A novel echocardiographic-derived classification after LAA closure can accurately predict incomplete ostial closure and significant peri-device leaks

Abstract

Abstract Background The assessment of residual peri-device leaks (PDL) after percutaneous left atrial appendage closure (LAAC) remains crucial in the post-procedural management. Clinical significance of PDL is still poorly understood and echocardiographic recognition of PDL remains challenging. This study aimed to verify a novel proposed echocardiographic classification for prediction of clinically significant PDL following LAAC. Methods We retrospectively evaluated our echocardiographic data of 72 patients who underwent percutaneous LAAC at the University Hospital Jena between September 2015 - 2018. All echo images were transferred to a workstation for offline analysis by two independent investigators. Total number of studies was 127. We proposed a morphological classification of LAA devices (Fig. 1A-C) based on the amount of echodensity and luceny inside the devices into three types: type A: homogenous echodensity in 0, 45, 90 and 135°; indicating completely thrombosed device, type B with inhomogeneous echo-lucencies (<50% of device) and type C: partially thrombosed device with echo-lucencies >50% of total, which we labeled “ice-cream cone” sign. Each type was then matched to the degree of PDL and other clinical and paraclinical parameters. Results Tab.1 shows patient's characteristics. PDL was found in 21% of patients. Four patients showed regression of PDL after 160 days. Patients with type C had the most percentage of PDL in three types at 6 months follow-up (type A: 7%, type B: 33%, type C 100%, p<0.001). Device size in patients with type C was largest in three types (type A: 25.9±3.6mm, type B: 25.8±3.4mm, type C 29.8±3.0mm, type A vs. B, p=0.018; type B vs. C, p=0.007). Mean compression rate after 45 days was 21±9.3% in type A vs. 14±7.4% in type C (p=0.022). Ice cream sign showed a sensitivity of 53.1%, specificity of 100% and positive predictive value of 100% for prediction of PDL. Conclusion Our data demonstrate that: 1) This novel classification irrespective of anticoagulation regimen, can accurately discriminate among various degrees of PDL, in such that type C or “ice cream sign” has a very high positive predictive value for PDL (100%). 2) Type A, the ideal type, is associated with smaller landing zones and a higher compression rate. Funding Acknowledgement Type of funding source: None