Transcription of Left Atrial Appendage Closure Devices - asecho.org
1 10/10/20171 Muhamed Sari MD, PhD, MPAD irector of Noninvasive Cardiology | Echo LabAssociate Professor of MedicineLeft Atrial Appendage Closure Devices2017 Echo Florida | Orlando, FLOctober 10, 2017 | 9:40 10:00 PM| 20 min DisclosuresSpeakers Bureau (Philips, Medtronic)Advisory Board (Siemens)Use of experimental Devices in approved clinical trials will be discussed10/10/20172 Upcoming JASE IssueLeft Atrial Appendage Occlusion/Exclusion: Procedural Image Guidance with Transesophageal Echocardiography (TEE)*Alan F. Vainrib, MD; ^Serge C. Harb, MD; ^Wael Jaber, MD; *Ricardo J BenensteinMD; *Anthony AizerMD; *Larry A Chinitz, MD; *Muhamed Saric, MD, PhDFrom *Leon H Charney Division of Cardiology New York University Langone Medical CenterNew York, NY and^Cleveland Clinic, Cleveland, OH Femoral venous access Trans-septal punctureLAA Sizing Device DeploymentPercutaneous LAA Occlusion: Procedural Steps10/10/20173 Percutaneous LAA Closure DevicesENDOCARDIALLAA EXCLUSIONEPICARDIALLAA EXCLUSIONWATCHMANLARIATAMULETP ercutaneous LAA Closure DevicesKarl Eugen HauptmannEberhard GrubeWATCHMANF irst to implant a Watchman device in 2002 in GermanyKurt AmplatzAMULETI nventor of Amplatzer family of devicesWilliam E.
2 CohnLARIATI nventor of Lariat deviceat Texas Heart Institute10/10/20174 WATCHMANPROCEDUREWATCHMANPROCEDURE10/10/ 2017510/10/2017 NYU DIVISION OF CARDIOLOGY9 WATCHMANPROCEDUREWATCHMANPROCEDURE10/10/ 20176 WATCHMANPROCEDUREWATCHMANPROCEDURE10/10/ 20177 WATCHMANPROCEDUREWATCHMANPROCEDURE10/10/ 2017810/10/2017 NYU DIVISION OF CARDIOLOGY15 WATCHMANPROCEDUREWATCHMANPROCEDURE10/10/ 20179 WATCHMANPROCEDURE10/10/2017 NYU DIVISION OF CARDIOLOGY18 WATCHMANPROCEDURE10/10/201710 WATCHMANPROCEDUREReal-time complementary & collaborative use offluoroscopy+ transesophageal echocardiography IMAGINGOFLAA DEVICECLOSUREPROCEDURE10/10/201711 LAA DEVICECLOSUREPROCEDURE: Atrial Appendage (LAA) deployment in LAAStep #1 LAA Sizing Demonstration of exclusion criteria10/10/201712 LAA Sizing: Endocardial DevicesSizing based on LAA diameterand orifice diameterSizing orifice diameterWatchman comes in 5 dimeter sizes, with 3-mm diameter QUARTERD iameter 24 mmWatchman Device Sizes10/10/201713 LAA DiameterDeviceDiameterDeviceCompressionS TEP#1----------------------------------- -------Measure LAA diameter at TEE angles 0, 45, 90 & 135 STEP#2---------------------------------- --------Select the largestLAA diameter #3-------------------------------------- ----Use a lookup table to select appropriately oversized Device Sizing0 DIAMETER26 mmDEPTH37 mmLA APPENDAGESIZING.
3 2D TEE45 DIAMETER19 mmDEPTH35 mm90 DIAMETER19 mmDEPTH30 mm135 DIAMETER18 mmDEPTH26 mmSelect the largest LAA measurements for Watchman device APPENDAGESIZING3D TEE | MULTIPLANERECONSTRUCTION(MPR)LONGAXESMPR assures measuring LAA diameter at same level in all long-axis allows for visualization of LAA orifice shape in short-axis on 3D TEE: NYU Twirl 10/10/201715 Dynamic change in size & shape of LAA orificeduring the cardiac on-image LAA diameter measurements may NOTbe Appendage Sizing on 3D TEEPAMVLAA Morphologies10/10 WIDTHS hould be less than Lariat diameter(< 40 mm)LARIATDIAMETER(40 mm)LAA Sizing: Lariat Device10/10/201717 Step #2 Transseptal punctureTrans-septal PunctureTEE provides guidance for trans-septal puncturein the posterior& inferioraspect of the interatrial << Foramen ovalePosterior AspectInferiorAspectFossa Ovalis | Right Atrial PerspectiveAtrial SeptumLAAAVPAI nfero-posterior punctureTrans-septal Puncture | Optimal LocationAnterior puncture10/10/201719 RAAVLAP osteriorAnteriorLARASVCI nferiorSuperiorTEE |AV SHORTAXISTEE |BICAVALVIEWT rans-septal Puncture | Optimal LocationTrans-septal Puncture | Optimal Location10/10/201720 Trans-septal Puncture | Optimal LocationTrans-septal Puncture | Optimal Location10/10/201721 SVCAVTVIVC<< Foramen ovalePosterior AspectInferiorAspectTrans-septal Puncture | Optimal LocationStep #3 LAA Occluder Device Deployment10/10/201722 LAA Occluder Device DeploymentComplementary roles of
4 Echocardiographyand fluoroscopyduring device Fluoroscopy ViewRAO Cranial ( Short axis )RAO Caudal( Long axis ) 10/10/201723 Equivalent ViewsWhat TEE views are equivalent to fluoroscopic RAO views?Fluoroscopy vs. TEERAO Cranial ( Short axis )45 View10/10/201724 Fluoroscopy vs. TEERAO Cranial ( Short axis )10/10/201725 LAA Fluoroscopy ViewRAO Caudal( Long axis ) 135 ViewLAA Fluoroscopy ViewRAO Caudal( Long axis ) 10/10/201726 TEE vs. FluoroscopyTEE 135 | RAO Caudal( Major or Long axis ) 10/10/201727 WatchmanWatchman Deployment10/10/201728 Watchman DeploymentPASSC heckPositionAnchoringSizeSealWhile the Watchman is still attached to its delivery cable, perform the positioned; no tiltANCHORINGTug TestSIZE15-30% CompressionSEALNo para-device leak3D TEE | Watchman Release10/10/201729 Biplane TEE | Watchman DeployedBiplane TEE | Watchman DeployedWatchmanProperly placed Watchman device at the orifice of the LA appendageMVPA10/10/201730 TEE | Watchman DeployedWatchmanWatchman device properly seals the LAA orifice(No color flow around the device)Watchman: Optimal vs.
5 Suboptimal Results10/10/201731 Amplatzer AmuletAmulet Device Deployment10/10/2017323D TEE | Amulet DeployedDiscLobeDiscLobe3D TEE | Amulet DeployedDiscMV10/10/201733 LariatJ Am SocEchocardiogr. 2014 Jul;27(7):699-708. 10/10/201734 Lariat ProcedureLARIAT Procedure: Pericardial Access10/10/201735 LARIAT Procedure: FluoroscopyEndocardialhardware Epicardialhardware MagnetsLARIAT Procedure: FluoroscopyMagnetsEndocardial BalloonEpicardial Snare10/10/201736 Lariat Procedure: 3D TEELAAMVA trial SeptumLAAL ariat Procedure: 3D TEELARIAT: Endocardial Wire Atrial SeptumLAA10/10/201737 Lariat Procedure: 3D TEELAAB alloon inflation at LAA orificeLARIAT Procedure: 3D TEELAA Prior to LigationLAA Post Ligation10/10/201738 LARIAT Procedure: Ligated LAALARIAT Procedure: 3D TEELAA Prior to LigationLAA Post Ligation10/10/201739 New York University LangoneMedical CenterThank You!
