1. Essential Imaging Tools
for
LAA Closure
Steven A. Goldstein MD FACC, FASE
MedStar Heart Institute
Washington Hospital Center
Saturday, February 18, 2017

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

3. LAA Anatomy

4. LA-Appendage Anatomy Highly variable structure (size and shape)
Long, hook-like true diverticulum of LA
Lies within the pericardium
Orifice is usually elliptical (not round)
Lies in more than 1 imaging plane
Often multi-lobed

5. 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:

6. Width = 2.9 cm
Depth = 5.6 cm

7. LAA Orifice Classification
Oval Foot-like Triangular Tear drop Round
68.9% 10% 7.7% 5.6%

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

10. Septation tissue between lobes can mimic a thrombus

11. Multi-Lobed LA-Appendage

12. Multilobed Atrial Appendage

13. LAA Anatomy/Assessment
LAA size, shape
Number of lobes
Measure ostium at 0º, 45º, 90º, 135º
Measure depth (length) of LAA
From LCx to a point 2 cm from limbus tip
From top of MV annulus “ “ “ “ “

14. LAA Anatomy/Assessment
Maximum LAA ostium and LAA depth
Max LAA ostium size should be ≥17 mm
LAA length should be equal to or greater
measurements determine size selection
≤ 31 mm to accommodate device sizes
than the ostium

15. LAA Anatomy/Assessment
Device Sizing
Maximum LAA
Ostium (mm)
Device Size (mm)
17 – 19
20 – 22
23 – 25
26 – 28
29 – 31 21 24 27 30 33

16. 4 Main Morphologies of LAA
Cactus
Windsock
Cauliflower
Chicken Wing
more likely
embolic event
Di Biase J Am Coll Cardiol 2012; 60:

17. Windsock Chicken wing Cauliflower Limited length More complex
internal characteristics
One dominant lobe
Sufficient length
Sharp bend in
dominant lobe

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

19. Case
21 year-old woman

21. Chicken Wing

22. Case

25. Case

28. Case

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

31. “Hammerhead” shape of LA-appendage

32. Case
Tuesday, Feb. 14, 2017

33. Very basal “cul-de-sac” (extra lobe)
Case 54
Very basal “cul-de-sac” (extra lobe)

34. Very basal “cul-de-sac” (extra lobe)
Case 54
Very basal “cul-de-sac” (extra lobe)

35. Case 54

36. Look for Thrombi

37. Case
Thrombus in LAA

40. Measurements 0º
45º
90º
135º

41. Landing
Zone

42. Transseptal Puncture

43. Site Specific Transseptal Puncture for Various Interventions
Transseptal PFO
closure
(higher crossing site for
medial leaks; lower
site for lateral leaks)
Paravalve leak closure
LVAD placement
Hemodynamic studies
LA-appendage closure
Pulmonary vein
interventions
Alkhouli J Am Coll Cardiol 2016;9(24):

44. Transseptal Crossing Preferred crossing location is posterior
Bicaval and short-axis views useful
X-plane useful
and inferior
Inferior on short-axis view
Posterior on bicaval view

45. The value of X-plane (biplane  2 orthogonal views)
Guidance of Transseptal Puncture
The value of X-plane (biplane  2 orthogonal views)

46. Case

48. Transseptal Puncture for Watchman
Too anterior
Slightly more posterior

49. Case
BH year-old woman
Watchman LAA closure
Case 16

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

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

53. Width = 1.2 cm
Length = 2.4 cm

55. 0°
45°
90°
135°
Prior to final deployment, check
position in 4 views: 0° 45° 90° 135°

57. LAA-occluder adjacent to L-pulmonary vein

58. Device Release Criteria P.A.S.S.
Position – device is at ostium of LAA
Anchor – fixation anchors engaged
Size – device compressed 8-20%
Seal - device spans ostium
- device is stable (tug test)
- all lobes of LAA covered
- absence of peri-leak

59. Device should be at or just distal to the LA-appendage ostium
Device Release Criteria
Device should be at or just distal
to the LA-appendage ostium

61. Peri-Leak

65. Iatrogenic ASD

67. LAA Occlusion Anticoagulation Post-Procedure
Warfarin and aspirin x 45 days
TEE at 45 days
If no or minimal (≤ 5 mm) peridevice flow
stop warfarin, start clopidogrel (75 mg),
continue aspirin until 6 mos post procedure

68. Case

69. PR year-old man
Watchman procedure performed
Successful insertion
Refused anticoagulation, despite protocol

74. The End