1. A Primer of LAA Closure: and Pattern Recognition
Essential Views
and Pattern Recognition
Steven A. Goldstein, MD
Director, Noninvasive Cardiology
Washington Hospital Center
Tuesday, February 26, 2013

2. I/we have no real or apparent conflicts of interest to report.
Steven A. Goldstein, MD
I/we have no real or apparent conflicts of interest to report.

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

5. 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

6. 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:

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

8. 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

9. Septation tissue between lobes can mimic a thrombus

10. Multi-Lobed LA-Appendage

11. Multilobed Atrial Appendage

13. Case 1

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

17. Case 2
Case 16

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

20. “Hammerhead” shape of LA-appendage

21. Case 3
NR year-old woman
Bilobed LAA

24. Case 4
BH year-old woman
Watchman LAA closure
Case 16

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

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

28. Width = 1.2 cm
Length = 2.4 cm

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

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

36. Case 5
Case 16

40. 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)

41. 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)

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

48. The End