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      Accuracy of Commonly-Used Imaging Modalities in Assessing Left Atrial Appendage for Interventional Closure: Review Article

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          Periprocedural imaging assessment for percutaneous Left Atrial Appendage (LAA) transcatheter occlusion can be obtained by utilizing different imaging modalities including fluoroscopy, magnetic resonance imaging (MRI), computed tomography (CT), and ultrasound imaging. Given the complex and variable morphology of the left atrial appendage, it is crucial to obtain the most accurate LAA dimensions to prevent intra-procedural device changes, recapture maneuvers, and prolonged procedure time. We therefore sought to examine the accuracy of the most commonly utilized imaging modalities in LAA occlusion. Institutional Review Board (IRB) approval was waived as we only reviewed published data. By utilizing PUBMED which is an integrated online website to list the published literature based on its relevance, we retrieved thirty-two articles on the accuracy of most commonly used imaging modalities for pre-procedural assessment of the left atrial appendage morphology, namely, two-dimensional transesophageal echocardiography, three-dimensional transesophageal echocardiography, computed tomography, and three-dimensional printing. There is strong evidence that real-time three-dimensional transesophageal echocardiography is more accurate than two-dimensional transesophageal echocardiography. Three-dimensional computed tomography has recently emerged as an imaging modality and it showed exceptional accuracy when merged with three-dimensional printing technology. However, real time three-dimensional transesophageal echocardiography may be considered the preferred imaging modality as it can provide accurate measurements without requiring radiation exposure or contrast administration. We will present the most common imaging modality used for LAA assessment and will provide an algorithmic approach including preprocedural, periprocedural, intraprocedural, and postprocedural.

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          Left atrial appendage studied by computed tomography to help planning for appendage closure device placement.

          To quantitatively study various morphologic parameters of the left atrial appendage (LAA) by computed tomography (CT) to aid the preoperative planning and implantation of left atrial appendage closure devices. In 612 cases of patients with or without atrial fibrillation (AF), a cardiac CT study was performed. The classification of general LAA morphology included ChickenWing type (18.3%), WindSock (46.7%), Cauliflower type (29.1%), and Cactus type (5.9%). Anatomical relationship of the LAA to the left superior pulmonary vein (LSPV) were classified as high type (superior to LSPV, 30.2%), mid type (parallel to LSPV, 58.1%), and low type (inferior to LSPV, 11.7%). LAA ostium could be classified into 5 types including oval (68.9%), foot-like (10%), triangular (7.7%), water drop-like (7.7%), and round (5.7%). Two-dimensional (2D) orthogonal method was obviously not accurate for determining the LAA orifice because the measurement was often unparallel to the LAA orifice. Two-dimensional oblique method was better than 3-dimensional method in reproducibility to determine the size of LAA ostium. The diameter calculated from the perimeter of the LAA ostium was superior to the diameter from direct measurement of the LAA ostium for selecting the occluder. The morphology of the LAA and the LA ostium are extremely complex and heterogeneous. Sixty-four-channel cardiac CT could assist preoperative planning of LAA closure device placement. The diameter of the LAA ostium calculated from the perimeter is the best parameter for sizing the LAA occluder. © 2010 Wiley Periodicals, Inc.
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            Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience.

            Thromboembolism due to atrial fibrillation (AF) is a frequent cause of stroke. More than 90% of thrombi in AF form in the left atrial appendage (LAA). Obliteration of the appendage may prevent embolic complications. We evaluated the feasibility and safety of implanting a novel device for percutaneous left atrial appendage transcatheter occlusion (PLAATO). LAA occlusion using the PLAATO system was attempted in 15 patients with chronic AF at high risk for stroke, who are poor candidates for long-term warfarin therapy. The implant consists of a self-expanding nitinol cage covered with a polymeric membrane (ePTFE). The LAA was successfully occluded in 15/15 patients (100%). Angiography and transesophageal echocardiography (TEE) during the procedure showed that the device was well-seated in all patients and that there was no evidence of perforation, device embolization, or interference with surrounding structures. In 1 patient, the first procedure was complicated by a hemopericardium, which occurred during LAA access. A second attempt 30 days later was successful with no untoward sequela. No other complications occurred. At 1-month follow-up, chest fluoroscopy and TEE revealed continued stable implant position with smooth atrial-facing surface and no evidence of thrombus. Thus, transcatheter closure of the LAA is feasible in humans. This novel implant technology may be appropriate for patients with AF who are not suitable candidates for anticoagulation therapy. Further trials are needed to show the long-term safety and its efficacy in reducing stroke.
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              Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure.

              Precise knowledge of left atrial appendage (LAA) orifice size is crucial for correct sizing of LAA closure devices. The aim of the present study was to determine the performance of real-time 3D transesophageal echocardiography (RT3DTEE) for LAA orifice size assessment, compared with 2D transesophageal echocardiography (2DTEE), and to investigate the impact of atrial fibrillation (AF) on LAA orifice size. One hundred thirty-seven patients (38 control subjects, 31 with paroxysmal AF, 38 with persistent AF and 30 with permanent AF) underwent 2DTEE and RT3DTEE. Both techniques were used to measure LAA orifice area. Clinically-indicated 64-slice computed tomography (CT) was used as reference technique in 46 patients. Two-dimensional TEE underestimated LAA orifice area, compared with RT3DTEE (1.99±0.94 cm(2) versus 3.05±1.27 cm(2); P<0.001). RT3DTEE showed higher correlation with CT for the assessment of LAA orifice area, compared with 2DTEE (r=0.92; 95% confidence interval, 0.85 to 0.95, versus r=0.72; 95% confidence interval, 0.54 to 0.83, respectively). At Bland-Altman analysis, RT3DTEE and 2DTEE underestimated LAA orifice area, compared with CT. However, RT3DTEE showed smaller bias (0.07 cm(2) versus 0.72 cm(2)) and narrower limits of agreement (-0.71 to 0.85 cm(2) versus -0.58 to 2.02 cm(2)) with CT, compared with 2DTEE. Among AF patients, a progressive increase in RT3DTEE-derived LAA orifice area was observed with increasing frequency of AF (P<0.001). At multivariate analysis, AF and left atrial volume index (P<0.001 for both) were independently associated with RT3DTEE-derived LAA orifice area. RT3DTEE is more accurate than 2DTEE for the assessment of LAA orifice size. A progressive increase in LAA orifice area is observed with increasing frequency of AF.

                Author and article information

                J Clin Med
                J Clin Med
                Journal of Clinical Medicine
                14 November 2018
                November 2018
                : 7
                : 11
                [1 ]Department of Internal Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA; morcos.ramez@ (R.M.); jcasale3@ (J.C.); rmanam@ (R.M.); patelv@ (V.P.)
                [2 ]Department of Cardiovascular Diseases, Florida Atlantic University, Boca Raton, FL 33431, USA; haltaii@ (H.A.T.); Pbansal@ (P.B.)
                [3 ]College of Medicine, Florida Atlantic University, Boca Raton, FL 33431, USA; acioci@ (A.C.); mkucharik2016@ (M.K.)
                [4 ]University of Miami, Coral Gables, FL 33124, USA; a.malhotra2@
                [5 ]Tenet Florida & Department of Cardiovascular Diseases, Florida Atlantic University, Boca Raton, FL 33431, USA
                Author notes
                [* ]Correspondence: brijmaini1@ ; Tel.: +1-561-498-2249
                © 2018 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (



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