CT based 3D printing is superior to transesophageal echocardiography for pre-procedure planning in left atrial appendage device closure

  • Edinrin Obasare
  • Sumeet K. Mainigi
  • D. Lynn Morris
  • Leandro Slipczuk
  • Igor Goykhman
  • Evan Friend
  • Mary Rodriguez Ziccardi
  • Gregg S. Pressman
Original Paper

Abstract

Accurate assessment of the left atrial appendage (LAA) is important for pre-procedure planning when utilizing device closure for stroke reduction. Sizing is traditionally done with transesophageal echocardiography (TEE) but this is not always precise. Three-dimensional (3D) printing of the LAA may be more accurate. 24 patients underwent Watchman device (WD) implantation (71 ± 11 years, 42% female). All had complete 2-dimensional TEE. Fourteen also had cardiac computed tomography (CCT) with 3D printing to produce a latex model of the LAA for pre-procedure planning. Device implantation was unsuccessful in 2 cases (one with and one without a 3D model). The model correlated perfectly with implanted device size (R2 = 1; p < 0.001), while TEE-predicted size showed inferior correlation (R2 = 0.34; 95% CI 0.23–0.98, p = 0.03). Fisher’s exact test showed the model better predicted final WD size than TEE (100 vs. 60%, p = 0.02). Use of the model was associated with reduced procedure time (70 ± 20 vs. 107 ± 53 min, p = 0.03), anesthesia time (134 ± 31 vs. 182 ± 61 min, p = 0.03), and fluoroscopy time (11 ± 4 vs. 20 ± 13 min, p = 0.02). Absence of peri-device leak was also more likely when the model was used (92 vs. 56%, p = 0.04). There were trends towards reduced trans-septal puncture to catheter removal time (50 ± 20 vs. 73 ± 36 min, p = 0.07), number of device deployments (1.3 ± 0.5 vs. 2.0 ± 1.2, p = 0.08), and number of devices used (1.3 ± 0.5 vs. 1.9 ± 0.9, p = 0.07). Patient specific models of the LAA improve precision in closure device sizing. Use of the printed model allowed rapid and intuitive location of the best landing zone for the device.

Keywords

Left atrial appendage Left atrial appendage closure device Three-dimensional printing Multi-modality imaging Atrial fibrillation 

Abbreviations

AF

Atrial fibrillation

ASD

Atrial septal defect

CCT

Cardiac computed tomography

GFR

Glomerular filtration rate

LAA

Left atrial appendage

LAA-CD

Left atrial appendage closure device

PFO

Patent foramen ovale

3D

Three-dimensional

TEE

Transesophageal echocardiography

2D

Two-dimensional

WD

Watchman device

Notes

Compliance with ethical standards

Conflict of interest

Dr. Morris receives research support and is a consultant for Boston Scientific. All other authors have reported no relationships relevant to the contents of this paper to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Institutional Review Board of the Einstein Healthcare Network and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

10554_2017_1289_MOESM1_ESM.mp4 (976 kb)
Video 1 Three-dimensional transesophageal echocardiography (TEE) clips from the left atrial appendage (LAA) depicted in Fig. 2. The LAA appendage orifice is partially obscured by the “Coumadin ridge”. In this patient standard two-dimensional TEE views underestimated the true orifice size. (MP4 976 KB)
10554_2017_1289_MOESM2_ESM.mp4 (899 kb)
Video 2 Three-dimensional transesophageal clips from the left atrial appendage (LAA) depicted in Fig. 2 (rotated). This video shows that after slight rotation of the image in Video 1, the orifice appears round and fairly narrow. (MP4 899 KB)
10554_2017_1289_MOESM3_ESM.mp4 (940 kb)
Video 3 Three-dimensional transesophageal clips from the left atrial appendage (LAA) depicted in Fig. 2 (further rotated). This video shows that further rotation of the image in Video 1, now reveals the orifice to be substantially larger and ovoid in shape. (MP4 939 KB)

Video 4 Two-dimensional transesophageal (TEE) image at 0 degrees for the left atrial appendage (LAA) depicted in Fig. 3. Imaging was difficult and it can be appreciated that the views obtained are off-axis and likely not through the center of the LAA (similarly in Videos 5 to 7). In addition, probe position was higher in the esophagus than is optimal for LAA imaging (as evidenced by the appearance of both the aortic and pulmonic valves in this image). In fact, TEE underestimated the size of device required for this patient. (AVI 5067 KB)

Video 5 Two-dimensional transesophageal image at 45 degrees for the left atrial appendage depicted in Fig. 3. (AVI 5549 KB)

Video 6 Two-dimensional transesophageal image at 90 degrees for the left atrial appendage depicted in Fig. 3. (AVI 6257 KB)

Video 7 Two-dimensional transesophageal image at 135 degrees for the left atrial appendage depicted in Fig. 3. (AVI 5510 KB)

References

  1. 1.
    Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (2009) Percutaneous closure of the left atrial appendage vs. warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374(9689):534–542.  https://doi.org/10.1016/S0140-6736(09)61343-X CrossRefPubMedGoogle Scholar
  2. 2.
    Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, Halperin JL, Holmes D (2013) Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) trial. Circulation 127(6):720–729.  https://doi.org/10.1161/CIRCULATIONAHA.112.114389 CrossRefPubMedGoogle Scholar
  3. 3.
    Reddy VY, Doshi S, Sievert H, Buchbinder M, Neuzil P, Huber K, Kar S, Halperin J, Whisenant B, Swarup V, Holmes D (2013) Long term results of PROTECT-AF. The mortality effects of left atrial appendage closure vs. warfarin for stroke prophylaxis in AF. Heart Rhythm Soc 10:E1412Google Scholar
  4. 4.
    Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, Huber K, Whisenant B, Kar S, Swarup V, Gordon N, Holmes D (2014) Percutaneous left atrial appendage closure vs. warfarin for atrial fibrillation: a randomized clinical trial. JAMA 312(19):1988–1998.  https://doi.org/10.1001/jama.2014.15192 CrossRefPubMedGoogle Scholar
  5. 5.
    Holmes DR, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY (2014) Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation vs. long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 64(1):1–12.  https://doi.org/10.1016/j.jacc.2014.04.029 CrossRefPubMedGoogle Scholar
  6. 6.
    Meier B, Blaauw Y, Khattab AA, Lewalter T, Sievert H, Tondo C, Glikson M (2015) EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. EuroIntervention 10(9):1109–1125.  https://doi.org/10.4244/EIJY14M08_18 CrossRefPubMedGoogle Scholar
  7. 7.
    Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S (2011) Safety of percutaneous left atrial appendage closure: results from the Watchman left atrial appendage system for embolic protection in patients with AF (PROTECT AF) clinical trial and the continued access registry. Circulation 123(4):417–424.  https://doi.org/10.1161/CIRCULATIONAHA.110.976449 CrossRefPubMedGoogle Scholar
  8. 8.
    Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, Sick P, Sievert H (2013) Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with watchman left atrial appendage closure technology). J Am Coll Cardiol 61(25):2551–2556.  https://doi.org/10.1016/j.jacc.2013.03.035 CrossRefPubMedGoogle Scholar
  9. 9.
    Hart RG, Pearce LA, Aguilar MI (2007) Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med 146(12):857–867CrossRefPubMedGoogle Scholar
  10. 10.
    Ezekowitz MD, Bridgers SL, James KE, Carliner NH, Colling CL, Gornick CC, Krause-Steinrauf H, Kurtzke JF, Nazarian SM, Radford MJ, Rickles FR (1992) Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. N Engl J Med 327(20):1406–1412.  https://doi.org/10.1056/NEJM199211123272002 CrossRefPubMedGoogle Scholar
  11. 11.
    Lip GY, Laroche C, Dan GA, Santini M, Kalarus Z, Rasmussen LH, Ioachim PM, Tica O, Boriani G, Cimaglia P, Diemberger I, Hellum CF, Mortensen B, Maggioni AP (2014) ‘Real-world’ antithrombotic treatment in atrial fibrillation: the EORP-AF pilot survey. Am J Med 127(6):519–529.e1.  https://doi.org/10.1016/j.amjmed.2013.12.022 CrossRefPubMedGoogle Scholar
  12. 12.
    Yang E (2014) A clinician’s perspective: novel oral anticoagulants to reduce the risk of stroke in nonvalvular atrial fibrillation–full speed ahead or proceed with caution? Vasc Health Risk Manag 10:507–522.  https://doi.org/10.2147/VHRM.S68117 CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Nieuwlaat R, Capucci A, Camm AJ, Olsson SB, Andresen D, Davies DW, Cobbe S, Breithardt G, Le Heuzey JY, Prins MH, Lévy S, Crijns HJ (2005) Atrial fibrillation management: a prospective survey in ESC member countries: the euro heart survey on atrial fibrillation. Eur Heart J 26(22):2422–2434.  https://doi.org/10.1093/eurheartj/ehi505 CrossRefPubMedGoogle Scholar
  14. 14.
    O’Brien EC, Holmes DN, Ansell JE, Allen LA, Hylek E, Kowey PR, Gersh BJ, Fonarow GC, Koller CR, Ezekowitz MD, Mahaffey KW, Chang P, Peterson ED, Piccini JP, Singer DE (2014) Physician practices regarding contraindications to oral anticoagulation in atrial fibrillation: findings from the outcomes registry for better informed treatment of atrial fibrillation (ORBIT-AF) registry. Am Heart J 167(4):601–609.e1.  https://doi.org/10.1016/j.ahj.2013.12.014 CrossRefPubMedGoogle Scholar
  15. 15.
    Reddy VY, Gibson DN, Kar S, O’Neill W, Doshi SK, Horton RP, Buchbinder M, Gordon NT, Holmes DR (2017) Post-approval U.S. experience with left atrial appendage closure for stroke prevention in atrial fibrillation. J Am Coll Cardiol 69(3):253–261.  https://doi.org/10.1016/j.jacc.2016.10.010 CrossRefPubMedGoogle Scholar
  16. 16.
    Saw J, Lempereur M (2014) Percutaneous left atrial appendage closure: procedural techniques and outcomes. JACC Cardiovasc Interv 7(11):1205–1220.  https://doi.org/10.1016/j.jcin.2014.05.026 CrossRefPubMedGoogle Scholar
  17. 17.
    Wunderlich NC, Beigel R, Swaans MJ, Ho SY, Siegel RJ (2015) Percutaneous interventions for left atrial appendage exclusion: options, assessment, and imaging using 2D and 3D echocardiography. JACC Cardiovasc Imaging 8(4):472–488.  https://doi.org/10.1016/j.jcmg.2015.02.002 CrossRefPubMedGoogle Scholar
  18. 18.
    Hahn RT, Abraham T, Adams MS, Bruce CJ, Glas KE, Lang RM, Reeves ST, Shanewise JS, Siu SC, Stewart W, Picard MH (2013) Guidelines for performing a comprehensive transesophageal echocardiographic examination: recommendations from the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr 26(9):921–964.  https://doi.org/10.1016/j.echo.2013.07.009 CrossRefPubMedGoogle Scholar
  19. 19.
    Donal E, Yamada H, Leclercq C, Herpin D (2005) The left atrial appendage, a small, blind-ended structure: a review of its echocardiographic evaluation and its clinical role. Chest 128(3):1853–1862.  https://doi.org/10.1378/chest.128.3.1853 CrossRefPubMedGoogle Scholar
  20. 20.
    Krishnaswamy A, Patel NS, Ozkan A, Agarwal S, Griffin BP, Saliba W, Tuzcu EM, Schoenhagen P, Kapadia SR (2012) Planning left atrial appendage occlusion using cardiac multidetector computed tomography. Int J Cardiol 158(2):313–317.  https://doi.org/10.1016/j.ijcard.2012.04.147 CrossRefPubMedGoogle Scholar
  21. 21.
    van Rosendael PJ, Katsanos S, van den Brink OW, Scholte AJ, Trines SA, Bax JJ, Schalij MJ, Marsan NA, Delgado V (2014) Geometry of left atrial appendage assessed with multidetector-row computed tomography: implications for transcatheter closure devices. EuroIntervention 10(3):364–371.  https://doi.org/10.4244/EIJV10I3A62 CrossRefPubMedGoogle Scholar
  22. 22.
    Wang Y, Di Biase L, Horton RP, Nguyen T, Morhanty P, Natale A (2010) Left atrial appendage studied by computed tomography to help planning for appendage closure device placement. J Cardiovasc Electrophysiol 21(9):973–982.  https://doi.org/10.1111/j.1540-8167.2010.01814.x CrossRefPubMedGoogle Scholar
  23. 23.
    Jacobs JE, Boxt LM, Desjardins B, Fishman EK, Larson PA, Schoepf J (2006) ACR practice guideline for the performance and interpretation of cardiac computed tomography (CT). J Am Coll Radiol 3(9):677–685.  https://doi.org/10.1016/j.jacr.2006.06.006 CrossRefPubMedGoogle Scholar
  24. 24.
    Obasare E, Melendres E, Morris DL, Mainigi SK, Pressman GS (2016) Patient specific 3D print of left atrial appendage for closure device. Int J Cardiovasc Imaging 32(10):1495–1497.  https://doi.org/10.1007/s10554-016-0933-x CrossRefPubMedGoogle Scholar
  25. 25.
    Vukicevic M, Mosadegh B, Min JK, Little SH (2017) Cardiac 3D printing and its future directions. JACC Cardiovasc Imaging 10(2):171–184.  https://doi.org/10.1016/j.jcmg.2016.12.001 CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Yushkevich PA, Piven J, Hazlett HC, Smith RG, Ho S, Gee JC, Gerig G (2006) User-guided 3D active contour segmentation of anatomical structures: significantly improved efficiency and reliability. Neuroimage 31(3):1116–1128.  https://doi.org/10.1016/j.neuroimage.2006.01.015 CrossRefPubMedGoogle Scholar
  27. 27.
    Shah SJ, Bardo DM, Sugeng L, Weinert L, Lodato JA, Knight BP, Lopez JJ, Lang RM (2008) Real-time three-dimensional transesophageal echocardiography of the left atrial appendage: initial experience in the clinical setting. J Am Soc Echocardiogr 21(12):1362–1368.  https://doi.org/10.1016/j.echo.2008.09.024 CrossRefPubMedGoogle Scholar
  28. 28.
    Nucifora G, Faletra FF, Regoli F, Pasotti E, Pedrazzini G, Moccetti T, Auricchio A (2011) Evaluation of the left atrial appendage with real-time three-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure. Circ Cardiovasc Imaging 4(5):514–523.  https://doi.org/10.1161/CIRCIMAGING.111.963892 CrossRefPubMedGoogle Scholar
  29. 29.
    Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, Horton R, Sanchez JE, Bai R, Mohanty S, Pump A, Cereceda Brantes M, Gallinghouse GJ, Burkhardt JD, Cesarani F, Scaglione M, Natale A, Gaita F (2012) Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol 60(6):531–538.  https://doi.org/10.1016/j.jacc.2012.04.032 CrossRefPubMedGoogle Scholar
  30. 30.
    Khurram IM, Dewire J, Mager M, Maqbool F, Zimmerman SL, Zipunnikov V, Beinart R, Marine JE, Spragg DD, Berger RD, Ashikaga H, Nazarian S, Calkins H (2013) Relationship between left atrial appendage morphology and stroke in patients with atrial fibrillation. Heart Rhythm 10(12):1843–1849.  https://doi.org/10.1016/j.hrthm.2013.09.065 CrossRefPubMedGoogle Scholar
  31. 31.
    Rajwani A, Nelson AJ, Shirazi MG, Disney PJ, Teo KS, Wong DT, Young GD, Worthley SG (2016) CT sizing for left atrial appendage closure is associated with favourable outcomes for procedural safety. Eur Heart J Cardiovasc Imaging.  https://doi.org/10.1093/ehjci/jew212 Google Scholar
  32. 32.
    Goitein O, Fink N, Hay I, Di Segni E, Guetta V, Goitein D, Brodov Y, Konen E, Glikson M (2017) Cardiac CT angiography (CCTA) predicts left atrial appendage occluder device size and procedure outcome. Int J Cardiovasc Imaging 33(5):739–747.  https://doi.org/10.1007/s10554-016-1050-6 CrossRefPubMedGoogle Scholar
  33. 33.
    Goitein O, Fink N, Guetta V, Beinart R, Brodov Y, Konen E, Goitein D, Di Segni E, Grupper A, Glikson M (2017) Printed MDCT 3D models for prediction of left atrial appendage (LAA) occluder device size: a feasibility study. EuroIntervention.  https://doi.org/10.4244/EIJ-D-16-00921 PubMedGoogle Scholar
  34. 34.
    Liu P, Liu R, Zhang Y, Liu Y, Tang X, Cheng Y (2016) The value of 3D printing models of left atrial appendage using real-time 3D transesophageal echocardiographic data in left atrial appendage occlusion: applications toward an era of truly personalized medicine. Cardiology 135(4):255–261.  https://doi.org/10.1159/000447444 CrossRefPubMedGoogle Scholar
  35. 35.
    Zhou Q, Song H, Zhang L, Deng Q, Chen J, Hu B, Wang Y, Guo R (2017) Roles of real-time three-dimensional transesophageal echocardiography in peri-operation of transcatheter left atrial appendage closure. Medicine 96(4):e5637.  https://doi.org/10.1097/MD.0000000000005637 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media B.V., part of Springer Nature 2017

Authors and Affiliations

  1. 1.Einstein Heart and Vascular InstituteEinstein Medical CenterPhiladelphiaUSA
  2. 2.Department of RadiologyEinstein Medical CenterPhiladelphiaUSA
  3. 3.Department of Internal MedicineEinstein Medical CenterPhiladelphiaUSA
  4. 4.Einstein Medical CenterPhiladelphiaUSA

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