Three-dimensional (3D) printing has been successful in guiding device sizing for left atrial appendage occlusion (LAAO) devices and 4-dimensional intracardiac echocardiography (4D ICE) has been shown to successfully guide LAAO intraprocedurally.1,2 We present the first known case of LAAO peridevice leak closure that utilized a combination of 3D printing and intraprocedural 4D ICE.
An 84-year-old woman with a history of persistent atrial fibrillation with a CHA2DS2-VASc score 5 taking Apixaban complicated by recurrent gastrointestinal bleeding was referred for LAAO. She underwent LAAO with a 31-mm Watchman FLX device under transesophageal echocardiographic guidance with no observable leak (Figure 1). Follow-up computed tomography (CT) imaging, using a dual source 192 slice CT scanner, at 6 weeks demonstrated a small lobe of the left atrial appendage that was not completely occluded, measuring 7 mm at the neck (Figure 2). The decision was made to plug the leak. Given the challenging nature of device sizing in the presence of an existing LAAO device, a 3D print of the left atrium was obtained using 30-second delayed phase imaging on CT images. While 3D volume rendering using CT imaging utilizes a process whereby pixels are automatically included in a model based on a specified window level, 3D-printed models are produced utilizing segmentation software, in which collections of pixels are first selected based on a preselected threshold range and then further edited manually by the designer. A single model often includes pixels from various threshold ranges to include the desired anatomical features to be visualized. The 3D printer we utilized is able to achieve a z-axis spatial resolution of 1.25 × 10-3 mm, allowing production of the highest resolution model possible from a CT scan with 0.6-mm slice thickness. In the xy plane, however, the 3D printer has a resolution of 50 μm, compared to 240 μm for the CT scanner.
Figure 1.
Intraprocedural transesophageal echocardiography showing biplane imaging during initial LAAO device placement, with no apparent peridevice leak.
Abbreviation: LAAO, Left atrial appendage occlusion.
Figure 2.
Axial (a) and sagittal (b) CT views 6 weeks post LAAO showing LAAO device and peridevice leak.
Abbreviation: CT, computed tomography; LAAO, Left atrial appendage occlusion.
Multiple sample devices were tested before implantation, ultimately settling on an Amplatzer Ductal Occluder II (ADO-II) 6-6 mm device. (Figure 3, Supplemental Video 1). Furthermore, to enhance intraprocedural imaging, 4D ICE was used to obtain multiplanar images without having to use transesophageal echocardiographic and general anesthesia, thereby allowing us to view the LAAO device and peridevice leak in 3D views as we had modeled on the 3D print (Figure 3; Supplemental Video 2). There was no device wastage given the appropriate use of the ADO-II as predicted by the 3D print model. CT imaging 6 weeks postprocedure showed successful LAAO by the Watchman FLX device and the ADO-II device, with no significant leak (Figure 4).
Figure 3.
Segmentation using 3D slicer software for 3D printing of left atrium with LAAO device (a and b). Preprocedural testing of Amplatzer Ductal Occluder II 6-6 mm device on the 3D print (c) and 4D intracardiac echocardiography imaging showing intraprocedural deployment of (d) ADO-II device for peridevice leak. Note that 3D model was created using a masked stereolithography apparatus 3D printer with transparent photopolymer resin (c).
Abbreviations: 3D, Three-dimensional; 4D, Four-dimensional; ADO-II, Amplatzer Ductal Occluder; LAAO, Left atrial appendage occlusion.
Figure 4.
Axial (a) and sagittal (b) CT views 6 weeks after peridevice leak closure showing LAAO device and ADO-II device.
Abbreviations: ADO-II device, Amplatzer Ductal Occluder II; CT, computed tomography; LAAO, Left atrial appendage occlusion.
Consent Statement
Consent was obtained from the patient for publication of this report and any accompanying images.
Funding
This article received departmental funding (grant number: GRT02254 72442C/P2015-0177/EH15-223-PD1).
Disclosure Statement
The authors report no conflict of interest.
Acknowledgments
Fazal Hussain–Video and freeze frame editing.
Footnotes
Supplemental data for this article can be accessed on the publisher’s website.
Supplemental Material
Preprocedural testing of Amplatzer Ductal Occluder II 6-6 mm device on 3D print model of the left atrium and left atrial appendage with embedded left atrial appendage occluder device.
4D intracardiac echocardiography clips during peridevice leak occlusion that show 3D images using multiplanar reconstruction of the Watchman FLX device with Amplatzer Ductal Occluder II device successfully occluding the peridevice leak.
References
- 1.DeCampos D., Teixeira R., Saleiro C., et al. 3D printing for left atrial appendage closure: a meta-analysis and systematic review. Int J Cardiol. 2022;356:38–43. doi: 10.1016/j.ijcard.2022.03.042. [DOI] [PubMed] [Google Scholar]
- 2.Ranard L.S., Khalique O.K., Donald E., et al. Transcatheter left atrial appendage closure using preprocedural computed tomography and intraprocedural 4-dimensional intracardiac echocardiography. Circ Cardiovasc Interv. 2021;14:e010686. doi: 10.1161/CIRCINTERVENTIONS.121.010686. [DOI] [PubMed] [Google Scholar]
Associated Data
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Supplementary Materials
Preprocedural testing of Amplatzer Ductal Occluder II 6-6 mm device on 3D print model of the left atrium and left atrial appendage with embedded left atrial appendage occluder device.
4D intracardiac echocardiography clips during peridevice leak occlusion that show 3D images using multiplanar reconstruction of the Watchman FLX device with Amplatzer Ductal Occluder II device successfully occluding the peridevice leak.