A Primer of LAA Closure: and Pattern Recognition

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Presentation transcript:

A Primer of LAA Closure: and Pattern Recognition Essential Views and Pattern Recognition Steven A. Goldstein, MD Director, Noninvasive Cardiology Washington Hospital Center Tuesday, February 26, 2013

I/we have no real or apparent conflicts of interest to report. Steven A. Goldstein, MD I/we have no real or apparent conflicts of interest to report.

LAA Anatomy

* * LA-Appendage Anatomy * * A “blind pouch” Characteristic triangular structure (“dog’s ear”) Highly variable structure 50% have multiple lobes Pectinate muscles * * * Caution to differentiate septation tissue b/w lobes from thrombus * Caution to differentiate prominent pectinate muscles from thrombus

LA-Appendage Anatomy Highly variable structure (size and shape) Long, hook-like true diverticulum of LA Lies within the pericardium Orifice is 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

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

Role of TEE in LAA Closure Identify all the lobes of LAA Measure the size of the LAA ostium Look for thrombus / dense spontaneous echo Atrial anatomy – ASD, PFO with R-L shunt Guidance for transeptal puncture contrast  closure may be contraindicated

Septation tissue between lobes can mimic a thrombus

Multi-Lobed LA-Appendage

Multilobed Atrial Appendage

Case 1

NW - 80 year-old man Severe symptomatic aortic stenosis TEE performed during the procedure

Case 2 Case 16

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 3 NR - 35 year-old woman Bilobed LAA

Case 4 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

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

Occluded LAA-occluder adjacent to L-pulmonary vein

Case 5 Case 16

Atrial Fibrillation Predisposing Factors to LA Thrombi Washington Hospital Center Nov, 2008  Jul, 2009 (8 months) 139 consecutive patients for TEE prior to Atrial fibrillation All underwent TEE prior to CV or ablation cardioversion (n=119) or ablation (n=20) New onset > 48 hrs (n=50) Chronic AC, but subtherapeutic (n=89)

Atrial Fibrillation Predisposing Factors to LA Thrombi Washington Hospital Center 19 (13.7%) patients had LA thrombi Independent risk factors: Reduced LV function (p=0.001) History of myocardial infarction (p=0.006) CHF (p=0.001)

Large thrombus in LAA and LA Case 6 Large thrombus in LAA and LA Case 16

The End