Left Atrial Appendage Closure Forum Challenging LAA Morphologies

Left Atrial Appendage Closure Forum Challenging LAA Morphologies: Beyond the Basics Creighton W. Don, MD University of Washington Puget Sound Veterans Administration Hospital

Creighton W. Don I have no relevant financial relationships

What is this? Chicken wing? Windsock? Cactus? Dog head? Who cares?

Left Atrial Appendage Morphology • What we are taught and why it doesn’t matter • LAA variants—more than you care to know • What really matters

What we are taught Windsock Chicken Wing Cauliflower

Stroke risk and LAA morphology • • • 932 patients with refractory AFIB CT/MRI evaluation of morphology Prevalence of stroke evaluated Di Baise L. JACC. 2012.

LAA Variants • • Chicken Wing Cauliflower Cactus Windsock 45% 12% 21% 22% Anan RA. J Atr Fibrillation. 2019 Aug-Sep; 12(2): 2183.

LA Diverticula Killeen RP. Int J Cardiovasc Imaging. 2010 Feb; 26(2): 241 -8. Suwalski G. Echocardiography. 2016 Sep; 33(9): 1368 -73.

More than just shape • • LAA Volume, orifice Filling velocity Trabeculation Number of lobes Basu-Ray I. Front Cardiovasc Med. 2018; 5: 131.

LAA Morphology and Velocity • Chicken wing • Non-CW Lee MJ. J Cardiovasc Electrophyiol, Vol. 26, pp 922 -927.

Plugging a hole

LAA Morphology: What matters • • Width and depth (relative to device) Number and position of lobes Stuff in the way Angle of LAA orifice to septum

Types of LAAs • Width and depth • Number and location of lobes • Depth/position of usable lobe Cressa L. Euro. Intervention 2019; 15: 88 -89.

Watchman Device Size (uncompress ed diameter) Maximum (20%) Compression Measured Diameter* Minimum (8%) Compression Measured Diameter* 21 16. 8 mm 19. 3 mm 24 19. 2 mm 22. 1 mm 27 21. 6 mm 24. 8 mm 30 24. 0 mm 27. 6 mm 33 26. 4 mm 30. 4 mm

Watchman Device • Implant Depth • Final delivery Depth Access Sheath Marker Band Loaded Device Length* 21 mm 20. 2 mm 24 mm 22. 9 mm 27 mm 26. 5 mm 30 mm 29. 4 mm 33 mm 31. 5 mm 24 mm Device length changes by 4 mm Depending on compression

Shallow LAA

Shallow LAA 24 • 24 mm diameter • 18 to 21 mm depth • 24 mm 21

Shallow LAA • • Wedge feet in distal trabecula Desheath 30 mm Device 12 mm 15 mm

Tissue compliance

Tissue Compliance

Stuff in the way • Tissue band 0 45 90 135

Constrained device

Multiple Lobes

Don’t miss a lobes

Don’t miss a lobe

Trajectory becomes key

Severe anterior takeoff

Severe Anterior Takeoff • Double curve Anterior Curve

Canted implant

• • Tucking in shoulder Anterior curve sheath Very posterior transseptal Extreme counterclock torque Advancing partially opened device

LAA Morphology: What matters • • Width and depth (relative to device) Number and position of lobes Stuff in the way Angle of LAA orifice to septum