Skip to main content

Advertisement

Log in

Computed tomography measurement for left atrial appendage closure

  • Invited Review Article
  • Published:
Cardiovascular Intervention and Therapeutics Aims and scope Submit manuscript

Abstract

Percutaneous left atrial appendage closure (LAAC) has been reported many therapeutic effects with regard to its safety and efficacy, and the number of patients with non-valvular atrial fibrillation undergoing LAAC is increasing worldwide. Although it is a highly safe procedure, further improvements are expected and preoperative planning is extremely important. For this purpose, transesophageal echocardiography has been mainly performed so far, however, nowadays, it is recommended to determine a more optimal treatment strategy combined with computed tomography. Preoperative CT predicts not only the risk of the intervention based on anatomical features of the left atrial appendage (LAA) but also the device type and size, sheath type, optimal location for septal puncture and pre-procedurally clarifies the left atrium and LAA dimensions. Furthermore, postoperative CT can evaluate device-related thrombus and peri-device leak, making it possible to observe the postoperative course using less invasive methods. This study reviews the practical utility of CT in pre- and post-LAAC.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

Abbreviations

AF:

Atrial fibrillation

ECG:

Electrocardiogram

MSCT:

Multi-slice computed tomography

DOAC:

Direct oral anticoagulant

DRT:

Device-related thrombus

HU:

Hounsfield unit

LA:

Left atrium

LAA:

Left atrial appendage

LAAC:

Left atrial appendage closure

LCx:

Left circumflex coronary artery

MPR:

Multiplanar reconstruction

OAC:

Oral anticoagulant

PDL:

Peri-device leak

TEE:

Transesophageal echocardiography

VR:

Volume rendering

References

  1. Marini C, De Santis F, Sacco S, et al. Contribution of atrial fibrillation to incidence and outcome of ischemic stroke: results from a population-based study. Stroke. 2005;36:1115–9.

    Article  PubMed  Google Scholar 

  2. Lip GY, Frison L, Halperin JL, Lane DA. Identifying patients at high risk for stroke despite anticoagulation: a comparison of contemporary stroke risk stratification schemes in an anticoagulated atrial fibrillation cohort. Stroke. 2010;41:2731–8.

    Article  CAS  PubMed  Google Scholar 

  3. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007;146:857–67.

    Article  PubMed  Google Scholar 

  4. Senoo K, Lane DA, Lip GY. Oral anticoagulants for stroke prevention in atrial fibrillation. Curr Probl Cardiol. 2014;39:319–44.

    Article  PubMed  Google Scholar 

  5. Hylek EM, Go AS, Chang Y, et al. Effect of intensity of oral anticoagulation on stroke severity and mortality in atrial fibrillation. N Engl J Med. 2003;349:1019–26.

    Article  CAS  PubMed  Google Scholar 

  6. Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.

    Article  CAS  PubMed  Google Scholar 

  7. Granger CB, Alexander JH, McMurray JJ, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.

    Article  CAS  PubMed  Google Scholar 

  8. Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369:2093–104.

    Article  CAS  PubMed  Google Scholar 

  9. Connolly SJ, Ezekowitz MD, Yusuf S, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–51.

    Article  CAS  PubMed  Google Scholar 

  10. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9.

    Article  CAS  PubMed  Google Scholar 

  11. Reddy VY, Sievert H, Halperin J, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014;312:1988–98.

    Article  PubMed  CAS  Google Scholar 

  12. Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64:1–12.

    Article  PubMed  Google Scholar 

  13. Holmes DR Jr, Doshi SK, Kar S, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol. 2015;65:2614–23.

    Article  PubMed  Google Scholar 

  14. Osmancik P, Herman D, Neuzil P, et al. 4-year outcomes after left atrial appendage closure versus nonwarfarin oral anticoagulation for atrial fibrillation. J Am Coll Cardiol. 2022;79:1–14.

    Article  PubMed  Google Scholar 

  15. Kar S, Doshi SK, Sadhu A, et al. Primary outcome evaluation of a next-generation left atrial appendage closure device: results from the PINNACLE FLX trial. Circulation. 2021;143:1754–62.

    Article  CAS  PubMed  Google Scholar 

  16. Lakkireddy D, Thaler D, Ellis CR, et al. Amplatzer amulet left atrial appendage occluder versus watchman device for stroke prophylaxis (Amulet IDE): a randomized, controlled trial. Circulation. 2021;144:1543–52.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Galea R, De-Marco F, Meneveau N, et al. Amulet or watchman device for percutaneous left atrial appendage closure: primary results of the SWISS-APERO randomized clinical trial. Circulation. 2021. https://doi.org/10.1161/CIRCULATIONAHA.121.057859.

    Article  PubMed  Google Scholar 

  18. So CY, Kang G, Villablanca PA, et al. Additive value of preprocedural computed tomography planning versus stand-alone transesophageal echocardiogram guidance to left atrial appendage occlusion: comparison of real-world practice. J Am Heart Assoc. 2021;10:e020615.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Staab W, Goth S, Sohns C, et al. Comparison of end-diastolic versus end-systolic cardiac-computed tomography reconstruction interval in patient’s prior to pulmonary vein isolation. Springerplus. 2014;3:218.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Patel AR, Fatemi O, Norton PT, et al. Cardiac cycle-dependent left atrial dynamics: implications for catheter ablation of atrial fibrillation. Heart Rhythm. 2008;5:787–93.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Korsholm K, Berti S, Iriart X, et al. Expert recommendations on cardiac computed tomography for planning transcatheter left atrial appendage occlusion. JACC Cardiovasc Interv. 2020;13:277–92.

    Article  PubMed  Google Scholar 

  22. Budoff MJ, Shittu A, Hacioglu Y, et al. Comparison of transesophageal echocardiography versus computed tomography for detection of left atrial appendage filling defect (thrombus). Am J Cardiol. 2014;113:173–7.

    Article  PubMed  Google Scholar 

  23. Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016;18:1609–78.

    Article  PubMed  Google Scholar 

  24. Di Biase L, Santangeli P, Anselmino M, et al. 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. 2012;60:531–8.

    Article  PubMed  Google Scholar 

  25. Naksuk N, Padmanabhan D, Yogeswaran V, Asirvatham SJ. Left atrial appendage: embryology, anatomy, physiology, arrhythmia and therapeutic intervention. JACC Clin Electrophysiol. 2016;2:403–12.

    Article  PubMed  Google Scholar 

  26. Korhonen M, Muuronen A, Arponen O, et al. Left atrial appendage morphology in patients with suspected cardiogenic stroke without known atrial fibrillation. PLoS ONE. 2015;10:e0118822.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  27. Korhonen M, Parkkonen J, Hedman M, et al. Morphological features of the left atrial appendage in consecutive coronary computed tomography angiography patients with and without atrial fibrillation. PLoS ONE. 2017;12:e0173703.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  28. Yu CM, Khattab AA, Bertog SC, et al. Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation. Nat Rev Cardiol. 2013;10:707–22.

    Article  PubMed  CAS  Google Scholar 

  29. Hosoda N, Asami M, Tanaka J, Usui T, Tanabe K. Usefulness of preprocedural dedicated computed tomography for complex case in percutaneous left atrial appendage closure. Cardiovasc Interv Ther. 2021;36:559–61.

    Article  PubMed  Google Scholar 

  30. Rajwani A, Nelson AJ, Shirazi MG, et al. CT sizing for left atrial appendage closure is associated with favourable outcomes for procedural safety. Eur Heart J Cardiovasc Imaging. 2017;18:1361–8.

    Article  PubMed  Google Scholar 

  31. Wang DD, Eng M, Kupsky D, et al. Application of 3-Dimensional computed tomographic image guidance to WATCHMAN implantation and impact on early operator learning curve: single-center experience. JACC Cardiovasc Interv. 2016;9:2329–40.

    Article  PubMed  Google Scholar 

  32. Wang K, Duan CY, Wu J, et al. Predictive value of neutrophil gelatinase-associated lipocalin for contrast-induced acute kidney injury after cardiac catheterization: a meta-analysis. Can J Cardiol. 2016;32(1033):e19-29.

    Google Scholar 

  33. Hołda MK, Koziej M, Wszołek K, et al. Left atrial accessory appendages, diverticula, and left-sided septal pouch in multi-slice computed tomography. Association with atrial fibrillation and cerebrovascular accidents. Int J Cardiol. 2017;244:163–8.

    Article  PubMed  Google Scholar 

  34. Abbara S, Mundo-Sagardia JA, Hoffmann U, Cury RC. Cardiac CT assessment of left atrial accessory appendages and diverticula. AJR Am J Roentgenol. 2009;193:807–12.

    Article  PubMed  Google Scholar 

  35. Troupis J, Crossett M, Scneider-Kolsky M, Nandurkar D. Presence of accessory left atrial appendage/diverticula in a population with atrial fibrillation compared with those in sinus rhythm: a retrospective review. Int J Cardiovasc Imaging. 2012;28:375–80.

    Article  PubMed  Google Scholar 

  36. Wan Y, He Z, Zhang L, et al. The anatomical study of left atrium diverticulum by multi-detector row CT. Surg Radiol Anat. 2009;31:191–8.

    Article  PubMed  Google Scholar 

  37. Şeker M. The characteristics of left atrial diverticula in normal sinüs rhythm patients. Surg Radiol Anat. 2020;42:377–84.

    Article  PubMed  Google Scholar 

  38. Sanfilippo AJ, Abascal VM, Sheehan M, et al. Atrial enlargement as a consequence of atrial fibrillation. A prospective echocardiographic study. Circulation. 1990;82:792–7.

    Article  CAS  PubMed  Google Scholar 

  39. Barbier P, Alioto G, Guazzi MD. Left atrial function and ventricular filling in hypertensive patients with paroxysmal atrial fibrillation. J Am Coll Cardiol. 1994;24:165–70.

    Article  CAS  PubMed  Google Scholar 

  40. Dittrich HC, Pearce LA, Asinger RW, et al. Left atrial diameter in nonvalvular atrial fibrillation: an echocardiographic study. Stroke Prevention in Atrial Fibrillation Investigators. Am Heart J. 1999;137:494–9.

    Article  CAS  PubMed  Google Scholar 

  41. Nakamura K, Funabashi N, Uehara M, et al. Left atrial wall thickness in paroxysmal atrial fibrillation by multislice-CT is initial marker of structural remodeling and predictor of transition from paroxysmal to chronic form. Int J Cardiol. 2011;148:139–47.

    Article  PubMed  Google Scholar 

  42. Behnes M, Akin I, Sartorius B, et al. –LAA Occluder View for post-implantation Evaluation (LOVE)–standardized imaging proposal evaluating implanted left atrial appendage occlusion devices by cardiac computed tomography. BMC Med Imaging. 2016;16:25.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Kaafarani M, Saw J, Daniels M, et al. Role of CT imaging in left atrial appendage occlusion for the WATCHMAN™ device. Cardiovasc Diagn Ther. 2020;10:45–58.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Qamar SR, Jalal S, Nicolaou S, Tsang M, Gilhofer T, Saw J. Comparison of cardiac computed tomography angiography and transoesophageal echocardiography for device surveillance after left atrial appendage closure. EuroIntervention. 2019;15:663–70.

    Article  PubMed  Google Scholar 

  45. Saw J, Fahmy P, DeJong P, et al. Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure. Eur Heart J Cardiovasc Imaging. 2015;16:1198–206.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Dukkipati SR, Kar S, Holmes DR, et al. Device-related thrombus after left atrial appendage closure: incidence, predictors, and outcomes. Circulation. 2018;138:874–85.

    Article  PubMed  Google Scholar 

  47. Fauchier L, Cinaud A, Brigadeau F, et al. Device-related thrombosis after percutaneous left atrial appendage occlusion for atrial fibrillation. J Am Coll Cardiol. 2018;71:1528–36.

    Article  PubMed  Google Scholar 

  48. Simard T, Jung RG, Lehenbauer K, et al. Predictors of device-related thrombus following percutaneous left atrial appendage occlusion. J Am Coll Cardiol. 2021;78:297–313.

    Article  PubMed  Google Scholar 

  49. Sedaghat A, Vij V, Al-Kassou B, et al. Device-related thrombus after left atrial appendage closure: data on thrombus characteristics, treatment strategies, and clinical outcomes from the EUROC-DRT-registry. Circ Cardiovasc Interv. 2021;14:e010195.

    Article  PubMed  Google Scholar 

  50. Banga S, Osman M, Sengupta PP, et al. CT assessment of the left atrial appendage post-transcatheter occlusion—a systematic review and meta analysis. J Cardiovasc Comput Tomogr. 2021;15:348–55.

    Article  PubMed  Google Scholar 

  51. Zhao MZ, Chi RM, Yu Y, et al. Value of detecting peri-device leak and incomplete endothelialization by cardiac CT angiography in atrial fibrillation patients post Watchman LAAC combined with radiofrequency ablation. J Cardiovasc Electrophysiol. 2021;32:2655–64.

    Article  PubMed  Google Scholar 

  52. Korsholm K, Jensen JM, Nielsen-Kudsk JE. Cardiac computed tomography for left atrial appendage occlusion: acquisition, analysis, advantages, and limitations. Interv Cardiol Clin. 2018;7:229–42.

    PubMed  Google Scholar 

  53. Yamamoto M, Adachi Y, Tsunaki T, Suzuki T. Newly developed collateral artery inside a left appendage closure device. JACC Cardiovasc Interv. 2021;14:2744–5.

    Article  PubMed  Google Scholar 

  54. Murtaza G, Murtaza KT, Dar T, et al. Left atrial appendage occlusion device embolization (the Laaode study): understanding the timing and clinical consequences from a worldwide experience. J Atr Fibrillation. 2021;13:2516.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

The author thanks Naoki Hosoda for his valuable contributions for providing excellent figures.

Funding

This research received no grant from any funding agency in the public, commercial or not-for-profit sectors.

Author information

Authors and Affiliations

Authors

Consortia

Corresponding author

Correspondence to Masahiko Asami.

Ethics declarations

Conflict of interest

Dr. Asami is a clinical proctor for Boston Scientific and has received remuneration from Boston Scientific, Abbott Medical, Edwards Lifesciences, Medtronic, Canon Medical Systems, and Ziosoft.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Asami, M., the OCEAN-SHD Investigators. Computed tomography measurement for left atrial appendage closure. Cardiovasc Interv and Ther 37, 440–449 (2022). https://doi.org/10.1007/s12928-022-00852-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12928-022-00852-4

Keywords

Navigation