Cardiac magnetic resonance imaging for left atrial appendage closure planning

Sapan Bhuta; Carolyn Cao; Justin Pieper; Matthew Tong; Juliet Varghese; Yuchi Han; Thura T. Harfi; Orlando P. Simonetti; Ralph Augostini; Steven J. Kalbfleisch; Salvatore Savona; Toshimasa Okabe; Muhammad R. Afzal; John D. Hummel; Emile G. Daoud; Mahmoud Houmsse

doi:10.1111/pace.14713

May 24, 2023Pacing and Clinical ElectrophysiologyOpen Access

Cardiac magnetic resonance imaging for left atrial appendage closure planning

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Why the study?

Following its use during a global iodine contrast media shortage, this study sought to assess the utility of CMR versus TEE for LAAC planning.

Does preoperative CMR provide comparable measurements to intraoperative TEE for left atrial appendage closure planning?

Structured PICO

Does preoperative CMR provide comparable measurements to intraoperative TEE for left atrial appendage closure planning?

P

Population

25 patients who underwent preoperative cardiac magnetic resonance imaging (CMR) for left atrial appendage closure (LAAC) with Watchman FLX or Amplatzer Amulet

I

Intervention

Preoperative cardiac magnetic resonance imaging (CMR) for LAAC planning

C

Comparator

Intraoperative transesophageal echocardiography (TEE) (performed in 18 patients)

O

Outcome

Accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per casesurrogate

CMR provides comparable measurements to TEE for LAA ostial diameter and device sizing, making it a viable alternative for LAAC planning when TEE or CCTA are contraindicated or unavailable.

Implication

CMR may offer a viable alternative to TEE for LAAC sizing and thrombus exclusion; leaves open need for prospective trials before broader adoption.

Abstract

BACKGROUND: Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. METHODS: This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland-Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. RESULTS: 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p = .229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p = .177), morphology (p = .422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland-Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR-TEE bias 0.7 mm, 95% CI [-1.1, 2.4], p = .420), but LAA depth was significantly larger with CMR versus TEE (CMR-TEE bias 7.4 mm, 95% CI [1.6, 13.2], p = .015). CONCLUSIONS: CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable.