J Cardiovasc Ultrasound.  2015 Dec;23(4):211-218. 10.4250/jcu.2015.23.4.211.

Predicting Peri-Device Leakage of Left Atrial Appendage Device Closure Using Novel Three-Dimensional Geometric CT Analysis

• Chung H
• Jeon B
• Chang HJ
• Han D
• Shim H
• Cho IJ
• Shim CY
• Hong GR
• Kim JS
• Jang Y
• Chung N

• KMID: 2144451
• DOI: http://doi.org/10.4250/jcu.2015.23.4.211

Abstract

BACKGROUND
After left atrial appendage (LAA) device closure, peri-device leakage into the LAA persists due to incomplete occlusion. We hypothesized that pre-procedural three-dimensional (3D) geometric analysis of the interatrial septum (IAS) and LAA orifice can predict this leakage. We investigated the predictive parameters of LAA device closure obtained from baseline cardiac computerized tomography (CT) using a novel 3D analysis system.
METHODS
We conducted a retrospective study of 22 patients who underwent LAA device closure. We defined peri-device leakage as the presence of a Doppler signal inside the LAA after device deployment (group 2, n = 5) compared with patients without peri-device leakage (group 1, n = 17). Conventional parameters were measured by cardiac CT. Angles theta and phi were defined between the IAS plane and the line, linking the LAA orifice center and foramen ovale.
RESULTS
Group 2 exhibited significantly better left atrial (LA) function than group 1 (p = 0.031). Pre-procedural theta was also larger in this group (41.9degrees vs. 52.3degrees, p = 0.019). The LAA cauliflower-type morphology was more common in group 2. Overall, the patients' LA reserve significantly decreased after the procedure (21.7 mm3 vs. 17.8 mm3, p = 0.035). However, we observed no significant interval changes in pre- and post-procedural values of theta and phi in either group (all p > 0.05).
CONCLUSION
Angles between the IAS and LAA orifice might be a novel anatomical parameter for predicting peri-device leakage after LAA device closure. In addition, 3D CT analysis of the LA and LAA orifice could be used to identify clinically favorable candidates for LAA device closure.

Keyword

Left atrial appendage; Peri-device leakage; Occlusion; Cardiac CT

MeSH Terms

Atrial Appendage*
Foramen Ovale
Humans
Retrospective Studies

Figure

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  Fig. 1 Flow diagram of the study population. LAA: left atrial appendage.

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  Fig. 2 Peri-device leakage identified by transesophageal echocardiography (TEE) color Doppler imaging. The TEE image shows incomplete device sealing with residual flow of 4 mm. The average flow rate was 10 cm/sec.

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  Fig. 3 A spherical coordinate system illustrates three dimensional image space where the vector direction of the LAA center is specified by two numbers. To measure the angles (θ, φ) between the IAS and LAA with a 3D approach, we defined one plane (IAS plane) with three points: the foramen ovale (P), an arbitrary point on IAS plane (U), a defined point at the intersection of aortic root and IAS plane (A) and the center of LAA orifice (L). LAA: left atrial appendage, IAS: interatrial septum, 3D: three-dimensional.

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  Fig. 4 The program was developed to measure the angle between the interatrial septum and left atrial appendage (LAA) orifice. In a real CT volume image, four points were defined to calculate the angle between the interatrial septum and LAA orifice: the center of LAA orifice (the point with thick arrows at A and B), the foramen ovale (the point with thick arrows at C, D, and E), an arbitrary point (the point with short thin arrow at D) and a defined point (point with long thin arrows in D and E).

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