Left Atrial Appendage Closure Devices - asecho.org

1 10/10/2017. 2017 Echo Florida | Orlando, FL. October 10, 2017 | 9:40 10:00 PM | 20 min left Atrial Appendage Closure Devices Muhamed Sari MD, PhD, MPA. Director of Noninvasive Cardiology | Echo Lab Associate Professor of Medicine Disclosures Speakers Bureau (Philips, Medtronic). Advisory Board (Siemens). Use of experimental Devices in approved clinical trials will be discussed 1. 10/10/2017. Upcoming JASE Issue left Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography (TEE). *Alan F. Vainrib, MD; ^Serge C. Harb, MD; ^Wael Jaber, MD;. *Ricardo J Benenstein MD; *Anthony Aizer MD; *Larry A Chinitz, MD; *Muhamed Saric, MD, PhD. From *Leon H Charney Division of Cardiology New York University Langone Medical Center New York, NY and ^Cleveland Clinic, Cleveland, OH. Percutaneous LAA Occlusion: Procedural Steps . Trans-septal puncture LAA. Sizing . Device Deployment . Femoral venous access 2. 10/10/2017. Percutaneous LAA Closure Devices WATCHMAN AMULET LARIAT.

2 ENDOCARDIAL EPICARDIAL. LAA EXCLUSION LAA EXCLUSION. Percutaneous LAA Closure Devices Karl Eugen Hauptmann Eberhard Grube Kurt Amplatz William E. Cohn WATCHMAN AMULET LARIAT. First to implant a Watchman device Inventor of Amplatzer Inventor of Lariat device in 2002 in Germany family of Devices at Texas Heart Institute 3. 10/10/2017. WATCHMAN PROCEDURE. WATCHMAN PROCEDURE. 4. 10/10/2017. WATCHMAN PROCEDURE. 10/10/2017 NYU DIVISION OF CARDIOLOGY 9. WATCHMAN PROCEDURE. 5. 10/10/2017. WATCHMAN PROCEDURE. WATCHMAN PROCEDURE. 6. 10/10/2017. WATCHMAN PROCEDURE. WATCHMAN PROCEDURE. 7. 10/10/2017. WATCHMAN PROCEDURE. 10/10/2017 NYU DIVISION OF CARDIOLOGY 15. WATCHMAN PROCEDURE. 8. 10/10/2017. WATCHMAN PROCEDURE. WATCHMAN PROCEDURE. 10/10/2017 NYU DIVISION OF CARDIOLOGY 18. 9. 10/10/2017. WATCHMAN PROCEDURE. IMAGING OF LAA DEVICE Closure PROCEDURE. Real-time complementary & collaborative use of fluoroscopy + transesophageal echocardiography 10. 10/10/2017. LAA DEVICE Closure PROCEDURE: ROAD MAP.

3 1. left Atrial Appendage (LAA) sizing 2. Trans-septal puncture 3. Device deployment in LAA. Step #1. LAA Sizing Demonstration of exclusion criteria 11. 10/10/2017. LAA Sizing: Endocardial Devices Anatomic orifice diameter Sizing orifice diameter Sizing based on LAA diameter and depth. Watchman Device Sizes Watchman comes in 5 dimeter sizes, with 3-mm diameter increments. 21 24 27 30 33. mm mm mm mm mm US QUARTER. Diameter 24 mm 12. 10/10/2017. Watchman Device Sizing STEP #1. ---------------------------------------- -- Measure LAA diameter at TEE angles 0, 45, 90 & 135 . STEP #2. ---------------------------------------- -- LAA Device Device Select the Diameter Diameter Compression largest LAA diameter measured. STEP #3. ---------------------------------------- -- Use a lookup table to select appropriately oversized device. LA Appendage SIZING: 2D TEE. 0 45 . Select the DIAMETER 26 DIAMETER 19. largest LAA mm mm measurements for Watchman device DEPTH DEPTH. sizing. 37 mm 35 mm 90 135.

4 DIAMETER 19 DIAMETER 18. mm mm DEPTH DEPTH. 30 mm 26 mm 13. 10/10/2017. LA Appendage SIZING. 3D TEE | MULTIPLANE RECONSTRUCTION (MPR). LONG AXES. MPR assures measuring LAA diameter at same level in all long-axis views. SHORT AXIS. MPR allows for visualization of LAA orifice shape in short-axis views. LAA on 3D TEE: NYU Twirl'. 14. 10/10/2017. LA Appendage Sizing on 3D TEE. PA. MV. Dynamic change in size & shape of LAA Direct on-image LAA diameter orifice during the cardiac cycle. measurements may NOT be precise. LAA Morphologies 15. 10/10/2017. LAA Sizing: Lariat Device LARIAT DIAMETER. (40 mm). LAA WIDTH. Should be less than Lariat diameter (< 40 mm). 16. 10/10/2017. Step #2. Transseptal puncture Trans-septal Puncture TEE provides guidance for trans-septal puncture in the posterior & inferior aspect of the interatrial septum. 17. 10/10/2017. Fossa Ovalis | Right Atrial Perspective SVC. AV. << Foramen ovale Inferior Aspect IVC TV. Posterior Aspect Trans-septal Puncture | Optimal Location PA.

5 LAA. AV. Anterior puncture Infero-posterior Atrial puncture Septum 18. 10/10/2017. Trans-septal Puncture | Optimal Location LA. Posterior LA Inferior Superior SVC. AV. RA RA. Anterior TEE | AV SHORT AXIS TEE | BICAVAL VIEW. Trans-septal Puncture | Optimal Location 19. 10/10/2017. Trans-septal Puncture | Optimal Location Trans-septal Puncture | Optimal Location 20. 10/10/2017. Trans-septal Puncture | Optimal Location SVC. AV. << Foramen Inferior ovale Aspect Posterior IVC TV Aspect Step #3. LAA Occluder Device Deployment 21. 10/10/2017. LAA Occluder Device Deployment Complementary roles of echocardiography and fluoroscopy during device deployment. LAA Fluoroscopy View RAO Cranial RAO Caudal ( Short axis') ( Long axis'). 22. 10/10/2017. Equivalent Views What TEE views are equivalent to fluoroscopic RAO views? Fluoroscopy vs. TEE. RAO Cranial 45 View ( Short axis'). 23. 10/10/2017. Fluoroscopy vs. TEE. RAO Cranial ( Short axis'). 24. 10/10/2017. LAA Fluoroscopy View 135 View RAO Caudal ( Long axis').

6 LAA Fluoroscopy View RAO Caudal ( Long axis'). 25. 10/10/2017. TEE vs. Fluoroscopy TEE 135 | RAO Caudal ( Major or Long axis'). 26. 10/10/2017. Watchman Watchman Deployment 27. 10/10/2017. PASS Check Watchman Deployment Position Anchoring While the Watchman is still attached to its delivery cable, Size perform the PASS check. Seal POSITION ANCHORING SIZE SEAL. Properly positioned; no tilt Tug Test 15-30% Compression No para-device leak 3D TEE | Watchman Release 28. 10/10/2017. Biplane TEE | Watchman Deployed Biplane TEE | Watchman Deployed PA. MV. Watchman Properly placed Watchman device at the orifice of the LA Appendage 29. 10/10/2017. TEE | Watchman Deployed Watchman Watchman device properly seals the LAA orifice (No color flow around the device). Watchman: Optimal vs. Suboptimal Results 30. 10/10/2017. Amplatzer Amulet Amulet Device Deployment 31. 10/10/2017. 3D TEE | Amulet Deployed Disc Disc Lobe Lobe 3D TEE | Amulet Deployed Disc MV. 32. 10/10/2017. Lariat J Am Soc Echocardiogr.

7 2014 Jul;27(7):699-708.. 33. 10/10/2017. Lariat Procedure LARIAT Procedure: Pericardial Access 34. 10/10/2017. LARIAT Procedure: Fluoroscopy Epicardial Endocardial hardware hardware Magnets LARIAT Procedure: Fluoroscopy Epicardial Snare Magnets Endocardial Balloon 35. 10/10/2017. Lariat Procedure: 3D TEE. LAA. Atrial Septum MV LAA. Lariat Procedure: 3D TEE. Atrial Septum LAA. LARIAT: Endocardial Wire 36. 10/10/2017. Lariat Procedure: 3D TEE. LAA. Balloon inflation at LAA orifice LARIAT Procedure: 3D TEE. LAA Prior to Ligation LAA Post Ligation 37. 10/10/2017. LARIAT Procedure: Ligated LAA. LARIAT Procedure: 3D TEE. LAA Prior to Ligation LAA Post Ligation 38. 10/10/2017. Thank You! New York University Langone Medical Center 39.