Michael Tsang

Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure

AIMS Left atrial appendage (LAA) device imaging after endovascular closure is important to assess for device thrombus, residual leak, positioning, surrounding structures, and pericardial effusion. Cardiac CT angiography (CCTA) is well suited to assess these non-invasively. METHODS AND RESULTS We report our consecutive series of non-valvular atrial fibrillation patients who underwent CCTA post-LAA closure with Amplatzer Cardiac Plug (ACP), Amulet (second generation ACP), or WATCHMAN devices. Patients underwent CCTA typically 1-6 months post-implantation. Prospective cardiac-gated CCTA was performed with Toshiba 320-detector or Siemens 2nd generation 128-slice dual-source scanners, and images interpreted with VitreaWorkstation™. GFR <30 mL/min/1.73 m(2) was an exclusion. We assessed for device thrombus, residual LAA leak, device embolization, position, pericardial effusion, optimal implantation, and device lobe dimensions. Forty-five patients underwent CCTA at median 97 days post-LAA closure (18 ACP, 9 Amulet, 18 WATCHMAN). Average age was 75.5 ± 8.9 years, mean CHADS2 score 3.1 ± 1.3, and CHADS-VASc score 4.9 ± 1.6. All had contraindications to oral anticoagulation. Post-procedure, 41 (91.1%) were discharged on DAPT. There was one device embolization (ACP, successfully retrieved percutaneously) and one thrombus (WATCHMAN, resolved with 3 months of warfarin). There were two pericardial effusions, both pre-existing and not requiring intervention. Residual leak (patency) was seen in 28/44 (63.6%), and the mechanisms of leak were readily identified by CCTA (off-axis device, gaps at orifice, or fabric leak). Mean follow-up was 1.2 ± 1.1year, with no death, stroke, or systemic embolism. CONCLUSION CCTA appears to be a feasible alternative to transoesophageal echocardiography for post-LAA device surveillance to evaluate for device thrombus, residual leak, embolization, position, and pericardial effusion.

Comparing Measurements of CT Angiography, TEE, and Fluoroscopy of the Left Atrial Appendage for Percutaneous Closure

Left atrial appendage (LAA) closure requires accurate preprocedural measurements, and trans‐esophageal echocardiography (TEE), cardiac computed tomography angiography (CCTA) and fluoroscopy can be utilized. However, correlations between these measurements remain inadequately assessed.

Left Atrial Appendage Closure for Atrial Fibrillation Is Safe and Effective After Intracranial or Intraocular Hemorrhage

BACKGROUND Atrial fibrillation (AF) affects 1%-2% of the general population and 13% of individuals older than 80 years of age. Anticoagulation has been the mainstay therapy to reduce stroke risk. Patients with previous intracranial hemorrhage (ICH) or intraocular hemorrhage (IOH) are at increased risk of recurrence if anticoagulation is continued or initiated. Left atrial appendage (LAA) closure may obviate the need for long-term anticoagulation in these patients. METHODS We report our consecutive series of patients with nonvalvular AF with previous ICH or IOH who underwent LAA closure with the AMPLATZER Cardiac Plug (ACP; St Jude Medical, St Paul, MN), AMPLATZER Amulet, or WATCHMAN (Boston Scientific, Natick, MA) device. Demographics, clinical status, procedural outcomes, and complications were collected at baseline, during the procedure, at 3 months, at 1 year, and annually thereafter. RESULTS Twenty-six patients with previous ICH (n = 24) or IOH (n = 2) underwent LAA closure (9 with the ACP, 3 with the Amulet, and 7 with the WATCHMAN). The mean age was 76 ± 7 years, and 61.5% were men with a mean CHADS2 (Congestive Heart Failure, Hypertension, Age, Diabetes, Stroke/Transient Ischemic Attack) score of 3.2 ± 1.4 and CHA2DS2-VASc (Congestive Heart Failure, Hypertension, Age [≥ 75 years], Diabetes, Stroke/Transient Ischemic Attack, Vascular Disease, Age [65-74 years], Sex [Female] score) of 4.9 ± 1.7. No procedure-related complications occurred. Mean follow-up was 11.9 ± 13.3 months. One patient died at 13 months (this death was not related to the procedure), and 1 patient had a transient ischemic attack at 20.6 months after the procedure. No ischemic stroke, haemorrhagic stroke, or bleeding problems occurred during follow-up. CONCLUSIONS In our consecutive series, LAA closure was found to be safe and effective in patients with AF and a history of ICH or IOH.

The prognostic importance of the diastolic pulmonary gradient, transpulmonary gradient, and pulmonary vascular resistance in patients undergoing transcatheter aortic valve replacement

To evaluate the association between markers of precapillary pulmonary hypertension (PH) and survival in transcatheter aortic valve replacement (TAVR).

Abstract 21337: Comparison of Cardiac Computerized Tomography Angiography and Transesophageal Echocardiography for Device Surveillance After Endovascular Left Atrial Appendage Closure

Background: Surveillance after left atrial appendage (LAA) closure is important to assess for device success and complications. There is limited data on the role of cardiac computerized tomography angiography (CCTA) for LAA device monitoring. Methods: We retrospectively analyzed consecutive patients with non-valvular atrial fibrillation who underwent LAA closure who had both trans-esophageal echocardiography (TEE) and CCTA performed post-LAA closure. Prospective cardiac-gated CCTA were performed with Toshiba 320-detector or Siemens 2nd generation 128-slice dual-source scanners. We assessed for residual contrast patency of the LAA by comparing linear attenuation coefficient (Hounsfield unit, HU) in the LAA and left atrium (LA) on CCTA. Residual contrast patency was categorized as due to peri-device leak (presence of ostial gap) or fabric leak (diffusion of contrast through device membrane). We also assessed for device compression, thrombus and pericardial effusion on CCTA. These were compared to TEE findings. Results: Sixty-one patients underwent CCTA at median 93.5d (1-267) post-LAA closure (55 WATCHMAN, 4 Amulet, 2 ACP). Post-procedural TEE was done at median 93d (0-289). The median age was 77.5yrs (60-88) and median CHADS-VASc score 4 (2-8). Procedural success was 100%. On TEE, the presence of any peri-device leak was 26 (41.9%), with >3mm leak observed in 10/62 (16.1%), and >5mm observed in none. The presence of residual contrast patency in the LAA was observed in 36/61 (59%) on CCTA, of these, 29 (80.5%) had peri-device leak, and 7 (19.4%) had fabric leak. The median linear attenuation coefficient in patients with residual contrast patency was 328 (133-652) HU, and all had >100 HU in the LAA and HU attenuation ratio LA/LAA of >0.25. Median maximum device compression was 5.7% in those with peri-device leak, and 19.4% (p=0.027) for those without peri-device leak on CCTA. Among patients with peri-device leak on CCTA, 89.6% had peri-device leak on TEE, with corresponding 93.8% sensitivity, 69.9% specificity, and AUC=0.82 (95% CI 0.72-0.93). Conclusions: CCTA is more sensitive than TEE for assessing peri-device leak after LAA closure. Greater device compression appears to be associated with lower incidence of peri-device leak.