Multimodality Imaging in Evaluating and Guiding Percutaneous Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) has emerged as an important intervention for stroke prevention in patients with nonvalvular atrial fibrillation (AF) who are unable to tolerate long-term anticoagulation. The development of advanced imaging technologies and techniques, such as three-dimensional (3D) echocardiography with multiplanar reconstruction, multidetector cardiac computed tomography (MDCT), 3D intracardiac echocardiography (ICE), 3D printing, and simulation, has revolutionized preprocedural planning, intraprocedural guidance, and postprocedural surveillance, ensuring improved precision and outcomes. Transesophageal echocardiography (TEE) remains a foundational imaging modality for assessing left atrial appendage morphology, excluding thrombi, and obtaining accurate measurements for device sizing. Recent advances in 3D TEE and multiplanar reconstruction techniques enable enhanced visualization of complex left atrial appendage anatomies, improving device selection and procedural planning. MDCT has a growing role, offering high-resolution 3D reconstructions for detailed anatomic assessment. Additionally, its applications in 3D printing and virtual device simulation provide patient-specific insights, facilitating optimal device sizing and improving procedural efficiency. Intraprocedurally, 3D ICE has gained traction as a valuable alternative to TEE. With its real-time imaging capabilities and high spatial resolution, 3D ICE allows precise guidance during transseptal puncture and device deployment while reducing the need for general anesthesia. Postprocedurally, both TEE and MDCT play critical roles in assessing device stability and identifying complications such as device-related thrombus and peridevice leak. This review highlights the evolving role of multimodality imaging in LAAO, including innovations such as 3D ICE, 3D printing, and simulation. The authors also review recent literature to establish state-of-the-art imaging practices, providing a comprehensive discussion of imaging applications across pre-, intra-, and postprocedural phases to optimize outcomes and minimize complications in LAAO.