Device Sizing Guided by Echocardiography-Based Three-Dimensional Printing is Associated with Superior Outcome after Percutaneous Left Atrial Appendage Occlusion

Abstract

Background:Left atrial appendage (LAA) occlusion is an alternative to anticoagulation for stroke prevention inpatients with atrial fibrillation. Accurate device sizing is crucial for optimal outcome. Patient-specific LAAmodels can be created using three-dimensional (3D) printing from 3D transesophageal echocardiographic(TEE) images, allowing in vitro model testing for device selection. The aims of this study were to assess theassociation of model-based device selection with procedural safety and efficacy and to determine if prepro-cedural model testing leads to superior outcomes.Methods:In 72 patients who underwent imaging-guided LAA occlusion, 3D models of the LAA were createdfrom 3D TEE data sets retrospectively (retrospective cohort). The optimal device determined by in vitro modeltesting was compared with the actual device used. Associations of model-match and model-mismatch devicesizing with outcomes were analyzed. In another 32 patients, device selection was prospectively guided by 3Dmodels in adjunct to imaging (prospective cohort). The impact of model-based sizing on outcomes was as-sessed by comparing the two cohorts.Results:Patients in the retrospective cohort with model-mismatch sizing had longer procedure times, moreimplantation failures, more devices used per procedure, more procedural complications, more perideviceleak, more device thrombus, and higher cumulative incidence rates of ischemic stroke and cardiovascularor unexplained death (P< .05 for all) over 3.062.3 years after LAA occlusion. Compared with the retrospectiveimaging-guided cohort, the prospective model-guided patients achieved higher implantation success andshorter procedural times (P< .05) without complications. Clinical device compression (r= 0.92) and protrusion(r= 0.95) agreed highly with model testing (P< .0001). Predictors for sizing mismatch were nonwindsockmorphology (odds ratio, 4.7) and prominent LAA trabeculations (odds ratio, 7.1).Conclusions:In patients undergoing LAA occlusion, device size selection in agreement with 3D-printed model-based sizing is associated with improved safety and efficacy. Preprocedural device sizing with 3D models inadjunct to imaging guidance may lead to superior outcomes. (J Am Soc Echocardiogr 2019;32:708-19.)