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 FACC Director, Noninvasive Cardiology Medstar Heart Institute Washington Hospital Center Tuesday, February 24, 2015

financial relationships DISCLOSURE I have N O relevant financial relationships

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

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 anatomy: ASD, PFO Identify other potential cardiac sources Provide guidance for transseptal puncture of embolism (eg atrial septal aneurysm, aortic debris)

LA-Appendage How to Image with TEE Begin with 4-chamber view (0º) Show MV in middle of sector Withdraw and anteflex probe With/without lateral flexion Also rotate from 0º to 135º 0º 45º 90º 135º

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

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

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

Case 2 KG - 21 year-old woman TEE for endocarditis

Chicken Wing

Case 3 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 4 NR - 35 year-old woman Bilobed LAA

Case 5 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°

Occluded LAA-occluder adjacent to L-pulmonary vein

The End

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

LA-Appendage Morphology Cactus Di Biase J Am Coll Cardiol 2012; 60:531-538

LA-Appendage Morphology Chicken Wing Di Biase J Am Coll Cardiol 2012; 60:531-538

LA-Appendage Morphology Windsock Di Biase J Am Coll Cardiol 2012; 60:531-538

LA-Appendage Morphology Cauliflower Di Biase J Am Coll Cardiol 2012; 60:531-538

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

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

Chicken Wing

Chicken Wing