Left Atrial Appendage Occlusion

Figures

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  Central Illustration. Current Advances and Remaining Challenges With LAAO CCT = cardiac computed tomography; DRT = device related thrombus; GA = general anesthesia; ICE = intracardiac echo; LAAO = left atrial appendage occlusion; RCT = randomized controlled trial; SDD = same day discharge; TEE = transesophageal echo.

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  Figure 1. The Left Atrial Appendage as a Nidus for Thrombus Formation in Patients With Atrial Fibrillation LAA = left atrial appendage.

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  Figure 2. Patient-Level Meta-analysis Illustrating 5-Year Pooled Outcomes of PROTECT AF and PREVAIL Trials CV = cardiovascular; HR = hazard ratio; PREVAIL = Evaluation of the WATCHMAN Left Atrial Appendage (LAA) Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy); PROTECT AF = WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients With Atrial Fibrillation; SE = systemic embolization.

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  Figure 3. Procedural Outcomes in the NCDR LAAO Registry (A) Procedural success in LAAO Registry compared with the early LAAO trials and their nested registries. (B) Procedural complications in the LAAO Registry. CAP = continuous access to PROTECT AF registry; EWOLUTION = Registry on WATCHMAN Outcomes in Real-Life Utilization); PE = pericardial effusion; TIA = transient ischemic attack.

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  Figure 4. Predictors of DRT in the LAAO Literature AF = atrial fibrillation; APT = antiplatelet therapy; DRT = device-related thrombus; LAA = left atrial appendage; LVEF = left ventricular ejection fraction; OAC = oral anticoagulation; TIA = transient ischemic attack.

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  Figure 5. Endothelialization after LAAO With Different Occluders Shown are the Amulet Occluder (A to C) and Watchman 2.5 Device (D to F). (A and D) Gross inspection showing both devices properly positioned. (B and E) Microscopic inspection using hematoxylin and eosin stain showing both devices with complete left atrial appendage cavity fibrosis and seal with no peridevice leak. (C and F) Scanning electron microscopy showing bare components of both devices with exposed fabric and/or exposed attachment hubs. Disruption of tissues covering the device during explant sloughed off neoendothelium on the Amulet Occluder, as the edge of the neoendothelium is not tapered and has sharp demarcations (C, red arrow). Reprinted with permission from Ellis et al. J Am Coll Cardiol EP. 2022;8(6):828-829. https://doi.org/10.1016/j.jacep.2022.01.024. MV = mitral valve; RBC = red blood cells.

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  Figure 6. Suggested Algorithm for Assessment of Device Thrombus and Hypoattenuating Thickening After LAAO With the Watchman FLX Device HAT = hypoattenuating thickening.

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  Figure 7. Mechanism of Peri-Device Leak After Left Atrial Appendage Occlusion With the Watchman Device Illustration of the different mechanisms of peri-device leaks. (A) Point to the non-coaxial device (white arrows). (B) Uncovered lobe. (C) Point to the proximal side lobe (white arrows).

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  Figure 8. Clinical Impact of Peri-Device Leak After Left Atrial Appendage Occlusion With the Watchman Device (A) Data from the Pivotal Trial (PROTECT AF, PREVAIL, and CAP-1). (B) Data from the NCDR LAAO Registry. CI = confidence interval; HR = hazard ratio; LAAO = left atrial appendage occlusion; PDL = peridevice leak; PREVAIL = Evaluation of the WATCHMAN Left Atrial Appendage (LAA) Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy); PROTECT AF = WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients With Atrial Fibrillation; SE = systemic embolization; TIA = transient ischemic attack.

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  Figure 9. Computational Modeling for Optimization of Left Atrial Appendage Occluder Implantation Illustration of the impact of device size and deployment location of leaks in 2 patients, one treated with the Watchman FLX device (A, B) and one treated with the Amulet device (C, D).

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  Figure 10. Simplified Imaging Protocol for ICE-Guided LAAO Contrary to the 4 traditional views obtained with transesophageal echo (0, 45, 90, 135 degrees), assessing LAAO with ICE can be adequately achieved with imaging obtaining 2 orthogonal views from 2 locations (mid left atrium and across the mitral valve). (A) Mid-left atrial view; (B) transmitral view. ICE = intracardiac echocardiogram; LAA = left atrial appendage.

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  Figure 11. Trends in Same-Day Discharge After Left Atrial Appendage Occlusion Data from Vizient Clinical Database (n = >45,000).