effects of left atrial appendage closure and oral anticoagulants in preventing stroke in patients with non-valvular atrial fibrillation: A protocol for systematic review and meta-analysis

BACKGROUND

This study aims to analyze and evaluate the difference in efficacy between left atrial appendage closure (LAAC) and oral anticoagulants (OA) in preventing stroke in patients with non-valvular atrial fibrillation (NVAF) through the method of meta-analysis. The purpose is to provide for the prevention of stroke in patients with NVAF valuable treatment guidance.

METHODS

This study is a comprehensive collection of randomized controlled studies of LAAC and OA in the prevention of stroke in patients with NVAF, and searches PubMed, Embase, the Cochrane Library, Web of Science, CNKI, SinoMed, VIP Database, WANFANG Database, and other Chinese and English databases by combining subject words with free words, and the retrieval time is from the establishment of each database to June 1, 2021. At the same time, searching the included literature and literature of related reviews by manual. Two researchers independently conduct literature screening and quality evaluation. Statistical software RevMan 5.3 and Stata 12.0 were used for meta-analysis.

RESULTS

This study evaluating the difference in efficacy between LAAC and OA in preventing stroke in patients with NVAF will be published in high-quality medical academic journals.

CONCLUSION

This study will give the best treatment strategy to prevent stroke in patients with NVAF, and provide some reference for clinical medical staff.OSF registration number: DOI 10.17605/OSF.IO/2UXPA (https://osf.io/2uxpa).

Length of stay following percutaneous left atrial appendage occlusion: Data from the prospective, multicenter Amplatzer Amulet Occluder Observational Study

Aims

To evaluate factors influencing the length of stay in patients undergoing percutaneous left atrial appendage occlusion (LAAO).

Methods and results

Patient characteristics, procedural data and the occurrence of serious adverse events were analyzed from the Amplatzer^TM Amulet^TM Occluder Observational Study. Patients were divided into three groups: same day (S, 0day, n = 60, 5.6%) early (E, 1day, n = 526, 48.9%), regular (R, 2-3days, n = 338, 31.4%) and late (L, ≥4days, n = 152, 14.1%) discharge and followed up for 60 days. Procedure and device related SAE during the in-hospital stay (S: 0.0% vs. E: 1.0% vs. R: 2.1% vs. L: 23%, p<0.0001) were a major trigger for a prolonged in-hospital stay. Of the 37 subjects in the late discharge group with an SAE prior to discharge, cardiac or bleeding complications were the most common underlying conditions, occurring in 26 subjects. Multinomial logistic analysis only identified HAS-BLED score as an independent influencing factor (p = 0.04) for a late discharge. After 60 days, mortality tended to be greatest in the late discharge group (S: 0.0% vs. E: 1.0% vs. R: 1.2% vs. L: 3.3%, p = 0.1066).

Conclusion

Over half of the subjects receiving an Amplatzer Amulet occluder were discharged within 1 day of the implant procedure. Serious adverse events were a major trigger for a late discharge after LAAO. Increased HAS-BLED score was associated with a prolonged in-hospital stay.

Diabetes induces remodeling of the left atrial appendage independently of atrial fibrillation in a rodent model of type-2 diabetes

BACKGROUND

Diabetic patients have an increased predisposition to thromboembolic events, in most cases originating from thrombi in the left atrial appendage (LAA). Remodeling of the LAA, which predisposes to thrombi formation, has been previously described in diabetic patients with atrial fibrillation, but whether remodeling of the LAA occurs in diabetics also in the absence of atrial fibrillation is unknown. To investigate the contribution of diabetes, as opposed to atrial fibrillation, to remodeling of the LAA, we went from humans to the animal model.

METHODS

We studied by echocardiography the structure and function of the heart over multiple time points during the evolution of diabetes in the Cohen diabetic sensitive rat (CDs/y) provided diabetogenic diet over a period of 4 months; CDs/y provided regular diet and the Cohen diabetic resistant (CDr/y), which do not develop diabetes, served as controls. All animals were in sinus rhythm throughout the study period.

RESULTS

Compared to controls, CDs/y developed during the evolution of diabetes a greater heart mass, larger left atrial diameter, wider LAA orifice, increased LAA depth, greater end-diastolic and end-systolic diameter, and lower E/A ratio-all indicative of remodeling of the LAA and left atrium (LA), as well as the development of left ventricular diastolic dysfunction. To investigate the pathophysiology involved, we studied the histology of the hearts at the end of the study. We found in diabetic CDs/y, but not in any of the other groups, abundance of glycogen granules in the atrial appendages , atria  and ventricles, which may be of significance as glycogen granules have previously been associated with cell and organ dysfunction in the diabetic heart.

CONCLUSIONS

We conclude that our rodent model of diabetes, which was in sinus rhythm, reproduced structural and functional alterations previously observed in hearts of human diabetics with atrial fibrillation. Remodeling of the LAA and of the LA in our model was unrelated to atrial fibrillation and associated with accumulation of glycogen granules. We suggest that myocardial accumulation of glycogen granules is related to the development of diabetes and may play a pathophysiological role in remodeling of the LAA and LA, which predisposes to atrial fibrillation, thromboembolic events and left ventricular diastolic dysfunction in the diabetic heart.

Left and right atrial appendage functional features as predictors for voltage-defined left atrial remodelling in patients with long-standing persistent atrial fibrillation

It was hypothesised that left atrial (LA) fibrosis identified by the presence of low-voltage areas (LVA) may influence the mechanical and electrical function of the left (LAA) and right (RAA) atrial appendage among the long-standing persistent atrial fibrillation (LSPAF) population. 140 consecutive patients underwent voltage mapping of LA with a multielectrode catheter following pulmonary vein isolation and restoration of sinus rhythm with cardioversion. Echocardiography determined LAA peak outflow and inflow velocities and intracardiac catheter-based mean LAA and RAA AF cycle length (AFCL) were obtained during AF before ablation. The impact of flow velocities and AFCL on the prevalence and location of LVA was further evaluated. LVA were detected in 54% of the patients. 14% of the patients presented severe global LVA burden > 20% of the total LA surface area. 29% of the patients presented a disseminated pattern of remodelling as 3 out of 5 LA segments were affected. LAA AFCL, RAA AFCL, LAA flow velocities did not predict the absolute presence of LVA. However LAA AFCL > 155 ms predicted disseminated LVA pattern and LAA AFCL > 165 ms severe LVA incidence. LAA AFCL > 155 ms was predictive for existence of LVA within antero-septal LA segments whilst LAA emptying velocity ≤ 0.2 m/s within lateral wall. Moreover RAA AFCL > 165 ms was strongly related to the presence of LAA AFCL > 15 ms and > 165 ms. LAA and RAA functional assessment was predictive of the presence of advanced stages of voltage-defined LA fibrosis and its regional distribution among LSPAF population.

Percutaneous left atrial appendage occlusion: A review of current devices, clinical evidence, patient selection, and post procedural antithrombotic management

Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.

Beyond Pulmonary Vein Isolation in Nonparoxysmal Atrial Fibrillation: Posterior Wall, Vein of Marshall, Coronary Sinus, Superior Vena Cava, and Left Atrial Appendage

The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites.

Left Atrial Appendage Closure: Technical Considerations of Endocardial Closure

Left atrial appendage closure (LAAC) is a safe and effective therapy for the prevention of stroke in patients with nonvalvular atrial fibrillation and high bleeding risk with oral anticoagulants. Multimodality imaging with transesophageal echocardiography and computed tomography angiography to define the anatomy and its implications on endocardial exclusion is becoming increasingly important. The only LAAC device currently approved for clinical use in the United States is the WATCHMAN device. Systematic assessment of the transseptal crossing site, left atrial appendage anatomy, adequate device size selection, and device postdeployment evaluation is essential for the safety and efficacy of the procedure.

Differentially expressed genes for atrial fibrillation identified by RNA sequencing from paired human left and right atrial appendages

Atrial fibrillation is a significant worldwide contributor to cardiovascular morbidity and mortality. Few studies have investigated the differences in gene expression between the left and right atrial appendages, leaving their characterization largely unexplored. In this study, differential gene expression was investigated in atrial fibrillation and sinus rhythm using left and right atrial appendages from the same patients. RNA sequencing was performed on the left and right atrial appendages from five sinus rhythm (SR) control patients and five permanent AF case patients. Differential gene expression in both the left and right atrial appendages was analyzed using the Bioconductor package edgeR. A selection of differentially expressed genes, with relevance to atrial fibrillation, were further validated using quantitative RT-PCR. The distribution of the samples assessed through principal component analysis showed distinct grouping between left and right atrial appendages and between SR controls and AF cases. Overall 157 differentially expressed genes were identified to be downregulated and 90 genes upregulated in AF. Pathway enrichment analysis indicated a greater involvement of left atrial genes in the Wnt signaling pathway whereas right atrial genes were involved in clathrin-coated vesicle and collagen formation. The differing expression of genes in both left and right atrial appendages indicate that there are different mechanisms for development, support and remodeling of AF within the left and right atria.

Thromboembolism in the Absence of Atrial Fibrillation

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.

Procedure planning and device positioning for left atrial appendage occlusion: insights from multi detector-row computed tomography with 3D fusion

To compare planned and achieved device position in patients undergoing left atrial appendage occlusion (LAAO). It is unclear how devices used for LAAO position themselves compared to what is planned. All patients undergoing LAAO at our institution had pre- and post-procedural multi detector-row computed tomography (MDCT) at 3 months (N = 52). Using dedicated software, both datasets were fused to superimpose the left atria in all planes. The effective device position was traced on the post-procedural MDCT and then imported in the pre-procedural dataset to allow comparisons. Planned and effective landing zones were compared with respect to size, location and orientation. The device's final position was in a significantly larger landing zone than planned (452 ± 174 vs. 351 ± 112 mm² for effective and planned landing zones, respectively, paired t-test: p < 0.0001), resulting in significantly less-than-intended area oversizing (41 ± 31 vs. 12 ± 28%, p < 0.0001). In terms of device orientation, there was a difference of 19.7° between the planned and effective landing zones (p < 0.0001). The Amplatzer device had a shallower-than-planned position in 70% of cases, whereas the Watchman device had a deeper-than-planned position in 75% of cases (p = 0.04). Incomplete occlusion was found in 17 patients (33%). In a multivariable model, oversizing at the effective landing zone was the only MDCT independent predictor of incomplete occlusion (OR: 0.96 per 1% increment, 95% CI 0.95-0.98, p = 0.009). MDCT fusion showed that LAAO device position and orientation are different than planned, and this is associated with incomplete occlusion of the LAA.

Relation of Left Atrial Appendage Morphology Determined by Computed Tomography to Prior Stroke or to Increased Risk of Stroke in Patients With Atrial Fibrillation

Left atrial appendage (LAA) morphology is considered to be associated with ischemic stroke, non-Chicken Wing LAA morphology increases the risk of thromboembolic events. However, existing classification of LAA morphology remains not well quantifiable and therefore may leave room for substantial subjective interpretation. This study aimed to assess interobserver and intraobserver agreements in LAA morphology and its real value in stroke prediction. A total of 2,264 atrial fibrillation patients who underwent computed tomography to explore the LAA anatomy were enrolled. All computed tomography images were given to 3 reviewers to judge the LAA morphology independently. A consensus between all 3 reviewers was only reached in 655 cases (28.9%). In which, 86 patients had previous stroke. Poor intraobserver consistency was observed between 2 times of reading in all the 3 reviewers (Kappa = 0.368, p = 0.014; Kappa = 0.350, p = 0.014; Kappa = 0.333, p = 0.015). Multivariate analysis showed that persistent atrial fibrillation (odds ratio [OR] 1.679; 95% confidence interval [CI] 1.031 to 2.736; p = 0.037), female gender (OR 1.761; 95% CI 1.037 to 2.994; p = 0.036) and age (OR 1.029; 95% CI 1.004 to 1.056; p = 0.025) were associated with previous stroke. LAA morphology was not associated with previous stroke and non-Chicken Wing LAA morphology did not increase the risk of stroke (OR 1.392; 95% CI 0.847 to 2.288; p = 0.192). In conclusion, high interobserver and intraobserver variabilities suggested that existing classification of LAA morphology was unreliable, the interpretation of the relation between LAA morphology and stroke needs caution.

Image-Based Flow Simulations of Pre- and Post-left Atrial Appendage Closure in the Left Atrium

PURPOSE

For patients with atrial fibrillation, the left atrial appendage (LAA) is often the site of thrombus formation due to low atrial ejection fraction that triggers strokes and other thromboembolic events. Recently introduced percutaneous LAA occlusion procedure is known to reduce LAA-induced strokes. Despite having the procedure, there are still 11% of the patients who continue to suffer from future strokes or transient ischemic attacks, not accounting for the procedural related complications. The high failure rate is largely due to the variabilities in LAA's shape, size, and contractility which may result in ineffectiveness of this procedure. To correctly identify the candidates and evaluate the effectiveness of the procedure, we rely on patient-specific CT scans which provides the exact LA and LAA geometries and predictive hemodynamic analysis to assist in evaluating quantitative flow parameters pre- and post-LAA occlusion procedures. Hemodynamic parameters are critical to predict adverse hemodynamic flow patterns in LAA as well as the effectiveness of LAA closure in individual patient. The aim of this paper is to establish an image-based patient-specific computational fluid dynamic (CFD) simulation framework specific to the prediction of treatment outcomes of LAA closure with atrial fibrillation. This framework utilizes automated LA/LAA image segmentation which yields significant reduction in image processing. One set of patient data with successful procedure outcome is used to illustrate the potential of the proposed framework.

METHODS

The proposed LAA occlusion simulation framework is composed of several components: (1) a novel image segmentation procedure, which is fully-automated to identify LA/LAA geometries from CT images, (2) a finite-element mesh generation procedure which transforms the surface geometry into a 3-D volume mesh and properly identified boundary planes, (3) performing CFD simulations with atrial fibrillation flow boundary conditions, and (4) analyzing flow characteristics (velocity, flow patterns, streamlines, vortices) within the LA for before and after LAA closure.

RESULTS

Based on the LA/LAA segmentation of a 65 year old female patient with chronic atrial fibrillation, a CFD analysis was pursued to examine flow characteristics upon LAA closure. The results showed that the flow velocity magnitudes were significantly reduced by a maximum factor of 2.21, flow streamlines were greatly stabilized, and mitral outflow appeared to be more organized. Vortices were dramatically reduced in size, number, intensity, as well as duration. During diastole, the peak vortex diameter was reduced from 2.8 to 1.5 cm, while the vortex duration was reduced from 0.210 to 0.135 s. These flow characteristics all indicated a reduced risk in future thrombus formation and strokes based on the established relationship between flow and thrombus formation. For the patient case under study, the effectiveness of the procedure is predicted and found to be consistent with the actual procedural outcome.

CONCLUSIONS

This framework successfully predicted patient-specific outcome of a LAA closure procedure for one patient with atrial fibrillation. It can be further developed into a useful tool for pre-procedural planning and candidate selection. More patient data are necessary for further validation studies.

[Evaluation of the volume and function of left atrial appendage and left atrium in patients with atrial fibrillation by three-dimensional transesophageal echocardiography and transthoracic echocardiography]

To evaluate the volume and function of left atrium and left atrial appendage in patients with atrial fibrillation by three-dimensional transesophageal echocardiography and transthoracic echocardiography.
 Methods: A total of 112 patients with atrial fibrillation were divided into two groups: a paroxysmal atrial fibrillation (ParAF) group (n=80) and a persistent atrial fibrillation (PerAF) group (n=32). Control group was people without atrial fibrillation (n=40). Clinical data of the participants were collected. Left atrial dimension (LAD), left atrial volume (LAV), left ventricular end-diastolic volume (LVEDV) and left ventricular end-systolic volume (LVESV) were measured by transthoracic echocardiography, while left atrial appendage peak emptying flow velocity (LAAeV), left atrial appendage peak filling flow velocity (LAAfV), left atrial appendage maximum volume (LAAVmax) and left atrial appendage minimum volume (LAAVmin) were measured by three-dimensional transesophageal echocardiography. Left atrial volume index (LAVI), left ventricular ejection fraction (LVEF) and left atrial appendage ejection fraction (LAAEF) were calculated. 
 Results: Compared with the control group, LAAEF, LAAeV and LAAfV in the ParAF group were decreased obviously, while LAD, LAV, LAVI, LAAVmax and LAAVmin in the ParAF group were increased obviously (P<0.05). Compared with the ParAF group, LAAEF, LAAeV and LAAfV in the PerAF group were also decreased obviously, and LAD, LAV, LAVI, LAAVmax and LAAVmin in the ParAF group were also increased obviously (P<0.05). There was no statistically significant difference in LVEDV, LVESV, LVEF between the ParAF group and the PerAF group (P<0.05).
 Conclusion: Left atrium and left atrial appendage were enlarged and the function of left atrial appendage was declined in patients with AF, and the changes were more obvious in patients with PerAF compared with patients with ParAF by three-dimensional transesophageal echocardiography and transthoracic echocardiography.

Left atrial appendage occlusion using LAmbre Amulet and Watchman in atrial fibrillation

BACKGROUND

Left atrial appendage closure (LAAC) has been suggested as an alternative to anticoagulation in non-valvular atrial fibrillation (AF). The present study aimed to compare a LAmbre LAA occluder system [Lifetech Scientific (Shenzhen) Co. Ltd., Shenzhen, China] with the most investigated Amulet (St. Jude Medical Inc., St. Paul, MN, USA) and Watchman (Boston Scientific, Plymouth, MN, USA) devices in terms of peri-procedural and short-term outcomes.

METHODS

This is a prospective observational study.

RESULTS

Overall, 140 patients (50 female, mean age 76.2±8.4 years) were consecutively enrolled. Mean CHA2DS2-VASc score was 3.8±1.5, and mean HAS-BLED score was 3.9±1.1. Baseline clinical characteristics were comparable between the three groups (LAmbre, n=30; Amulet, n=74; Watchman, n=36); the LAmbre group had significantly more patients with complicated LAA morphology (p=0.006). The implant success rate was 100% in LAmbre, 99% in Amulet, and 100% in Watchman group (p=0.638). The number of device repositions was not significantly different between groups (0.7±1.1 in LAmbre, 1.0±2.0 in Amulet, and 1.4±1.8 in Watchman group, p=0.345). Fluoroscopic and procedural times were similar between groups. Major peri-procedural adverse events did not differ between groups (0% vs. 0% vs. 2.8%, p=0.233). Six months' follow-up showed good device stability and patients' clinical condition in all groups.

CONCLUSION

LAmbre, Amulet, and Watchman exhibit remarkable implant success rate, low risk of peri-procedural adverse events, and good clinical outcomes.

Mitochondrial and Contractile Function of Human Right Atrial Tissue in Response to Remote Ischemic Conditioning

Background Remote ischemic preconditioning ( RIPC ) by repeated brief cycles of limb ischemia/reperfusion attenuates myocardial ischemia/reperfusion injury. We aimed to identify a functional parameter reflecting the RIPC -induced protection in human. Therefore, we measured mitochondrial function in right atrial tissue and contractile function of isolated right atrial trabeculae before and during hypoxia/reoxygenation from patients undergoing coronary artery bypass grafting with RIPC or placebo, respectively. Methods and Results One hundred thirty-seven patients under isoflurane anesthesia underwent RIPC (3×5 minutes blood pressure cuff inflation on the left upper arm/5 minutes deflation, n=67) or placebo (cuff uninflated, n=70), and right atrial appendages were harvested before ischemic cardioplegic arrest. Myocardial protection by RIPC was assessed from serum troponin I/T concentrations over 72 hours after surgery. Atrial tissue was obtained for isolation of mitochondria ( RIPC /placebo: n=10/10). Trabeculae were dissected for contractile function measurements at baseline and after hypoxia/reoxygenation (60 min/30 min) and for western blot analysis after hypoxia/reoxygenation ( RIPC /placebo, n=57/60). Associated with cardioprotection by RIPC (26% decrease in the area under the curve of troponin I/T), mitochondrial adenosine diphosphate-stimulated complex I respiration (+10%), adenosine triphosphate production (+46%), and calcium retention capacity (+37%) were greater, whereas reactive oxygen species production (-24%) was less with RIPC than placebo. Contractile function was improved by RIPC (baseline, +7%; reoxygenation, +24%). Expression and phosphorylation of proteins, which have previously been associated with cardioprotection, were not different between RIPC and placebo. Conclusions Cardioprotection by RIPC goes along with improved mitochondrial and contractile function of human right atrial tissue. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT 01406678.

Relation of Left Atrial Appendage Remodeling by Magnetic Resonance Imaging and Outcome of Ablation for Atrial Fibrillation

The left atrial appendage (LAA) is a nonpulmonary vein trigger site in atrial fibrillation (AF). The association of LAA structural remodeling (SRM) identified by late gadolinium enhancement magnetic resonance imaging (LGE-MRI) and AF ablation outcome has never been described. This study sought to investigate the clinical significance of LAA-SRM in AF patients who undergo ablation therapy. Consecutive patients with AF who underwent catheter ablation therapy within 14 days following MRI scan were included in this study. LAA-SRM was assessed using LGE-MRI images to quantify the extent of LAA-LGE. Patients were followed for arrhythmia recurrence after the ablation procedure. A total of 74 patients were included in the study, 68% were male, with a mean age of 72 years. Mean LAA-LGE extent was 9%. There were 37 arrhythmia recurrences (50%) observed over a mean follow-up period of 18 months. The recurrence rate was significantly higher (73.3% vs 37.5%; p = 0.045) in patients with LAA-LGE extent in the highest tier (T4) compared with the lowest tier (T1). LAA-LGE extent was independently associated with arrhythmia recurrence (adjusted hazard ratio [HR] 1.054; 95% confidence interval [CI] 1.008 to 1.103). In addition, there was an approximately fourfold increased risk of arrhythmia recurrence (adjusted HR 4.117, 95% CI 1.260 to 13.459) in patients with advanced LAA-SRM (T4 vs T1). In conclusion, the extent of LAA-SRM identified by LGE-MRI is associated with arrhythmia recurrence after AF ablation.

Role of cardiac imaging and three-dimensional printing in percutaneous appendage closure

Atrial fibrillation is the most frequent cardiac arrhythmia, affecting up to 13% of people aged>80 years, and is responsible for 15-20% of all ischaemic strokes. Left atrial appendage occlusion devices have been developed as an alternative approach to reduce the risk of stroke in patients for whom oral anticoagulation is contraindicated. The procedure can be technically demanding, and obtaining a complete left atrial appendage occlusion can be challenging. These observations have emphasized the importance of preprocedural planning, to optimize the accuracy and safety of the procedure. In this setting, a multimodality imaging approach, including three-dimensional imaging, is often used for preoperative assessment and procedural guidance. These imaging modalities, including transoesophageal echocardiography and multislice computed tomography, allow acquisition of a three-dimensional dataset that improves understanding of the cardiac anatomy; dedicated postprocessing software integrated into the clinical workflow can be used to generate a stereolithography file, which can be printed in a rubber-like material, seeking to replicate the myocardial tissue characteristics and mechanical properties of the left atrial appendage wall. The role of multimodality imaging and 3D printing technology offers a new field for implantation simulation, which may have a major impact on physician training and technique optimization.

Circulating Galectin-3 is Associated With Left Atrial Appendage Remodelling and Thrombus Formation in Patients With Atrial Fibrillation

BACKGROUND

Left atrial appendage (LAA) is gaining increasing attention in patients with atrial fibrillation (AF) in the context of cardioembolic stroke. Galectin-3 (Gal-3) is a mediator of profibrotic pathways and is associated with an increased incidence of heart failure. However, the role of Gal-3 in LAA remodelling and thrombus formation in AF has not been evaluated.

METHODS

This prospective study included 153 consecutive patients with paroxysmal (n=58), persistent (n=55) or permanent (n=40) nonvalvular AF. The serum level of Gal-3 was measured by enzyme-linked immunosorbent assay. The morphology and function of LAA were determined by transoesophageal echocardiography.

RESULTS

Left atrial appendage thrombus was observed in 22 patients (2 in paroxysmal AF, 11 in persistent AF and 9 in permanent AF). Significant differences among patients with different types of AF were found in terms of LAA morphology (orifice diameter and depth) and function (flow velocity and tissue Doppler contracting velocity) as well as serum levels of Gal-3. Furthermore, patients with persistent or permanent AF had higher levels of Gal-3. High Gal-3 level was closely related to LAA flow velocity and occurrence of LAA thrombus. Multivariate logistic regression analysis revealed that Gal-3 was an independent determinant of LAA thrombus in patients with AF. Receiver operating characteristic (ROC) curves related to LAA thrombus formation established a cut-off point for Gal-3 >18.95ng/ml.

CONCLUSIONS

Cardiac rhythm disturbances caused by AF may lead to morphologic and functional remodelling of LAA. The serum level of Gal-3 was significantly correlated with LAA remodelling in patients with AF. High levels of Gal-3 were also a predicator for LAA thrombus formation.

Catheter-based left atrial appendage closure

BAKGRUNN

Atrieflimmer er en vanlig tilstand i befolkningen og gir økt risiko for hjerneslag. Antikoagulasjonsbehandling er effektivt for å forebygge tromboembolisme ved atrieflimmer, men av ulike grunner blir mange atrieflimmerpasienter med indikasjon for antikoagulasjonsbehandling ikke behandlet. Kateterbasert lukking av venstre atriums aurikkel er en ny metode for å forebygge hjerneslag ved atrieflimmer.

MATERIALE OG METODE

I perioden september 2014-april 2016 gjennomgikk 27 pasienter med atrieflimmer og høy risiko for hjerneslag forsøk på kateterbasert lukking av venstre atriums aurikkel ved Oslo universitetssykehus. Antikoagulasjonsbehandling var vurdert som kontraindisert hos 26 av pasientene. Vi presenterer resultater fra prosedyre, ekkokardiografikontroller og kliniske hendelser i oppfølgingsperioden på ett år.

RESULTATER

Aurikkelplugg ble vellykket implantert hos 26 pasienter. To pasienter fikk komplikasjoner i forbindelse med prosedyren: En fikk hjerneslag og en fikk transfusjonskrevende lyskeblødning. En pasient fikk hjertetamponade fem måneder etter prosedyren. En pasient som grunnet anatomisk vanskelige forhold ikke fikk implantert aurikkelplugg, døde av hjerneslag i oppfølgingsperioden. Tre pasienter hadde klinisk transitorisk iskemisk anfall (TIA). Det var ingen forekomst av intrakranial eller gastrointestinal blødning.

FORTOLKNING

Kateterbasert lukking av venstre atriums aurikkel er gjennomførbart, men innebærer risiko for komplikasjoner og bør forbeholdes pasienter med høy risiko for hjerneslag og kontraindikasjon mot antikoagulasjonsbehandling.

Atrial thrombogenesis in atrial fibrillation : Results from atrial fibrillation models and AF-patients

Atrial fibrillation (AF) is the most common cause of thromboembolic complications. The risk of suffering a thromboembolic complication depends on the accompanying cardiac risk factors and the patient's age. For patients who have an increased risk, which is now classified using the CHA2DS2-VASc score, initiation of long-term oral anticoagulation is the first-line treatment. In AF, thrombi arise in the left atrial appendage. The present review will summarize the basic pathophysiology of thrombogenesis in AF and will provide the molecular basis of a process called prothrombotic endocardial remodeling. Despite oral anticoagulation being a central component of therapy, the present results can be used to support concomitant therapy with statins, angiotensin II blockers, etc. to inhibit atrial thromogenesis.

In Paroxysmal Atrial Fibrillation Patients, the Neutrophil-to-lymphocyte Ratio Is Related to Thrombogenesis and More Closely Associated with Left Atrial Appendage Contraction than with the Left Atrial Body Function

Objective The neutrophil-to-lymphocyte ratio (NLR) is an inflammation marker that can be used to detect atrial inflammatory changes, which may contribute to a reduced left atrial (LA) function and thrombosis. Our study aimed to determine whether or not the association of NLR with the LA appendage (LAA) function in relation to thrombogenesis differs from the association with the LA body function in paroxysmal atrial fibrillation (PAF) patients. Methods A total of 183 PAF patients were studied. The LA volume index, mitral flow velocity (A), and mitral annular motion velocity (A') were examined using transthoracic echocardiography. The LAA area, LAA wall motion velocity, and presence of spontaneous echo contrast (SEC) were examined using transesophageal echocardiography. Results The NLR of patients with cerebral embolism was significantly greater than in patients without the disorder. A cut-off point of 2.5 for the NLR had a sensitivity of 71% and a specificity of 74% in predicting cerebral embolism. The patients with an NLR ≥2.5 had a higher CHADS2 score and greater LA volume index or LAA area than those with an NLR <2.5. The NLR was an independent risk factor for SEC and was significantly correlated with the LAA wall motion velocity (r=-0.409) in 153 patients without SEC and with the LAA wall motion velocity and LAA area (r=-0.583, r=0.654, respectively) in 30 patients with SEC, but not with the LA volume index, A, or A' in either group. Conclusion In PAF patients, a high NLR indicates thrombogenesis with a high degree of certainty and is associated with reduced LAA contraction rather than with the LA body function.

[Quantitative Measurements on the Blood Flow Fields of Left Atrial Appendage using Vector Flow Mapping in Patients with Nonvalvular Atrial Fibrillation]

OBJECTIVE

To quantify the hemodynamic characteristics of patients with nonvalvular atrial fibrillation.

METHODS

Twenty patients with paroxysmal atrial fibrillation and 15 patients with persistent atrial fibrillation enrolled in this study,while 12 patients with sinus rhythms served as controls. The hemodynamic characteristics of the patients in left atrial appendage were measured by transesophageal echocardiography (TEE) and vector flow mapping (VFM) using indicators such as vectors,vortex and energy loss (EL).

RESULTS

① Significant differences appeared between the patients with atrial fibrillation and the controls in heart rate,size of left atrium,size of left atrial appendage (LAA),and velocities of LAA filling and emptying. ② Regular vectors in LAA in early systole and late diastole were found in the patients with paroxysmal atrial fibrillation and the controls; whereas,irregular vectors with direction alternating were visualized in the whole cardiac cycle in the patients with persistent atrial fibrillation. ③ Small vortexes were observed at the opening of the left atrial appendage in late diastole in the patients with paroxysmal atrial fibrillation and the controls. ④ Peak EL values occurred in early systole and late diastole in the patients with paroxysmal atrial fibrillation and the controls. But the patients with persistent atrial fibrillation had increased EL values over the whole cardiac cycle.

CONCLUSION

VFM can visualize and quantify the hemodynamics of LAA in patients with different heart rhythms. It may provide a new method for assessing atrial fibrillation.

Relationship Between Pulmonary Venous Flow and Prosthetic Mitral Valve Thrombosis

BACKGROUND

Prosthetic valve thrombosis (PVT) may impair pulmonary venous flow (PVF) and left atrial appendage (LAA) functions. An investigation was conducted to determine the association between left superior PVF and LAA functions and mitral PVT.

METHODS

This observational case-control study included 100 consecutive patients (87 females, 13 males; mean age 59 years; range 35-71 years) with mechanical mitral PVT, and 50 age- and gender-matched otherwise healthy controls with normally functioning mitral prostheses. All patients were included after comprehensive transesophageal echocardiography (TEE) examinations for the presence and quantification of PVT, the left atrial diameter, and LAA length. Peak systolic velocity (PSV), velocity-time integral of systolic flow (VTI-s), peak diastolic velocity (PDV), velocity-time integral of diastolic flow (VTI-d), systolic fraction (SFr) of the left upper PVF and the flow of the LAA orifice were each recorded using color-guided pulsed-wave Doppler imaging during TEE.

RESULTS

The PSV [30 cm/s (range: 13-77 cm/s) versus 44 cm/s (range: 16-71 cm/s)], respectively (p = 0.002), VTI-s [(2.85 cm (range: 0.5-10.7 cm) versus 5 cm (range: 1.3-12.7 cm)], respectively (p <0.001), VTI-d [(3 cm (range: 0.6-9.7 cm) versus 4.2 cm (range: 1.5-8.3 cm)], respectively (p <0.001), SFr (45.5% (range: 15.66-67.44%) versus 50 % (range: 21.11-82.61%)], respectively (p = 0.008), and LAA orifice velocity [(23 cm/s (range: 11-75 cm/s) versus 34 cm/s (range: 10-112 cm/s)], respectively (p = 0.011) were each significantly lower in patients with PVT compared to controls. The PDV was similar between groups. Patients with obstructive PVT (n = 21) had a lower PDV and a higher VTI-d compared to those with non-obstructive PVT.

CONCLUSIONS

Mitral mechanical PVT is associated with decreased systolic PVF and LAA function. The presence of obstructive PVT is associated with further limitations of diastolic flow velocity, and a compensatory prolongation of diastolic flow of the left upper pulmonary vein.

Simultaneous Closure of a Left Atrial Appendage through an Atrial Septal Defect and the Atrial Septal Defect

Left atrial appendage (LAA) occlusion can be employed as an alternative treatment to oral anticoagulation in patients with atrial fibrillation to prevent embolic events. Atrial septal defect (ASD) may be related with right heart dysfunction and allow paradoxical embolism to occur. However, occlusion of both LAA through atrial access with ostium secundum ASD and ASD in the same setting is unusual. Therefore, we report a case in which a LAA and an ASD was sequentially occluded.

Percutaneous closure of the left atrial appendage in patients with diabetes mellitus

BACKGROUND

Left atrial appendage closure is a preventive treatment of atrial fibrillation-related thrombo-embolism. Patients with diabetes mellitus have increased risk for a negative outcome in percutaneous cardiac interventions. We assessed whether percutaneous left atrial appendage closure is safe and effective in patients with diabetes mellitus.

METHODS

We included 78 patients (mean age of 74.4 ± 8.3 years) with indication for left atrial appendage closure in an open-label observational single-centre study.

RESULTS

Patients with diabetes mellitus ( n = 31) were at higher thrombo-embolic and bleeding risk (CHA₂DS₂-VASc: 4.5 ± 0.9, HAS-BLED: 4.7 ± 0.7) compared to patients without diabetes mellitus ( n = 47, CHA₂DS₂-VASc: 3.5 ± 1.0, HAS-BLED: 4.1 ± 0.8; p < 0.001 for both). Pre- and periprocedural risk was elevated in patients with diabetes mellitus (Euro II-Score: 6.6 ± 3.7 vs 3.9 ± 1.9, p < 0.01; Society of Thoracic Surgeons (STS)-Score: 4.0 ± 2.5 vs 2.6 ± 1.2, p < 0.01). Procedural success was similar. Periprocedural major adverse cardiac and cerebrovascular events occurred in one patient from the control group (2.1%), whereas patients with diabetes mellitus had no events ( p = 0.672). Follow-up of 6 months revealed no bleeding complication in both groups. No stroke occurred in follow-up, and left atrial appendage flow velocity reduction (55.6 ± 38.6 vs 51.4 ± 19.1 cm/s, p = 0.474) and rate of postinterventional leakage in the left atrial appendage were comparable (0% vs 2.1%, p = 0.672).

CONCLUSION

Despite patients with diabetes mellitus are high-risk patients, the outcome of percutaneous left atrial appendage closure is similar to patients without diabetes mellitus.

Age-related changes in morphology of left atrial appendage in patients with atrial fibrillation

The purpose of this study was to evaluate the relationship between age and frequency of left atrial appendage (LAA) morphology in patients with atrial fibrillation (AF) compared with sinus rhythm (SR). We enrolled 145 AF patients, and 199 SR patients for the control group without any cardiovascular disease. LAA volume index (LAAVi) and morphology were assessed by electrocardiogram-gated computed tomography angiography. LAA morphology was classified into "chicken wing" or "non-chicken wing" according to the previously described classification. There was no significant trend in frequency of non-chicken wing morphology among ages in the SR group (p = 0.36 for trend), whereas the frequency was negatively related to age in the AF group (p = 0.002 for trend). In multivariable logistic regression, age > 65 (odds ratio [OR] 0.42, p = 0.002) and duration of AF (OR 0.53, p = 0.010) and LAAVi (OR 0.62, p = 0.017) were independent factors of non-chicken wing LAA morphology in the AF group. LAA morphology is affected by age, especially in patients with AF. When we utilize non-chicken wing LAA morphology as a stroke risk factor in patients with AF, we should pay attention to their age.

Comparison of Morphologic Features and Flow Velocity of the Left Atrial Appendage Among Patients With Atrial Fibrillation Alone, Transient Ischemic Attack, and Cardioembolic Stroke

The left atrial appendage (LAA) is a major source of emboli responsible for cardioembolic stroke (CES). We hypothesized that there could be differences in the morphologic and functional features of LAAs among patients with atrial fibrillation (AF) alone, patients with cardioembolic transient ischemic attack (CETIA), and patients with CES. Patients with AF and CETIA/CES were included in either a CETIA group or a CES group. Patients with AF without past histories of stroke were included in an AF/non-CVA (cerebrovascular accident) group. Cardiac computerized tomography and transesophageal echocardiography were employed for morphologic and functional assessments of LAAs. Cauliflower LAA morphology increased and chicken wing LAA morphology decreased in frequency in the following order: AF/non-CVA, CETIA, and CES group. LAA orifice diameters were larger in the CETIA and CES groups than in the AF/non-CVA group. LAA flow velocity was higher in the CES group than in the other groups. Multiple multinominal regression analyses showed that the cauliflower morphology was associated with CETIA and CES; however, after LAA orifice diameters and flow velocity were adjusted, LAA morphology was associated with neither of them. Receiver operating characteristic curve analysis showed that LAA orifice diameter and flow velocity accurately predicted CETIA (c-statistic 0.839) and CES (c-statistic 0.896), respectively. In conclusion, cauliflower LAA morphology is associated with an increased risk of CETIA and CES through its large LAA orifice diameters and low LAA flow velocity. There are clear differences in LAA orifice diameters and flow velocity among patients with AF alone, CES, and CETIA.

Initial Results of Combined MitraClip® Implantation and Left Atrial Appendage Occlusion

BACKGROUND

Atrial fibrillation is present in 30-50% of patients undergoing percutaneous mitral valve repair. The presence of a formal contraindication to oral anticoagulation is also very common in these patients. In this context, percutaneous left atrial appendage occlusion (LAAO) may be a valid alternative for these patients. The study aim was to assess the feasibility, safety, and technical considerations of the combination of percutaneous mitral valve repair using the MitraClip system and LAAO. The present study describes the multicenter experience of combined MitraClip and LAAO procedures.

METHODS

Between April 2012 and April 2016, six patients were successfully treated with the combined procedure.

RESULTS

In all patients, mitral valve repair was performed before LAAO. Both procedures were successfully performed in all cases without any relevant procedural complication or mortality.

CONCLUSIONS

According to the results of the present study, a combination of both techniques appears to be feasible and safe, with favorable in-hospital outcomes.

Incidence and Clinical Impact of Device-Associated Thrombus and Peri-Device Leak Following Left Atrial Appendage Closure With the Amplatzer Cardiac Plug

OBJECTIVES

Routine device surveillance after successful left atrial appendage closure is recommended to evaluate for intermediate to late complications. The aim of this study was to assess the incidence and clinical impact of these complications on cardiovascular events.

METHODS

Centers participating in the Amplatzer Cardiac Plug multicenter study were requested to submit their post-procedural transesophageal echocardiograms for independent adjudication. Thirteen of 22 centers contributed all their post-procedural echocardiograms, which included 344 from 605 consecutive patients. These images were submitted to a core laboratory and reviewed by 2 independent experts for peri-device leak, device-associated thrombus, device embolization, device migration, left atrial appendage thrombus, and left atrial thrombus. Clinical events were prospectively collected by each center.

RESULTS

Of the 344 transesophageal echocardiograms, 339 were deemed analyzable. Patients' mean age was 74.4 ± 7.5 years, and 67.3% were men. The mean CHADS2 score was 2.7 ± 1.3, the mean CHA2DS2-VASc score was 4.3 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.2. Amplatzer Cardiac Plug implantation was successful in all patients. Periprocedural major adverse events occurred in 2.4%. Median clinical follow-up duration was 355 days (range 179 to 622 days). Follow-up transesophageal echocardiography was performed after a median of 134 days (range 88 to 227 days). Device-associated thrombus was observed in 3.2% and peri-device leak in 12.5% (5.5% minimal, 5.8% mild, 0.6% moderate, 0.6% severe). Neither device-associated thrombus nor peri-device leak was associated with an increased risk for cardiovascular events. Independent predictors of device-associated thrombus were smoking (odds ratio: 5.79; p = 0.017) and female sex (odds ratio: 4.22; p = 0.027).

CONCLUSIONS

Following successful left atrial appendage closure with the Amplatzer Cardiac Plug, the presence of peri-device leak was relatively low, and device-associated thrombus was infrequent. Neither was associated with increased risk for thromboembolism.

Left and right atrial feature tracking in acute myocarditis: A feasibility study

PURPOSE

The present study aims at evaluating the feasibility and reproducibility of cardiac magnetic resonance (CMR) feature tracking (FT) derived strain and strain rate (SR) parameters of the left and right atrium (LA, RA) in patients with acute myocarditis as well as their potential to detect diastolic dysfunction. In addition, the diagnostic value of LA and RA strain parameters in the setting of acute myocarditis is investigated.

METHODS

CMR cine data of 30 patients with CMR-positive acute myocarditis were retrospectively analyzed. 25 age- and gender-matched healthy individuals served as a control. Analysis of longitudinal strain and SR of both atria was performed in two long-axis views using a dedicated FT-software. LA and RA deformation was analyzed including reservoir function (total strain [ε_s], peak positive SR [SR_s]), conduit function (passive strain [ε_e], peak early negative SR [SR_e]) and booster pump function (active strain [ε_a], peak late negative SR [SR_a]). Intra- and inter-observer reproducibility was assessed for all strain and SR parameters using Bland-Altman analyses, intra-class correlation coefficients (ICCs) and coefficients of variation (CV).

RESULTS

FT analyses of both atria were feasible in all patients and controls. Reproducibility was good for reservoir and conduit function parameters and moderate for booster pump function parameters. Myocarditis patients demonstrated an impaired LA reservoir and conduit function when compared to healthy controls (LA ε_s: 32±17 vs. 46±13, p=0.019; LA SR_s: 1.5±0.5 vs. 1.8±0.5, p=0.117; LA SR_e: -1.3±0.5 vs. -1.9±0.5, p<0.001), while LA booster pump function was preserved. In logistic regression and ROC-analyses, LA SR_e proved to be the best independent predictor of acute myocarditis (AUC 0.80), and using LA SR_e with a cut-off of -1.6s^-1 resulted in a diagnostic sensitivity of 83% and a specificity of 80%. Changes in RA phasic function parameters showed a tendency to parallel those of the LA and showed no additional effect with respect to the diagnostic potential in acute myocarditis.

CONCLUSIONS

Myocarditis patients exhibit an impaired atrial reservoir and conduit function, what might be indicative of ventricular diastolic dysfunction. LA SR_e was the best predictor for the presence of acute myocarditis in our study, pointing towards the discriminative power of atrial strain analysis in the CMR-based diagnosis of acute myocarditis.

Cardiac CT Angiography (CCTA) predicts left atrial appendage occluder device size and procedure outcome

AIM

To investigate the role of cardiac CT angiography (CCTA) in predicting optimal left atrial appendage (LAA) occluder size and procedure outcome.

METHODS AND RESULTS

Thirty-six patients underwent pre-procedural CCTA. CCTA and TEE LAA orifice diameters and perimeters were compared with the implanted device size. CCTA 3D configuration was correlated with procedure outcome. Watchman™ device (N = 18): diameters were 21 ± 4, 26 ± 5 and 25 ± 3 mm for TEE, CCTA and inserted device, respectively. Average perimeters were 61 ± 10, 74 ± 8 and 78 ± 11 mm for TEE, CCTA and inserted device, respectively. Better agreement with the device size was found for CCTA compared to TEE (Bland-Altman). ACP™ device (N = 15): diameters were 20 ± 5, 25 ± 4 and 23 ± 4 for TEE, CCTA and inserted device, respectively. Average perimeters were 58 ± 11, 72 ± 15 and 72 ± 13 mm for TEE, CCTA and inserted device, respectively. Excellent correlation and agreement with the device size was found for CCTA compared to TEE. CCTA perimeter >100 mm and "cactus" 3D configuration had a specificity of 96 and 81% respectively for procedure failure.

CONCLUSIONS

CCTA LAA ostial perimeter predicted better the optimal occluder size as compared with the currently used LAA TEE diameter. Moreover, CCTA 3D data may help in predicting potential complications.