title: Application of 3-Dimensional Computed Tomographic Image Guidance to WATCHMAN Implantation and Impact on Early Operator Learning Curve: Single-Center Experience.
abstract: The aim of this study was to examine the impact of 3-dimensional (3D) computed tomographic (CT) guided procedural planning for left atrial appendage (LAA) occlusion on the early operator WATCHMAN learning curve.
  
  
  
  Traditional WATCHMAN implantation is dependent on 2-dimensional transesophageal echocardiographic (TEE) sizing and intraprocedural guidance.
  
  
  
  LAA occlusion with the WATCHMAN device was performed in 53 patients. Pre-procedural case plans were generated from CT studies with recommended device size, catheter selection, and C-arm angle for deployment.
  
  
  
  All 53 patients underwent successful LAA occlusion with the WATCHMAN. Three-dimensional CT LAA maximal-width sizing was 2.7 ± 2.2 mm and 2.3 ± 3.0 mm larger than 2-dimensional and 3D TEE measurements, respectively (p ≤ 0.0001). By CT imaging, device selection was 100% accurate. There were 4 peri-WATCHMAN leaks (<4.5 mm) secondary to accessory LAA pedunculations. By 2-dimensional TEE maximal-width measurements alone, 62.3% (33 of 53) would have required larger devices. Using 3D TEE maximal-width measurements, 52.8% of cases (28 of 53) would have required larger devices. Three-dimensional TEE length would have inappropriately excluded 10 patients from WATCHMAN implantation. Compared with the average of 1.8 devices used per implantation attempt in PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) (82% success rate), the present site averaged 1.245 devices per implantation attempt (100% success rate). There were no intraprocedural screen failures and no major adverse cardiac events.
  
  
  
  Three-dimensional CT image case planning provides a comprehensive and customized patient-specific LAA assessment that appears to be accurate and may possibly facilitate reducing the early WATCHMAN implantation learning curve.
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan. Electronic address: dwang2@hfhs.org.
authors.forename: Dee Dee
authors.initials: DD
authors.lastname: Wang
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Marvin
authors.initials: M
authors.lastname: Eng
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Daniel
authors.initials: D
authors.lastname: Kupsky
authors.affiliation: Henry Ford Innovation Institute, Henry Ford Health System, Detroit, Michigan.
authors.forename: Eric
authors.initials: E
authors.lastname: Myers
authors.affiliation: Henry Ford Innovation Institute, Henry Ford Health System, Detroit, Michigan.
authors.forename: Michael
authors.initials: M
authors.lastname: Forbes
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Mehnaz
authors.initials: M
authors.lastname: Rahman
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Mohammad
authors.initials: M
authors.lastname: Zaidan
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Sachin
authors.initials: S
authors.lastname: Parikh
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Janet
authors.initials: J
authors.lastname: Wyman
authors.affiliation: Division of Radiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Milan
authors.initials: M
authors.lastname: Pantelic
authors.affiliation: Division of Radiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Thomas
authors.initials: T
authors.lastname: Song
authors.affiliation: Division of Radiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Jeff
authors.initials: J
authors.lastname: Nadig
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Patrick
authors.initials: P
authors.lastname: Karabon
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: Adam
authors.initials: A
authors.lastname: Greenbaum
authors.affiliation: Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
authors.forename: William
authors.initials: W
authors.lastname: O'Neill
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D059925:Anatomic Landmarks; D020517:Atrial Appendage / Q000000981:diagnostic imaging*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation*; D002983:Clinical Competence; D019560:Echocardiography, Three-Dimensional; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D021621:Imaging, Three-Dimensional; D059032:Learning Curve; D008297:Male; D008824:Michigan; D011237:Predictive Value of Tests; D011474:Prosthesis Design; D011857:Radiographic Image Interpretation, Computer-Assisted; D015203:Reproducibility of Results; D055989:Septal Occluder Device; D013813:Therapy, Computer-Assisted / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*; D016896:Treatment Outcome
keywords: 3D printing; CT; WATCHMAN; left atrial appendage closure