Imaging Modalities for Left Atrial Appendage Occlusion: Post-Procedural Transesophageal Echocardiography vs Cardiac Computed Tomography
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Background
The left atrial appendage (LAA) is considered a primary site for thrombus formation due to blood stagnation in the appendage. Left atrial appendage occlusion (LAAO) at the orifice is often a viable approach for preventing thromboembolism. Post LAAO evaluation with transesophageal echocardiography (TEE) is considered the standard modality to examine for potential complications. The use of cardiac computed tomography (CCTA) has recently emerged as a potential alternative to TEE.
Methods
Databases of Pubmed, Embase, Cochrane Library, and Web of Science were investigated for review studies on post LAAO evaluation with TEE and CCTA.
Results
TEE allows assessment of device position, thrombi, peri-device leaks (PDLs), biventricular function, and valve function with clinically informative images. CCTA also allows prediction of device behavior, position, and stability. CCTA further produces high-resolution images for evaluation of heart, vasculature, and devices. It more accurately detects device thrombi and PDLs, thereby better protecting against thromboembolic complications. CCTA involves fewer personnel and potentially lower costs. Among the disadvantages of TEE are that it is invasive, risks esophageal perforations and respiratory compromise, and requires many personnel which add to costs. For CCTA there is a risk of worsening renal function with resultant kidney injury which is of particular concern in chronic kidney disease (CKD). Moreover, CCTA utilizes x-ray radiation which increases risk of long term cancer.
Conclusion
While head to head comparisons are limited, CCTA has some key advantages over TEE in post LAAO evaluation such as higher rates of detection for PDLs, LAATs, and device positioning as well as ease and speed of performance. Further investigations will help determine the patient level outcomes, population outcomes, and the cost benefits of CCTA vs TEE.
