Role of Echocardiography during Left Atrial Appendage Occlusion

Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this presentation, the crucial role of two- and three-dimensional transesophageal echocardiography in the pre- and post-procedural assessment and intra procedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures will be discussed. Over 90% cardiogenic emboli were identified from the left atrial appendage (LAA) in patients with nonvalvular AF. Percutaneous LAA exclusion/occlusion techniques have been devised as a new treatment option for the management of stroke in the patients with contraindications to Warfarin. Up to now, extensive studies have been focused on the application of different percutaneous LAA closure devices, which confirm interventional therapy can effectively prevent the cerebral embolic events caused by AF with similar benefits of Warfarin.These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a trans-septally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a trans-septally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA. According to author’s experience in 340 cases, the most important points to be considered to have a successful implantation are: 1) Optimal patient selection 2) A very accurate trans-septal approach 3) co-axial orientation of the delivery sheath 4) Perfect sizing of the LAA ostium and definition of LAA anatomy. Some interesting cases will also be discussed.