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Contrast Enhanced Transesophageal Echocardiographic 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 in patients with nonvalvular atrial fibrillation and concomitant risk factors for stroke. Transesophageal echocardiography 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 critically important in spatially resolving the borders of the left atrial appendage, which ultimately led to successful device implantation 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 contrast agents, Contrast echocardiography CASE PRESENTATION A 76-year-old man with permanent atrial fibrillation presented for left atrial appendage (LAA) closure device implantation as part of the WATCHMAN Continued Access PROTECT AF Registry (Atritech, Inc, Plymouth, MN). 1 His concomitant risk factors for stroke included a history of stroke, diabetes mellitus, and age > 75 years, yielding a 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 performed and a 24-mm WATCHMAN LAA closure device was deployed into the LAA through a 14Fr transseptal access system. TEE imaging performed 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 Doppler imaging appeared to reveal flow communication between this cavity and the left atrium, further heightening suspicion for a nonexcluded accessory lobe (Video 2 and Figure 2). To more definitely define this anatomy, an ultrasound contrast agent (Definity [perflutren lipid microsphere injectable suspension]; Lantheus Medical Imaging, North Billerica, MA) was intravenously injected with concomitant TEE imaging (Video 3 and Figure 3). Contrast-enhanced imaging clearly revealed lack of contrast agent within the suspicious cavity ad- jacent to the LAA, consistent with the transverse sinus (a potential space created because of pericardial reflections). The device was sub- sequently released, with an excellent postprocedural result. Follow-up TEE imaging at 45 days revealed a well-seated device with complete exclusion of the LAA and no peridevice leak (Video 4). DISCUSSION The percutaneous implantation of a LAA closure device offers an al- ternative to chronic oral anticoagulation in patients with nonvalvular atrial fibrillation and concomitant risk factors for stroke. TEE imaging plays a key role in defining LAA anatomy and guiding device implan- tation. The LAA is a complex structure; approximately 80% of LAAs contain accessory lobes, which are often visualized only with careful multiplane TEE imaging. 3 Additionally, other cardiac structures (in- cluding the transverse sinus) lie in close anatomic proximity and can complicate TEE assessment. In this case, two-dimensional and color Doppler imaging were insufficient to adequately determine if an accessory lobe of the LAA existed, even with the excellent spatial resolution afforded by TEE imaging. Contrast-enhanced TEE imaging markedly improved the delineation of tissue borders and ultimately led to successful device release. Although ultrasound contrast agents Figure 1 Single-frame image (same view as Video 1). Red arrow = LAA closure device, yellow area = echo-free space adjacent to, and apparently communicating with, the LAA consistent with an accessory lobe. From Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.L.M., A.M., K.C.H.); and Atritech, Inc, Plymouth, MN (G.G.L.). Reprint requests: Michael L. Main, MD, Cardiovascular Consultants, 4330 Wornall Road, Suite 2000, Kansas City, MO 64111 (E-mail: [email protected]). 0894-7317/$36.00 Copyright 2010 by the American Society of Echocardiography. doi:10.1016/j.echo.2010.02.009 1007.e3

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Page 1: Contrast Enhanced Transesophageal Echocardiographic Guidance of Left Atrial Appendage Closure Device Implantation

From Saint Lu

K.C.H.); and A

Reprint reque

Road, Suite 2

0894-7317/$3

Copyright 201

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

Page 2: Contrast Enhanced Transesophageal Echocardiographic Guidance of Left Atrial Appendage Closure Device Implantation

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.