A Novel Echocardiographic-Based Classification for the Prediction of Peri-Device Leakage following Left Atrial Appendage Occluder Implantation

Abstract

(1) Background: The assessment of residual peri-device leakages (PDL) after left atrial appendage occlusion (LAAO) remains crucial for post-procedural management. Our study aimed to verify a novel echocardiographic classification for the prediction of PDL. (2) Methods: Echocardiographic data of 72 patients who underwent percutaneous LAAO were evaluated. All echo images were analyzed by two independent investigators using standard analysis software (Image-Arena IA-4.6.4.44 by TomTec®, Munich, Germany). A total number of 127 studies was evaluated. Forty-four patients had baseline studies, at 45 days and at 6 months post-implantation. We propose a morphological classification of LAA devices based on the amount of echodensity inside the devices into three types: type A showing complete homogenous thrombosis, type B incompletely thrombosed device with inhomogeneous echo-free space <50% of device, and type C with partially thrombosed device in which the echo free space was >50% of device in various planes, which we called the “ice-cream cone” sign. Each type was matched to the degree of PDL and clinical outcome parameters. (3) Results: Patients with type C had the highest percentage of PDL at 45 days follow-up (type A: 24%, type B: 31%, type C 100% PDL, p < 0.001) and at 6 months follow-up (type A: 7%, type B: 33%, type C 100% PDL, p < 0.001). Notably, device size in patients with PDL was larger than that in patients without PDL at 6 months follow-up (25.6 ± 3.5 mm vs. 28.7 ± 3.4 mm, p = 0.004). Device size in patients with type C appearance was the largest of the three types (type A: 25.9 ± 3.6 mm, type B: 25.8 ± 3.4 mm, type C 29.8 ± 3.0 mm, type A vs. C; p = 0.019; type B vs. C, p = 0.007). (4) Conclusions: In conclusion, PDL are common post-LAAO, and their frequency is underestimated and under-recognized. PDL are much more common in patients with larger LAA ostial sizes and likely lower longitudinal compression. Type C appearance of the LAAO devices (“ice-cream cone sign”) has a high positive predictive value for PDL. Further studies are needed for better delineation of the clinical importance of this proposed classification.

Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice

“…This includes when to check, what modality to use and what consequence should be taken in patients with insufficient closure. 16 …”

“…This includes when to check, what modality to use and what consequence should be taken in patients with insufficient closure. 16 In a study from Denmark, the number of PDLs was higher when assessed with CT compared with transoesophageal echocardiogram (TEE), with a large discrepancy between modalities in leak quantification. 17 Using transoesophageal echocardiography, a PDL was present in 110 patients (32%), while cardiac CT found 210 patients (61%) with PDL at the disc and contrast patency in 204 patients (59%).…”

“…Although the assessment of residual PDL after LAAO remains crucial for postprocedural management, there is a lack of knowledge and recommendations on how to assess PDL. This includes when to check, what modality to use and what consequence should be taken in patients with insufficient closure 16…”

Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage

“…Our study group recently proposed a novel echocardiographic classification for the prediction of PDLs based on morphology and the amount of echodensity inside the devices, which features three types [17].…”

Peridevice leak: Achilles' heel of left atrial appendage occlusion?

“…While cardiac CT was clearly more sensitive for the detection of PDL, it was only at the expense of repetitive radiation exposure and IV contrast load. Hamadanchi et al 2 described a novel echocardiographic‐based classification for the prediction of PDL following LAAO in 72 patients. Type A showed complete homogenous thrombosis, type B incompletely thrombosed device with inhomogeneous echo‐free space <50% of device, and type C with partially thrombosed device in which the echo‐free space was >50% of the device in various planes, which we called the “ice‐cream cone” sign.…”