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Cardiology syngo DynaCT Cardiac Interventional Left Atrial Appendage Closure Supported by syngo DynaCT Cardiac Courtesy of Markus Füller, MD, Georg von Bodman, MD, and Michael Block, MD Klinik Augustinum, Department of Cardiology, Munich, Germany Treatment Interventional LAA closure with the Watchman device (Boston Scientific) was performed under conscious sedation using TEE guidance. After transseptal puncture of the atrial septum an Amplatz Extra Stiff-wire was inserted into the left upper pulmonary vein and the Watchman access system was introduced into the left atrium. Then a 5F pigtail catheter was advanced and positioned in proximity to the LAA ostium. After additional insertion of a transvenous temporary pacing lead into the right ventricular apex, rotational angiography (RA) was performed under rapid ventricular pacing with a rate of 200 beats per minute. During a breathhold maneuver 65 cc of a mixture of 46% contrast medium (iodine concentration 350 mg/cc) and 56% saline was injected at a rate of 15 cc/sec. with the start of the 200° C-arm rotation 2 seconds after beginning of contrast medium injection (Fig. 2). The three dimensional dataset was reconstructed using syngo DynaCT Cardiac and the segmented model of the LAA was shown as an overlay on the live fluoroscopy image using syngo iPilot enhanced (Fig. 3). Evaluation of these overlay images revealed that the LAA ostium could be best visualized in orthogonal planes by fluoroscopy in a RAO 21°, caudal 20° and a LAO 104°, caudal 6° angulation. Implantation of a 24 mm Watchman device was performed using standard technique. Evaluation of the device after implantation showed adequate device compression, minimal protrusion into the left atrium, complete seal of the LAA and stable position during the tug test (Fig. 4 and 5). After interventional LAA closure the patient was under dual antiplatelet therapy with Aspirin and Clopidogrel for six months. Since TEE examination after six months showed a favourable result of the Watchman device, clopidogrel therapy then could be discontinued and the patient remained under therapy with aspirin. Under this medical regimen no further bleeding events occurred. Comments Recent interest has focused on the left atrial appendage (LAA) as a potential source of thromboembolism and stroke in patients with atrial fibrillation, which may be amenable to permanent occlusion by catheter delivered devices. Interventional LAA closure is usually performed under guidance with TEE and conventional fluoroscopy. Precise anatomic characterization and visualization of the LAA are necessary for proper device selection, sizing, and implantation. TEE is the primary imaging modality for interventional LAA closure; nevertheless, image quality can be impaired and TEE cannot provide a clear three dimensional visualization of LAA anatomy. The supplementary use of intra-procedural 3D imaging using syngo DynaCT Cardiac has the potential to save additional contrast medium, facilitate and accelerate the procedure, and helps to make the treatment safer. Patient History A 82-year-old male patient presented with recurrent large subcutaneous hematomas and suffusion bleeding under oral anticoagulation with phenprocoumon and additional steroid therapy for treatment of polymyalgia rheumatica. Oral anticoagulation was required for persistent atrial fibrillation with a CHA2DS2- VASc-Score of five points. The patient had undergone aortocoronary bypass grafting 20 years ago and had had a cerebrovascular transient ischemic attack two months before. Diagnosis The patient was referred for interventional left atrial appendage (LAA) closure. Preprocedural evaluation using transesophageal echocardiography (TEE) demonstrated suitable anatomic characteristics of the patient’s LAA (Fig. 1). Contact hanno.herrmann@siemens.com Markus Füller, MD 40  AXIOM Innovations | December 2013 | www.siemens.com/angiography


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