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Published on: February 26, 2013
A Novel Echocardiographic-Based Classification for the Prediction of Peri-Device Leakage following Left Atrial
Ali Hamadanchi1, Shun Ijuin1,2, Franz Haertel1
1Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany.
Insights
Residual peri-device leakages (PDL) after left atrial appendage occlusion (LAAO) are common and often underestimated. A novel echocardiographic classification, the "ice-cream cone" sign (Type C), accurately predicts PDL, particularly in patients with larger device sizes.
Area of Science:
- Cardiology
- Medical Imaging
- Echocardiography
Background:
- Residual peri-device leakages (PDL) are critical to assess after left atrial appendage occlusion (LAAO).
- Accurate prediction of PDL is essential for effective post-procedural management.
- Current methods for PDL assessment may underestimate their prevalence.
Purpose of the Study:
- To validate a novel echocardiographic classification system for predicting PDL after LAAO.
- To correlate device morphology with the presence and degree of PDL.
- To investigate the relationship between device size, PDL, and LAA morphology.
Main Methods:
- Echocardiographic data from 72 patients undergoing percutaneous LAAO were analyzed.
- A new classification system (Type A, B, C) based on echodensity within the LAAO device was proposed.
- Device types were correlated with PDL presence at 45 days and 6 months, and clinical outcomes.
Main Results:
- Type C devices (ice-cream cone sign) showed 100% PDL at both 45 days and 6 months (p < 0.001).
- Patients with PDL had significantly larger device sizes compared to those without PDL at 6 months (28.7 ± 3.4 mm vs. 25.6 ± 3.5 mm, p = 0.004).
- Type C devices were associated with the largest device sizes (29.8 ± 3.0 mm, p < 0.05 vs. A and B).
Conclusions:
- PDL are common after LAAO and frequently under-recognized.
- The proposed Type C "ice-cream cone" sign is a strong predictor of PDL.
- Larger LAA ostial sizes and potentially reduced longitudinal compression are associated with increased PDL risk.
Abstract:
(1) Background: The assessment of residual peri-device leakages (PDL) after left atrial appendage occlusion (LAAO) remains crucial for post-procedural management. Our study aimed to verify a novel echocardiographic classification for the prediction of PDL. (2) Methods: Echocardiographic data of 72 patients who underwent percutaneous LAAO were evaluated. All echo images were analyzed by two independent investigators using standard analysis software (Image-Arena IA-4.6.4.44 by TomTec®, Munich, Germany). A total number of 127 studies was evaluated. Forty-four patients had baseline studies, at 45 days and at 6 months post-implantation. We propose a morphological classification of LAA devices based on the amount of echodensity inside the devices into three types: type A showing complete homogenous thrombosis, type B incompletely thrombosed device with inhomogeneous echo-free space <50% of device, and type C with partially thrombosed device in which the echo free space was >50% of device in various planes, which we called the "ice-cream cone" sign. Each type was matched to the degree of PDL and clinical outcome parameters. (3) Results: Patients with type C had the highest percentage of PDL at 45 days follow-up (type A: 24%, type B: 31%, type C 100% PDL, p < 0.001) and at 6 months follow-up (type A: 7%, type B: 33%, type C 100% PDL, p < 0.001). Notably, device size in patients with PDL was larger than that in patients without PDL at 6 months follow-up (25.6 ± 3.5 mm vs. 28.7 ± 3.4 mm, p = 0.004). Device size in patients with type C appearance was the largest of the three types (type A: 25.9 ± 3.6 mm, type B: 25.8 ± 3.4 mm, type C 29.8 ± 3.0 mm, type A vs. C; p = 0.019; type B vs. C, p = 0.007). (4) Conclusions: In conclusion, PDL are common post-LAAO, and their frequency is underestimated and under-recognized. PDL are much more common in patients with larger LAA ostial sizes and likely lower longitudinal compression. Type C appearance of the LAAO devices ("ice-cream cone sign") has a high positive predictive value for PDL. Further studies are needed for better delineation of the clinical importance of this proposed classification.
