Case-Based Discussion Regarding Challenges in Patient Selection and Procedural Planning in Left Atrial Appendage Occlusion Sidakpal S. Panaich, MD, Thomas.

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Date of download: 6/3/2016 Copyright © The American College of Cardiology. All rights reserved. From: Imaging the Left Atrial Appendage Prior to, During,

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Case-Based Discussion Regarding Challenges in Patient Selection and Procedural Planning in Left Atrial Appendage Occlusion Sidakpal S. Panaich, MD, Thomas Munger, MD, Paul Friedman, MD, Charanjit S. Rihal, MD, David R. Holmes, MD Mayo Clinic Proceedings Volume 93, Issue 5, Pages 630-638 (May 2018) DOI: 10.1016/j.mayocp.2018.03.015 Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 1 Algorithm for appropriate patient selection for left atrial appendage occlusion (LAAO). aHigh HAS-BLED scores (typically ≥3), history of coronary artery disease on dual antiplatelet therapy, and patients with end-stage renal disease (creatinine clearance <15-30 mL/min/1.73 m2 [to convert to mL/s/m2, multiply by 0.0167]). bEndocardial LAAO has not be tested in randomized trials for this indication, and epicardial LAAO (Lariat) is not Food and Drug Administration approved. AF = atrial fibrillation; CABG = coronary artery bypass graft; LAA = left atrial appendage. Mayo Clinic Proceedings 2018 93, 630-638DOI: (10.1016/j.mayocp.2018.03.015) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 2 Computed tomographic (CT) and transesophageal echocardiographic (TEE) images showing large left atrial appendages (LAAs) not suitable for the Watchman device. A, Cardiac gated CT (top) and TEE (bottom) images showing a large LAA ostium beyond the suggested upper limits for the Watchman device (average diameter of 40 mm). B, Cardiac gated CT images (coronal section [top] and 3-dimensional reconstruction [bottom]) showing an LAA with depth shorter than the ostium width (average diameter of 36 mm and length of 28 mm). Mayo Clinic Proceedings 2018 93, 630-638DOI: (10.1016/j.mayocp.2018.03.015) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions

Figure 3 Intracardiac echocardiography (ICE)–guided procedure for patient G. A, Transseptal puncture (arrow) guided by ICE (placed in the right atrium). B, The Watchman device (thin, long arrow) being deployed under ICE guidance via the device sheath (thick, short arrow). C, A deployed device with adequate compression (20 mm as measured, resulting in ∼25% compression for the device). D, Fluoroscopic image of the deployed 27-mm Watchman device (arrow). Mayo Clinic Proceedings 2018 93, 630-638DOI: (10.1016/j.mayocp.2018.03.015) Copyright © 2018 Mayo Foundation for Medical Education and Research Terms and Conditions