Clinical Case
An 87 year old female with a past medical history significant for paroxysmal atrial fibrillation was referred for closure of Left Atrial Appendage. She had an additional history of ascending thoracic aortic aneurysm, hyperthyroidism s/p ablation, hypertension, hyperlipidemia, and bleeding related to ophthalmic hemorrhages.
A pre-procedure CT scan with contrast was completed to evaluate the Left Atrial Appendage.
"The 4D Volume ICE is a novel alternative imaging modality for LAA occlusion especially in patients unsuitable for transesophageal echo or general anesthesia. It allows clear real-time 3D/4D visualization and placement of left atrial appendage occlusion device. The Multiplanar Reconstruction functionality allows to reliably assess the PASS criteria necessary to safely implant the Watchman device1."
Dr. Carlos Sanchez
Specialist in Interventional Cardiology and Advanced Structural Heart Disease at Riverside Methodist Hospital in Columbus, Ohio
Pre-Procedure
01Pre-Deployment
04PASS Criteria and Deployment
054D Compression
02Post-Deployment
02Color flow Doppler analysis
Both 2D and 4D color Doppler assessment were used to evaluate the presence of any residual leak around the device before and after deployment.
Pre-Procedural CT Exam
A pre-procedural computed-tomography (CT) exam with contrast was performed to evaluate the anatomy and dimensions of the Left Atrial Appendage (LAA).
CT scan reconstructions included multiplanar reformats according to left atrial appendage closure protocol.
The estimated LAA ostium measurement was determined to be 18.2 mm.
Pre-deployment evaluation
Prior to intervention, using the ACUSON AcuNav Volume catheter in the 2D imaging mode, baseline imaging and measurements were obtained of the Left Atrial Appendage.
An anatomical overview was conducted to include evaluation of the pericardial space to rule out effusion.
*This image should be obtained post deployment as well.
LAA ostium measurements
Measurements were then obtained using the multiplanar reconstruction planes (MPR). The coronal plane measurements were the most useful in helping determine device size.
Additional measurements
The AcuNav Volume ICE catheter allows the clinician to obtain multiple measurements of the LAA efficiently, meeting the PASS criteria, reducing multiple angles in separate views. By comparison, the transesophageal (TEE) exam requires measurements be obtained in multiple angles from separate views.
To generate left atrial appendage ostium diameter and appendage depth measurements, multiplanar reconstruction planes were used to determine appropriate device size.
Depending on patient anatomy, a slight posterior tilt may be required to better visualize a greater portion of the septum.
Transseptal puncture
The ACUSON AcuNav Volume catheter was then positioned in the mid-right atrium in the “Home View.” The catheter was rotated clockwise to approximately the 4 o’clock position to obtain the atrial septal view.
The recommended septal location for a transseptal puncture, providing best access to the left atrial appendage, is in the posterior-inferior region of the atrial septum.
Dilation of septum
Upon completion of the transseptal puncture, a wire was then placed into the left atrium as a guide.
As demonstrated in this example, under fluoroscopy and Volume ICE guidance, the atrial septum was then dilated for insertion of the ACUSON AcuNav Volume catheter.
This workflow helped with the positioning of the Volume ICE catheter into the left atrium.
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Position: device is distal to or at the ostium of the LAA and there is no tilt.
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Anchor: fixation anchors engaged and device is stable; “Tug Test” is performed
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Size: device is compressed at least 8 – 20% of original size2
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Seal: device spans ostium and all lobes are covered; no paradevice leak.
Using the D’art tool is also useful to evaluate device size and position.
4D device size with compression
Once the device is opened in the LAA the MPR’s were again used to align for the best measurement planes. This was used to determine compression of the device in the LAA prior to deployment.
Multiple measurements were then made in the coronal plane.
Coronal plane
4D device size with compression
Once the device is opened in the LAA the MPR’s were again used to align for the best measurement planes. This was used to determine compression of the device in the LAA prior to deployment.
Multiple measurements were then made in the coronal plane.
Color flow Doppler analysis
Both 2D and 4D color Doppler assessment were used to evaluate the presence of any residual leak around the device before and after deployment.
Color flow Doppler analysis
Both 2D and 4D color Doppler assessment were used to evaluate the presence of any residual leak around the device before and after deployment.
Pre-Procedural CT Exam
A pre-procedural computed-tomography (CT) exam with contrast was performed to evaluate the anatomy and dimensions of the Left Atrial Appendage (LAA).
CT scan reconstructions included multiplanar reformats according to left atrial appendage closure protocol.
The estimated LAA ostium measurement was determined to be 18.2 mm.
Pre-deployment evaluation
Prior to intervention, using the ACUSON AcuNav Volume catheter in the 2D imaging mode, baseline imaging and measurements were obtained of the Left Atrial Appendage.
An anatomical overview was conducted to include evaluation of the pericardial space to rule out effusion.
*This image should be obtained post deployment as well.
LAA ostium measurements
Measurements were then obtained using the multiplanar reconstruction planes (MPR). The coronal plane measurements were the most useful in helping determine device size.
Additional measurements
The AcuNav Volume ICE catheter allows the clinician to obtain multiple measurements of the LAA efficiently, meeting the PASS criteria, reducing multiple angles in separate views. By comparison, the transesophageal (TEE) exam requires measurements be obtained in multiple angles from separate views.
To generate left atrial appendage ostium diameter and appendage depth measurements, multiplanar reconstruction planes were used to determine appropriate device size.
Depending on patient anatomy, a slight posterior tilt may be required to better visualize a greater portion of the septum.
Transseptal puncture
The ACUSON AcuNav Volume catheter was then positioned in the mid-right atrium in the “Home View.” The catheter was rotated clockwise to approximately the 4 o’clock position to obtain the atrial septal view.
The recommended septal location for a transseptal puncture, providing best access to the left atrial appendage, is in the posterior-inferior region of the atrial septum.
Dilation of septum
Upon completion of the transseptal puncture, a wire was then placed into the left atrium as a guide.
As demonstrated in this example, under fluoroscopy and Volume ICE guidance, the atrial septum was then dilated for insertion of the ACUSON AcuNav Volume catheter.
This workflow helped with the positioning of the Volume ICE catheter into the left atrium.
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Position: device is distal to or at the ostium of the LAA and there is no tilt.
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Anchor: fixation anchors engaged and device is stable; “Tug Test” is performed
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Size: device is compressed at least 8 – 20% of original size2
Prior to deployment of the Watchman Left Atrial Occluder the PASS criteria must be met.
Deployment criteria-PASS
Seal: device spans ostium and all lobes are covered; no paradevice leak.
Using the D’art tool is also useful to evaluate device size and position.
4D device size with compression
Once the device is opened in the LAA the MPR’s were again used to align for the best measurement planes. This was used to determine compression of the device in the LAA prior to deployment.
Multiple measurements were then made in the coronal plane.
Coronal plane
4D device size with compression
Once the device is opened in the LAA the MPR’s were again used to align for the best measurement planes. This was used to determine compression of the device in the LAA prior to deployment.
Multiple measurements were then made in the coronal plane.
Color flow Doppler analysis
Both 2D and 4D color Doppler assessment were used to evaluate the presence of any residual leak around the device before and after deployment.
Color flow Doppler analysis
Both 2D and 4D color Doppler assessment were used to evaluate the presence of any residual leak around the device before and after deployment.