Usable implantation depth for watchman left atrial appendage occlusion is greater with appendage angiography than transesophageal echocardiography

ObjectivesTo compare left atrial appendage (LAA) angiography to transesophageal echocardiography (TEE) for assessing usable LAA depth. BackgroundTEE is typically employed for procedural measurement of LAA ostial diameter and depth. Since angiography enhances distal LAA anatomy, we sought to compare angiography to TEE for determining usable LAA depth. MethodsSeventy five Watchman device cases were retrospectively evaluated. Two independent cardiologists measured intraoperative LAA ostial diameter and depth at standard 0 degrees, 45 degrees, 90 degrees, and 135 degrees TEE omniplane views and in the right anterior oblique (RAO) 30 degrees, caudal (CAUD) 30 degrees angiographic view. ResultsThe average age and CHA(2)DS(2)VASc score were 74 (7.2) years and 4.6 (+/- 1.3), respectively. The average ostial diameter and depth (mm) by TEE were 0 degrees: 19.6 and 26.5; 45 degrees: 17.5 and 26.6; 90 degrees: 18.3 and 25.1; 135 degrees: 19.5 and 23.3. The ostial diameter and depth (mm) by RAO 30 degrees CAUD 30 degrees angiography were 21.1 and 29.7. This angiographic view corresponds to a TEE view between 90 degrees and 135 degrees. In comparison to angiography, TEE 90 degrees underestimated the LAA ostial diameter by 2.9 +/- 3.7 mm (P<0.001) and by 1.9 +/- 4.0 mm at TEE 135 degrees (P<0.01); Pearson's r 0.53 angiography/TEE 90 degrees and 0.50 angiography/TEE 135 degrees. More importantly, TEE 90 degrees underestimated the true usable LAA depth by 5.4 +/- 5.8 mm (P<0.001) and by 7.3 +/- 6.1 mm at TEE 135 degrees (P<0.001); Pearson's r 0.39 angiography/TEE 90 degrees and 0.30 angiography/TEE 135 degrees. ConclusionsCompared to TEE, LAA angiography provides additional depth information and may be particularly valuable when patients have insufficient depth for Watchman by TEE measures.