Abstract
Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. We included 50 patients who underwent percutaneous LAA occlusion with the Watchman device and had acceptable three-dimensional transesophageal echocardiography images of LAA pre- and post-device placement. We measured offline the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Patients were elderly (mean age 76 ± 8years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1 ± 3.2 vs. post-device 21.5 ± 3.4mm, p < 0.001), diameter 2 (20.6 ± 3.9 vs. 22.1 ± 3.6mm, p < 0.001), minimum diameter (17.6 ± 3.1 vs. 21.3 ± 3.4mm, p < 0.001), maximum diameter (21.5 ± 3.9 vs. 22.4 ± 3.6mm, p = 0.022), circumference (63.6 ± 10.7 vs. 69.6 ± 10.5mm, p < 0.001), and area (3.1 ± 1.1 vs. 3.9 ± 1.2 cm2, p < 0.001). Eccentricity index decreased after procedure (1.23 ± 0.16 vs. 1.06 ± 0.06, p < 0.001). LUPV peak S and D velocities did not show a significant difference (0.29 ± 0.15 vs. 0.30 ± 0.14cm/s, p = 0.637; and 0.47 ± 0.19 vs. 0.48 ± 0.20cm/s, p = 0.549; respectively). LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.
Highlights
The left atrial appendage (LAA) is the most common source of thrombi in patients with non-valvular AF, accounting for approximately 90% of cases.[1]
There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1, diameter 2 (20.6±3.9 vs. 22.1±3.6 mm, p
Based on current guidelines, percutaneous LAA occlusion can be considered in selected patients with non-valvular AF who are at increased risk of stroke and have contraindications to long-term anticoagulation.[2]. Based on recent randomized clinical trials that have demonstrated procedural safety and efficacy for ischemic stroke prevention with percutaneous LAA occlusion [3, 4], the US Food and Drug Administration has approved the Watchman device (Boston Scientific, Maple Grove, Minnesota) for use in percutaneous LAA occlusion
Summary
The left atrial appendage (LAA) is the most common source of thrombi in patients with non-valvular AF, accounting for approximately 90% of cases.[1]. The Watchman is the only device approved for LAA occlusion in the United States and has been increasingly utilized in real-world clinical practice[5]. The impact of the Watchman device on the LAA orifice and adjacent structures such as the left upper pulmonary vein (LUPV) is not well studied except in an animal model.[6]. Accurate assessment of anatomic LAA characteristics is crucial for correct sizing and safe placement of LAA closure devices.[10] Transesophageal echocardiography (TEE) is recommended before and during Watchman implantation to measure the LAA size[11]. [12,13,14,15] The aim of this study was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of LAA orifice using 3D TEE and assess its impact on the adjacent LUPV hemodynamics The depth and orifice diameters of the LAA are usually measured using twodimensional (2D) TEE, it has been shown that three-dimensional (3D) TEE is more accurate than 2D TEE and provides measurements that correlate better with those obtained by computed tomography. [12,13,14,15] The aim of this study was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of LAA orifice using 3D TEE and assess its impact on the adjacent LUPV hemodynamics
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