title: Left atrial appendage and pulmonary artery anatomic relationship by cardiac-gated computed tomography: Implications for late pulmonary artery perforation by left atrial appendage closure devices.
abstract: Delayed pulmonary artery (PA) perforation and tamponade caused by implantable left atrial appendage (LAA) closure devices has been reported in patients with close proximity between these structures. The LAA and PA anatomic relationship (LAA-PAar) has not been analyzed systematically.
  
  
  
  The purpose of this study was to identify LAA-PAar variants potentially susceptible to this complication using cardiac-gated computed tomography angiography.
  
  
  
  We studied 100 consecutive patients with atrial fibrillation undergoing cardiac-gated computed tomography angiography of the left atrium. The LAA-PAar was classified into 3 types on the basis of the location, length, and thickness of the segment of contact between the PA and/or its branches and the LAA: type 1, no contact; type 2, contact involving the proximal LAA (defined as the proximal 15 mm extending into the LAA from its ostium, or the LAA proximal to the first major bend arising <15 mm from the ostium); and type 3, contact limited to the distal LAA.
  
  
  
  LAA-PAar types 1, 2, and 3 were present in 7 (7%), 28 (28%), and 65 (65%) patients, respectively. For LAA-PAar type 2, the mean contact segment thickness and length were 0.6 ± 0.3 and 18.1 ± 10.6 mm, respectively. For LAA-PAar type 3, the distance between the LAA orifice and the segment of contact was <30 mm in 52 patients (80%).
  
  
  
  In this series, the LAA came in direct contact with the main PA in the majority of patients. Contact involved the proximal LAA (where the fixation components of most LAA closure devices are positioned) in 28% of patients, posing potential vulnerability to PA perforation.
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: amirh@tlvmc.gov.il.
authors.forename: Amir
authors.initials: A
authors.lastname: Halkin
authors.affiliation: Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Clara
authors.initials: C
authors.lastname: Cohen
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Raphael
authors.initials: R
authors.lastname: Rosso
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Ehud
authors.initials: E
authors.lastname: Chorin
authors.affiliation: Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Michael
authors.initials: M
authors.lastname: Schnapper
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Simon
authors.initials: S
authors.lastname: Biner
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Yan
authors.initials: Y
authors.lastname: Topilsky
authors.affiliation: Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, Haifa, Israel.
authors.forename: Avinoam
authors.initials: A
authors.lastname: Shiran
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Haim
authors.initials: H
authors.lastname: Shmilovich
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Dotan
authors.initials: D
authors.lastname: Cohen
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Gad
authors.initials: G
authors.lastname: Keren
authors.affiliation: Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
authors.forename: Shmuel
authors.initials: S
authors.lastname: Banai
authors.affiliation: Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Radiology, Tel Aviv Medical Center, Tel Aviv, Israel.
authors.forename: Galit
authors.initials: G
authors.lastname: Aviram
mesh_terms: D000368:Aged; D020517:Atrial Appendage / Q000000981:diagnostic imaging* / Q000473:pathology; D001281:Atrial Fibrillation / Q000473:pathology / Q000601:surgery; D000072226:Computed Tomography Angiography / Q000379:methods*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*; D007557:Israel; D008297:Male; D008875:Middle Aged; D019919:Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D011651:Pulmonary Artery / Q000000981:diagnostic imaging* / Q000293:injuries / Q000473:pathology; D055989:Septal Occluder Device; D057772:Vascular System Injuries / Q000209:etiology / Q000473:pathology / Q000517:prevention & control*
keywords: Atrial fibrillation; Left atrial appendage closure; Pulmonary artery