A Novel Measurement of Percutaneous Left Atrial Appendage Occlusion Device Peri-Device Leak Using Major and Minor...

Assessment for percutaneous left atrial appendage occlusion device peri-device leak (pLAAO-PDL) is an important decision point in determining anticoagulation strategy. Measurement of leak size is commonly done with TEE by measuring the 2D vena contracta of the leak. A potential concern is that by measuring a leak only in 2D, there is a risk of missing a larger crescentic leak spanning a more significant circumferential area. Such findings, though largely undiscussed in the current literature, could impact clinical decision-making regarding continuation of anticoagulation.

TEE reports for patients receiving a plug-like left atrial appendage occlusion device (LAAO) at Atrium Health Wake Forest Baptist or at Atrium Health Carolina's Medical Center from 2021 to 2024 were reviewed. Any reported leaks of 2.5 mm or greater were re-measured by an attending cardiologist with experience in LAAO imaging using standard 2D VC measurements, as well as a traced 3D vena contracta area (3D VCA) with measurement of major and minor axes.

Twenty-nine leaks were remeasured. There was a statistically significant difference between the measured 2D VC and the major axis of the 3D VCA, which was on average three times larger. Three different morphologies of device leak were identified, including punctate, crescentic, and multi-punctate.

3D TEE is useful in distinguishing punctate leaks from crescentic leaks and highlights the fact that leaks cannot be assumed to be uniform in morphology. Given the elevated thromboembolic risks with PDLs, it is reasonable to add 3D TEE imaging to the routine implantation and monitoring of LAAO devices.