A simple method to detect leaks after left atrial appendage occlusion with Watchman.

BACKGROUND: We evaluated the efficacy of a new method in identifying peri-device leak (PDL) using morphology of the thrombus formed inside the left atrial appendage (LAA) as seen on follow-up transesophageal echo (TEE). METHOD: A total of 291 consecutive patients undergoing Watchman procedure were included in this analysis. TEE was performed at 45 days postprocedure. Based on the presence of the thrombus inside the LAA behind the device, patients were grouped as (1) white (W) group: LAA completely filled with thrombus (n = 101), 2) nonwhite (NW) group: LAA completely black or mixed (part black and part white; n = 190). Follow-up TEE was repeated at 6 and 12 months. RESULTS: Baseline characteristics were comparable between groups except the device size, number of patients with chicken-wing morphology, and prevalence of left atrial "smoke" that were significantly higher in the NW group. Detection of black appearance was comparable between the pre-coil closure image and the NW population (26/36 [72.2%] vs 99/154 [64.3%], p = .37). After adjusting for clinically relevant covariates, NW appearance of the LAA was associated with the presence of significant leak (odds ratio: 47.96, 95% confidence interval: 2.91-790.2, p < .001). The 11 patients with mixed appearance at the 6-month TEE remained unchanged (part black and part white) at the 12-month TEE. LAA appearance was white in all 36 patients following coil closure. CONCLUSION: Our findings demonstrated white and nonwhite appearance of the appendage on TEE to be reliable markers of complete closure and leak respectively, following LAA occlusion with the Watchman device.

Simple electrocardiographic criteria for rapid identification of wide QRS complex tachycardia: The new limb lead algorithm.

BACKGROUND: The electrocardiogram (ECG) is essential for the differential diagnosis of wide QRS complex tachycardia (WCT). OBJECTIVE: The purpose of this study was to evaluate the diagnostic value of a novel ECG algorithm on the basis of the morphological characteristics of the QRS on the limb leads. METHODS: The limb lead algorithm (LLA) was evaluated by analyzing 528 monomorphic WCTs with electrophysiology-confirmed diagnoses. In the LLA, ventricular tachycardia (VT) is diagnosed in the presence of at least 1 of the following: (1) monophasic R wave in lead aVR; (2) predominantly negative QRS in leads I, II, and III; and (3) opposing QRS complex in the limb leads: concordant monophasic QRS in all 3 inferior leads and concordant monophasic QRS in 2 or 3 of the remaining limb leads with a polarity opposite to that of the inferior leads. The diagnostic performance of the LLA was compared with that of the Brugada, Vereckei, and R-wave peak time (RWPT) algorithms. RESULTS: Of 528 WCT cases, 397 were VT and 131 supraventricular tachycardia. The interobserver agreement for the LLA was excellent (κ = 0.98), better than that for the other algorithms. The overall accuracy of the LLA (88.1%) was similar to that of Brugada (85.4%) and Vereckei (88.1%) algorithms but was higher than that of the RWPT algorithm (70.8%). The LLA had a lower sensitivity (87.2%) than did Brugada (94.0%) and Vereckei (92.4%) algorithms, but not the RWPT algorithm (67.8%). Furthermore, the LLA showed a higher specificity (90.8%) than did Brugada (59.5%), Vereckei (76.3%), and RWPT (80.2%) algorithms. CONCLUSION: The LLA is a simple yet accurate method to diagnose VT when approaching WCTs on the ECG.