Usefulness of preprocedural dedicated computed tomography for complex case in percutaneous left atrial appendage closure
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IMAGES IN CARDIOVASCULAR INTERVENTION
Usefulness of preprocedural dedicated computed tomography for complex case in percutaneous left atrial appendage closure Naoki Hosoda1 · Masahiko Asami2 · Jun Tanaka2 · Takehito Usui1 · Kengo Tanabe2 Received: 1 June 2020 / Accepted: 3 September 2020 © Japanese Association of Cardiovascular Intervention and Therapeutics 2020
Keywords Left atrial appendage closure · Left atrial appendage occlusion · Computed tomography An 86-year-old male with persistent atrial fibrillation (CHA2DS2-VASc score five points and HAS-BLED score three points) was referred for treatment of repeated gastrointestinal bleeding. He had a history of coronary artery bypass grafting and was taking an antiplatelet drug. A neurologist, interventional cardiologists, imaging cardiologist, and anesthesiologist of the local multidisciplinary brain–heart team decided to perform percutaneous left atrial appendage closure (LAAC) [1]. Transesophageal echocardiography (TEE) revealed no thrombus in the LAA and suitability for LAAC based on anatomical features. The maximum orifice diameter and depth of the LAA were 25.0 mm and 25.7 mm, respectively, at 135° by pre-procedural TEE. ECG-gated computed tomography angiography (CTA) was performed with the patient leaning 45° in a prone position on the left side using 320-row multi-detector CT before LAAC. The scan parameters were as follows: a collimation of 320 rows × 0.5 mm, a rotation time of 350–400 ms, and a tube voltage of 120 kV. The tube current (270–400 mA) was selected according to the standard deviation of the noise level measured on the CT projection radiograph. WATCHMAN access system® (WAS: Boston Scientific, Massachusetts, USA) also used the same protocol and was fused with CTA of each patient. In this patient, CTA demonstrated no thrombus and showed chicken-wing morphology. Normal pre-procedural CT was reconstructed as a dedicated volume-rendering (VR) image Naoki Hosoda and Masahiko Asami contributed equally to this work. * Masahiko Asami [email protected] 1
Department of Radiology, Mitsui Memorial Hospital, Tokyo, Japan
Division of Cardiology, Mitsui Memorial Hospital, Kanda‑Izumicho 1, Chiyoda‑ku, Tokyo 101‑8643, Japan
2
(Fig. 1a–b). Using this, we were able to specify the location of the fossa ovalis and accurate LAA morphology. Based on this information, the superior-posterior position in fossa ovalis was considered optimal septal puncture site despite an unusual position. Furthermore, a single-curve WAS was selected to deliver the device to the LAA (Fig. 1c–f). When we use a WATCHMAN® device (Boston Scientific, Massachusetts, USA), enough LAA depth is essential for a successful procedure. Our patient had a lobe of sufficient size only in the posterior. To deliver WAS to the posterior lobe in depth and to obtain the co-axiality of WAS and the posterior lobe, it was necessary to use the single-curve WAS and to go through the superior-posterior position of fossa. Otherwise, we would not deploy the device at an optimal position. Therefore
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