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


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.


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



Atrial fibrillation


Atrial septal defect


Cardiac computed tomography


Glomerular filtration rate


Left atrial appendage


Left atrial appendage closure device


Patent foramen ovale




Transesophageal echocardiography




Watchman device



Funding for this project was provided by the Rosenau Family Foundation.

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)


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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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