Two-dimensional versus three-dimensional transesophageal echocardiography in percutaneous left atrial appendage occlusion
Abstract
Background: Real-time three-dimensional transesophageal echocardiography (RT3D TEE) enables
better visualization of the left atrial appendage (LAA) and may be superior to real-time two-dimensional
transesophageal echocardiography (RT2D TEE) for LAA occlusion (LAAO). The aim of this study was
to assess inter- and intra-observer variability of RT2D TEE and RT3D TEE measurements of LAA,
and to assess the accordance of RT2D TEE and RT3D TEE with appropriate occluder selection.
Methods: Transesophageal echocardiography was performed in 40 patients during LAAO. RT2D
TEE and RT3D TEE measurements of the ostium and landing zone were performed independently by
two echocardiographers. The appropriate choice of occluder was confirmed with fluoroscopic criteria.
After the procedures, RT2D TEE and RT3D TEE evaluation were repeated separately by the same
echocardiographers.
Results: The mean ostium diameters by RT2D TEE obtained by the two observers were 23.6 ± 4.2 vs.
24.8 ± 5.2 (p = 0.04), and the mean landing zone diameters were 17.7 ± 4.4 vs. 19.4 ± 3.9 (p < 0.01).
In the case of RT3D TEE, the ostium diameters were 29.6 ± 5.3 vs. 29.4 ± 6.4 (p = not significant
[NS]) and the landing zone diameters were 21.4 ± 3.8 vs. 21.6 ± 3.9 (p = NS). Intra-observer differences
were absent in the case of RT3D TEE. The comparison of RT2D TEE vs. RT3D TEE analyses
performed by the same echocardiographer revealed significant differences in the ostium and landing
zone measurements (both p < 0.01). Agreement between the suggested device size was better for RT3D
TEE (weighted kappa was 0.62 vs. 0.28, respectively).
Conclusions: The results obtained with RT3D TEE showed significantly larger dimensions of the
ostium and the landing zone. RT3D TEE showed lesser inter- and intra-observer variability and better
agreement with the implanted device.
Keywords: left atrial appendage occlusionreal-time two- and three-dimensional transesophageal echocardiographyAmplatzer Occluder
References
- Go A, Hylek E, Phillips K, et al. Prevalence of Diagnosed Atrial Fibrillation in Adults. JAMA. 2001; 285(18): 2370.
- Connolly SJ, Ezekowitz MD, Yusuf S, et al. RE-LY Steering Committee and Investigators. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009; 361(12): 1139–1151.
- Patel MR, Mahaffey KW, Garg J, et al. ROCKET AF Investigators. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011; 365(10): 883–891.
- Granger CB, Alexander JH, McMurray JJV, et al. ARISTOTLE Committees and Investigators. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011; 365(11): 981–992.
- Deplanque D, Leys D, Parnetti L, et al. SAFE II Investigators. Secondary prevention of stroke in patients with atrial fibrillation: factors influencing the prescription of oral anticoagulation at discharge. Cerebrovasc Dis. 2006; 21(5-6): 372–379.
- Swaans MJ, Post MC, Rensing BJ, et al. Percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation. Neth Heart J. 2012; 20(4): 161–166.
- Kleinecke C, Park JW, Gödde M, et al. Twelve-month follow-up of left atrial appendage occlusion with Amplatzer Amulet. Cardiol J. 2017; 24(2): 131–138.
- Bellmann B, Tilz RR, Rillig A. Elektrische Isolation des linken Vorhofohrs. Herz. 2017; 42(4): 364–372.
- Camm AJ, Lip GYH, De Caterina R, et al. ESC Committee for Practice Guidelines (CPG). 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the European Heart Rhythm Association. Eur Heart J. 2012; 33(21): 2719–2747.
- Neuzner J, Dietze T, Paliege R, et al. Left atrial appendage closure with the Amplatzer™ Cardiac Plug: Rationale for a higher degree of device oversizing at implantation. Cardiol J. 2015; 22(2): 201–205.
- De Backer O, Arnous S, Ihlemann N, et al. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart. 2014; 1(1): e000020.
- Clemente A, Avogliero F, Berti S, et al. Multimodality imaging in preoperative assessment of left atrial appendage transcatheter occlusion with the Amplatzer Cardiac Plug. Eur Heart J Cardiovasc Imaging. 2015; 16(11): 1276–1287.
- Jilaihawi H, Doctor N, Kashif M, et al. Aortic annular sizing for transcatheter aortic valve replacement using cross-sectional 3-dimensional transesophageal echocardiography. J Am Coll Cardiol. 2013; 61(9): 908–916.
- Meier B, Blaauw Y, Khattab AA, et al. Document Reviewers. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. Europace. 2014; 16(10): 1397–1416.
- Viles-Gonzalez JF, Kar S, Douglas P, et al. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol. 2012; 59(10): 923–929.
- Holmes DR, Reddy VY, Turi ZG, et al. PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009; 374(9689): 534–542.
- Heist EK, Refaat M, Danik SB, et al. Analysis of the left atrial appendage by magnetic resonance angiography in patients with atrial fibrillation. Heart Rhythm. 2006; 3(11): 1313–1318.
- Vaitkus PT, Wang DD, Guerrero M, et al. Left atrial appendage closure with amplatzer septal occluder in patients with atrial fibrillation: CT-based morphologic considerations. J Invasive Cardiol. 2015; 27(5): 258–262.
- Budge LP, Shaffer KM, Moorman JR, et al. Analysis of in vivo left atrial appendage morphology in patients with atrial fibrillation: a direct comparison of transesophageal echocardiography, planar cardiac CT, and segmented three-dimensional cardiac CT. J Interv Card Electrophysiol. 2008; 23(2): 87–93.
- Shah SJ, Bardo DME, Sugeng L, et al. Real-time three-dimensional transesophageal echocardiography of the left atrial appendage: initial experience in the clinical setting. J Am Soc Echocardiogr. 2008; 21(12): 1362–1368.
- Yosefy C, Laish-Farkash A, Azhibekov Y, et al. A New Method for Direct Three-Dimensional Measurement of Left Atrial Appendage Dimensions during Transesophageal Echocardiography. Echocardiography. 2016; 33(1): 69–76.
- Nucifora G, Faletra FF, Regoli F, et al. Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure. Circ Cardiovasc Imaging. 2011; 4(5): 514–523.
- Faletra FF, Pedrazzini G, Pasotti E, et al. 3D TEE during catheter-based interventions. JACC Cardiovasc Imaging. 2014; 7(3): 292–308.
- Brinkman V, Kalbfleisch S, Auseon A, et al. Real time three-dimensional transesophageal echocardiography-guided placement of left atrial appendage occlusion device. Echocardiography. 2009; 26(7): 855–858.
