Left Atrial Appendage Occlusion: Expanding Indications and New Developments

Figures

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  Figure 1. Key design features of the WATCHMAN 2.5, WATCHMAN-FLX, and Amulet devices Abbreviation: LAA, left atrial appendage.

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  Figure 2. Common anatomic considerations for LAAO. (a) CT imaging of LAA thrombus; (b) slow flow in the LAA. Filling defect that persists with delayed acquisition is likely thrombus (panel A), but if it becomes homogenous, it is likely slow flow (panel B); (c) challenging anatomy with large LAA and multiple lobes; (d) note that given adequate implantation depth, LAAO was still successful in this patient. Videos of panels A-C are included in the supplement Abbreviations: CT, computed tomograph; LAA, left atrial appendage; LAAO, left atrial appendage occlusiony.

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  Figure 3. Device-related thrombus (DRT). The 2D and 3D TEE images of DRT attached to the LA surface of a Watchman 2.5 device Abbreviations: 2D, two-dimensional; 3D, three-dimensional; LA, left atrial; TEE, transesophageal echocardiography.

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  Figure 4. TEE and CT images of a patient with peridevice leak (PDL). (a) TEE of a significant PDL >5 mm visualized posteriorly on color flow Doppler with Nyquist decreased to visualize lower velocity flow. (b) 3D TEE en face view of the Watchman device with a peridevice gap visualized posteriorly (arrow). (c) Cardiac CT demonstrating the leak communicates with a posterior lobe Abbreviations: 3D, three-dimensional; CT, computed tomography; TEE, transesophageal echocardiography.

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  Figure 5. PDL closure with an AVP 2 device. (a) Significant PDL was identified by TEE (similar to the patient in Figure 3). (b) The PDL was wired and closed with a single 12 mm AVP 2 device (arrow), which is deliverable through a standard 5F catheter Abbreviations: AVP, amplatzer vascular plug; PDL, peridevice leak; TEE, transesophageal echocardiography.

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  Figure 6. Example of combined TAVR ​+ ​Watchman LAAO. (a) Use of the pre-TAVR CT scan to measure both the AV annulus (left top panel) and LAA for Watchman placement (right top and bottom panel); (b) correlation of CT and TEE sizing; (c) fluoroscopic images of Watchman placement in RAO caudal view, separating TAVR and Watchman devices for visualization; (d) final TEE following successful 27 mm Watchman FLX Pro Abbreviations: AV, aortic valve; CT, computed tomography; LAA, left atrial appendage; LAAO, left atrial appendage occlusion; RAO, right anterior oblique, TAVR, transcatheter aortic valve replacement; TEE, transesophageal echocardiography.

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  Figure 7. Example of combined M-TEER ​+ ​LAAO. (a and b) Use of TEE prior to M-TEER to assess severity and mechanism of MR and size for Watchman placement; (c and d) placement of three Edwards Pascal/ACE devices; (e and f) successful placement of Watchman FLX Pro device via the same TSP and femoral venous access site used for M-TEER, using fluoroscopy and TEE for guidance Abbreviations: LAAO, left atrial appendage occlusion; M-TEER, mitral transcatheter edge-to-edge repair; MR, mitral regurgitation; TEE, transesophageal echocardiography; TSP, transseptal puncture.

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  Figure 8. Coumadin Ridge Edema after AF ablation. Panel A: baseline images of the LAA prior to AF ablation. Panel B: significant coumadin ridge edema post AF ablation. Device implanted slightly deeper within the LAA to avoid anchoring along the edematous ridge Abbreviations: AF, atrial fibrillation; LAA, left atrial appendage.

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  Figure 9. ICE image analysis using 3D MPR to mimic traditional TEE views. Panel A: baseline LAA images from the mid-LA vantage point manipulated to mirror traditional TEE views. Panel B: postimplant TEE images demonstrating identical anatomy to baseline ICE images with a well-seated Watchman device in place Abbreviations: 3D, three-dimensional; ICE, intracardiac echocardiography; LA, left atrial; LAA, left atrial appendage; MPR, multiplanar reconstruction; TEE, transesophageal echocardiography.

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  Figure 10. Key ICE imaging views of the LAA using 2D imaging. Panel A: mid-left atrial (LA) view. Panel B: left upper pulmonary vein (LUPV) view. Panel C: mitral valve (MV) or transmitral view Abbreviations: 2D, two-dimensional; ICE, intracardiac echocardiography; LAA, left atrial appendage.

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  Figure 11. ICE 3D multiplanar reconstruction (MPR) of the LAA. Each panel corresponds to the similar panel from Figure 10. Labels are provided for spatial orientation. Panel A: mid-left atrial (LA) view. Panel B: left upper pulmonary vein (LUPV) view. Panel C: mitral valve (MV) or transmitral view Abbreviations: 3D, three-dimensional; ICE, intracardiac echocardiography; LAA, left atrial appendage.