Clinical Impact of Preprocedural CT-Based 3D Computational Simulation of Left Atrial Appendage Occlusion with Amulet

Figures

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  Figure 1. Illustrative case of a 70-year-old man with paroxysmal atrial fibrillation, CHADS-VASc score of 4, HAS-BLED score of 4, and previous intracranial haemorrhage scheduled for LAAO. Measurements of the os and landing zone, respectively, by 3D TEE were 23 × 31 mm and 19 × 22 mm, and those by CT were 22 × 30 mm and 19 × 22 (18.6 × 21.9 mm, left panel). Standard of care assessment had chosen for a 25 Amulet, with team's confidence 6 out of 10. FEops 3D rendering volume showed a chicken wing morphology (middle panel). Computation simulation of a 22 Amulet revealed limited compression (5.0 to 5.9%) and apposition both in proximal and distal positions, while a 25 Amulet had a better compression (12.6 to 14.4%) and apposition (see colour code, green 0 mm distance between device and appendage and red 2 mm) with good sealing of the os. A 25 Amulet with distal position was chosen with confidence 8 out of 10. Postimplantation images showed perfect position and sealing (right panel).

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  Figure 2. Case examples influenced by FEops. (a–d): patient 13, with a very large appendage, with mean landing zone of 31 mm on TOE (a), and chicken wing morphology with poor confidence (6 out of 10) for a 34 Amulet. FEops (c) confirmed good anchoring and sealing with a 34, with good angiographic results (d). (e–h): patient 3, implanted under local anaesthesia with intracardiac echocardiography. Windsock morphology on angiography (e) and 3D volume (f). Although initial assessment with CT (landing zone 16 × 18 mm) decided for a 20 mm, simulation with a 22 Amulet was preferred (g) with good angiographic results (h). (i–l): patient 6, reverse chicken wing morphology on TOE (i) and angiography (j), with an initial 22 Amulet selected based on TOE (3D landing zone 18 × 21 mm) and CT (landing zone 14 × 21 mm), but with a preferred 20 Amulet simulation (k) and good angiographic results once implanted (l). (m–p): patient 9, windsock with large os and almost no depth on angiography (m) and 3D volume (o), with landing zone 22 × 31 mm on CT (n); a 31 mm Amulet could not be implanted after multiple attempts. Note the absence of apposition (red) posterosuperior on the FEops simulation (p).