Clin Res Cardiol 107, Suppl 1, April 2018

Additional value of preprocedural measurements by 3D transesophageal echocardiography for percutaneous left atrial appendage occlusion

E. Altiok1, M.-M. Becker1, W. Moersen1, K. Mischke2, J. Schröder1, N. Marx1, S. Reith1

1Med. Klinik I - Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen, Aachen; 2Med. Klinik I, Leopoldina-Krankenhaus Schweinfurt, Schweinfurt;

Background. Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative to oral anticoagulation in selected patients with atrial fibrillation. Aim. This study sought to evaluate the additional value of preprocedural measurements by 3D transesophageal echocardiography (TEE) for percutaneous left atrial appendage occlusion. Methods. In 47 consecutive patients (age 76±8 years, 29 male) LAA occlusion was performed by the Amplatzer Cardiac Plug (St. Jude Medical, Minneapolis, MN, USA) device. Conventional cardiac angiography (CCA) as well as 2D TEE and 3D TEE were performed for preprocedural measurements of LAA dimensions before transcatheter occlusion (table 1) and additional assessment of device morphology after implantation by CCA. Furthermore, preprocedural eccentricity of the device landing zone of LAA as expressed by the ratio of maximal and minimal diameter (Ratio max-min) was assessed by 3D TEE. At 6 months follow-up 2D TEE was repeated to evaluate procedural success. Results. Transcatheter LAA occlusion was successfully performed in all patients with selection of device size after adequate measurement of maximal diameter by CCA as recommended. Postprocedural peri-device leaks were identified in 11 patients (23%) by 2D TEE at follow-up. Device morphology  after implantation was classified by CCA into the following three types: ‘square’ as a sign of low deformation of the lobe indicating an undersizing in 9 patients (19%), ‘tire’ as the optimal deformation of the lobe in 28 patients (60%), and ‘strawberry’ as a sign of excessive deformation of the lobe indicating an oversizing in 10 patients (21%). ‘Tire’ type was associated with lower occurrence of peri-device leaks (11%) compared to ‘square’ type (56%) and ‘strawberry’ type (30%; p=0.0188). Preprocedural more eccentric LAA morphology (Ratio max-min=1.45; AUC=0.689, p=0.0158) was a predictor for postprocedural ‘strawberry’ type device deformation, indicating an oversizing due to inadequate device selection by CCA measurements in these patients, while patients with ‘square’ or ‘tire’ types had a more circular shape of the device landing zone (Ratio max-min=1.35). Conclusions. Undersizing as well as oversizing of the LAA occluder device, as defined by deformation type by CCA, was associated with postprocedural peri-device leaks. Assessment of eccentricity of the LAA landing zone by 3D TEE may indicate inadequate device selection leading to oversizing in patients with more eccentric LAA morphology when CCA measurements of maximal diameter are used as the reference method. Table 1:  Measurements of device landing zone  CCA   2D TEE  3D TEE  Diameter RAO 40° Cranial 20° (mm)  21.0±3.6  -  -  Diameter RAO 40° Caudal 20° (mm)  21.4±4.2  -  -  Diameter 45° (mm)  -  17.0±3.4  -  Diameter 90° (mm)  -  17.4±3.7  -  Diameter 135° (mm)  -  18.8±3.8  -  Maximal diameter (mm)  22.2±3.9  19.7±3.7   22.2±4.1  Area by 3D assessment (cm²)  -  -  2.9±1.1  Area derived mean diameter by 3D assessment (mm)  -  -  19.0±3.6  Ratio of maximal and minimal diameter by 3D assessment  -  -  1.4±0.3 CCA = conventional cardiac angiography, RAO = right anterior oblique, TEE = transesophageal echocardiography

http://www.abstractserver.de/dgk2018/jt/abstracts//V1142.htm