Related Experiment Video
Updated: Jan 9, 2026
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Echocardiographic Evaluation for Safe and Complete Transcatheter Left Atrial Appendage Closure
Mizuki Miura1, Akihiro Isotani2, Masato Fukunaga2
1Department of Medicine, Division of Cardiology, Teikyo University School of Medicine, Tokyo, Japan.
Insights
The CLOSE-PML sign enhances transcatheter left atrial appendage (LAA) closure by optimizing Amplatzer Amulet device placement. This checklist improves procedural safety and efficacy for durable LAA sealing.
Area of Science:
- Cardiology
- Medical Imaging
- Interventional Procedures
Background:
- Transcatheter left atrial appendage (LAA) closure is a key stroke prevention strategy in atrial fibrillation.
- Standard echocardiography checklists may not fully capture all potential device-structure interactions.
- Optimizing device positioning is crucial for procedural success and long-term efficacy.
Objective:
To demonstrate transcatheter left atrial appendage (LAA) closure guided by an expanded transesophageal echocardiography checklist, the CLOSE-PML sign (circumflex artery, lobe compression, orientation, separation, elliptical disc, plus pulmonary structures [pulmonary artery and veins], mitral valve, leak), to optimize Amplatzer Amulet occluder positioning and enhance procedural safety and efficacy.
Key Steps:
Beyond the standard CLOSE sign, PML adds: 1) pulmonary structures: confirm unobstructed left upper pulmonary vein flow and ≥1.5-mm clearance from the pulmonary artery; 2) mitral valve: verify normal leaflet motion and absence of new mitral regurgitation; and 3) leak: exclude substantial peridevice leak on color Doppler, confirming complete LAA sealing.
Potential Pitfalls:
Neglecting PML risks left upper pulmonary vein obstruction, pulmonary artery injury with delayed tamponade, new mitral regurgitation, and residual leaks predisposing to thrombus.
Take-Home Message:
Integrating PML with the CLOSE sign heightens intraprocedural vigilance, ensures systematic assessment of device-structure interactions, and promotes effective, durable transcatheter LAA closure.
