Multimodality imaging assessment of the left atrial appendage for percutaneous closure

Left atrial appendage (LAA) closure has emerged as a critical therapeutic option for stroke prevention in patients with atrial fibrillation who are unsuitable for long-term oral anticoagulation. Multimodality imaging plays a pivotal role throughout the LAA closure process, from pre-procedural planning to long-term follow-up. This review focuses on the complementary roles of cardiac computed tomography (CCT) and transesophageal echocardiography (TEE), outlining their respective strengths and limitations in various phases of LAA management, while also discussing the roles of intracardiac echocardiography (ICE) and fluoroscopy. Pre-procedurally, CCT and TEE provide detailed anatomical characterization of the LAA, including morphology, ostial dimensions, and adjacent structures, aiding device sizing and selection. TEE, with its real-time imaging capabilities, remains essential intra-procedurally for guiding device deployment, assessing sealing, and identifying complications such as pericardial effusion or device embolization. The role of ICE as a lesser invasive intraprocedural alternative is steadily growing. Post-procedural and long-term follow-up imaging relies on both modalities to evaluate for residual leaks, device-related thrombus, embolization and other potential complications. The integration of CCT and TEE enhances procedural safety, accuracy, and long-term efficacy. This review underscores the importance of a tailored, patient-specific approach to imaging, leveraging the synergistic advantages of CCT and TEE to optimize outcomes in LAA closure.