Left Atrial Appendage Occlusion/Exclusion

22 Pages·2017·13.6 MB·English

1 68
Left Atrial Appendage Occlusion/Exclusion:
2 69
3 70
Procedural Image Guidance with Transesophageal
4 71
5 72
Echocardiography
6 73
7 74
8 75
9 QQQ444 AlanF.Vainrriibb,MD,SergeC.Harrbb,MD,WaelJabbeerr,MD,RicardoJ.Benensteiinn,MD,AAnntthhoonnyyAizzeerr,MD, 76
10 LarryA.Chiniittzz,MD,andMuhamedSarriicc,MD,PhD,NewYork,NewYork;andCleveland,Ohio 77
11 78
12 79
13 80
14 Atrialfibrillationisthemostcommonarrhythmiaworldwideandisamajorriskfactorforembolicstroke.Inthis 81
15 article,theauthorsdescribethecrucialroleoftwo-andthree-dimensionaltransesophagealechocardiography 82
16 in the pre- and postprocedural assessment and intraprocedural guidance of percutaneous left atrial 83
17 appendage(LAA)occlusionprocedures.Althoughrecentadvanceshavebeenmadeinthefieldofsystemic 84
18 anticoagulationwiththenoveloralanticoagulants,thesemedicationscomewithasignificantriskforbleeding 85
19 86
andarecontraindicatedinmanypatients.Becausethromboembolisminatrialfibrillationtypicallyarisesfrom
20 87
thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been
21 88
devisedasalternativestosystemicanticoagulation.Currently,surgicalLAAexclusionistypicallyperformed
22 89
as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently,
23 90
24 severalpercutaneouslydelivereddevicesforLAAexclusionfromthesystemiccirculationhavebeendevel- 91
25 oped,someofwhichhavebeenshowninclinicaltrialstoreducetheriskforthromboembolism.Thesedevices 92
26 useaneitherpurelyendocardialLAAocclusionapproach,suchastheWatchmanandAmuletprocedures,or 93
27 bothanendocardialandapericardial(epicardial)approach,suchastheLariatprocedure.IntheWatchman 94
28 andAmuletprocedures,atransseptallydeliveredstructurecomposedofnitinolisplacedintheLAAorifice, 95
29 therebyexcludingtheLAAfromthesystemiccirculation.IntheLariatprocedure,amagnetlinkiscreatedbe- 96
30 97
tween a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by
31 98
epicardialsutureligationoftheLAA.(JAmSocEchocardiogr2017;-:---.)
32 99
33 100
Keywords: Transesophageal echocardiography, 3D, Left atrial appendage occlusion, Lariat device,
34 101
35 Watchmandevice,Amuletdevice,Atrialfibrillation 102
36 103
37 104
38 Atrial fibrillation (AF) is the most common cardiac arrhythmia, agulation but have been shown to have inferior efficacy compared 105
39 106
affecting>3millionpeopleintheUnitedStatesalone.Theprevalence withanticoagulation.
40 107
ofAFincreaseswithage.TheincidenceofAFintheUnitedStatesis Satisfactoryanticoagulationwithoralwarfarinwithatargetinterna-
41 108
projectedtoincreaseto7.56millionby2050because oftheaging tionalnormalizedratioof$2to3hasbeendemonstratedtoreduce
42 109
population.1 theriskforstrokeandsystemicembolismby67%comparedwithpla-
43 110
44 Becauseofitssignificantmorbidityandmortality,AFisassociated cebo4 and by 45% compared with aspirin.5 Newer anticoagulants 111
45 with substantial personal, societal, and economic costs. AF is esti- (such as dabigatran, apixaban, and rivaroxaban) have been shown 112
46 matedtocosttheUnitedStatesapproximately$6billioneachyear.2 tobeatleastnoninferiortowarfarininnonvalvularAF.6-8 113
47 Systemic thromboembolism is the major complication of both Unfortunately,allanticoagulantshavesignificantbleedingriskand 114
48 valvularandnonvalvularAF.Theleftatrialappendage(LAA)isthe maybecontraindicatedincertainpatients.Theriskformajorbleeding 115
49 most common site of thrombus formation, accounting for 91% of (typicallydefinedasareductioninhemoglobin levelof$2mg/dL, 116
50 117
left heart thrombi in patients with nonrheumatic AF and 57% of transfusionof2Uofpackedredcells,orsymptomaticbleedingoccur-
51 118
thrombiinpatientswithrheumaticAF.3 ringatacriticalsiteorresultingindeath)witheitherwarfarinornewer
52 119
Anticoagulation with orally, intravenously, or subcutaneously agentsisestimatedat1.4%to>3%peryear.9
53 120
administeredcompoundsisthemostcommonmethodofpreventing Because most thrombi related to nonvalvular AF typically
54 121
55 thromboembolism in patients with AF. Antiplatelet agents such as reside in the LAA, surgical or percutaneous techniques of LAA 122
56 aspirinorclopidogrelcanbeusedasanalternativetosystemicantico- exclusionhavebeendevelopedasalternativestosystemicantico- 123
57 agulant and antiplatelet therapy. These exclusion procedures act 124
58 FromtheLeonH.CharneyDivisionofCardiologyNewYorkUniversityLangone locally at the level of the LAA to prevent thrombi from entering 125
59 MedicalCenter,NewYork,NewYork(A.F.V.,R.J.B.,A.A.,L.A.C.,M.S.);andthe the systemic circulation. 126
60 ClevelandClinic,Cleveland,Ohio(S.C.H.,W.J.). SurgicaltechniquesusedforLAAexclusionhaveincludedligation, 127
61 Reprint requests: Muhamed Saric, MD, PhD, New York University, 560 First clipping, stapling, and amputation.10-12 A major limitation of these 128
62 129
Avenue,NewYork,NY10016(E-mail:[email protected]). proceduresisthattheyaretypicallyperformedasadjunctstoother
63 130
64 0894-7317/$36.00 cardiac procedures, and therefore only a small number of patients 131
65 Copyright2017PublishedbyElsevierInc.onbehalfoftheAmericanSocietyof withAFareeligibleforthem. 132
66 Echocardiography. Percutaneous LAA occlusion/exclusion devices (Figure 1) include 133
67 https://doi.org/10.1016/j.echo.2017.09.014 the PLAATO (eV3, Plymouth, MN; no longer on the market), 134
1
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
2 Vainribetal JournaloftheAmericanSocietyofEchocardiography
-2017
135 Watchman (Boston Scientific, TheLAAorificeisseparatedfromtheleft-sidedpulmonaryveins 202
Abbreviations
136 Maple Grove, MN), Amplatzer by the ligament of Marshall (also referred to as the left lateral or 203
137 2D=Two-dimensional LAAoccluders(AmplatzerCardiac ‘‘Coumadin’’ridge).TheLAAmaycontainoneormorelobes,defined 204
138 PlugandAmulet;St.JudeMedical, asprotrusionsfromitsmainbody.19 205
139 3D=Three-dimensional Minneapolis,MN),13-15andLariat AnatomicvariantsoftheLAAarewelldescribed20andinclude 206
140 AF=Atrialfibrillation (Sentre-HEART,PaloAlto,CA).16-18 the windsock, the broccoli (or cauliflower), the cactus, and the 207
141 208
142 ASD=Atrialseptaldefect IntheUnitedStates,currently chicken wing (Figure 3). Of the known LAA variants, the 209
the only device specifically chicken-wing morphology is the most common. However, it is
143 210
144 LAA=Leftatrialappendage approved by the US Food and alsoknowntocausethegreatestproceduraldifficultywithregard 211
145 PDL=Para-deviceleak Drug Administration for LAA to LAA occlusion/exclusion. This is due to its broad width and 212
146 occlusion is the Watchman de- shallow depth, which create a difficult situation regardless of 213
147 PEF=Pericardialeffusion vice,whichwasclearedforgen- the type of device used. 214
148 TEE=Transesophageal eralclinicaluseinMarch2015. LAAanatomyistypicallyestablishedduringthescreeningpro- 215
149 echocardiography TheLariatdevicehasreceived cess using gated cardiac computed tomographic angiography. It 216
150 217
class II clearancefrom theFood may also be confirmed using both intraprocedural TEE and fluo-
151 218
andDrugAdministrationviathe510(k)protocol.Thisdeviceisnot roscopy.
152 219
specifically approved for percutaneous LAA exclusion but rather
153 220
for ‘‘facilitating suture placement and knot tying in surgical applica-
154 CorrespondenceofFluoroscopicandTransesophageal 221
155 tionsinwhichsofttissueisbeingapproximatedand/orligatedwith EchocardiographicViewsoftheLAA 222
156 a pre-tied polyester suture.’’ Nevertheless, the Lariat has entered 223
Itisimportantthatacommonlanguagebedevelopedbetweeninter-
157 into clinical practice. There is increasing use of both devices in the 224
ventionalists, who are typically most familiar with fluoroscopy, and
158 UnitedStates. 225
echocardiographersperformingintraproceduralTEE.
159 TheAmplatzerCardiacPlugUSpivotaltrialbeganenrollmentin 226
160 2013, but it was discontinued because of slower enrollment. The The right anterior oblique caudal view is equivalent to approxi- 227
161 mately 135(cid:127) on TEE and typically reveals the major axis of the 228
second-generation Amplatzer LAA occluder, referred to as the
162 LAAorifice(Figure4). 229
Amulet device, is currently being investigated in the United States
163 The right anterior oblique cranial view is equivalent to approxi- 230
intheAmulettrial.
164 mately45(cid:127) onTEEandtypicallyrevealstheminoraxisoftheLAA 231
TheWatchman,Amplatzer CardiacPlug,and Amuletdeviceare
165 orifice(Figure5). 232
166 delivered using peripheral venous access and transseptal puncture 233
167 (a fully endovascular approach). In contrast, the Lariat procedure 234
168 uses both an endocardial and a pericardial (epicardial) approach to 235
169 createamagnetlinkbetweenendocardialandpericardialwires,fol- OVERVIEWOFPERCUTANEOUSLAAOCCLUSION/ 236
170 lowedbyepicardialsutureligationoftheLAA.Anotherdevicethat EXCLUSIONPROCEDURES 237
171 QQQ111can ligate the LAA ligationusing an endocardial and a pericardial 238
117722 approach is the LASSO device (Aegis Medical Innovations, Irrespective of the LAA occlusion/exclusion device used, the 239
173 240
Vancouver,BC,Canada).Thissystemuseselectricalmappingrather basic steps are common to all percutaneous LAA occlusion/
174 241
thanamagneticlinktolocateandligatetheLAAandiscurrentlybe- exclusion procedure. All percutaneous LAA occluder implanta-
175 242
ingtestedintheopen-labelLASSOAFtrial. tion procedures begin with peripheral venous access, which is
176 243
177 All percutaneous LAA occlusion/exclusion procedures would typically obtained through the right femoral vein. Subsequently, 244
178 not be possible without two-dimensional (2D) and three- a transseptal puncture is performed to gain access to the left 245
179 dimensional 3D transesophageal echocardiography (TEE). In atrium. Thereafter, specific steps for deployments of individual 246
180 thisreview,wediscusstheroleof2Dand3DTEEforperiproce- occluder devices are taken. 247
181 duralguidanceofthepercutaneousLAAocclusion/exclusionde- 248
182 vices either currently commercially available or under clinical 249
183 250
investigation in the United States, namely, the Watchman, TRANSSEPTALPUNCTUREFORPERCUTANEOUSLAA
184 251
Amulet, and Lariat. OCCLUDERS
185 252
186 253
Overview
187 254
188 LAAANATOMY After peripheral venous access is obtained, typically through the 255
189 femoral vein, a transseptal needle delivery catheter and dilator are 256
190 Detailed knowledge of LAA anatomy is essential for successful passedthroughtheinferiorvenacavaintotherightatriumandtempo- 257
191 percutaneous LAA closure procedures. The LAA is a complex rarilyplacedinthesuperiorvenacava.Thereafter,atransseptalnee- 258
192 ‘‘fingerlike’’ projection from the anterolateral portion of the left dleisadvancedthroughthedeliverycatheter. 259
193 atrium. Internally, it begins with an orifice that is typically ovoid Usingtransesophagealechocardiographicguidance,thewholesys- 260
194 261
and thus has a major and a minor orifice diameter. This orifice tem is then withdrawn from the superior vena cava into the right
195 262
opens to its neck region, then its body, and ultimately ends in atrium and positioned against the inferior and posterior portion of
196 263
its apex (Figure 2). theinteratrialseptum.Thedelivercatheteristhenadvancedagainst
197 264
The anatomic definition of LAA ‘‘orifice’’ is typically different theinteratrialseptumtotenttheinteratrialseptumatanappropriate
198 265
199 from the ‘‘orifice’’ defined as the landing zone for various LAA location. Fluoroscopy and TEE are essential in guiding the proper 266
200 occluder devices. This is addressed in detail with each individual locationoftenting.Theneedleisthenadvanced,creatingatransseptal 267
201 occluder device description below. puncture. 268
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
JournaloftheAmericanSocietyofEchocardiography Vainribetal 3
Volume-Number-
269 336
270 337
271 338
272 339
273 340
274 341
275 342
276 343
277 344
278 345
279 346
280 347
281 348
282 349
283 350
284 351
285 352
286 353
287 354
288 355
289 356
290 357
291 358
292 359
293 360
294 361
295 362
296 363
297 364
298 365
O
299 P 366
F
300 = 367
C
301 4 368
b
302 e 369
w
303 & 370
304 nt 371
305 pri 372
Figure 1 Percutaneous LAA occlusion/exclusion devices. Images of percutaneously delivered LAA occluder devices. (A) The
306 373
PLAATOLAAoccluderisnolongeronthemarket.(B)TheWatchmandeviceiscurrentlyapprovedbytheFoodandDrugAdminis-
307 374
trationandisinuseintheUnitedStates.(C)TheAmplatzercardiacplug(left)isnotavailableintheUnitedStates.TheAmplatzer
308 375
Amulet device (right)is currently undergoing clinical investigation inthe United States. (D) TheLariat device iscurrently in use in
309 376
theUnitedStatesbywayofa510(k)approval.
310 377
311 378
312 379
313 380
314 381
315 382
316 383
317 384
318 385
319 386
320 387
321 388
322 389
323 390
324 391
325 392
O
326 P 393
F
327 = 394
C
328 4 395
b
329 e 396
w
330 & 397
331 nt 398
332 pri 399
Figure2 LAAdiameteranatomy.LAAanatomyisdemonstratedongrosspathology(A)and2DTEE(B).Correspondingstructuresare
333 400
labeledonpathologyand2DTEE(yellowarrows).
334 401
335 402
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
4 Vainribetal JournaloftheAmericanSocietyofEchocardiography
-2017
403 470
404 471
405 472
406 473
407 474
408 475
409 476
410 477
411 478
412 479
413 480
414 481
415 482
416 483
417 484
418 485
419 486
420 487
421 488
O
422 P 489
F
423 C= 490
424 4 491
b
425 we 492
426 & 493
427 nt 494
428 pri 495
Figure3 LAAshapes.ThreemainLAAmorphologiesaredemonstratedon2DTEEandpathologicspecimencasts.Thecastimages
429 aremodifiedwithpermissionfromErnstG,Sto€llbergerC,AbzieherF,Veit-DirscherlW,BonnerE,BibusB,SchneiderB,SlanyJ. 496
430 497
Morphologyoftheleftatrialappendage.AnatRec1995;242:553–561.
431 498
432 499
433 500
434 501
435 502
436 503
437 504
438 505
439 506
440 507
441 508
442 509
443 510
444 511
445 512
446 513
447 514
448 515
449 516
450 517
451 518
452 519
453 520
454 521
455 522
456 523
457 524
458 525
459 526
460 527
461 528
462 529
463 530
464 531
465 532
466 533
Figure4 TEEversusfluoroscopy,rightanterioroblique(RAO)caudalview.Transesophagealechocardiographicequivalentviewsof
467 534
theRAOcaudalfluoroscopicviewaredemonstrated.TheRAOcaudalviewcanbesimulatedon2DTEEbyobtainingalong-axisview
468 535
oftheLAA(typicallyabout135(cid:127))andthenrotatingtheimagecounterclockwise.
469 536
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
JournaloftheAmericanSocietyofEchocardiography Vainribetal 5
Volume-Number-
537 604
538 605
539 606
540 607
541 608
542 609
543 610
544 611
545 612
546 613
547 614
548 615
549 616
550 617
551 618
552 619
553 620
554 621
555 622
556 623
557 624
558 625
559 626
560 627
561 628
562 629
563 630
564 631
565 O 632
P
566 F 633
=
567 C 634
4
568 b 635
e
569 w 636
&
570 637
nt
571 pri 638
572 Figure5 TEEversusfluoroscopy,rightanterioroblique(RAO)cranialview.Transesophagealechocardiographicequivalentviewsof 639
573 theRAOcranialfluoroscopicviewaredemonstrated.TheRAOcranialviewcanbesimulatedon2DTEEbyobtainingashort-axisview 640
574 oftheLAA(typicallyabout45(cid:127))andthenrotatingtheimagecounterclockwise. 641
575 642
576 643
Theinferoposteriorpuncturepositionallowsthemostdirectroute and 3D transesophageal biplane imaging) can improve transseptal
577 644
totheanterolaterallylocatedLAA.Thisisincontrasttoothertrans- puncturesafetyandoverallproceduralsuccess.22
578 645
579 septal procedures suchas MitraClip (Abbott Vascular, Abbott Park, Using 2D and 3D TEE, assessment of the interatrial septum 646
580 IL) implantation and transcatheter mitral valve replacement, which firstincludesidentificationoftheposition,thickness,andmobility 647
581 require a superior and posterior transseptal puncture to ensure of the fossa ovalis. Subsequently, color Doppler imaging is used 648
582 adequateheightabovethemitralvalve. to assess for baseline patent foramen ovale or atrial septal defect 649
583 Two commonly used transseptal delivery catheters are the (ASD). 650
584 Mullins introducer (Medtronic, Minneapolis, MN), and the Usingbiplaneimagingoftheinteratrialseptum(anterior-posterior 651
585 652
Agilis steerable introducer (St. Jude Medical). The most inoneplane,superior-inferiorintheother)thetransseptalneedleis
586 653
commonly used transseptal needle is the Brockenbrough needle guidedtowardtheinferiorandposteriorportionofthefossaovalis.
587 654
(Medtronic), but a radiofrequency needle (Baylis Medical, After slight needle assembly advancement toward the left atrium,
588 655
Montreal, QC, Canada) can be helpful to cross thick, fibrotic, thetentingoftheinteratrialseptumidentifiesthelocationofthetrans-
589 656
590 or patched septa.21 Transseptal catheters and needles are de- septal needle on echocardiography (Figure 7, Video 1 available at 657
591 picted in Figure 6. http://www.onlinejase.com). It is of utmost importance to do the 658
592 Once the transseptal puncture of the procedure has been transseptalpunctureintheinferiorandposterioraspectoftheintera- 659
593 completed, the dilator and sheath are then advanced to avoid left trialseptum(Figure8). 660
594 atrial wall injury. Awire is subsequently passed into the left atrium Whenthe echocardiographer providesreal-timeTEEtoaninter- 661
595 and typically positioned in the left superior pulmonary vein; the ventionalist,itisusefultolabelsuperior,inferior,anterior,andposte- 662
596 663
dilatorandsheatharethenremoved. riorlocationsontheechocardiographicimage.
597 664
Aftertransseptalpuncturehasbeenperformed,3DTEEusing3D
598 665
zoom of the interatrial septum may be helpful to confirm that the
599 666
EchocardiographicGuidanceofTransseptalPuncture transseptalpuncturehasoccurredinafavorablelocation.Astep-by-
600 667
601 Although transseptal puncture can be performed with adequate stepapproachfortheproductionofhigh-qualityviewsoftheintera- 668
602 safetyusingacombinationofoperatortactilefeedbackandfluoros- trial septum by 3D TEE has been previously described using the 669
603 copy, echocardiography (2D TEE, intracardiac echocardiography, TUPLE(tiltup,thenleft)maneuver.23 670
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
6 Vainribetal JournaloftheAmericanSocietyofEchocardiography
-2017
671 738
672 739
673 740
674 741
675 742
676 743
677 744
678 745
679 746
680 747
681 748
682 749
683 750
684 751
685 752
686 753
687 754
688 755
689 756
690 757
691 758
692 759
693 760
694 761
695 762
696 763
697 764
698 765
699 766
700 767
701 768
702 769
703 770
704 771
705 772
O
706 P 773
707 F= 774
C
708 4 775
b
709 e 776
w
710 & 777
711 nt 778
712 pri 779
Figure6 Transseptaldevices.Commonlyuseddevicesfortransseptalpunctureworldwide.
713 780
714 781
715 782
716 Atrialseptalaneurysmandmarkedlipomatoushypertrophyof TheWatchmanprocedurebeginswithvenousaccessandtranssep- 783
717 the interatrial septum may present anatomic challenges to suc- tal puncture, as described previously. Subsequently, the Watchman 784
718 cessful transseptal puncture. The presence of a large atrial septal 12-Fr delivery system with a pigtail catheter is advanced into the 785
719 aneurysm should be communicated to the interventionalist, as leftatriumoverthewireandthenplacedintotheLAA.Next,iodin- 786
720 787
excessive advancement of the transseptal needle may lead to atedcontrastisinjectedintotheLAAtodefineitsanatomyonfluo-
721 788
perforation of the left atrial free wall. In the presence of lipoma- roscopy. TheWatchman device is then positioned and delivered in
722 789
tous hypertrophy, it is important to guide the transseptal punc- the LAA ostium. Finally, the device is released after stability and
723 790
ture through the thin central portion of the fossa ovalis rather optimalpositionare confirmedbybothechocardiographyandcine
724 791
725 than the hypertrophied limbs.24 fluoroscopy with intravenous contrast. An animated description of 792
726 the Watchman procedure can be viewed on YouTube: https:// 793
727 www.youtube.com/watch?v=8O2Hba-JQoQ&feature=youtu.be&list 794
728 =PL63i2jgsqsT_Jzpx5tTAI_rM56xo6JDUj. 795
WATCHMANPROCEDURE
729 OfallpercutaneousLAAoccluderdevices,theWatchmanhasthe 796
730 Overview mostoutcomesdata,whichhavedemonstrateditsnoninferiorityto 797
731 TheWatchmanisatransseptallydelivered,self-expandingnickeltita- chronicwarfarintherapyinarandomizedtrial.15Possibleprocedural 798
732 799
nium device with fixation barbs, covered by a permeable polyester complicationsincludepericardialeffusion(PEF),deviceembolization,
733 800
fabric. The device is delivered under fluoroscopic and echocardio- and procedure-related stroke.25 After device implantation, patients
734 801
735 graphic guidance and is available in five sizes (21, 24, 27, 30, and typically require warfarin therapy for 45days, followed by dual- 802
736 33mm) on the basis of the device diameter on its left atrial side antiplatelettherapy(withaspirinandclopidogrel)for6monthsand 803
737 (Figure9). thenaspirinaloneforlifetopreventclotformation.15 804
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
JournaloftheAmericanSocietyofEchocardiography Vainribetal 7
Volume-Number-
805 872
806 873
807 874
808 875
809 876
810 877
811 878
812 879
813 880
814 881
815 882
816 883
817 884
818 885
819 886
820 887
821 888
822 889
823 890
824 891
825 892
826 893
827 894
828 895
829 896
830 897
831 898
832 899
833 900
834 901
835 902
836 903
837 904
838 905
839 906
840 907
841 908
842 909
843 O 910
P
844 F 911
=
845 C 912
4
846 b 913
e
847 w 914
&
848 nt 915
849 pri 916
850 Figure 7 Transseptal puncture guidance by TEE: part 1. Two-dimensional TEE with biplane imaging demonstrates the interatrial 917
851 septuminthemidesophagealshort-axisandbicavalviewsduringthetransseptalpunctureportionofanLAAocclusion/exclusion 918
852 procedure(A,B).Notethetentingintheinferiorandposteriorportionofthefossaovalis,whichistheideallocationforpuncture. 919
853 Video1correspondsto(A)and(B).Three-dimensionalTEEoftheinteratrialseptumfromtherightatrialperspectiveatbaselinebefore 920
854 transseptalpuncture(C)andfollowingtransseptalpuncture(D).Thisviewdemonstratestheanatomiclocationofthefossaovalis 921
855 (whitedottedcircles)atbaseline(C)andcatheter-relateddropout(D).AV,Aorticvalve;IVC,inferiorvenacava;LA,leftatrium;RA, 922
856 rightatrium;SVC,superiorvenacava;TV,tricuspidvalve. 923
857 924
858 925
859 BaselineComprehensiveAssessment LAASizingSpecifictotheWatchman 926
860 AllpercutaneousLAAocclusion/exclusiondevicesrequirecompre- LAAlandingzonesizeandLAAdeptharemeasuredduringthebaseline 927
861 hensive baseline intraprocedural 2D and 3DTEE. This echocardio- proceduralassessmentfortheWatchmanprocedure.On2DTEE,the 928
862 graphicassessmentfocusesonestablishingthepresence orabsence LAAis imagedat 0(cid:127),45(cid:127), 90(cid:127),and135(cid:127) (Figure10). Measurements 929
863 930
ofanypreexistingintracardiacthrombus(whichwouldleadtopro- of the LAA are performed at these imaging angles to determine the
864 931
cedurecancellation),baselinedegreeofPEF,aswellasanatomicchar- maximal diameter of the anticipated landing zone and appendage
865 932
acteristicsoftheLAAandinteratrialseptum.Thesizeandpositionof depth. For the Watchman, the LAA landing zone is measured from
866 933
867 theLAAbodyandLAAorifice,thepresenceorabsenceofvalvular thetopofthemitralvalveannulusorcircumflexcoronaryarterytoa 934
868 abnormalities, mobile aortic atheroma (>4mm), and intracardiac point 2cm below the tip of the left upper pulmonary vein limbus. 935
869 shuntarealsoestablished. DepthismeasuredfromtheplaneoftheLAAorificetotheLAAapex. 936
870 937
871 938
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
8 Vainribetal JournaloftheAmericanSocietyofEchocardiography
-2017
939 1006
940 1007
941 1008
942 1009
943 1010
944 1011
945 1012
946 1013
947 1014
948 1015
949 1016
950 1017
951 O 1018
P
952 F 1019
=
953 C 1020
4
954 b 1021
e
955 w 1022
&
956 1023
nt
957 pri 1024
958 Figure8 TransseptalpunctureguidancebyTEE:part2.(A)Three-dimensionalTEEdemonstratingtheLAAinitsanatomicorientation 1025
959 andrelationshiptotheinteratrialseptum.(B)TheidealpathtotheLAAisdemonstrated,whichisfacilitatedbytransseptalpuncturein 1026
960 theinferiorandposteriorportionoftheinteratrialseptum.AV,Aorticvalve;PA,pulmonaryartery. 1027
961 1028
962 1029
963 1030
964 1031
965 1032
966 1033
967 1034
968 1035
969 1036
970 1037
971 1038
972 1039
O
973 P 1040
F
974 C= 1041
975 4 1042
b
976 we 1043
977 & 1044
978 print 1045
979 1046
Figure 9 Watchman device sizes. Chart demonstrating available Watchman device sizes (21-to 33-mm diameter), maximal LAA
980 1047
orificerangeforeachWatchmandevicesize,andcompressedWatchmandiametersafterimplantation.
981 1048
982 1049
Becauseofthetomographicnatureof2Dimaging,thereisadegree OtherPossibleExclusionCriteriafortheWatchman
983 1050
ofuncertaintythatthe2Dtransesophagealechocardiographicland- Device
984 1051
ing zone diameter measurements are done in the same plane. This
985 1052
limitation can be overcome using multiplanar reconstruction 3D Atrialseptalaneurysmexcursiondistance>15mm.Atrialseptal
986 1053
987 TEE. In multiplanar reconstruction mode, two long axes of the aneurysmmaybeconsideredanindicationforanticoagulation 1054
988 LAAarealignedtovisualizetheshort-axisplaneoftheLAA,allowing evenifLAAisexcluded. 1055
989 precisemeasurementofthelandingzonediameter(Figure11). Large interatrial shunt. This is a semiquantitative criterion; no 1056
990 Onceechocardiographicmeasurementshavebeenperformed,the specific definition for a large shunt on color Doppler or after 1057
991 largestLAAlandingzonediameterisselectedfordevicesizing.The agitatedsalineinjectionisgiven. 1058
992 device is typically oversized compared with the largest measured Mobileaorticplaque>4mminthickness. 1059
993 LAAdiameterby8%to20%. Significantmitralstenosis(mitralvalvearea<1.5cm2). 1060
994 PEFwiththickness>2mm. 1061
995 1062
996 LAAAnatomicExclusionCriteriafortheWatchmanDevice 1063
997 EchocardiographicGuidancefortheWatchman 1064
998 LAAorificediameterthatiseithertoosmall(<16.8mm)ortoo Procedure 1065
999 1066
large(>30.4mm). After transseptal puncture has been guided by fluoroscopy and
1000 1067
LAAdepththatistooshallow(LAAdepthlessthanlargestLAA echocardiography, the Watchman 12-Fr delivery system with a
1001 1068
orificediameter). pigtail catheter is advanced into the left atrium. The delivery sys-
1002 1069
1003 ThedepthofasecondaryLAAlobe(ifpresent)cannotbetoo tem is then guided into the left atrium with both fluoroscopic 1070
1004 close to the LAA orifice (must be >1cm away), which could and 2D or 3D transesophageal echocardiographic guidance. 1071
1005 leadtoanuncoveredportionoftheLAA. Three-dimensionalTEEhastheadvantageofallowingvisualization 1072
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
JournaloftheAmericanSocietyofEchocardiography Vainribetal 9
Volume-Number-
1073 1140
1074 1141
1075 1142
1076 1143
1077 1144
1078 1145
1079 1146
1080 1147
1081 1148
1082 1149
1083 1150
1084 1151
1085 1152
1086 1153
1087 1154
1088 1155
1089 1156
1090 1157
1091 1158
1092 1159
1093 1160
1094 1161
1095 1162
1096 1163
1097 1164
1098 O 1165
1099 FP 1166
1100 C= 1167
4
1101 b 1168
e
1102 w 1169
1103 & 1170
1104 print 1171
1105 Figure10 LAAsizingforWatchmandeviceon2DTEE.Two-dimensionalTEEdemonstratessizingfortheWatchmandevice.TheLAA 1172
1106 orificediameteranddeptharemeasuredat0(cid:127)(A),45(cid:127) (B),90(cid:127) (C),and135(cid:127)(D). 1173
1107 1174
1108 1175
1109 1176
1110 1177
1111 1178
1112 1179
1113 1180
1114 1181
1115 1182
1116 1183
1117 1184
1118 1185
1119 1186
1120 1187
1121 1188
1122 1189
1123 1190
1124 O 1191
1125 FP 1192
=
1126 C 1193
4
1127 b 1194
e
1128 w 1195
1129 & 1196
nt
1130 pri 1197
1131 Figure11 LAAsizingforWatchmandeviceon3DTEE.Three-dimensionalTEEmultiplanarreconstruction(MPR)demonstratingLAA 1198
1132 orificesizing.Usingasingle-beat3Dzoomcapture,theentireLAAandsurroundingstructuresareacquired.Using3DQsoftware 1199
1133 withinQLAB(PhilipsHealthcare,Amsterdam,theNetherlands),anMPRisobtained.Itisadvantageoustohavetheredandgreen 1200
1134 planeslocked,leavingtheblueplanefreeforadjustment.TheredandgreenplanesareorientedtowardtheLAAapex.Theblueplane 1201
1135 isthenorientedtowardtheplaneoftheLAAorifice,typicallyattheleveloftheleftcircumflexcoronaryartery(LCx).Thisallowscor- 1202
1136 respondingmeasurementstobeperformedinmultipleaxes.LUPV,Leftupperpulmonaryvein. 1203
1137 1204
1138 1205
1139 1206
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK
10 Vainribetal JournaloftheAmericanSocietyofEchocardiography
-2017
1207 1274
1208 1275
1209 1276
1210 1277
1211 1278
1212 1279
1213 1280
1214 1281
1215 1282
1216 1283
1217 1284
1218 1285
1219 1286
1220 1287
1221 1288
1222 1289
1223 1290
1224 1291
1225 1292
1226 1293
1227 1294
1228 1295
1229 1296
1230 1297
1231 O 1298
1232 FP 1299
1233 C= 1300
4
1234 b 1301
e
1235 w 1302
1236 & 1303
1237 print 1304
1238 Figure12 Watchmandevicedeployment.Two-dimensionalTEEwithbiplaneimagingand3DTEEdemonstratingpartial(A,B)and 1305
1239 complete(C,D)deploymentoftheWatchmanLAAoccluderdevicewithintheLAA.Video2correspondsto(A)and(C),whileVideo3 1306
1240 correspondsto(B)and(D).LA,Leftatrium;LV,leftventricle;MV,mitralvalve. 1307
1241 1308
1242 1309
1243 1310
1244 1311
1245 1312
1246 1313
1247 1314
1248 1315
1249 1316
1250 1317
1251 O 1318
P
1252 F 1319
=
C
1253 4 1320
1254 eb 1321
w
1255 1322
&
1256 nt 1323
1257 pri 1324
1258 Figure13 WatchmandevicePASSimplantationcriteria.BeforereleaseoftheWatchmanLAAoccluderdevice,thefourso-called 1325
1259 PASS criteria (position, anchor, size, and seal) must be met. (A) First, the Watchman device must be properly positioned within 1326
1260 theLAAorifice(i.e.,nottilted).(B)Second,thedevicecannotdemonstrateexcessivemotiononthe‘‘tugtest’’(thedeviceispulled 1327
1261 backwardwhilestillattachedtothethreadedinsertandvisualizedusingfluoroscopyandechocardiography).Video4correspondsto 1328
1262 (B).(C)Third,compressionmeasurementsareperformedat0(cid:127),45(cid:127),90(cid:127),and135(cid:127).Alineisdrawnfromshouldertoshoulderwiththe 1329
1263 threadedinsertinview(thisislocatedatthecenterofthedevice)toensurethatthedeviceismeasuredatthelocationofitsmaximal 1330
1264 width.(D)Finally,aPDLof<5mmisconsideredanadequatesealbetweenthedeviceandtheLAA.IfanyofthePASScriteriaarenot 1331
1265 met,theWatchmandevicecanberecapturedandthenrepositioned,oranewdevicesizemaybeselected. 1332
1266 1333
1267 oftheentirelengthsofcathetersastheytraversetheleftatriumto After the guide catheter is advanced toward the LAA orifice, a 1334
1268 reachtheLAA. pigtailcatheteristhreadedthroughtheguidecatheter,andcontrast 1335
1269 1336
Italsoprovidesclearimagingofthedistancebetweenthetipofthe angiographyisperformedtofluoroscopicallyevaluatetheLAA.On
1270 1337
guidecatheterintheleftatriumrelativetotheatrialseptumtopreventacci- 2D and 3D echocardiography, this produces copious amounts of
1271 1338
dentaltransseptalpuncturesitedecannulationbackintotherightatrium. bubblesthatobscureimaging.
1272 1339
1273 1340
REV5.5.0DTD YMJE3902_proof 28October2017 12:28pm ceJK