Comparison of cardiac computed tomography angiography and transoesophageal echocardiography for device surveillance after left atrial appendage closure

Abstract

Aims: Device surveillance after left atrial appendage (LAA) closure (LAAC) is important to assess device positioning, peri-device leak (PDL) and device-related thrombus (DRT). There are limited data on the role of cardiac CT angiography (CCTA) after LAAC. We therefore sought to compare CCTA to transoesophageal echocardiography (TEE) in patients who successfully underwent LAAC.Methods and results: We report our consecutive series of non-valvular atrial fibrillation patients who underwent LAAC and had CCTA and TEE post LAAC. Prospective cardiac-gated CCTA was performed with the Toshiba 320-detector or Siemens second-generation 128-slice dual-source scanner, and post-processing was performed with IMPAX 3D reformats. Glomerular filtration rate <30 mL/min/1.73 m² was an exclusion for CCTA. Device positioning, PDL or fabric leak, ratio of left atrial (LA) to LAA linear attenuation coefficient, and DRT were analysed. One hundred and two patients underwent LAAC (79 WATCHMAN, 17 Amulet, 6 ACP). Mean age was 76.4±7.5 years, CHADS2 score 3.0±1.3, and CHADS-VASc score 4.6±1.6. CCTA was performed at a mean of 105.2±54.8 days, and TEE at a mean of 124.9±100.3 days post LAAC. LAA patency was observed in 52/100 (52%), with 45 (86.5%) via PDL and seven (13.5%) through fabric leak. Linear attenuation coefficient <100 HU and LA:LAA ratio <0.25 were seen in occluded devices. PDL was only observed in 35/102 (34.3%) on TEE. Mean device compression was greater with sealed devices (11.3±4.3% versus 8.2±4.0%, p<0.001). There was only one DRT, which was observed on both TEE and CCTA.Conclusions: CCTA is a suitable alternative to TEE for device surveillance post LAAC. CCTA was more sensitive than TEE for assessing PDL and can delineate the cause of residual LAA contrast patency.

A simple method to detect leaks after left atrial appendage occlusion with Watchman

“…Moreover, sensitivity for assessing leak has been reported to be lower with TEE, especially the 2-D TEE, than other imaging methods. 5,14 In the current series, the same limitation of 2-D TEE was observed; inconclusive TEE in 44 patients with "NW" appearance were confirmed for the presence of leak by the 3-D TEE.…”

CT assessment of the left atrial appendage post-transcatheter occlusion – A systematic review and meta analysis

“…(Table 3, Figure 3). In the three studies that reported the average gap size on both CCTA and TEE (12,19,20), the average gap size between the modalities was not significantly different. Four studies (11,15,18,20,21) evaluated adequate LAA device closure on CCTA by assessing both the peridevice gap and contrast enhancement in the LAA distal to the device.…”

“…In the three studies that reported the average gap size on both CCTA and TEE (12,19,20), the average gap size between the modalities was not significantly different. Four studies (11,15,18,20,21) evaluated adequate LAA device closure on CCTA by assessing both the peridevice gap and contrast enhancement in the LAA distal to the device. The prevalence of incomplete LAA closure in these studies was 60%, 98%, and 51%, amongst which 38%, 28%,43% of patients respectively had peridevice gap (27,30,32).…”

“…The prevalence of LAA patency was 67% among patients in studies using delayed phase imaging compared with 60% in those using only early phase imaging. (10,12,13,14,20,21,22,23,24) (Supplementary file; table). Two studies (11,25) reported LAA assessment in early and delayed phase techniques, which detected a 25% to 50% higher prevalence of LAA patency on the delayed imaging.…”

“…Clinical outcomes, including stroke, TIA, or DRT, were reported in 14 studies. (10,12,13,14,15,16,17,18,19,20,21,22,23,24) None of these compared outcomes between patient groups based on the presence or absence of LAA patency or DRT. Moreover, a wide clinical follow-up span was observed, with a median value of 377.5 (222-758.3) days.…”