contrast enhanced transesophageal echocardiographic guidance of left atrial appendage closure device...
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doi:10.1016/j.
Contrast Enhanced TransesophagealEchocardiographic Guidance of Left Atrial Appendage
Closure Device Implantation
Michael L. Main, MD, George G. Latus, BS, Anthony Magalski, MD, and Kenneth C. Huber, MD, Kansas City,Missouri; Plymouth, Minnesota
The percutaneous implantation of a left atrial appendage closure device offers an alternative to chronic oral anti-coagulation inpatients with nonvalvular atrial fibrillation andconcomitant risk factors for stroke. Transesophagealechocardiography plays a key role in defining left atrial appendage anatomy and in guiding device implantation.The authors describe a case in which contrast-enhanced transesophageal echocardiography was criticallyimportant in spatially resolving the borders of the left atrial appendage, which ultimately led to successful deviceimplantation with cessation of warfarin therapy. (J Am Soc Echocardiogr 2010;23:1007.e3-1007e4.)
Keywords: Atrial fibrillation, Left atrial appendage, Left atrial appendage closure device, Ultrasound contrastagents, Contrast echocardiography
Figure 1 Single-frame image (same view as Video 1). Red arrow= LAA closure device, yellow area = echo-free space adjacentto, and apparently communicating with, the LAA consistentwith an accessory lobe.
CASE PRESENTATION
A 76-year-old man with permanent atrial fibrillation presented for leftatrial appendage (LAA) closure device implantation as part of theWATCHMAN Continued Access PROTECT AF Registry (Atritech,Inc, Plymouth, MN).1 His concomitant risk factors for stroke includeda history of stroke, diabetes mellitus, and age > 75 years, yieldinga CHADS score of 4.2 Following baseline transesophageal echocar-diographic (TEE) assessment of the LAA in multiple planes and exclu-sion of intracardiac thrombus, transseptal puncture was performedand a 24-mm WATCHMAN LAA closure device was deployedinto the LAA through a 14Fr transseptal access system. TEE imagingperformed immediately following device deployment (but prior to re-lease) revealed adequate seating of the device in the LAA. However,a large cavity was noted adjacent to the device consistent with a non-excluded accessory LAA lobe (Video 1 and Figure 1). Color Dopplerimaging appeared to reveal flow communication between this cavityand the left atrium, further heightening suspicion for a nonexcludedaccessory lobe (Video 2 and Figure 2). To more definitely definethis anatomy, an ultrasound contrast agent (Definity [perflutren lipidmicrosphere injectable suspension]; Lantheus Medical Imaging,North Billerica, MA) was intravenously injected with concomitantTEE imaging (Video 3 and Figure 3). Contrast-enhanced imagingclearly revealed lack of contrast agent within the suspicious cavity ad-jacent to the LAA, consistent with the transverse sinus (a potentialspace created because of pericardial reflections). The device was sub-sequently released, with an excellent postprocedural result. Follow-upTEE imaging at 45 days revealed a well-seated device with completeexclusion of the LAA and no peridevice leak (Video 4).
ke’s Mid America Heart Institute, Kansas City, MO (M.L.M., A.M.,
tritech, Inc, Plymouth, MN (G.G.L.).
sts: Michael L. Main, MD, Cardiovascular Consultants, 4330 Wornall
000, Kansas City, MO 64111 (E-mail: [email protected]).
6.00
0 by the American Society of Echocardiography.
echo.2010.02.009
DISCUSSION
The percutaneous implantation of a LAA closure device offers an al-ternative to chronic oral anticoagulation in patients with nonvalvularatrial fibrillation and concomitant risk factors for stroke. TEE imagingplays a key role in defining LAA anatomy and guiding device implan-tation. The LAA is a complex structure; approximately 80% of LAAscontain accessory lobes, which are often visualized only with carefulmultiplane TEE imaging.3 Additionally, other cardiac structures (in-cluding the transverse sinus) lie in close anatomic proximity andcan complicate TEE assessment. In this case, two-dimensional andcolor Doppler imaging were insufficient to adequately determine ifan accessory lobe of the LAA existed, even with the excellent spatialresolution afforded by TEE imaging. Contrast-enhanced TEE imagingmarkedly improved the delineation of tissue borders and ultimatelyled to successful device release. Although ultrasound contrast agents
1007.e3
Figure 3 Single-frame image (same view as Video 3). Red arrow= LAA closure device, yellow area = transverse sinus.
Figure 2 Single-frame image (same view as Video 2). Red arrow= LAA closure device, yellow area = echo-free space to adjacentto, and apparently communicating with, the LAA consistent withan accessory lobe.
1007.e4 Main et al Journal of the American Society of EchocardiographySeptember 2010
have proven useful during interventional cardiac procedures4 (specif-ically for assessment of ‘‘myocardium at risk’’ during alcohol septal ab-lation in patients with hypertrophic cardiomyopathy), we believe thisis the first report documenting the utility of contrast-enhanced TEEimaging to better define both LAA and contiguous structural anatomyduring percutaneous LAA closure device implantation.
REFERENCES
1. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al,for the PROTECT AF Investigators. Percutaneous closure of the left atrial
appendage versus warfarin therapy for prevention of stroke in patientswith atrial fibrillation: a randomized non-inferiority trial. Lancet 2009;374:534-42.
2. Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ.Validation of clinical classification schemes for predicting stroke: resultsfrom the national registry of atrial fibrillation. JAMA 2001;285:2864-70.
3. Veinot JP, Harrity PJ, Gentile F, Khanderia BK, Bailey KR, Eickholt JT, et al.Anatomy of the normal left atrial appendage; a quantitative study of age re-lated changes in 500 autopsy hearts: implications for echocardiographic ex-amination. Circulation 1997;96:3112-5.
4. Mulvagh SL, Rakowski H, Vannan MA, Abdelmoneim SS, Becher H,Bierig SM, et al. American society of echocardiography consensus state-ment on the clinical applications of ultrasonic contrast agents in echocardi-ography. J Am Soc Echocardiogr 2008;11:1179-201.