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Left Atrial Appendage Landing Zone - Tips And Tricks For Safety Left Atrial Appendage Closure
Jakub Batko1, Daniel J. Rams1, Krzysztof Bartuś, Prof.2, Artur Bartoszcze, MD, PhD2, Grzegorz Filip, MD, PhD2, Radosław Litwinowicz, MD, PhD2.
1Jagiellonian University Medical College, Kraków, Poland, 2Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, JP II Hospital, Kraków, Poland.

BACKGROUND: Closure of the left atrial appendage (LAAC) is one of the technically simplest procedures in cardiac surgery. However, there are some isolated scenarios, in which left atrial appendage closure can cause fatal complications such as massive myocardial infarction or coronary artery perforation.
The aim of this study was to evaluate the anatomic topography of the circumferential artery and left atrial appendage, and to define safety zones for implanted closure systems and stapling devices.
METHODS: Left coronary artery with its branches and selected cardiac structures were segmented from 116 contrast enhanced computed tomography scans and three dimensional visualized, using semi-automatic algorithms. The part of left circumflex artery (Cx), localized under left atrial appendage (LAA) was divided into 3 equal parts. Four points were located in the ends of predefined parts, starting from point no 1 at the entry point. The distance less than 2mm was evaluated as dangerous distance, basing on mean thickness of left atrium.

Image 1 - Visualisation of measurements
RESULTS: The mean distance between Cx and LAA landing zone was 4.2±1,6mm, from 5.1±2.6mm in point 1 to 3.5±1.9mm in point 3. The mean distance between Cx and LAA neck bend was 5.2±1.7mm, from 4.3±1.9mm in point 2, to 6.6±2.5mm in point 4. The mean distance between Cx and LAA bottom surface was 6.1±2mm, from 5.9±2,4mm in point 2, to 6.3±2,6mm in point 4. In 38,8% of patients, at least one Cx and LAA distance was smaller than 2mm in at least one dimension, in 19% patients in at least two dimensions, in 3,5% patients in all three dimensions. Those distances occurred in 30.2% in LAA landing zone dimension, in 19.8% in LAA neck bend dimension and in 11.2% in bottom surface of LAA dimension.
CONCLUSIONS: The study showed that the most of the dangerous distances (30.2%) were presented in the dimension of the LAA landing zone. Presented data showed that dimensions located more distally from orifice of LAA are safer in terms of Cx damage. Therefore, LAAC procedure should always be performed with caution, to avoid iatrogenic complications.

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