Analysis Of Several Indexes On Immediate Effect Of Left Atrial Appendage Closure By Transesophageal Echocardiography

BackgroundLeft atrial appendage closure(LAAC)is a hotspot in recent years for prevention of stroke in patients with non-valvular atrial fibrillation.Leftatrial appendage(LAA)has a complex morphological structure with obvious individual differences.The left atrial appendage is divided into four types typically:cauliflower type,chicken wing type,wind direction type and cactus type.This difference requires special implant strategies.Transesophageal echocardiography(TEE)plays an important role in this procedure which is not only used for preoperative screening contraindications,intraoperative guidance,but also evaluating the immediate effect of surgery.At present,there are few studies concerning the effect of shape on the surgical results.The aim of this study was to explore the difference on the LAAC surgical indicators between different shaped LAA by TEE,While comparing the TEE measurements of different planes of this four shapes and angiographic measurements regarding for choosing an appropriatedevice size.Thus helping clinical physicianto further acknowledge their clinical application.The Research methodThis study enrolled in our hospital and other hospitals forty-seven patients who planed to implant watchman LAAC from January 2013 to December 2016.TEE was used to access the shape,number of lobes,maximum diameter of LAA ostium and depth(by 0°,45°,90°,135°plane)preoperatively,guiding the whole operation,completing the surgery.The appropriate occluder size selected by combining the measurements with TEE and fluoroscopy.We record the maximum ostium of LAA by fluoroscopy,occluder size,occluder compression ratio,occluder residual shunt width and shoulder protrusion after this procedure.we analyze the difference of these LAAC immediate effected indexes between these four LAA types,comparing the correlation between device size and TEE measurements by different planes different shapes,angiographic measurements.The Research resultOne patient's LAA opening diameter was too large to closure even with the largest Watchman size,and the other one was failed to plant either cause she appeared pericardial effusion during the operation,the remaining 45 cases patients(95.7%)were successfully implanted with Watchman device(29 males and 16 females,mean age(66.82 ± 9.21)years.Among them,21 cases were cauliflower(46.7%),7 cases were chickenwing(15.6%),2caseswere windsock(4.4%),15 case werecactus(33.3%).There were 30 cases of multi-leaves(66.7%),10 cases of double leaves(22.2%),4 cases of single leaf(8.9%),one case was failed identified.1.The relation between LAA morphology and these associated indicators of operational immediate effectShoulder protrusion:There was a statistically significant difference in shoulder protrusion between the four shapes of LAA(P = 0.029),which were 5 cases of cauliflower(35.7%),0 case of chicken wing,1 case of windsock(7.1%)and 8 cases of cactus(57.1%)respectively.The length of shoulder protrusion was a statistically significant difference(P = 0.021)between the different shapes of LAA:the windsock(5±7.07)mm,the cactus(3.23+3.11)mm,the cauliflower(2±3.60)mm and the chicken wing(0).There were statistically significant differences in the shoulder protrusion and its length of different LAA(P=0.029 and P=0.021,respectively),The different probability of shoulder protrusion between cactus-shaped LAA and cauliflower,chicken wing have more statistical significance,The length of shoulder protrusion between cactus-shaped LAA and chicken wing has more statistical significance.Residual shunt:12 cases(26.7%)showed residual peri-device flow,The peri-device residual flow of one patiernt was 5mm,another one was 8mm,the rest were ? 3mm;There were 5 cases(45.5%)of cauliflower,2 cases of windsock(18.2%),0 cases of chicken wings,4 cases of cactus(36.4%),cause lacking of sufficient cases,P value can not be calculated.Compression ratios:The minimum compression ratio was(18.24 ±6.52)%and the maximum compression ratio was(25.76 ± 6.07)%.The compression ratio between the four types of LAA were(21.55 ± 7.32)%of Cauliflower,(19.28 ±3.03)%of chicken wing,(21.37 ± 7.97)%of cactus,P value were 0.784,.There was no significant correlation between left atrial appendage's morphology and occluder compression ratio(P>0.05).Occluder size:Cauliflower-shaped LAA size was(28.71 ±3.09)mm,chicken wing-shaped LAA size was(26.57 ±2.07)mm,windsock-shaped LAA size was(31.50 ±2.12),cactus-shaped LAA size was(28.4 ±2.97)mm,P=0.176,The LAA shape was no relation with the instrument size.others:Occluder size selection:There was no significant difference in the LAA's maximum ostium(P=0.391)and depth(P=0.686)measurement by four plane(P>0.05).The TEE measurements of cactus-shaped LAA in 90 degrees plane(R=0.659.P=0.008)had a greater reference value than angiographic measurements(R=0.361,P=0.3 8),While chicken wing type(R=1,P=0.000)and cauliflower type(R=0.779,P=0.008)were on the contrary,angiographic measurements was more valuable than TEE.2)There was no statistically significant correlation between the number of lobes and the shoulder protrusion value(r=0.069,P=0.672),the residual shunt(r=0.551,P=0.1),thecompression ratio(r=0.283,P=0.1),the device size(r=0.099,P=0.528).3)The compression ratio(r=0.115,P=0.512)was not statistically related to the residual shunt(P>0.05)Conclusion:1.The variation of left atrial appendage morphology is related to the device shoulder protrusion,but had no correlation with occluder residual shunt degree and device compression ratio.The cactus is more inclined to appear occluder shoulder protrusion thancauliflowerand chicken wing,the shoulder protrusion of cactus type is larger than the chicken wing-shaped LAA.2.For reference to the size of the device selection,Cactus-shaped LAA ostium in the TEE 90 degree measurements has a greater value of the reference value than angiographicmeasurements,While for the chicken wing and cauliflower-shaped LAA,TEE measurements are less valuable.3.other:The number of lobes of LAA was not related to the instant effect of LAAC.The compression ratio of the occluder is not statistically related to the residual shunt.