Essential Imaging Tools for LAA Closure Steven A. Goldstein MD FACC, FASE MedStar Heart Institute Washington Hospital Center Saturday, February 18, 2017

financial relationships DISCLOSURE I have N O relevant financial relationships

LAA Anatomy

LA-Appendage Anatomy Highly variable structure (size and shape) Long, hook-like true diverticulum of LA Lies within the pericardium Orifice is usually elliptical (not round) Lies in more than 1 imaging plane Often multi-lobed

Left Atrial Appendage Dimensions (Silicone casts from 11 specimens) Mean Range SD Length Os long diameter Os short diameter 44.9 mm 17.4 mm 10.9 mm 27-60 mm 10-24 mm 5-20 mm 9.6 mm 4 mm 4.2 mm Su (Royal Brompton, London – National Heart and Lung Institute) Heart 2008;94:1166-1170

Width = 2.9 cm Depth = 5.6 cm

LAA Orifice Classification Oval Foot-like Triangular Tear drop Round 68.9% 10% 7.7% 5.6%

Left Atrial Appendage Lobes Autopsy study (n=500) 2 lobes 3 lobes 1 lobe 4 lobes 54% 23% 20% 3% Veinot Circulation 1997;96:3112-3115

LA-Appendage Closure Role of TEE Identify all the lobes of the LAA Measure the size of the LAA ostium Look for thrombus/ dense “smoke” Look for atrial septal anatomy: ASD, PFO Identify other potential cardiac sources Provide guidance for transseptal puncture of embolism (eg atrial septal aneurysm, aortic debris)

Septation tissue between lobes can mimic a thrombus

Multi-Lobed LA-Appendage

Multilobed Atrial Appendage

LAA Anatomy/Assessment LAA size, shape Number of lobes Measure ostium at 0º, 45º, 90º, 135º Measure depth (length) of LAA From LCx to a point 2 cm from limbus tip From top of MV annulus “ “ “ “ “

LAA Anatomy/Assessment Maximum LAA ostium and LAA depth Max LAA ostium size should be ≥17 mm LAA length should be equal to or greater measurements determine size selection ≤ 31 mm to accommodate device sizes than the ostium

LAA Anatomy/Assessment Device Sizing Maximum LAA Ostium (mm) Device Size (mm) 17 – 19 20 – 22 23 – 25 26 – 28 29 – 31 21 24 27 30 33

4 Main Morphologies of LAA Cactus Windsock Cauliflower Chicken Wing more likely embolic event Di Biase J Am Coll Cardiol 2012; 60:531-538

Windsock Chicken wing Cauliflower Limited length More complex internal characteristics One dominant lobe Sufficient length Sharp bend in dominant lobe

Prevalence of Prior Stroke/TIA According to LAA Morphology Stroke rate (%) Di Biase J Am Coll Cardiol 2012; 60:531-538

Case 21 year-old woman

Chicken Wing

Case

Case

Case

ER - 88 year-old man Chronic atrial fibrillation Cardioversion  reverted to atrial fibrillation Coumadin problematic  “easy bruising” Referred to Watchman Trial Pre-procedure TEE . . . .

“Hammerhead” shape of LA-appendage

Case Tuesday, Feb. 14, 2017

Very basal “cul-de-sac” (extra lobe) Case 54 Very basal “cul-de-sac” (extra lobe)

Very basal “cul-de-sac” (extra lobe) Case 54 Very basal “cul-de-sac” (extra lobe)

Case 54

Look for Thrombi

Case Thrombus in LAA

Measurements 0º 45º 90º 135º

Landing Zone

Transseptal Puncture

Site Specific Transseptal Puncture for Various Interventions Transseptal PFO closure (higher crossing site for medial leaks; lower site for lateral leaks) Paravalve leak closure LVAD placement Hemodynamic studies LA-appendage closure Pulmonary vein interventions Alkhouli J Am Coll Cardiol 2016;9(24):2465-80

Transseptal Crossing Preferred crossing location is posterior Bicaval and short-axis views useful X-plane useful and inferior Inferior on short-axis view Posterior on bicaval view

The value of X-plane (biplane  2 orthogonal views) Guidance of Transseptal Puncture The value of X-plane (biplane  2 orthogonal views)

Case

Transseptal Puncture for Watchman Too anterior Slightly more posterior

Case BH - 76 year-old woman Watchman LAA closure Case 16

BH - 76 year-old woman Longstanding, chronic atrial fibrillation Multiple cardioversions  failed Referred for Protect – Watchman Trial

Successful placement of 21 mm LA-appendage occluder device with TEE guidance

Width = 1.2 cm Length = 2.4 cm

0° 45° 90° 135° Prior to final deployment, check position in 4 views: 0° 45° 90° 135°

LAA-occluder adjacent to L-pulmonary vein

Device Release Criteria P.A.S.S. Position – device is at ostium of LAA Anchor – fixation anchors engaged Size – device compressed 8-20% Seal - device spans ostium - device is stable (tug test) - all lobes of LAA covered - absence of peri-leak

Device should be at or just distal to the LA-appendage ostium Device Release Criteria Device should be at or just distal to the LA-appendage ostium

Peri-Leak

Iatrogenic ASD

LAA Occlusion Anticoagulation Post-Procedure Warfarin and aspirin x 45 days TEE at 45 days If no or minimal (≤ 5 mm) peridevice flow stop warfarin, start clopidogrel (75 mg), continue aspirin until 6 mos post procedure

Case

PR - 71 year-old man Watchman procedure performed Successful insertion Refused anticoagulation, despite protocol

The End