Preprocedural 3D Transesophageal Echocardiography for the Prediction of Device Deformation Morphology and Peri-Device Leaks After Transcatheter Left Atrial Appendage Occlusion with the AmplatzerTM Device

<b>Background/Objectives</b>: Percutaneous left atrial appendage occlusion (LAAO) has become an alternative to oral anticoagulation in selected patients with atrial fibrillation. The results of transcatheter LAAO were evaluated by conventional cardiac angiography (CCA), fluoroscopy, and 2D and 3D transesophageal echocardiography (TEE). <b>Methods</b>: In 47 consecutive patients (76 ± 8 years), LAAO was performed with the Amplatzer^TM device. CCA and 2D and 3D TEE were performed for LAA measurements. The eccentricity of the device landing zone was assessed by 3D TEE as the ratio of the maximal and minimal diameters. The device size was selected depending on the CCA maximal diameter. The postprocedural device lobe morphology was classified by fluoroscopy as "square" type (sign of undersizing), "tire" type (optimal deformation), and "strawberry" type (sign of oversizing). After 6 months, TEE was repeated to evaluate peri-device leaks (PDLs). <b>Results</b>: The postprocedural device morphology was "square" type in 9 (19%), "tire" type in 28 (60%), and "strawberry" type in 10 patients (21%). After 6 months, peri-device leaks were observed in 11 patients (23%), with the lowest incidence in the "tire"-type group (11%) compared with "square" type (56%) and "strawberry" type (30%) (<i>p</i> = 0.019). The 3D TEE eccentricity index with a cut-off value of ≤1.29 (indicating a more circular morphology) was a very specific predictor for excluding postprocedural device deformation of the "strawberry" type (AUC = 0.689; sensitivity 48.7%, specificity 100%). <b>Conclusions</b>: Undersizing as well as oversizing of the LAA occluder, as characterized by deformation type by fluoroscopy, was associated with postprocedural PDLs. The eccentricity of the LAA landing zone by 3D TEE may indicate inadequate size selection of the Amplatzer^TM device leading to oversizing in patients with a more eccentric LAA.