1. 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

2. financial relationships
DISCLOSURE
I have N O relevant
financial relationships

3. LAA Anatomy

4. * # 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

6. 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

7. 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:

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

9. 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)

10. 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 º
90º 135º

11. Septation tissue between lobes can mimic a thrombus

12. Multi-Lobed LA-Appendage

13. Multilobed Atrial Appendage

14. Case 1

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

18. 4 Main Morphologies of LAA
Cactus
Windsock
Cauliflower
Chicken Wing
more likely
embolic event
Di Biase J Am Coll Cardiol 2012; 60:

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

20. Case 2
KG year-old woman
TEE for endocarditis

21. Chicken Wing

22. Case 3
Case 16

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

25. “Hammerhead” shape of LA-appendage

26. Case 4
NR year-old woman
Bilobed LAA

29. Case 5
BH year-old woman
Watchman LAA closure
Case 16

30. BH year-old woman
Longstanding, chronic atrial fibrillation
Multiple cardioversions  failed
Referred for Protect – watchman Trial

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

33. Width = 1.2 cm
Length = 2.4 cm

35. 0°
45°
90°
135°
Prior to final deployment, check
position in 4 views: 0° 45° 90° 135°

37. Occluded LAA-occluder adjacent to L-pulmonary vein

38. The End

39. Case 5
Case 16

45. Atrial Fibrillation Predisposing Factors to LA Thrombi
Washington Hospital Center
Nov, 2008  Jul, (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)

46. 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)

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

53. LA-Appendage Morphology
Cactus
Di Biase J Am Coll Cardiol 2012; 60:

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

55. LA-Appendage Morphology
Windsock
Di Biase J Am Coll Cardiol 2012; 60:

56. LA-Appendage Morphology
Cauliflower
Di Biase J Am Coll Cardiol 2012; 60:

57. 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

58. 4 Main Morphologies of LAA
Cactus
Windsock
Cauliflower
Chicken Wing
Di Biase J Am Coll Cardiol
2012; 60:

59. Chicken Wing

60. Chicken Wing