Usefulness of preprocedural 3-dimensional computed tomography planning in assisting one-stage pulmonary veins isolation with concomitant left atrial appendage occlusion procedure: A pilot study

Background: The optimal imaging modality for selecting the device size in patients with atrial fibrillation undergoing one-stop left atrial appendage occlusion (LAAO) with concomitant pulmonary vein isolation (PVi) remains undefined. We compared preprocedural 3-dimensional computed tomography (3D CT) with intra-procedural transesophageal echocardiography (TEE) and left atrial appendage (LAA) angiography in guiding one-stage PVi and LAAO.

Methods: We measured the LAA ostium diameter using an interactive 3D CT system with a central line-based approach and compared these measurements with those from intra-procedural TEE and angiography, and the actual device size. The optimal compression ratio was used to assess the attainment rates of the three imaging modalities.

Results: Twenty-two patients (median age: 68.5 years, 21.8 % female) underwent the one-stage procedure. The median LAA ostium diameter measured by 3D CT (24.3 mm, interquartile range [IQR] = 22.0-27.0 mm) was closer to the Watchman device size (27.0 mm, IQR = 24.0-31.0 mm, P = 0.127) compared to TEE (21.2 mm, IQR = 18.4-22.7 mm, P < 0.001) and angiography (22.5 mm, IQR = 17.9-25.1 mm, P < 0.001). 3D CT had a better attainment rate for the optimal compression ratio than TEE (10.8 %, IQR = 7.4-16.5 % vs. 22.7 %, IQR = 19.2-29.3 %, P < 0.001) and angiography (19.7 %, IQR = 15.1-24.1 %, P = 0.001). All patients underwent successful device implantation without peri-device leak or complications during the periprocedural period and follow-up.

Conclusions: In this pilot study, a preprocedural central line-based 3D CT planning system appeared to be more effective than intraoperative TEE and angiography in measuring the LAA ostium diameter to guide device size selection in patients with atrial fibrillation undergoing one-stop LAAO with concomitant PVi.