# Echocardiographic Evaluation for Safe and Complete Transcatheter Left Atrial Appendage Closure

## TL;DR

This paper introduces an enhanced echocardiography checklist to improve the safety and effectiveness of transcatheter left atrial appendage closure procedures.

## Contribution

The novel contribution is the expanded CLOSE-PML sign, which adds critical checks for pulmonary structures, mitral valve, and leak assessment.

## Key findings

- The PML checklist helps prevent complications like pulmonary vein obstruction and new mitral regurgitation.
- Including PML with the CLOSE sign improves device positioning and reduces residual leaks.
- The method promotes safer and more durable transcatheter left atrial appendage closure.

## Abstract

To demonstrate transcatheter left atrial appendage (LAA) closure guided by an expanded transesophageal echocardiography checklist, the CLOSE-PML sign (circumflex artery, lobe compression, orientation, separation, elliptical disc, plus pulmonary structures [pulmonary artery and veins], mitral valve, leak), to optimize Amplatzer Amulet occluder positioning and enhance procedural safety and efficacy.

Beyond the standard CLOSE sign, PML adds: 1) pulmonary structures: confirm unobstructed left upper pulmonary vein flow and ≥1.5-mm clearance from the pulmonary artery; 2) mitral valve: verify normal leaflet motion and absence of new mitral regurgitation; and 3) leak: exclude substantial peridevice leak on color Doppler, confirming complete LAA sealing.

Neglecting PML risks left upper pulmonary vein obstruction, pulmonary artery injury with delayed tamponade, new mitral regurgitation, and residual leaks predisposing to thrombus.

Integrating PML with the CLOSE sign heightens intraprocedural vigilance, ensures systematic assessment of device-structure interactions, and promotes effective, durable transcatheter LAA closure.