Follow-up Transesophageal Echocardiography Research Articles

Characteristics and incidence of peri-device leaks after left atrial appendage closure in patients with prior electrical isolation of left atrial appendage during catheter ablation

Abstract Background Patients who undergo electrical isolation of left atrial appendage (eLAAi) during atrial fibrillation (AF) ablation have a higher subsequent risk of thromboembolism. In post-ablation patients with eLAAi who undergo mechanical LAA closure (LAAC), there are limited data on imaging and clinical outcomes during follow-up, particularly peri-device leaks (PDLs). Purpose We investigated imaging outcomes on ~1 year follow up transesophageal echocardiography (TEE) for PDL and clinical outcomes in patients who had undergone LAAc after sustaining eLAAi from catheter ablation. Methods We analyzed data from TEEs at ~1 year follow up in patients who had undergone LAAC with either the Watchman or Watchman-FLX device. The images were analyzed for evidence of any discernible PDL which also which also included the absence of thrombosis/obliteration of the distal LAA. "Severe" PDL was categorized as the leak size of >5 mm on follow up TEE imaging. Baseline characteristics, imaging and clinical outcomes were compared with univariate comparison using Fisher’s exact test, between the two subgroups of LAAC patients stratified according to prior h/o eLAAi. Results A total of 532 patients underwent LAAC at our center between 03/2015 and 10/2022, with data available on ~1 year follow-up TEE imaging. Of these, 21 (3.9%) had undergone eLAAi during AF ablation prior to LAAC. At ~1 year follow up TEE imaging, the patients with prior h/o eLAAi had a numerically higher incidence of any PDL (42.9% vs 26.5%, p = 0.09). The incidence of severe PDL was significantly higher in the subgroup of patients with prior eLAAi as compared to patients without prior eLAAi (14.3% vs 3.3%, p = 0.04; Figure). There was no statistically-significant difference in the subsequent risk of thromboembolism between the eLAAi and control subgroups (4.8% vs 6.1%, p = 1.0) over an average follow-up of 577±331 days post-LAAC. Conclusions A prior history of eLAAi during AF ablation was associated with a higher risk of severe PDLs (>5mm) on follow up imaging after LAAC. The finding of severe PDL in the eLAAi subgroup might be attributable to ostial fibrosis as a result of ablation which might affect the LAA endocardial surface interaction with the device fabric. The occurrence of a higher risk of severe PDL in patients with prior eLAAi after LAAC might necessitate PDL closure or resumption of anticoagulation in such patients to mitigate the risk of subsequent thromboembolism.igure showing our study schema and compa

Comparative effectiveness of different management strategies for left atrial appendage thrombus in patients on optimal NOAC therapy

Abstract Background Left atrial appendage (LAA) thrombus is the primary cause of stroke and systemic embolism in atrial fibrillation (AF). Novel oral anticoagulants (NOACs) effectively reduce the prevalence of LAA thrombosis and stroke risk. Nonetheless, there is no clear advice for patients with a NOAC-resistant thrombus, necessitating individualized decision-making without strong support of the current guidelines. Aims To analyze patients diagnosed with an LAA thrombus despite adequate NOAC therapy and to compare the efficacy of various therapeutic strategies in achieving thrombus resolution. Methods We retrospectively analyzed patients scheduled for cardioversion or catheter ablation of AF between 2014 and 2023 who were diagnosed with LAA thrombus despite being on optimal NOAC therapy. These patients underwent follow-up transesophageal echocardiography (TEE) or cardiac CT angiography. Changes in treatment modalities were divided into four groups: transition to an alternative NOAC, switch to a vitamin K antagonist (VKA), the addition of an antiplatelet agent, or the deliberate maintenance of the current treatment. Results We analyzed the data of 90 patients comprising 103 cycles of treatment. The patients were either on rivaroxaban (41%), apixaban (32%), dabigatran (15%) or on edoxaban (12%) at the time of the initial TEE. A change to a different NOAC was observed in 37% of cases, transition to a VKA in 22%, supplementation with antiplatelet therapy in 16%, while deliberate absence of treatment modification in 25% of cases. Subsequent follow-up TEE (or CT angiography in a minority of cases) was performed at a median of 68 [43 – 94] days from the baseline evaluation. Successful thrombus resolution was achieved in 72% of cases. Evaluation of therapeutic strategies revealed that any modification of treatment was three times more effective than deliberate no change in treatment; thrombus resolution was observed in 60 (81%) vs. 17 (59%) cases (OR 3.03 [1.18 - 7.75], p = 0.021). Nevertheless, no particular strategy demonstrated superior efficacy over others. Conclusions Resolution of LAA thrombus in patients already on adequate NOAC treatment may require a revision of the prior anticoagulation strategy; however, none of the commonly employed strategies appears to exhibit distinct superiority over the rest.

Valvulitis: un nuevo criterio ecocardiográfico para el diagnóstico de endocarditis infecciosa de bioprótesis de válvula aórtica

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Efficacy of four different Left atrial Appendage closure techniques during cardiac surgery-A transesophageal echocardiography follow-up study

ObjectivesClosure of left- atrial appendage (LAA) is a routine part of AF ablation surgery and significantly reduces stroke rates. Different LAA closure techniques are used in cardiac surgery with variable results. We therefore evaluated the efficacy of four different LAA closure techniques in patients undergoing cardiac surgery. Methods149 patients who underwent concomitant LAA closure during cardiac surgery between 2015 and 2019 were included in this retrospective transesophageal echocardiography (TEE) study. Four different LAA closure techniques were evaluated: LAA clipping (n=62), suture ligation (n=28), stapler resection (n=30), surgical LAA excision (n=29). Successful LAA closure was defined as absence of LAA perfusion and absence of a stump >10 mm. ResultsThe mean patients age was 68.7 ± 9.4 years, 61.7% were male. No complications related to LAA closure were observed. Mean follow-up was 36.5±8 months. TEE follow-up showed the following LAA closure success rates: LAA clip 98.4%, surgical excision 93.1%, stapler resection 76.6% and suture ligation 39.2%. Suture ligation resulted in a high rate of recanalisation (50%) and residual stumps (10.8%), whereas stapler resection resulted in a high rate of residual stumps (23.4%). Overall, four patients (2.7%) had a stroke during follow-up. In detail, 2 of 27 (7.4%) patients with unsuccessful LAA closure had a stroke, whereas 2 of the 122 (1.6%) patients with successful LAA closure had a stroke. ConclusionsIn our study, LAA clipping and surgical LAA excision have proven to be both successful LAA closure methods. External LAA ligation and stapler resection resulted in low rates of successful LAA closure and should be avoided.

Valvulitis: a new echocardiographic criterion for the diagnosis of bioprosthetic aortic valve infective endocarditis

Introduction and objectivesDiffuse homogeneous hypoechoic leaflet thickening, with a wavy leaflet motion documented by transesophageal echocardiography (TEE), has been described in some cases of prosthetic valve endocarditis (PVE) involving aortic bioprosthesis (AoBio-PVE). This echocardiographic finding has been termed valvulitis. We aimed to estimate the prevalence of valvulitis, precisely describe its echocardiographic characteristics, and determine their clinical significance in patients with AoBio-PVE. MethodsFrom 2011 to 2022, 388 consecutive patients with infective endocarditis (IE) admitted to a tertiary care hospital were prospectively included in a multipurpose database. For this study, all patients with AoBio-PVE (n=86) were selected, and their TEE images were thoroughly evaluated by 3 independent cardiologists to identify all cases of valvulitis. ResultsThe prevalence of isolated valvulitis was 12.8%, and 20.9% of patients had valvulitis accompanied by other classic echocardiographic findings of IE. A total of 9 out of 11 patients with isolated valvulitis had significant valve stenosis, whereas significant aortic valve regurgitation was documented in only 1 patient. Compared with the other patients with AoBio-PVE, cardiac surgery was less frequently performed in patients with isolated valvulitis (27.3% vs 62.7%, P=.017). In 4 out of 5 patients with valve stenosis who did not undergo surgery but underwent follow-up TEE, valve gradients significantly improved with appropriate antibiotic therapy. ConclusionsValvulitis can be the only echocardiographic finding in infected AoBio and needs to be identified by imaging specialists for early diagnosis. However, this entity is a diagnostic challenge and additional imaging techniques might be required to confirm the diagnosis. Larger series are needed.

Twice-daily rivaroxaban after percutaneous left atrial appendage closure for atrial fibrillation.

Background and aim: Rivaroxaban is an emerging oral anticoagulant for postoperative anticoagulation after percutaneous left atrial appendage closure (LAAC). Because a once-daily dosing regimen of rivaroxaban causes fluctuations in the drug plasma concentration, we studied the feasibility and safety of twice-daily rivaroxaban as a postoperative anticoagulation regimen for patients with atrial fibrillation (AF) undergoing LAAC. Methods: This study involved patients with AF who underwent LAAC and took rivaroxaban postoperatively. A total of 326 patients who received a standard total dose (15 or 20mg) of rivaroxaban based on their creatinine clearance rate were divided into the twice-daily (BID) rivaroxaban group (n = 208) and once-daily (QD) rivaroxaban group (n = 118) according to their anticoagulation strategy. Transesophageal echocardiography was recommended at 3-6months postoperatively to check for device-related thrombosis (DRT). Clinical outcomes were evaluated during postoperative anticoagulation. Results: The median CHA2DS2-VASc score (4 [3, 5] vs. 4 [3, 5], p = 0.28) and HAS-BLED score (2 [2, 3] vs. 2 [2, 3], p = 0.48) were not significantly different between the groups. During the anticoagulation period (4.1 ± 0.7 vs. 4.1 ± 0.9 months, p = 0.58), 148 (71.2%) patients in the BID group and 75 (63.6%) in the QD group underwent follow-up transesophageal echocardiography. There were no statistically significant differences between the two groups in terms of DRT (1.4% vs. 2.7%, p = 0.60), minor bleeding (8.2% vs. 11.0%, p = 0.39), thromboembolic events (1.0% vs. 0.8%, p = 1.00), major bleeding (0.5% vs. 0.8%, p = 1.00), or death. Conclusion: A short course of twice-daily rivaroxaban following LAAC is a feasible alternative regimen with a low rate of major bleeding events, DRT, and thromboembolic events for patients with AF.

Three-dimensional intracardiac echocardiography for left atrial appendage sizing and percutaneous occlusion guidance.

Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. We aimed at reporting procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transoesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing. Among 274 patients undergoing left atrial appendage occlusion (LAAO) with a Watchman FLX, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel (NUVISION™) 3D-ICE one (54 patients). Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks ≥ 3 mm at follow-up TEE. 3D-ICE measurements of maximum landing zone correlated highly with pre-procedural TEE reference values [Pearson's: 0.94; P < 0.001; bias: -0.06 (-2.39, 2.27)]. The agreement between 3D-ICE-based device selection and final device size was 96.3% vs. 79.1% with 2D-ICE (P = 0.005). The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (P = 0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs. 44.5%; P = 0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients vs. 45.9% of 2D-ICE ones (P = 0.065). Intracardiac echocardiography-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for FLX size selection and may provide better guidance during device deployment.

Left atrial appendage closure in patients with left atrial appendage thrombus guided by intracardiac echocardiography

BackgroundData regarding left atrial appendage closure (LAAC) in patients with left atrial appendage (LAA) thrombus are limited. Recently published cases have mostly been guided by transesophageal echocardiography. Intracardiac echocardiography (ICE) is now widely used during LAAC procedures. ObjectiveThis is the first study to report the feasibility of LAAC in patients with LAA thrombus guided by ICE. MethodsPatients with persistent LAA thrombus despite anticoagulation or contraindications to anticoagulation who underwent a modified ICE-guided LAAC procedure between June 2021 and April 2023 were included. Periprocedural events and clinical outcomes during follow-up were recorded. ResultsA total of 12 patients (mean age 65 ± 7 years; 92% male) were included: 10 with persistent LAA thrombus and 2 with contraindications to anticoagulation. Most of the thrombus was at the apex (n = 6), followed by the body (n = 3) and the ostium (n = 3). A LAmbre device was used and successfully implanted in all patients with the guidance of ICE. No thrombotic material was retrieved from patients with the protection of cerebral protection device (n = 11). No patient experienced severe periprocedural complications. All patients completed transesophageal echocardiography follow-up, and no device-related thrombus or peridevice leak > 3 mm was detected. None of the patients experienced stroke/transient ischemic attack, systemic embolism, or major bleeding events during a median follow-up of 147 days (interquartile range 80–306 days). ConclusionLAAC using the LAmbre device guided by ICE may be feasible in patients with LAA thrombus when performed by experienced operators.

The predictive value of compression rate on residual leak after left atrial appendage occlusion with watchman FLX

Abstract Background Incomplete left atrial appendage (LAA) occlusion due to residual leaks may occur after percutaneous closure procedure with Watchman FLX. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations. Purpose The aim of this study is to evaluate the correlation between compression rate and leak presence after left atrial appendage closure. Methods This is an observational retrospective study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center between January 2021 and August 2022. TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: &amp;gt;30%. The rate of leak between groups was compared using the Chi-square test. Results 203 patients (mean age 79± 8 years) were included in the study. The implanted device size was 20 mm in 7 (3.4%), 24 mm in 30 (14.8%), 27 mm in 49 (24.1%), 31 mm in 75 (36.9%) and 35 mm in 42 (20.7%) patients. Based on the compression rate, patients were classified into group 1: &amp;gt;30% [n=37 (18.2%)] and group 2: ≤30% [n=166 (81.8%)]. Mean compression rate was 38.5% and 21.3% in group 1 and 2 respectively. At follow-up TEE, 1 (2.7%) patient in group 1 and 32 (19.3%) patients in group 2 were found to have a residual leak of &amp;gt;1 mm. When comparing leaks between the two groups, there was 1 leak in group 1 whereas in group 2 there were 32 leaks (1/37 vs 32/166, p value 0.01, RR 0.14, 95% CI, 0.02-0.74). Conclusion Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.

Gender Specified In-Hospital Outcome after Left Atrial Appendage Closure with a Dual Occlusive Mechanism Device

Background: Recent studies have suggested an increased rate of adverse events in women following left atrial appendage occlusion (LAAO), particularly with dual occlusive mechanism devices. Objectives: This study aimed to investigate gender disparities in in-hospital adverse events and short-term device-related outcomes in an experienced center using dual occlusive mechanism devices exclusively. Methods: In a single-center retrospective study, patients who received dual occlusive mechanism devices (Amplatzer cardiac plug and Amulet) were analyzed. We assessed gender differences in patient characteristics, LAAO indications, procedural data, in-hospital complications, and short-term device-related outcomes in the form of one-month follow-up transesophageal echocardiography. Results: Among 474 patients, 211 (45%) were women. At device implantation, women were significantly older (77.45±6.98 years vs. 75.89±7.26; p = 0.01), with higher CHA2DS2Vasc scores (5.03±1.46 vs. 4.28±1.51; p &lt; 0.01) and lower HASBLED scores (3.78±1.06 vs. 4.03±1.12; p = 0.01) compared to men. Men had a higher prevalence of coronary artery disease (52% vs. 32%; p &lt; 0.01). LAAO indications did not significantly differ. Device success was 99% in men and 98% in women (p = 0.75). In-hospital complications, including deaths, major bleedings, and pericardial effusion, did not significantly vary by gender. Rates of device-related thrombus and device closure with a residual jet ≤ 5 mm were similar. Conclusions: In a large cohort of consecutive LAAO patients at an experienced center, gender was not linked to higher in-hospital complications.

Persistence of left atrial thrombus in patients with hypertrophic cardiomyopathy and atrial fibrillation.

We recently demonstrated that patients with atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) have an increased risk of left atrial (LA) thrombus. In this study, we aimed to evaluate thrombus management, thrombus persistence, and thromboembolic events for HCM and non-HCM patients with AF and LA thrombus. From a cohort of 2,155 AF patients undergoing transesophageal echocardiography (TEE) for any indication, this study included 122 patients with LA thrombus (64 HCM patients and 58 non-HCM controls). There was no difference in mean CHA2DS2-VASc scores between HCM and control patients (3.9 ± 2.2 vs 3.8 ± 2.0, p = 0.88). Ten (16%) and 4 (7%) patients in the HCM and control groups, respectively, were in sinus rhythm at the time of TEE identifying the LA thrombus (p = 0.13). In all patients, the anticoagulation strategy was modified after the LA thrombus diagnosis. A total of 36 (56%) HCM patients and 34 (59%) control patients had follow-up TEE at median 90 and 62days, respectively, after index TEE. The HCM group had significantly higher 90-day rates of persistent LA thrombus compared to the control group (88% vs 29%; p < 0.001). In adjusted models, HCM was independently associated with LA thrombus persistence. Among patients with LA thrombus, the 5-year cumulative incidence of thromboembolic events was 11% and 2% in HCM and control groups, respectively (p = 0.22). Among patients with AF with LA thrombus identified by TEE, those with HCM appear to have a higher risk of LA thrombus persistence than non-HCM patients despite anticoagulation.

Occult deterioration of an aortic annular abscess: how do we diagnose a pseudoaneurysm periaortic valve? A case report

BackgroundInfectious endocarditis (IE) is a disease caused by the colonization of toxic microorganisms on the endocardium of heart valves [1]. Although much progress has been made in the diagnosis and treatment of IE, its complications, such as annular abscesses [2], still have a high mortality rate. In this case, we describe a patient with infective endocarditis complicated by occult deteriorated aortic annular abscess.Case presentationA 44-year-old man was admitted due to weakness of his right limbs and unclear speech for 10 h. He had recurrent fevers for 1 month before admission. Transthoracic echocardiography showed a mix-echoic vegetation attached to the bicuspid aortic valve, moderate aortic regurgitation and a possible aortic annular abscess. Blood cultures were negative and empiric antibiotic therapy was begun. The patient did not have fever again and seem to be clinically improved. However, follow-up transesophageal echocardiography revealed a large periaortic abscess led to aortic sinus pseudoaneurysm. The patient underwent mechanical prosthetic valve replacement and annulus reconstruction successfully. Perivalvular abscess may be insidious deterioration in patients who seem to be clinically improved, which requires us to pay more attention.DiscussionOccult deterioration of an aortic annular abscess is rare and more attention should be paid. Re-evaluation of echocardiography is required even if the patient’s symptoms improve.

Intracardiac echocardiographic imaging with a cartosound module for guidance of left atrial appendage closure: a comparative study with transesophageal echocardiographic imaging.

In most clinical trials, intracardiac echocardiography (ICE) has provided fewer views than the four standard views provided by transesophageal echocardiography (TEE) when assessing left atrial appendage closure (LAAC) devices. This study aimed to determine if ICE guided by the CartoSound system achieve adequate high-quality views and similar clinical outcomes as TEE during LAAC. This study prospectively enrolled 202 patients who underwent LAAC using either ICE (n = 69), TEE (n = 121), or a combination of ICE and TEE (n = 12) as the procedural imaging under local anesthesia. A novel multi-angled "FLAVOR" approach was used for assessment in the ICE group. ICE allowed visualization of the implanted devices in all patients at all proposed angles with long-axis views while two-dimensional (2D) TEE showed short-axis views in 1 or 2 angles in 24.2% of cases, which was more prevalent when the pulmonary ridge was covered by the occluder. In the combined ICE-TEE cohort, 2D-TEE failed to detect peri-device leak in 1 patient. The complication rates were similar between the ICE and TEE groups. Shorter fluoroscopy time, lower radiation dose and contrast usage were founded in the ICE group. At first TEE follow-up, the rate and degree of peri-device leak were similar between the ICE and TEE groups. A systematic ICE protocol using a CartoSound module to guide LAAC was reliable for comprehensive long-axis imaging assessment compared with 2D/3D TEE under local anesthesia with a shorter fluoroscopy time, lower radiation dose, and less use of contrast.

Left atrial appendage anatomical changes following radiofrequency-based ostial isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial appendage (LAA) electrical isolation (ei) may be achieved via radiofrequency (RF) energy applications at the level of the appendage ostium targeting the sites of earliest activation recorded by a mapping catheter. Notably, RF has long been used in vascular, orthopedic, and aesthetic surgery to promote thermal-induced collagen matrix contraction, fibrosis, and tissue retraction. LAA anatomical changes associated to RF-induced tissue retraction have never been reported. Purpose To quantify the anatomical changes of the LAA ostium following RF-based LAAei. Methods Thirty-four consecutive patients requiring AF ablation with LAAei underwent transesophageal echocardiography (TEE) within 7 days before (baseline TEE) and apx 6 months after (follow-up TEE) ablation. The diameter of LAA orifice and landing zone were measured at 4 different views (0°, 45°, 90°, 135°). Measurements were performed by two independent reviewers blinded to the patient’s identity. Results Among 43 AF patients (67±6yrs, 72.1% males), the LAA morphology was classified as chicken wing in 19 (44.2%) patients, windsock in 12 (27.9%), cactus in 8 (18.6%), and cauliflower in 4 (9.3%). At baseline TEE, the mean maximum and mean minimum ostial diameters were 25±4mm and 22±4mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 26±4mm and 23±3mm, respectively. On average, LAAei was achieved after 17±6 minutes of RF at a power of 45W. Follow-up TEE was performed 294±136 days after LAAei. The median LAA contraction velocity was 0.1 m/s (IQR: 0.02-0.18) and was significantly impaired in all patients. At follow-up TEE, the mean maximum and mean minimum ostial diameters were 19±4mm and 17±3mm, respectively. The mean maximum and mean minimum diameters of the landing zone were 20±4mm and 18±4mm, respectively. The mean relative reduction of the ostium and the landing zone was -24.4% and -22.5%, respectively. Box-Whisker plots of the maximum and minimum ostial diameters before and after LAAei are reported in Fig.1. Conclusion RF led to a &amp;gt;20% reduction of the diameters of the ostium and the landing zone. These changes may have important implications for a successful percutaneous occlusion procedure and justify a staged approach of isolation and occlusion.

3D intracardiac echocardiography for left atrial appendage sizing and percutaneous occlusion guidance

Abstract Funding Acknowledgements Type of funding sources: None. Background Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. Purpose To report procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing. Methods Among 274 patients undergoing LAAO, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel 3D-ICE one (54 patients; Fig.1). Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks≥3mm at follow-up TEE. Results 3D-ICE measurements of maximum landing zone correlated highly with preprocedural TEE reference values [Pearson’s: 0.94; p&amp;lt;0.001; bias: -0.06 (-2.39, 2.27)] (Fig.2). The agreement between 3D-ICE-based device selection and final device size was 96.3% versus 79.1% with 2D-ICE (p=0.005). The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (p=0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs 44.5%; p=0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients versus 45.9% of 2D-ICE ones (p=0.065). Conclusions ICE-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for device size selection and may provide better guidance during device deployment.

PO-04-065 THREE-DIMENSIONAL INTRACARDIAC ECHOCARDIOGRAPHY FOR LEFT ATRIAL APPENDAGE SIZING AND PERCUTANEOUS OCCLUSION GUIDANCE

Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. To report procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing. Among 274 patients undergoing LAAO with a Watchman FLX, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel (NUVISION™) 3D-ICE one (54 patients). Technical success was defined as successful device implantation without periprocedural evidence of leaks≥3mm on color Doppler. Procedural success was a composite of technical success plus absence of procedure- or device-related major complications. Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks≥3mm at follow-up TEE. We also compared mean and maximum mean and maximum landing zone (LZ) diameters obtained from same patient’s TEE and 3D-ICE; these measurements were used to assess the degree of correlation and agreement between the two imaging techniques. Procedural success was achieved in all 274 patients; all final devices met release criteria. The agreement between 3D-ICE-based device selection and final device size was 96.3% versus 79.1% with 2D-ICE (p=0.005). No major procedure- and device-related adverse events were documented The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (p=0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs 44.5%; p=0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients versus 45.9% of 2D-ICE ones (p=0.065). 3D-ICE measurements of maximum and mean LZ correlated highly with preprocedural TEE reference values [Pearson’s: 0.94; p<0.001; bias: -0.06 (-2.39, 2.27)] (Figure 1). ICE-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for FLX size selection and may provide better guidance during device deployment.

PO-03-168 IMPORTANCE OF COMPRESSION RATE DURING LEFT ATRIAL APPENDAGE CLOSURE WITH WATCHMAN FLX

Left atrial appendage (LAA) closure is an option for patient with atrial fibrillation that cannot take oral anticoagulant due to high bleeding risk. Before release of device PASS (position, anchor, size and seal) criteria must be verified. Optimal compression rate for watchman FLX device is between 10-30% according to company recommendations. The study evaluates the correlation between compression rate and leak presence after left atrial appendage closure. This is a study including patients that underwent LAA closure under transesophageal echocardiography (TEE) with at least one follow-up where complete LAA closure was assessed by TEE in our center. All TEE images were reviewed by the first author. Compression rate was calculated based on intraprocedural TEE images using the following formula: (original device size—size after deployment)/original device size*100. Patients were divided into 2 groups based on the compression rate: group 1: 10-30%; group 2: >30%. The rate of leak between groups was compared using the Chi-square test. 83 patients (mean age 77± 7 years) were included in the study. The implanted device size was 20 mm in 2 (2.4%), 24 mm in 11 (13.2%), 27 mm in 21 (25.3%), 31 mm in 32 (38.5%) and 35 mm in 17 (20.4%) patients. Based on the compression rate, patients were classified into group 1: >30% [n=11 (13.2%)] and group 2: ≤30% [n=72 (86.7%)]. Mean compression rate was 37.1% and 20.78% in group 1 and 2 respectively. At follow-up TEE, 20 (24%) patients were found to have a residual leak of <5 mm. When comparing leaks between the two groups, there was no leak in patients with > 30% compression rate whereas in the group with ≤30% there were 20 leaks (0/11 vs 20/72, p value 0.04, RR 0, 95% CI, 0-1). Devices with compression rate ≤30% were associated with significantly higher risk of residual leak.

PO-02-134 REAL WORLD CLINICAL MANAGEMENT AFTER SURGICAL LEFT ATRIAL APPENDAGE EXCISION

Surgical left atrial appendage (LAA) closure is an increasingly utilized approach to mitigate the risk of cardioembolic stroke in patients with atrial fibrillation (AF). Optimal stroke prevention management after surgical LAA management with respect to imaging and continuation of oral anticoagulation (OAC) is not well understood. To elucidate real world clinical management of patients undergoing surgical LAA management. Over a 7-year period at a single center, 458 participants carried a diagnosis of AF and underwent surgical exclusion of their LAA during concomitant cardiac surgery. Clinical follow-up, including transesophageal echocardiography (TEE) data and OAC use were catalogued via chart review. Success of LAA ligation was defined as maximal stump depth < 1.0 cm (with no distal leak) in all dimensions imaged. Of the 458 participants, 115 (25%) had a post-operative TEE (with average post-operative time of 36 weeks). Of these 115 patients, 95 were discharged from cardiac surgery on OAC and 83/115 (72%) had successful LAA closure by TEE criteria; 19/115 had inadequate closure and 13/115 did not have sufficient image quality to assess LAA closure. Among the 83 patients with TEE-verified successful LAA closure, 7 had stroke during follow-up; of these strokes 3/7 occurred within 4 weeks of cardiac surgery. Only 1/7 patients was not on OAC at the time of their stroke. (Table 1) Among the 83 patients with successful LAA closure, 70 had been discharged on OAC following cardiac surgery. Of these 47/70 subsequently had their OAC discontinued; 43/47 of those discontinuations occurred after the TEE. Most patients undergoing surgical LAA management do not receive follow-up TEE imaging. When TEE is performed, surgical excision of the LAA is shown to have a moderate success rate. Clinical management after surgical LAA management, with regard to LAA imaging and OAC continuation, is highly heterogeneous.

Mitral Valve Replacement for Enlarged Libman-Sacks Endocarditis in a Patient with Persistent Primary Antiphospholipid Syndrome and Recurrent Stroke: A Case Report.

BACKGROUND Anticardiolipin antibodies in patients with Libman-Sacks endocarditis (LS) are indicative of comorbid antiphospholipid syndrome (APS) and can result in cerebral infarctions. We describe a case of LS and primary APS with recurrent cerebral infarctions despite anticoagulation treatment. The patient underwent surgery for enlarged LS vegetation with high titers of antiphospholipid antibodies. CASE REPORT A 41-year-old Japanese man was admitted to hospital for small cerebral infarction recurrence in a left parietal lesion. At age 35, the patient had suffered multiple cerebral infarctions. He was found to have high serum titers of all 3 antiphospholipid antibodies. Transesophageal echocardiography (TEE) findings were normal. Differential diagnosis ruled out other autoimmune diseases and a clinical diagnosis of primary APS was made. Warfarin anticoagulation was started. When cerebral infarction recurred 6 years after the first episode, serum titers of antiphospholipid antibodies remained high, and TEE showed a 7×8 mm area of mitral vegetation. A TEE results from his first admission revealed a 5×6 mm area of mitral vegetation, which was believed to be related to the current vegetation. As anticoagulation produced no improvement, the mitral valve was replaced with a mechanical valve. Examination of the excised vegetation found it to be consistent with LS. The patient made good progress within 3 years after surgery. CONCLUSIONS LS size can increase despite anticoagulation in cases with high titers of all 3 antiphospholipid antibodies and cerebral infarction. Such patients require ongoing TEE follow-up and surgical treatment should be considered.

623 PERCUTANEOUS LEFT ATRIAL APPENDAGE CLOSURE AND TRANSCATHETER CEREBRAL EMBOLIC PROTECTION: TWO CASES REPORT

Abstract Introduction Percutaneous left atrial appendage closure (LAAC) in AF patients is not inferior to oral anticoagulation (OAC) in terms of systemic embolism. LAA Closure is usually contraindicated in presence of intracardiac thrombus, a condition far from uncommon. The feasibility and safety of transcatheter cerebral embolic protection (TCEP) has been reported in literature as a successful off – label option in retrieving embolic debris during percutaneous LAAC. We present two cases of Watchman Flex insertion in the setting of LAA thrombus and prophylactic use of TCEP. Cases report The first patient was an 88-year-old male with history of symptomatic AF and post – traumatic cerebral bleeding, who was referred to LAAC because of high risk of bleeding in using OAC. Transthoracic echocardiography (TTE) documented a severely dilatated left atrial and preserved left ventricular systolic function. Transesophageal echocardiography (TEE) revealed a “chicken wing” shaped LAA with spontaneous echo-contrast and sludge effect confirmed with echo-contrast medium “SonoVue”. ECG – gated cardiac CT (CCT) showed a LAA filling defect and confirmed the diagnosis of LAA thrombus. The second patient was a 75-year-old man with valvular permanent AF and history of multiple ischemic strokes despite of OAC therapy with Warfarin. TTE documented a dilated left ventricle with severely depressed ejection fraction; TEE revealed a “windstock” shaped LAA with incompletely distal opacification with echo-contrast medium “SonoVue”. Both patients were candidate to LAAC with concomitant use of CEPDs in the event of neurological complication. TriGUARD 3 cerebral protection (TG3, Keystone Heart) was deployed in the aortic arch through right femoral artery access before LAAC procedure. Following transseptal puncture Watchman Flex device (Boston Scientific, Marlborough, MA) was deployed without complications or residual peri-device leaks. At the end the TriGurad 3 device was retracted and no debris were noted at the post operatory inspection. The first patient was discharged afterward with daily acetylsalicylic acid 100 mg and Clopidogrel 75 mg and the second patient with daily acetylsalicylic acid 100 mg and Warfarin. Both patients underwent follow-up TEE at four weeks. Neither device – related complications nor thrombotic/hemorrhagic adverse events have been not reported so far. Discussion Both patients were at very high risk for stroke and bleeding. They were not theoretically candidate to LAAC because of intracardiac thrombus. The prophylactic use of TCEP (including TG3) has been reported in a small retrospective study by Tarantini et al. and in some case series. Procedures were always successful and uneventful. Moreover, small captured debris on the device on visual examination proved its efficacy. The use of TCEP has been mentioned even by Beneduce et al. as a safer and more feasible strategy in AF patients. Conclusion Prophylactic use of TCEP during The Watchman Flex device implantation is safe and feasible.