Απεικονιστικές τεχνικές στην σύγκλειση του ωτίου του αριστερού κόλπου. Κ. Αγγέλη Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο

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1 Απεικονιστικές τεχνικές στην σύγκλειση του ωτίου του αριστερού κόλπου Κ. Αγγέλη Α Πανεπιστημιακή Καρδιολογική Κλινική Ιπποκράτειο Νοσοκομείο

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4 LAA Anatomy Koplay et al, European society of Radiology

5 LAA Anatomic Relation The LAA is lying in the left atrioventricular groove and in close relation with the left circumflex artery, with the left superior pulmonary vein posteriorly, with the mitral valve annulus medially, and with the left phrenic nerve laterally. Regazzoli et al. BioMed Research International Volume 2015

6 Anatomic Variants of LAA Morphology Sample images taken from explanted hearts Chicken wing Cauliflower Windsock Cactus Beigel et al, J Am Coll Cardiol Img 2014;7:

7 Anatomic Variants of LAA Morphology Morphologies and Modalities Cauliflower Windsock Cactus Chicken wing

8 LAA shape/morphology & size vary widely

9 Other LAA Shapes

10 Trabecular structures which might be misinterpreted as thrombi! Ernst et al, The Anatomical Record 242: (1995)

11 LAA Morphology and Risk of Stroke in AF Di Biase et al, J Am Coll Cardiol 2012;60:531 8)

12 Another Angiographic Classification Shi A, et al. J Interna Med Research 2012;40:1560-7

13 Orifice of the LAA and Pectinate Muscles Beigel et al, J Am Coll Cardiol Img 2014;7:

14 Ostium of the LA appendage Variant morphologies

15 MOrifice of the LAA and Pectinate Musclese The orifice of the appendage is usually oval, whereas round, triangular, and water-drop shapes are observed less frequently. The left lateral ridge separates the orifices of the left pulmonary veins from the LAA orifice. The smooth muscular wall of the LA vestibule separates the orifice from the mitral annulus. John P. Veinot et al. Circulation. 1997;96:

16 Role of LAA in LA function LAA: Useless or Priceless? Acts as: a reservoir during LV systole, a conduit for blood transiting from the PVs to the LV during early diastole, an active contractile chamber that augments left ventricular filling in late diastole, and a suction source that refills itself in early systole Regazzoli et al. BioMed Research International Volume 2015

17 Role of LAA in LA function The profile is triphasic in a normal SR, which includes early atrial systole before P wave on ECG (above baseline); high amplitude late systolic wave (above the baseline) after P wave, and a late diastolic wave (below baseline) occurring during LAA filling. Abdelmoneim et al, JAFIB, 2014;7:1

18 Echo Guidance of LAA Closure Pre-Procedural Imaging

19 Assess LAA According to Device

20 Assess LAA Anatomy

21 Assess LAA Anatomy

22 Assess LAA Anatomy

23 Assess LAA Anatomy

24 Assess LAA Anatomy

25 Assess LAA Anatomy

26 LAA Studied by CT to Plan Closure Device Placement LAA could be classified into 4 types including ChickenWing (A,B), WindSock (C, D), Cauliflower (E), and Cactus type (F). The shape of the LAA orifice could be classified into 5 types including oval (G), triangular (H), foot-like (I, J), water drop-like (K), and round type (L). Wang et al, J Cardiovasc Electrophysiol, Vol. 21, pp , 2010

27 CT Imaging Techniques CT images Postmortem images Type I: smooth LAA origin with a short and poorly defined appendicular limbus. Type II: the limbus is defined and larger. Type III: the limbus originates at a low level and is short. Lopez-Miguez et al, Cardiovasc Electrophysiol,25; , 2014

28 LAA morphologies by cardiac CT, MRI, and autopsies LAA: The Missing Piece in the Puzzle Romero et al, J Cardiovasc Electrophysiol, Vol. 26, pp , September 2015.

29 Preprocedural ΤΕΕ 0 degrees 0 degrees First Department of Cardiology, University of Athens

30 Preprocedural ΤΕΕ 45 degrees 45 degrees First Department of Cardiology, University of Athens

31 Preprocedural ΤΕΕ 90 degrees 90 degrees First Department of Cardiology, University of Athens

32 Preprocedural ΤΕΕ 135 degrees 135 degrees First Department of Cardiology, University of Athens

33 3D LAA Imaging A Watchman 24mm was selected First Department of Cardiology, University of Athens

34 WATCHMAN: TEE measurements

35 ACP: TEE measurements

36 Echo Guidance of LAA Closure

37 Transseptal Puncture: TEE Access to the LA is via a transseptal puncture, performed under TEE in multiple imaging planes, principally 45 and 90, ensuring a posterior puncture and avoidance of the aortic root. Tenting of the atrial septum (arrow) due to pressure from the needle prior to puncture.

38 Transseptal Puncture

39 Pigtail in LUPV

40 First Department of Cardiology, University of Athens Catheter in LAA

41 Catheter in LAA 3D Imaging First Department of Cardiology, University of Athens

42 Device Deployment First Department of Cardiology, University of Athens

43 Device Deployment- Measurements First Department of Cardiology, University of Athens

44 Fluoroscopic Closure Assessment First Department of Cardiology, University of Athens

45 Ultrasound Closure Assessment First Department of Cardiology, University of Athens

46 3D Imaging of Watchman Device First Department of Cardiology, University of Athens

47 3D Imaging of Watchman Device First Department of Cardiology, University of Athens

48 Final Result Fluoroscopic First Department of Cardiology, University of Athens

49 Atrial Septum Integrity Evaluation First Department of Cardiology, University of Athens

50 WATCHMAN Release Criteria: PASS

51 ACP/Amulet Release Criteria: 5 signs

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53 Summary LAA anatomy is complex and varies widely in size and morphology Pre-procedural, procedural and post-procedural TEE is the gold standard imaging modality for closure of the LAA Knowledge of TEE views to scrutinize LAA anatomy, accurate measurements and familiarity with steps of procedure are crucial for successful LAA closure