Impact of Preprocedure Imaging for Left Atrial Appendage Occlusion

Quick Takes

  • A retrospective analysis from the NCDR LAAO registry showed that preprocedure imaging is used infrequently (one in five) prior to Watchman implantation and that patients who underwent preprocedural anatomic assessment of LAA had slightly better device and procedural success rates compared to patients who did not undergo preprocedure imaging.
  • Preprocedural imaging offers the advantage of knowing appendage anatomy, ruling out thrombus, and aborting cases which are not suitable for closure. Limitations include increased utilization and contrast exposure without significant impact on major adverse events.
  • Further randomized, controlled studies are warranted to investigate the cost-effectiveness and net clinical benefit of preprocedure imaging prior to LAAO.

Study Questions:

What is the rate of use of preprocedure computed tomography (CT)/magnetic resonance imaging (MRI) and its association with safety and effectiveness of left atrial appendage occlusion (LAAO) procedures?

Methods:

The National Cardiovascular Data Registry (NCDR) LAAO Registry was used to evaluate patients who underwent attempted LAAO with the Watchman and Watchman FLX devices between January 1, 2016, and June 30, 2021. Safety and effectiveness of LAAO procedures was compared by use versus nonuse of preprocedural CT/MRI. Outcomes of interest included implant success (deployment and release of device), device success (device released with peri-device leak <5 mm), and procedure success (device released with peri-device leak <5 mm and no in-hospital MAE [major adverse events]). Multivariable logistic regression was used to assess the relationship between preprocedure imaging and outcomes.

Results:

Preprocedure CT/MRI was used for 18.2% (n = 20,851) of the 114,384 procedures in this study. CT/MRI use was more common among government and university hospitals, and hospitals in the Midwest and South; it was less common among patients with uncontrolled hypertension, abnormal renal function, and without prior thromboembolism. Overall rates of implant success, device success, and procedure success were 93.4%, 91.2%, and 89.4%, respectively. Preprocedure CT/MRI was independently associated with an increased likelihood of implant success (odds ratio [OR], 1.08; 95% confidence interval [CI], 1.00-1.17), device success (OR, 1.10; 95% CI, 1.04-1.16), and procedural success (OR, 1.07; 95% CI, 1.02-1.13). MAE were uncommon (2.3%) and not associated with use of preprocedure CT/MRI (OR, 1.02; 95% CI, 0.92-1.12).

Conclusions:

Preprocedure CT/MRI was associated with an increased likelihood of successful LAAO implant; however, the magnitude of benefit appears small and it was not associated with MAE.

Perspective:

The current study was a retrospective analysis from the NCDR LAAO Registry and showed that preprocedure imaging is used infrequently (one in five) prior to Watchman implantation and that patients who underwent preprocedural anatomic assessment of LAA had slightly better device and procedural success rates compared to patients who did not undergo preprocedure imaging. Preprocedural imaging offers the advantage of knowing appendage anatomy, ruling out thrombus, and aborting cases which are not suitable for closure. On the other hand, it comes with increased utilization and contrast exposure without significant impact on MAE. Further randomized, controlled studies are warranted to investigate the cost-effectiveness and net clinical benefit of preprocedure imaging prior to LAAO.

Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Computed Tomography, Magnetic Resonance Imaging, Nuclear Imaging

Keywords: Arrhythmias, Cardiac, Atrial Appendage, Coronary Occlusion, Device Removal, Diagnostic Imaging, LAAO Registry, Magnetic Resonance Imaging, National Cardiovascular Data Registries, Registries, Thrombosis, Thromboembolism, Tomography, X-Ray Computed, Vascular Diseases


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