Background: Various clinical trials provide evidence about the safety, effectiveness, and therapeutic success of percutaneous left atrial appendage closure (LAAC) using various occlusion devices. These devices are foreign materials implanted into the left atrium and may deteriorate left atrial (LA) function. The aim of this study was to evaluate the change in transesophageal echocardiography (TEE)-derived LA strain after LAAC. Methods and Results: The study included 95 patients (age: 75 ± 6.7 years, 67% male) who underwent percutaneous LAAC. LA strain was evaluated at three different time intervals by TEE (baseline, 45 days, and 180 days after the procedure). All data were analyzed using the software Image-Arena (TomTec^®). Seventy patients had atrial fibrillation, whereas 25 were in sinus rhythm at baseline and during follow-up. Analysis was performed for peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) from segments of the lateral wall in mid-esophageal four-chamber view. PACS was obtained in patients with sinus rhythm during examinations. Compared to baseline, PALS increased at 45 days after the procedure (12.4% ± 8.4% at baseline vs. 16.0% ± 10.6% after 45 days, P = 0.001) and remained stable from 45 days to 180 days after procedure (13.8% ± 9.1% after 45 days vs. 17.2% ± 12.6% after 180 days, P = 0.092). Similarly, PACS increased at 45 days after the procedure (5.8% ± 3.9% at baseline vs. 10.6% ± 7.6% after 45 days, P = 0.001) and remained stable from 45 days to 180 days after the procedure (7.6% ± 4.5% after 45 days vs. 7.9% ± 3.1% after 180 days, P = 0.876).Conclusions: Our study demonstrated for the first time the improvement in TEE-derived LA strain following LAAC within 45 days of implantation. The findings suggest improved LA function following LAAC.

(1) Background: The assessment of residual peri-device leakages (PDL) after left atrial appendage occlusion (LAAO) remains crucial for post-procedural management. Our study aimed to verify a novel echocardiographic classification for the prediction of PDL. (2) Methods: Echocardiographic data of 72 patients who underwent percutaneous LAAO were evaluated. All echo images were analyzed by two independent investigators using standard analysis software (Image-Arena IA-4.6.4.44 by TomTec^®, Munich, Germany). A total number of 127 studies was evaluated. Forty-four patients had baseline studies, at 45 days and at 6 months post-implantation. We propose a morphological classification of LAA devices based on the amount of echodensity inside the devices into three types: type A showing complete homogenous thrombosis, type B incompletely thrombosed device with inhomogeneous echo-free space 50% of device in various planes, which we called the “ice-cream cone” sign. Each type was matched to the degree of PDL and clinical outcome parameters. (3) Results: Patients with type C had the highest percentage of PDL at 45 days follow-up (type A: 24%, type B: 31%, type C 100% PDL, p < 0.001) and at 6 months follow-up (type A: 7%, type B: 33%, type C 100% PDL, p < 0.001). Notably, device size in patients with PDL was larger than that in patients without PDL at 6 months follow-up (25.6 ± 3.5 mm vs. 28.7 ± 3.4 mm, p = 0.004). Device size in patients with type C appearance was the largest of the three types (type A: 25.9 ± 3.6 mm, type B: 25.8 ± 3.4 mm, type C 29.8 ± 3.0 mm, type A vs. C; p = 0.019; type B vs. C, p = 0.007). (4) Conclusions: In conclusion, PDL are common post-LAAO, and their frequency is underestimated and under-recognized. PDL are much more common in patients with larger LAA ostial sizes and likely lower longitudinal compression. Type C appearance of the LAAO devices (“ice-cream cone sign”) has a high positive predictive value for PDL. Further studies are needed for better delineation of the clinical importance of this proposed classification.

A 78-year-old man presented with effort dyspnoea and oedema. He had undergone a replacement of ascending aorta for acute aortic dissection 3 years earlier, and no problems have been detected in post-operative computed tomography (CT). Echocardiogram showed a compressed right ventricle from extra-cardiac structures, resulting in right ventricular outflow tract (RVOT) stenosis and subsequent pulmonary hypertension (Panel A; Supplementary data online , Video S1). Computed tomography revealed a huge aortic pseudoaneurysm originating from peripheral anastomosis of the artificial aortic graft, which compressed the right ventricle as well as the superior vena cava, right atrium, and pulmonary artery (Panels B and C; Supplementary data online , Video S2). Additional reconstructed 3D-rendered CT clearly demonstrated that the RVOT was pinched and constricted by the aortic pseudoaneurysm (Panels D and E; Supplementary data online , Video S3). He was diagnosed with right heart failure due to compression around the RVOT by post-operative aortic pseudoaneurysm. He underwent a redo with a total arch replacement with an open stent graft to release the compression. During surgery, we found bleeding at the anastomosis between the graft and the aorta. We considered that the aortic tissue was fragile and the aortic wall would be dissected one after another by suturing haemostasis, so we added Bentall surgery. Post-operative computed tomography revealed the expanded RVOT (Panel F; Supplementary data online , Video S4) resulting in a haemodynamic normalization. He was discharged home 77 days after surgery. This is the first case of an aortic pseudoaneurysm that compressed the RVOT and led to a right heart failure.

A woman in her 70 s presented with fatigue and dyspnoea during exertion. Six years ago, she had been implanted with a dual chamber pacemaker with the lead placement at the high septal site of the right ventricle. Echocardiography demonstrated the presence of the previously detected left ventricular septal bulge along with a newly observed systolic turbulent mosaic at left ventricular outflow tract (LVOT) and a systolic anterior motion (SAM) of the mitral valve. Electrophysiological pacing study and simultaneously performed echocardiography demonstrated that the apical pacing decreases the pressure gradient at the left ventricular outflow tract LVOT. We changed the lead position of the pacemaker from the high septal to the apical site of the right ventricle. During the follow-up period, recurrence of the obstruction at the LVOT with SAM was not detected. In the case with septal bulge, it is necessary to choose the apical position as the pacemaker lead placement.

Hiroyuki Matsumoto, Shun Ijuin, Toshihiko Terashi, Jan Henzel; Right-Side Cardiac Metastasis of Squamous Cell Carcinoma from Esophagogastric Junction Cance