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Samaras A, Papazoglou AS, Balomenakis C, Bekiaridou A, Moysidis DV, Patsiou V, Orfanidis A, Giannakoulas G, Kassimis G, Fragakis N, Saw J, Landmesser U, Alkhouli MA, Tzikas A. Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis. Eur Heart J 2024; 45:214-229. [PMID: 38088437 DOI: 10.1093/eurheartj/ehad828] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/02/2023] [Accepted: 10/19/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND AND AIMS Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion. METHODS A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks. RESULTS Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively). CONCLUSIONS Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.
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Affiliation(s)
- Athanasios Samaras
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Andreas S Papazoglou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Balomenakis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Dimitrios V Moysidis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Orfanidis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | | | - Apostolos Tzikas
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- European Interbalkan Medical Center, Department of Cardiology, Asklipiou 10, Pylaia, Thessaloniki 57001, Greece
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Mostafa MR, Eid MM, Abuelazm M, Al-Abdouh A, Najim M, Hassan AR, El-Sakka AA, Renjithal SLM, Malik MA, Mohamed S, Balmer-Swain M, Paul TK, Goldsweig AM. Meta-Analysis of the Outcomes of Peri-Device Leak After Left Atrial Appendage Closure. Am J Cardiol 2023; 204:325-332. [PMID: 37572568 DOI: 10.1016/j.amjcard.2023.07.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/14/2023]
Abstract
Left atrial appendage closure (LAAC) reduces the risk of thromboembolic stroke in atrial fibrillation. Peri-device leak (PDL) after LAAC may affect the subsequent risk of thromboembolism. We conducted a systematic review and meta-analysis to evaluate the effect of PDL after LAAC. We searched PubMed/Medline, Embase, and Google Scholar for studies reporting outcomes of PDL after LAAC from inception through October 2022. The primary outcome was the composite of stroke, transient ischemic attack (TIA), or systemic embolism (SE). Secondary outcomes included all-cause and cardiovascular mortality, ischemic stroke, TIA, and device-related thrombus. Outcomes were pooled using random-effects models. We used I2 statistics to assess statistical heterogeneity; I2 >50% considered significant heterogeneity. This study included 54,279 patients from 11 studies (6 observational, 2 nonrandomized controlled trials [non-RCTs] primary results, 2 RCT post hoc analyses, and 1 analysis combining 2 RCTs data). PDL was associated with a significant increase in the composite outcome of stroke, TIA, or SE (odds ratio 1.63, 95% confidence interval 1.06 to 2.52, p = 0.03, I2 = 43%) as compared with cases with no PDL. There were no significant differences in all-cause or cardiovascular mortality, ischemic stroke, TIA, or device-related thrombus. In conclusion, PDL after LAAC is associated with an increased risk of thromboembolism (composite stroke, TIA, or SE) without impacting mortality.
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Affiliation(s)
- Mostafa Reda Mostafa
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Magdi Eid
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Abuelazm
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mostafa Najim
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Abdul Rhman Hassan
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amro A El-Sakka
- Department of Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Muhammad Ahmed Malik
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Sarah Mohamed
- Department of Medicine, Cairo University School of Medicine, Cairo, Egypt
| | - Mallory Balmer-Swain
- Department Cardiology, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Timir K Paul
- Department of Cardiovascular Medicine, University of Tennessee at Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts.
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He YG, Yang SH, Xu L, Wang Y, Qin XT, Chen PP, Zhao YJ. The Effect of Peri-Device Leaks on Ischaemic Stroke/Transient Ischaemic Attack/Systemic Embolism after Left Atrial Appendage Closure: A Systematic Review and Meta-Analysis. Cardiology 2023; 148:581-592. [PMID: 37459844 DOI: 10.1159/000532019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 07/10/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a safe and effective method for preventing embolic events in patients with non-valvular atrial fibrillation. However, peri-device leaks (PDLs) are sometimes unavoidable. Controversy exists regarding whether PDLs lead to embolic events. OBJECTIVES This study aimed to explore the association between PDLs and embolic events, including ischaemic stroke, transient ischaemic attacks (TIAs), and systemic embolism (SE). METHODS We conducted a systematic search of the PubMed, Web of Science, MEDLINE, and Cochrane Library databases for studies published up to September 25, 2022, to compare the rate of ischaemic stroke/TIA/SE between the PDL group and the non-PDL group after LAAC. RESULTS Thirteen studies comprising 54,405 patients were included in the meta-analysis. The PDL group detected by transoesophageal echocardiography (TEE) had a significantly higher rate of ischaemic stroke/TIA/SE than the non-PDL group (OR: 1.20, 95% CI: 1.08-1.33, p = 0.0009). However, no difference in ischaemic stroke/TIA/SE was found between the PDL and non-PDL subgroups of the cardiac computed tomography angiography (CCTA) group (OR: 1.12, 95% CI: 0.51-2.50, p = 0.77). CCTA and TEE showed different rates of PDL detection, with the CCTA group having a higher rate of PDL detection (p < 0.0001), especially for trivial leaks. CONCLUSIONS PDL detected by TEE increases the risk of embolic events after LAAC. However, no association was found between PDL and ischaemic stroke/TIA/SE in the CCTA group, which showed a higher rate of PDL detection than TEE, particularly for trivial leaks. In the future, CCTA may be used to explore the relationship between PDL size and ischaemic stroke/TIA/SE.
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Affiliation(s)
- Yin-Ge He
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China,
| | - Shao-Hua Yang
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Liang Xu
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Yan Wang
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Xu-Tan Qin
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Pan-Pan Chen
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Yu-Jie Zhao
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
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Rashid HN, Layland J. Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation. IJC HEART & VASCULATURE 2021; 32:100688. [PMID: 33354620 PMCID: PMC7744943 DOI: 10.1016/j.ijcha.2020.100688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/21/2020] [Accepted: 11/27/2020] [Indexed: 12/30/2022]
Abstract
Atrial fibrillation is one of the most common cardiovascular disorders encountered by clinicians in clinical practice. Patients with atrial fibrillation are at risk of cerebrovascular and systemic embolic events, which may be attenuated by commencement of anticoagulation therapy. Even so, due to extremely high bleeding risk certain patients may not be suitable for long-term anticoagulation therapy. The left atrial appendage is a common site for thrombus formation in patients with atrial fibrillation. Left atrial appendage exclusion, either surgical or percutaneous, has been performed to ostensibly reduce the risk of cerebrovascular events and potentially minimise or omit anticoagulation therapy in select patients. This review summarises the role of the left atrial appendage in cerebrovascular events, current evidence with modification of the left atrial appendage and future trials that may change practice with these procedures.
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Key Words
- ACC, American College of Cardiology
- AF, Atrial fibrillation
- AHA, American Heart Association
- Atrial fibrillation
- DRT, Device related thrombus
- ESC, European Society of Cardiology
- FDA, Food and Drug Administation
- HR, Hazard ratio
- LAA, Left atrial appendage
- LAAE, Left atrial appendage exclusion
- LGE, Late gadolinium enhancement
- Left atrial appendage occluder
- Left atrial appendage occlusion
- OAC, Oral anticoagulation
- OR, Odds ratio
- Stroke
- TOE, Trans-oesopheageal echocardiogram
- Thrombosis
- Watchman device
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Affiliation(s)
- Hashrul N. Rashid
- Monash Cardiovascular Research Centre, Monash University, Melbourne, Australia
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
| | - Jamie Layland
- Department of Cardiovascular Research, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Melbourne, Australia
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Suradi HS, Park J, Poulin MF, Kavinsky CJ. Case report: percutaneous closure of residual leak following left atrial appendage occlusion. Eur Heart J Case Rep 2020; 4:1-4. [PMID: 32974486 PMCID: PMC7501943 DOI: 10.1093/ehjcr/ytaa139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/21/2020] [Accepted: 05/01/2020] [Indexed: 11/13/2022]
Abstract
Background Transcatheter left atrial appendage occlusion (LAAO) using Watchman device has been demonstrated to be efficacious in decreasing stroke risk in patients with atrial fibrillation who are not suitable for long-term anticoagulation. Residual leaks are frequently encountered following LAAO procedures and their clinical implications and optimal management remain controversial. Case summary In this report, we describe a case of peri-Watchman device leak treated successfully with percutaneous device closure using an Amplatzer Vascular Plug II device. Discussion The clinical implications of peri-device leaks remain controversial with general consensus to continue anticoagulation along with serial imaging for larger leaks (>5 mm). As an alternative strategy, percutaneous closure of these leaks has been attempted in hope of avoiding anticoagulation and minimizing the risk of stroke and should be studied further.
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Affiliation(s)
- Hussam S Suradi
- Division of Cardiovascular Medicine, Rush University Medical Center, 1717 W. Congress Parkway, Kellogg 317, Chicago, IL 60612, USA
| | - Jeffrey Park
- Division of Cardiovascular Medicine, Rush University Medical Center, 1717 W. Congress Parkway, Kellogg 317, Chicago, IL 60612, USA
| | - Marie-France Poulin
- Division of Cardiovascular Medicine, Rush University Medical Center, 1717 W. Congress Parkway, Kellogg 317, Chicago, IL 60612, USA
| | - Clifford J Kavinsky
- Division of Cardiovascular Medicine, Rush University Medical Center, 1717 W. Congress Parkway, Kellogg 317, Chicago, IL 60612, USA
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Westcott SK, Wung W, Glassy M, Singh GD, Smith TW, Fan D, Rogers JH. A novel clock‐face method for characterizing peridevice leaks after left atrial appendage occlusion. Catheter Cardiovasc Interv 2020; 96:E387-E392. [DOI: 10.1002/ccd.28796] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 02/10/2020] [Indexed: 11/08/2022]
Affiliation(s)
- Sarah K. Westcott
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - William Wung
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - Matthew Glassy
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - Gagan D. Singh
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - Thomas W. Smith
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - Dali Fan
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
| | - Jason H. Rogers
- Division of Cardiovascular MedicineUniversity of California Davis Medical Center Sacramento California
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Adedinsewo D, Salwa N, Sennhauser S, Farhat S, Winder J, Lesser E, White L, Landolfo C, Venkatachalam KL, Pollak P, Parikh P. Clinical Outcomes following Left Atrial Appendage Occlusion: A Single-Center Experience. Cardiology 2020; 146:106-115. [PMID: 32810847 DOI: 10.1159/000509277] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 06/08/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Percutaneous left atrial appendage closure is an established alternative to anticoagulation therapy for stroke prophylaxis among patients with nonvalvular atrial fibrillation. There are currently no guidelines on the choice of antithrombotic therapy following placement of the Watchman® device, the optimal time to discontinue anticoagulation or the duration of follow-up imaging after device deployment. Our main objective was to evaluate clinical outcomes among these patients. METHODS We conducted a retrospective review of patients who received a Watchman® device at Mayo Clinic sites between January 2010 and December 2018. We constructed Cox-proportional hazard models to evaluate the effect of specific variables on clinical outcomes. RESULTS 231 patients were identified (33% female), median age was 77 years, CHA2DS2-VASc score was 5 and HASBLED score was 4. We found no difference in clinically significant bleeding based on initial antithrombotic choice. However, patients with prior gastrointestinal bleeding were more likely to have a bleeding event in the first 6 weeks following Watchman® implantation (HR 9.40, 95% CI 2.15-41.09). Device sizes of 24-27 mm were significantly associated with a decreased risk of thromboembolic events (HR 0.15, 95% CI 0.04-0.55) compared to 21-mm devices. Peridevice leak (PDL) sizes appeared to either remain the same or increase on follow-up imaging. DISCUSSION/CONCLUSIONS This observational study showed no statistically significant difference in bleeding risk related to initial antithrombotic choice. Smaller device sizes were associated with thromboembolic events, and longitudinal PDL assessment using transesophageal echocardiography showed these frequently do not decrease in size. Larger studies are needed.
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Affiliation(s)
- Demilade Adedinsewo
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA,
| | - Najiyah Salwa
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Susie Sennhauser
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Salman Farhat
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Jeffery Winder
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Elizabeth Lesser
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Launia White
- Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida, USA
| | - Carolyn Landolfo
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - K L Venkatachalam
- Division of Cardiovascular Medicine, Electrophysiology and Pacing Service, Mayo Clinic, Jacksonville, Florida, USA
| | - Peter Pollak
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Pragnesh Parikh
- Division of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida, USA
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Left atrial appendage orifice diameter measured with trans-esophageal echocardiography is independently related with peri-device leakage after Watchman device implantation. Int J Cardiovasc Imaging 2019; 35:1831-1839. [DOI: 10.1007/s10554-019-01625-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Accepted: 05/06/2019] [Indexed: 12/16/2022]
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Spaziano M, Fernandez Lopez L, Cazalas M, Bouvier E, Horvilleur J, Garot P. Procedure planning and device positioning for left atrial appendage occlusion: insights from multi detector-row computed tomography with 3D fusion. Int J Cardiovasc Imaging 2019; 35:1721-1731. [PMID: 31250161 DOI: 10.1007/s10554-019-01607-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/19/2019] [Indexed: 01/08/2023]
Abstract
To compare planned and achieved device position in patients undergoing left atrial appendage occlusion (LAAO). It is unclear how devices used for LAAO position themselves compared to what is planned. All patients undergoing LAAO at our institution had pre- and post-procedural multi detector-row computed tomography (MDCT) at 3 months (N = 52). Using dedicated software, both datasets were fused to superimpose the left atria in all planes. The effective device position was traced on the post-procedural MDCT and then imported in the pre-procedural dataset to allow comparisons. Planned and effective landing zones were compared with respect to size, location and orientation. The device's final position was in a significantly larger landing zone than planned (452 ± 174 vs. 351 ± 112 mm2 for effective and planned landing zones, respectively, paired t-test: p < 0.0001), resulting in significantly less-than-intended area oversizing (41 ± 31 vs. 12 ± 28%, p < 0.0001). In terms of device orientation, there was a difference of 19.7° between the planned and effective landing zones (p < 0.0001). The Amplatzer device had a shallower-than-planned position in 70% of cases, whereas the Watchman device had a deeper-than-planned position in 75% of cases (p = 0.04). Incomplete occlusion was found in 17 patients (33%). In a multivariable model, oversizing at the effective landing zone was the only MDCT independent predictor of incomplete occlusion (OR: 0.96 per 1% increment, 95% CI 0.95-0.98, p = 0.009). MDCT fusion showed that LAAO device position and orientation are different than planned, and this is associated with incomplete occlusion of the LAA.
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Affiliation(s)
- Marco Spaziano
- Department of Cardiology, Institut Cardiovasculaire Paris-Sud - Hôpital Privé Jacques Cartier (Ramsay Générale de Santé), 6 Avenue du Noyer Lambert, Massy, 91300, France
- Department of Cardiology, McGill University Health Centre, Montreal, Canada
| | - Leticia Fernandez Lopez
- Department of Cardiology, Institut Cardiovasculaire Paris-Sud - Hôpital Privé Jacques Cartier (Ramsay Générale de Santé), 6 Avenue du Noyer Lambert, Massy, 91300, France
| | | | - Erik Bouvier
- Department of Cardiology, Institut Cardiovasculaire Paris-Sud - Hôpital Privé Jacques Cartier (Ramsay Générale de Santé), 6 Avenue du Noyer Lambert, Massy, 91300, France
| | - Jérôme Horvilleur
- Department of Cardiology, Institut Cardiovasculaire Paris-Sud - Hôpital Privé Jacques Cartier (Ramsay Générale de Santé), 6 Avenue du Noyer Lambert, Massy, 91300, France
| | - Philippe Garot
- Department of Cardiology, Institut Cardiovasculaire Paris-Sud - Hôpital Privé Jacques Cartier (Ramsay Générale de Santé), 6 Avenue du Noyer Lambert, Massy, 91300, France.
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Han Z, Wu X, Chen Z, Ji W, Liu X, Liu Y, Di W, Li X, Yu H, Zhang X, Xu B, Lan RF, Xu W. Residual flow may increase the risk of adverse events in patients received combined catheter ablation and transcatheter left atrial appendage closure for nonvalvular atrial fibrillation: a meta-analysis. BMC Cardiovasc Disord 2019; 19:138. [PMID: 31182014 PMCID: PMC6558863 DOI: 10.1186/s12872-019-1123-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/31/2019] [Indexed: 01/29/2023] Open
Abstract
Background Catheter ablation (CA) and left atrial appendage closure (LAAC) have been combined into a novel one-stop procedure for patients with atrial fibrillation (AF). However, postoperative complications are relatively common in patients undergoing LAAC; the complications, including residual flow, increase in the risk of bleeding, or other adverse events, are unknown in patients receiving one-stop therapy. Therefore, we tried to evaluate the adverse events of CA and LAAC hybrid therapy in patients with nonvalvular AF. Methods We performed a meta-analysis and computer-based literature search to identify publications listed in the PubMed, Embase, and Cochrane library databases. Studies were included if patients received CA and LAAC hybrid therapy and reported adverse events. Results Overall 13 studies involving 952 patients were eligible based on the inclusion criteria. In the periprocedural period, the pooled incidence of pericardial effusion was 3.15%. The rates of bleeding events and residual flow were 5.02 and 9.11%, respectively. During follow-up, the rates of all-cause mortality, embolism events, bleeding events, AF recurrence, and residual flow were 2.15, 5.24, 6.95, 32.89, and 15.35%, respectively. The maximum occurrence probability of residual flow events was 21.87%. Bleeding events were more common in patients with a higher procedural residual flow event rate (P = 0.03). A higher AF recurrence rate indicated higher rates of embolism events (P = 0.04) and residual flow (P = 0.03) during follow-up. Conclusions Bleeding events were more common in patients with a higher procedural residual flow event rate. However, combined CA and LAAC therapy is reasonably safe and efficacious in patients with nonvalvular AF. Further studies on the safety and efficacy of CA or LAAC alone are necessary in future.
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Affiliation(s)
- Zhonglin Han
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Xiang Wu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Zheng Chen
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Wengqing Ji
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Xuehua Liu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Yu Liu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Wencheng Di
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Xiaohong Li
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Hongsong Yu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Xinlin Zhang
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Biao Xu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Rong Fang Lan
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China
| | - Wei Xu
- Department of Cardiology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Zhongshan Road No.321, Nanjing, 210000, China.
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Glassy MS, Wung W, Westcott S, Smith TW, Fan D, Rogers JH, Singh GD. Watchman Occlusion in Long-Standing Persistent Atrial Fibrillation. JACC Cardiovasc Interv 2019; 12:1018-1026. [DOI: 10.1016/j.jcin.2019.04.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 03/05/2019] [Accepted: 04/02/2019] [Indexed: 11/24/2022]
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Glassy MS, Sharma G, Singh GD, Smith TWR, Fan D, Rogers JH. Usable implantation depth for watchman left atrial appendage occlusion is greater with appendage angiography than transesophageal echocardiography. Catheter Cardiovasc Interv 2019; 93:E311-E317. [PMID: 30311343 DOI: 10.1002/ccd.27916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/09/2018] [Accepted: 09/09/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVES To compare left atrial appendage (LAA) angiography to transesophageal echocardiography (TEE) for assessing usable LAA depth. BACKGROUND TEE is typically employed for procedural measurement of LAA ostial diameter and depth. Since angiography enhances distal LAA anatomy, we sought to compare angiography to TEE for determining usable LAA depth. METHODS Seventy five Watchman device cases were retrospectively evaluated. Two independent cardiologists measured intraoperative LAA ostial diameter and depth at standard 0°, 45°, 90°, and 135° TEE omniplane views and in the right anterior oblique (RAO) 30°, caudal (CAUD) 30° angiographic view. RESULTS The average age and CHA2 DS2 VASc score were 74 (±7.2) years and 4.6 (±1.3), respectively. The average ostial diameter and depth (mm) by TEE were 0°: 19.6 and 26.5; 45°: 17.5 and 26.6; 90°: 18.3 and 25.1; 135°: 19.5 and 23.3. The ostial diameter and depth (mm) by RAO 30° CAUD 30° angiography were 21.1 and 29.7. This angiographic view corresponds to a TEE view between 90° and 135°. In comparison to angiography, TEE 90° underestimated the LAA ostial diameter by 2.9 ± 3.7 mm (P < 0.001) and by 1.9 ± 4.0 mm at TEE 135° (P < 0.01); Pearson's r 0.53 angiography/TEE 90° and 0.50 angiography/TEE 135°. More importantly, TEE 90° underestimated the true usable LAA depth by 5.4 ± 5.8 mm (P < 0.001) and by 7.3 ± 6.1 mm at TEE 135° (P < 0.001); Pearson's r 0.39 angiography/TEE 90° and 0.30 angiography/TEE 135°. CONCLUSIONS Compared to TEE, LAA angiography provides additional depth information and may be particularly valuable when patients have insufficient depth for Watchman by TEE measures.
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Affiliation(s)
- Matthew S Glassy
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
| | - Gaurav Sharma
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
| | - Gagan D Singh
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
| | - Thomas W R Smith
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
| | - Dali Fan
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
| | - Jason H Rogers
- Division of Cardiovascular Medicine, University of California Davis Medical Center, California
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Phillips KP, Pokushalov E, Romanov A, Artemenko S, Folkeringa RJ, Szili-Torok T, Senatore G, Stein KM, Razali O, Gordon N, Boersma LVA. Combining Watchman left atrial appendage closure and catheter ablation for atrial fibrillation: multicentre registry results of feasibility and safety during implant and 30 days follow-up. Europace 2019; 20:949-955. [PMID: 29106523 PMCID: PMC5982721 DOI: 10.1093/europace/eux183] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 05/11/2017] [Indexed: 01/19/2023] Open
Abstract
Aims Long-term results from catheter ablation therapy for atrial fibrillation (AF) remain uncertain and clinical practice guidelines recommend continuation of long-term oral anticoagulation in patients with a high stroke risk. Left atrial appendage closure (LAAC) with Watchman has emerged as an alternative to long-term anticoagulation for patients accepting of the procedural risks. We report on the initial results of combining catheter ablation procedures for AF and LAAC in a multicentre registry. Methods and results Data were pooled from two prospective, real-world Watchman LAAC registries running in parallel in Europe/Middle-East/Russia (EWOLUTION) and Asia/Australia (WASP) between 2013 and 2015. Of the 1140 patients, 139 subjects at 10 centres underwent a concomitant AF ablation and LAAC procedure. The mean CHA2DS2-VASc score was 3.4 ± 1.4 and HAS-BLED score 1.5 ± 0.9. Successful Watchman implantation was achieved in 100% of patients. The overall 30-day serious adverse event (SAE) rate was 8.7%, with the device and/or procedure-related SAE rate of 1.4%. One pericardial effusion required percutaneous drainage, but there were no strokes, device embolization, or deaths at 30 days. The 30-day bleeding SAE rate was 2.9% with 55% of patients prescribed NOAC and 38% taking warfarin post-procedure. Conclusion The outcomes from these international, multicentre registries support the feasibility and safety of performing combined procedures of ablation and Watchman LAAC for patients with non-valvular AF and high stroke risk. Further data are needed on long-term outcomes for the hybrid technique on all-cause stroke and mortality.
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Affiliation(s)
- Karen P Phillips
- HeartCare Partners, Greenslopes Private Hospital, Brisbane, Australia
| | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Aleksandr Romanov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Sergey Artemenko
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | | | | | | | - Omar Razali
- National Heart Institute, Kuala Lumpur, Malaysia
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Lindner S, Behnes M, Wenke A, Sartorius B, Ansari U, Akin M, Mashayekhi K, Vogler N, Haubenreisser H, Schoenberg SO, Borggrefe M, Akin I. Assessment of peri-device leaks after interventional left atrial appendage closure using standardized imaging by cardiac computed tomography angiography. Int J Cardiovasc Imaging 2018; 35:725-731. [PMID: 30421354 DOI: 10.1007/s10554-018-1493-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 11/01/2018] [Indexed: 11/30/2022]
Abstract
Cardiac computed tomography angiography (cCTA) has recently been proposed for evaluation of successful interventional left atrial appendage closure (LAA/LAAC). This prospective longitudinal observational study aims to assess this proposal by applying a standardized imaging protocol to detect and quantify peri-device leaks (PDL) after LAAC. cCTA datasets of consecutive patients 6 months after successful LAAC were acquired on a third generation dual-source computed tomography system and reconstructed with a slice thickness of 0.5 mm. The standardized multi-planar reconstruction LAA occluder view for post-implantation evaluation (LOVE) algorithm was used to assess PDL in relation to LAA morphology and implanted LAAC devices. A total of 49 patients (median age 80 years, 24% female) were included consecutively. Overall PDL rate was 31%. Leak rates among different left atrial appendage morphologies varied largely. Windsock type had the highest incidence of PDL (47%). AMPLATZER™ AMULET™ device type revealed slightly higher PDL rates than WATCHMAN™ type and showed larger leaks. However, no statistical differences were found. PDL can be sized best in LOVE sagittal views, whereas a synopsis of LOVE sagittal, axial and coronal views allows further examination and detection of small leaks. PDL are common after successful interventional LAAC, which can be accurately detected and sized by standardized cCTA imaging protocols.
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Affiliation(s)
- Simon Lindner
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany.
| | - Annika Wenke
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Uzair Ansari
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Kambis Mashayekhi
- Clinic for Cardiology and Angiology II, Universitaetszentrum Freiburg Bad Krozingen, University of Freiburg, Bad Krozingen, Germany
| | - Nils Vogler
- Institute of Clinical Radiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site Heidelberg/Mannheim, Mannheim, Germany
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15
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Dieker W, Behnes M, Fastner C, Sartorius B, Wenke A, Sing-Gill I, El-Battrawy I, Kuschyk J, Papavassiliu T, Hoffmann U, Mashayekhi K, Schoenberg SO, Borggrefe M, Henzler T, Akin I. Impact of left atrial appendage morphology on thrombus formation after successful left atrial appendage occlusion: Assessment with cardiac-computed-tomography. Sci Rep 2018; 8:1670. [PMID: 29374188 PMCID: PMC5786001 DOI: 10.1038/s41598-018-19385-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/27/2017] [Indexed: 11/09/2022] Open
Abstract
A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHA2DS2-VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.
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Affiliation(s)
- Wulf Dieker
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Annika Wenke
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ishar Sing-Gill
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jürgen Kuschyk
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theano Papavassiliu
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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Turagam M, Atkins D, Earnest M, Lee R, Nath J, Ferrell R, Bartus K, Badhwar N, Rasekh A, Cheng J, Di Biase L, Natale A, Wilber D, Lakkireddy D. Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry. J Cardiovasc Electrophysiol 2017; 28:1433-1442. [DOI: 10.1111/jce.13343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mohit Turagam
- Division of Cardiovascular Medicine; University of Missouri Hospital and Clinics; Columbia MO USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Randall Lee
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Jayant Nath
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Ryan Ferrell
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | | | - Nitish Badhwar
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Abdi Rasekh
- Baylor St. Luke's Medical Center; Houston TX USA
| | - Jie Cheng
- Texas Heart Institute; Houston TX USA
| | - Luigi Di Biase
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - Andrea Natale
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
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Abstract
Incomplete left atrial appendage closure (LAAC) occurs in ∼30-40 % of cases following both surgical and percutaneous closure methods. Incomplete surgical LAAC may further be classified as incompletely surgically ligated LAA (ISLL) or LAA stump. ISLL is associated with a significantly increased risk of thrombus formation/thromboembolism. Moreover, this risk is highest in the absence of oral anticoagulation (OAC) and inversely correlates with the size of the ISLL neck. Not only routine screening for ISLL seems critical, but also long-term OAC should strongly be considered in this high-risk cohort. Alternatively, complete endocardial occlusion using a surrogate method may represent a reasonable option, particularly in those intolerant to long-term OAC therapy. Although thrombus formation/thromboembolic events have also been described in patients with incomplete LAAC following percutaneous occlusion, an association between the two remains less clear. However, given the rise and growing interest in percutaneous LAAC methods, additional research in this area is clearly warranted.
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Affiliation(s)
- Arash Aryana
- Mercy Medical Group and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA.
| | - André d'Avila
- Instituto de Pesquisa em Arritmia Cardiaca, Hospital Cardiologico, Florianopolis, Santa Catarina, Brazil
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Rodríguez Fernández A, Bethencourt González A. Técnicas de imagen en el intervencionismo percutáneo estructural: cierre de comunicación interauricular y oclusión de la orejuela izquierda. Rev Esp Cardiol 2016. [DOI: 10.1016/j.recesp.2016.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Rodríguez Fernández A, Bethencourt González A. Imaging Techniques in Percutaneous Cardiac Structural Interventions: Atrial Septal Defect Closure and Left Atrial Appendage Occlusion. ACTA ACUST UNITED AC 2016; 69:766-77. [PMID: 27354151 DOI: 10.1016/j.rec.2016.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 04/06/2016] [Indexed: 11/19/2022]
Abstract
Because of advances in cardiac structural interventional procedures, imaging techniques are playing an increasingly important role. Imaging studies show sufficient anatomic detail of the heart structure to achieve an excellent outcome in interventional procedures. Up to 98% of atrial septal defects at the ostium secundum can be closed successfully with a percutaneous procedure. Candidates for this type of procedure can be identified through a systematic assessment of atrial septum anatomy, locating and measuring the size and shape of all defects, their rims, and the degree and direction of shunting. Three dimensional echocardiography has significantly improved anatomic assessments and the end result itself. In the future, when combined with other imaging techniques such as cardiac computed tomography and fluoroscopy, 3-dimensional echocardiography will be particularly useful for procedure guidance. Percutaneous closure of the left atrial appendage offers an alternative for treating patients with atrial fibrillation and contraindication for oral anticoagulants. In the future, the clinical focus may well turn to stroke prevention in selected patients. Percutaneous closure is effective and safe; device implantation is successful in 94% to 99% of procedures. However, the procedure requires an experienced cardiac structural interventional team. At present, 3-dimensional echocardiography is the most appropriate imaging technique to assess anatomy suitability, select device type and size, guide the procedure alongside fluoroscopy, and to follow-up the patient afterwards.
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Percutaneous closure of the left atrial appendage for stroke prevention in atrial fibrillation: an alternative to lifelong anticoagulation? Crit Care Nurs Q 2016; 38:371-84. [PMID: 26335216 DOI: 10.1097/cnq.0000000000000081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Atrial fibrillation is an important risk factor for thromboembolic stroke and it significantly increases the risk of stroke. The left atrial appendage (LAA) is the most common site of thrombus formation in nonvalvular atrial fibrillation, and the recent applications of percutaneous LAA closure devices offer a promising alternative for patients who are unable to tolerate lifelong anticoagulation. Critical care nurses who understand the procedures and are familiar with the various devices used for LAA closure will be well prepared to provide optimum care and appropriate education for these patients.
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Xu H, Xie X, Wang B, Ma S, Wang F. Efficacy and Safety of Percutaneous Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation: A Meta-analysis of Contemporary Studies. Heart Lung Circ 2016; 25:1107-1117. [PMID: 27199213 DOI: 10.1016/j.hlc.2016.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 02/17/2016] [Accepted: 03/25/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) occlusion has emerged as an important treatment for patients with nonvalvular atrial fibrillation (NVAF) who are at high stroke risk and have contraindications for anticoagulation. However, literature about the efficacy and safety of LAA occlusion is minimal to date. We performed a meta-analysis to assess the rates of stroke events and adverse events for patients treated with occlusion devices. METHODS We conducted a comprehensive search on PubMed, Web of Science, OVID, SCOPUS databases and the Cochrane Central Register of Controlled Trials databases from inception to December 31, 2014 for studies of percutaneous LAA occlusion for patients with NVAF. Studies were included in the meta-analysis if at least 10 patients were studied with six months or more of follow-up period and reported at least one outcome of interest. RESULTS A total of 2779 patients in 25 studies were included in the meta-analysis. Two were randomised control trials (RCTs), others were cohort studies. The adjusted incidence rate of stroke was 1.2/100 person-years (PY) (95% confidence interval [CI], 0.9-1.6/100 PY). The ischaemic and haemorrhagic stroke rates were 1.1/100 PY (95% CI, 0.8-1.4/100 PY) and 0.2/100 PY (95% CI, 0.1-0.3/100 PY), respectively. The combined efficacy outcomes (stroke or transient ischaemic attacks [TIAs], systemic embolism, or cardiovascular death) was 2.7/100 PY (95% CI, 1.9- 3.4/100 PY). Major bleeding and pericardial effusions were the most commonly observed adverse events at a rate of 2.6% (95% CI, 1.5%-3.6%) and 2.5% (95% CI, 1.8%-3.2%), respectively. CONCLUSIONS Percutaneous LAA occlusion is a reasonably efficacious and safe therapeutic option in patients with NVAF who are at high risk for stroke and contraindicated for long-term anticoagulation.
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Affiliation(s)
- Haiyan Xu
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, P. R. China
| | - Xiongwei Xie
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, P. R. China
| | - Bingjian Wang
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, P. R. China
| | - Shuren Ma
- Department of Cardiology, Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, P. R. China
| | - Fang Wang
- Department of Cardiology, Shanghai General Hospital of Nanjing Medical University, Shanghai, P. R. China.
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Gianni C, Di Biase L, Trivedi C, Mohanty S, Gökoğlan Y, Güneş MF, Bai R, Al-Ahmad A, Burkhardt JD, Horton RP, Krumerman AK, Palma EC, Valderrábano M, Gibson D, Price MJ, Natale A. Clinical Implications of Leaks Following Left Atrial Appendage Ligation With the LARIAT Device. JACC Cardiovasc Interv 2016; 9:1051-7. [DOI: 10.1016/j.jcin.2016.01.038] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/18/2015] [Accepted: 01/28/2016] [Indexed: 11/17/2022]
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Behnes M, Akin I, Sartorius B, Fastner C, El-Battrawy I, Borggrefe M, Haubenreisser H, Meyer M, Schoenberg SO, Henzler T. --LAA Occluder View for post-implantation Evaluation (LOVE)--standardized imaging proposal evaluating implanted left atrial appendage occlusion devices by cardiac computed tomography. BMC Med Imaging 2016; 16:25. [PMID: 27009279 PMCID: PMC4806427 DOI: 10.1186/s12880-016-0127-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 03/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background A standardized imaging proposal evaluating implanted left atrial appendage (LAA) occlusion devices by cardiac computed tomography angiography (cCTA) has never been investigated. Methods cCTA datasets were acquired on a 3rd generation dual-source CT system and reconstructed with a slice thickness of 0.5 mm. An interdisciplinary evaluation was performed by two interventional cardiologists and one radiologist on a 3D multi-planar workstation. A standardized multi-planar reconstruction algorithm was developed in order to assess relevant clinical aspects of implanted LAA occlusion devices being outlined within a pictorial essay. Results The following clinical aspects of implanted LAA occlusion devices were evaluated within the most appropriate cCTA multi-planar reconstruction: (1) topography to neighboring structures, (2) peri-device leaks, (3) coverage of LAA lobes, (4) indirect signs of neo-endothelialization. These are illustrated within concise CT imaging examples emphasizing the potential value of the proposed cCTA imaging algorithm: Starting from anatomical cCTA planes and stepwise angulation planes perpendicular to the base of the LAA devices generates an optimal LAA Occluder View for post-implantation Evaluation (LOVE). Aligned true axial, sagittal and coronal LOVE planes offer a standardized and detailed evaluation of LAA occlusion devices after percutaneous implantation. Conclusions This pictorial essay presents a standardized imaging proposal by cCTA using multi-planar reconstructions that enables systematical follow-up and comparison of patients after LAA occlusion device implantation. Electronic supplementary material The online version of this article (doi:10.1186/s12880-016-0127-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mathias Meyer
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Wunderlich NC, Beigel R, Swaans MJ, Ho SY, Siegel RJ. Percutaneous interventions for left atrial appendage exclusion: options, assessment, and imaging using 2D and 3D echocardiography. JACC Cardiovasc Imaging 2016; 8:472-488. [PMID: 25882576 DOI: 10.1016/j.jcmg.2015.02.002] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 01/22/2015] [Accepted: 02/05/2015] [Indexed: 12/26/2022]
Abstract
Percutaneous left atrial appendage (LAA) exclusion is an evolving treatment to prevent embolic events in patients with nonvalvular atrial fibrillation. In the past few years multiple percutaneous devices have been developed to exclude the LAA from the body of the left atrium and thus from the systemic circulation. Two- and 3-dimensional transesophageal echocardiography (TEE) is used to assess the LAA anatomy and its suitability for percutaneous closure to select the type and size of the closure device and to guide the device implantation procedure in conjunction with fluoroscopy. In addition, 2- and 3-dimensional TEE is also used to assess the effectiveness of device implantation acutely and on subsequent follow-up examination. Knowledge of the implantation options that are currently available along with their specific characteristics is essential for choosing the appropriate device for a given patient with a specific LAA anatomy. We present the currently available LAA exclusion devices and the echocardiographic imaging approaches for evaluation of the LAA before, during, and after LAA occlusion.
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Affiliation(s)
| | - Roy Beigel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; The Heart Institute, Sheba Medical Center, and the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Siew Yen Ho
- Cardiac Morphology Unit, Royal Brompton Hospital, London, United Kingdom
| | - Robert J Siegel
- The Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Hornung M, Gafoor S, Id D, Vaskelyte L, Hofmann I, Franke J, Sievert H, Bertog SC. Catheter-based closure of residual leaks after percutaneous occlusion of the left atrial appendage. Catheter Cardiovasc Interv 2015; 87:1324-30. [DOI: 10.1002/ccd.26318] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 10/09/2015] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Dani Id
- CardioVascular Center Frankfurt; Frankfurt Germany
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Phillips KP, Walker DT, Humphries JA. Combined catheter ablation for atrial fibrillation and Watchman® left atrial appendage occlusion procedures: Five-year experience. J Arrhythm 2015; 32:119-26. [PMID: 27092193 PMCID: PMC4823577 DOI: 10.1016/j.joa.2015.11.001] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/16/2015] [Accepted: 11/04/2015] [Indexed: 11/25/2022] Open
Abstract
Background Patients with atrial fibrillation (AF) may benefit from undergoing concomitant interventions of left atrial catheter ablation and device occlusion of the left atrial appendage (LAA) as a two-pronged strategy for rhythm control and stroke prevention. We report on the outcome of combined procedures in a single center case series over a 5-year timeframe. Methods Ninety-eight patients with non-valvular AF and a mean CHA2DS2-VASc score 2.6±1.0 underwent either first time, or redo pulmonary vein isolation (PVI) procedures, followed by successful implant of a Watchman® device. Results All procedures were generally uncomplicated with a mean case time of 213±40 min. Complete LAA occlusion was achieved at initial implant in 92 (94%) patients. Satisfactory LAA occlusion was achieved in 100% of patients at 12 months, with a complete LAA occlusion rate of 86%. All patients discontinued oral anticoagulation. Persistent late peri-device leaks were more frequently associated with device angulation or shoulder protrusion, and were associated with a significantly lower achieved device compression of 12±3% vs. 15±5% (p<0.01) than complete occlusion. One ischemic stroke was recorded over a mean follow-up time of 802±439 days. Twelve months׳ freedom from detectable AF was achieved in 77% of patients. Conclusions Combined procedures of catheter ablation for AF and Watchman® LAA implant appear to be feasible and safe, with excellent rates of LAA occlusion achieved and an observed stroke rate of 0.5% per year during mid-term follow-up. Incomplete occlusion was associated with lower achieved device compression and was more frequently associated with suboptimal device position.
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Affiliation(s)
- Karen P Phillips
- HeartCare Partners, GenesisCare, Greenslopes Private Hospital, Newdegate St, Greenslopes, Brisbane, QLD 4120, Australia
| | - Daniel T Walker
- HeartCare Partners, GenesisCare, Greenslopes Private Hospital, Newdegate St, Greenslopes, Brisbane, QLD 4120, Australia
| | - Julie A Humphries
- HeartCare Partners, GenesisCare, Greenslopes Private Hospital, Newdegate St, Greenslopes, Brisbane, QLD 4120, Australia
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Noheria A, Syed FF, DeSimone CV, Asirvatham SJ. Optimization Of Stroke Prophylaxis Strategies In Nonvalvular AF -Drugs, Devices Or Both? J Atr Fibrillation 2015; 8:1156. [PMID: 27957183 DOI: 10.4022/jafib.1156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 06/09/2015] [Accepted: 06/27/2015] [Indexed: 11/10/2022]
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia with the prevalence increasing over time. AF probably afflicts ≥2% of worldwide adult population and increases with age.[1-3] In the Framingham Heart Study, the lifetime risk of having at least one episode of AF for 40-year-old men and women was 26% and 23% respectively.[4].
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Affiliation(s)
- Amit Noheria
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Faisal F Syed
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
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Guérios ÊE, Gloekler S, Schmid M, Khattab A, Nietlispach F, Meier B. Double device left atrial appendage closure. EUROINTERVENTION 2015; 11:470-6. [DOI: 10.4244/eijy14m07_03] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Bhatt HV, Fischer GW. Atrial Fibrillation: Pathophysiology and Therapeutic Options. J Cardiothorac Vasc Anesth 2015; 29:1333-40. [PMID: 26384632 DOI: 10.1053/j.jvca.2015.05.058] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Indexed: 11/11/2022]
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CT imaging for left atrial appendage closure: A review and pictorial essay. J Cardiovasc Comput Tomogr 2015; 9:89-102. [DOI: 10.1016/j.jcct.2015.01.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 01/04/2015] [Accepted: 01/16/2015] [Indexed: 11/22/2022]
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Abstract
Atrial fibrillation is associated with a markedly increased risk of thromboembolic stroke. At present, lifelong antithrombotic therapy with warfarin or a novel oral anticoagulant is indicated for prophylaxis in the majority of patients. Left atrial appendage occlusion devices have been developed as an alternative to these agents, aiming to avoid issues around consistency of anticoagulation, bleeding risk, and drug-related side effects. The best evidence is available for Boston Scientific's WATCHMAN device. The safety and efficacy of WATCHMAN and other similar devices have been questioned, although the increasing body of evidence supports a role in selected settings. A recently updated randomized controlled trial of WATCHMAN (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation [PROTECT-AF]) demonstrates its noninferiority to warfarin and suggests an advantage in terms of functional outcome for patients, with superior net clinical benefit 6 to 9 months after starting treatment. The procedural risk associated with device implantation remains substantial, although improving device design and increasing operator experience means that this should decrease in the future. As the body of data and overall experience around WATCHMAN grow, it may come to be recognized as the best option in selected patients.
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Affiliation(s)
- George Couch
- Bye-Fellow in Pathology, Downing College , Cambridge , UK
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Abstract
Percutaneous left atrial appendage (LAA) closure is being increasingly used as a treatment strategy to prevent stroke in patients with atrial fibrillation (AF) who have contraindications to anticoagulants. Several approaches and devices have been developed in the last few years, each with their own unique set of advantages and disadvantages. In this article, the published studies on surgical and percutaneous approaches to LAA closure are reviewed, focusing on stroke mechanisms in AF, LAA structure and function relevant to stroke prevention, practical differences in procedural approach, and clinical considerations surrounding management.
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Affiliation(s)
- Faisal F Syed
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Jaguszewski M, Manes C, Puippe G, Salzberg S, Müller M, Falk V, Lüscher T, Luft A, Alkadhi H, Landmesser U. Cardiac CT and echocardiographic evaluation of peri-device flow after percutaneous left atrial appendage closure using the AMPLATZER cardiac plug device. Catheter Cardiovasc Interv 2014; 85:306-12. [PMID: 25205611 DOI: 10.1002/ccd.25667] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 07/15/2014] [Accepted: 09/06/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVES The aim of the study was to examine frequency, size, and localization of peri-device leaks after percutaneous left atrial appendage (LAA)-closure with the AMPLATZER-Cardiac-Plug (ACP) by using a multimodal imaging approach, i.e. combined cardiac-CT and TEE follow-up. BACKGROUND Catheter-based LAA-occlusion using ACP aims to reduce the risk of stroke in patients with atrial fibrillation. Detection of peri-device leaks after ACP implantation by TEE is challenging, the few available data are inconsistent and the frequency of LAA leaks after ACP implantation remains therefore unclear. METHODS Cardiac-CT using a multi-phase protocol and a second-generation dual-source-CT-system was performed in 24 patients with non-valvular atrial fibrillation starting 3 months after LAA-closure by ACP. Color Doppler multiplane TEE was used to evaluate peri-device flow. RESULTS Cardiac-CT follow-up detected any persistent LAA contrast filling in 62% of patients (n = 15), but leak-sizes were small (1.5 ± 1.4 mm). Peri-device leaks were almost exclusively localized at the posterior portion of the LAA-orifice (>90%). TEE follow-up revealed peri-device flow in 36% of patients (jet-sizes: ≤ 4 mm). ACP-lobe compression (>10%) and perpendicular ACP-lobe orientation to the LAA-neck axis, that was also dependent on LAA anatomy, were substantially more frequent in patients with complete LAA closure. CONCLUSION The present study evaluates for the first time peri-device flow after LAA closure by ACP using a combined cardiac-CT and TEE follow-up. Persistent LAA-perfusion was frequently detected, leak-sizes were small and were less frequent when lobe compression was >10% and lobe orientation was perpendicular to the LAA-neck axis, that was also related to the LAA anatomy. The clinical significance of these small leaks after LAA-closure using ACP needs to be further evaluated in future studies.
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Affiliation(s)
- Milosz Jaguszewski
- Division of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
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Lam SCC, Bertog S, Gafoor S, Vaskelyte L, Boehm P, Ho RWJ, Franke J, Hofmann I, Sievert H. Left atrial appendage closure using the Amulet device: an initial experience with the second generation amplatzer cardiac plug. Catheter Cardiovasc Interv 2014; 85:297-303. [PMID: 25158644 DOI: 10.1002/ccd.25644] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 07/06/2014] [Accepted: 08/17/2014] [Indexed: 11/09/2022]
Abstract
OBJECTIVES Aim of this study was to demonstrate the feasibility, safety, and short-term outcome of left atrial appendage (LAA) closure with a new generation LAA closure device. BACKGROUND The Amulet device (AGA, St Jude Medical, Minneapolis, MN) is a new generation of the amplatzer cardiac plug (ACP), specifically designed for LAA closure. This new version is designed to facilitate the implantation process and minimize procedural or device-related complications. METHODS The device was implanted in 17 patients with nonvalvular atrial fibrillation (AF). Clinical data were obtained at baseline, during the procedure, at discharge, at 30 and 90 days. RESULTS All devices were implanted successfully. Device sizes ranged from 20 mm to 31 mm. A 12 French (Fr) or 14 Fr delivery sheath was used depending on the selected device size. Full and partial recapture was performed in 1 case and 3 cases, respectively. There was 1 procedure-related pericardial effusion successfully managed with pericardiocentesis. There was no device embolization. The mean length of stay was 2.1 ± 0.3 days. At 90 days, there were no deaths, strokes, systemic thromboembolism, or bleeding complications. There was no device-related thrombus or pericardial effusion at 90-day TEE. In 2 of the 17 patients minimal peridevice flow (smaller than 2 mm) was present. CONCLUSIONS The Amulet device, which has new novel features as compared with the first generation ACP, is a feasible option for LAA closure. From our initial experience, implantation of the Amulet is associated with high success rate and good short-term outcome.
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De Backer O, Arnous S, Ihlemann N, Vejlstrup N, Jørgensen E, Pehrson S, Krieger TDW, Meier P, Søndergaard L, Franzen OW. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart 2014; 1:e000020. [PMID: 25332785 PMCID: PMC4195925 DOI: 10.1136/openhrt-2013-000020] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/13/2014] [Accepted: 04/29/2014] [Indexed: 12/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. One of its most devastating complications is the development of thromboembolism leading to fatal or disabling stroke. Oral anticoagulation (OAC, warfarin) is the standard treatment for stroke prevention in patients with AF with an increased stroke risk. However, there are several obstacles to long-term OAC therapy, including the risk of serious bleeding, several drug–drug interactions and the need for frequent blood testing. Although newer oral anticoagulants have been developed, these drugs also face issues of major bleeding and non-compliance. Therefore, alternative treatment options for stroke prevention in patients with AF with a high stroke risk are needed. Percutaneous left atrial appendage (LAA) occlusion is an evolving therapy, which should be taken into consideration in those patients with non-valvular AF with a high stroke risk and contraindications for OAC. This article aims to discuss the rationale for LAA closure, the available LAA occlusion devices and their clinical evidence until now. Moreover, we discuss the importance of proper patient selection, the role of various imaging techniques and the need for a more tailored postprocedural antithrombotic therapy.
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Affiliation(s)
- O De Backer
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Arnous
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Ihlemann
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Vejlstrup
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - E Jørgensen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Pehrson
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - T D W Krieger
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - P Meier
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - L Søndergaard
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - O W Franzen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
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Lam SCC, Bertog S, Sievert H. Incomplete left atrial appendage occlusion and thrombus formation after Watchman implantation treated with anticoagulation followed by further transcatheter closure with a second-generation Amplatzer Cardiac Plug (Amulet device). Catheter Cardiovasc Interv 2014; 85:321-7. [PMID: 24550125 DOI: 10.1002/ccd.25456] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 01/14/2014] [Accepted: 02/16/2014] [Indexed: 11/09/2022]
Abstract
We report a case of incomplete left atrial appendage (LAA) closure after Watchman device (Atritech, Boston Scientific, Natrick, MA) implantation which subsequently developed a thrombus 3 years after the initial procedure. The thrombus resolved after a short period of anticoagulation with warfarin, and the LAA was successfully occluded with a second-generation Amplatzer Cardiac Plug (Amulet device, AGA, St Jude Medical, Minneapolis, MN). Incomplete LAA closure may be associated with increased risk of thrombus formation and further closure with a second device after a course of anticoagulation may be a reasonable and feasible strategy. © 2014 Wiley Periodicals, Inc.
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Syed FF, Friedman PA. Left Atrial Appendage Closure for Stroke Prevention: Emerging Technologies. Card Electrophysiol Clin 2014; 6:141-160. [PMID: 27063829 DOI: 10.1016/j.ccep.2013.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Current anticoagulant therapies aimed at stroke prevention in atrial fibrillation (AF) are increasingly challenged by a complex patient population at significant risk of bleeding. Mounting evidence shows that left atrial appendage (LAA) closure is an effective strategy for reducing stroke risk in patients with nonvalvular AF, without the need for anticoagulation. Several approaches and devices have been developed in recent years, each with their own set of advantages and disadvantages. This article reviews these approaches, identifies pertinent aspects, and outlines necessary or ongoing research in establishing LAA closure as a safe and effective approach to stroke risk reduction.
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Affiliation(s)
- Faisal F Syed
- Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Paul A Friedman
- Division of Cardiovascular Diseases, College of Medicine, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Sick PB. Left Atrial Appendage Occlusion for Stroke Prevention in Patients with Nonrheumatic Atrial Fibrillation. J Atr Fibrillation 2013; 6:923. [PMID: 28496896 DOI: 10.4022/jafib.923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/29/2013] [Accepted: 07/29/2013] [Indexed: 11/10/2022]
Abstract
Introduction: Atrial fibrillation is a common rhythm disorder, which is related to a higher risk of thrombembolism resulting in a high rate of cerebral stroke or transient ischemic attacks. According to the CHADS2- or CHA2DS2Vasc-Score there is an indication for oral anticoagulation to prevent patients from mostly disabling strokes. However, more than 50% of patients are not adequately treated with oral anticoagulation due to different reasons, especially contraindications. More than 90% of thrombi develop in the left atrial appendage (LAA), which lead to the idea of developing devices to exclude the LAA from the systemic circulation to prevent patients from embolisations. Another approach is surgical ligation or removal of the LAA during operation procedures. Content: Different devices and their clinical data are discussed in this review. Available literature for most of the devices is evaluated and last but not least some surgical results are discussed at the end. Existing data of randomized and non-randomized studies show that the concept of LAA-occlusion instead of anticoagulation therapy works. However, complication rates during intervention have to be kept in mind, but with adequate training also new and inexperienced operators can do the procedure safely. Most data and the only randomized studies are available for the Watchman Device. Despite some few complications like pericardial effusions, bleeding complications and thrombus formation on the devices, the data showed a non inferiority of device-implantation in comparison with anticoagulation therapy in the first few years. In long term follow up more than 4 years after implantation, there is even a superiority of the device compared with anticoagulation therapy, safety issues are no longer significantly different despite some periprocedural complications. This has to be reflected with the background, that operators could treat 3 patients with a totally new method, thereafter all patients had to be randomized into the study. So experience was limited in the first phase of this trial. Surgical data vary much due to different techniques of LAA-occlusion. With newer devices results are also promising. Conclusion: LAA-occlusion is a developing field of interventional and surgical techniques. The concept of LAA-occlusion could be proved in one randomized trial. At least for patients contraindicated for anticoagulation therapy, LAA-occlusion is a real alternative to only aspirin therapy or doing nothing. With emerging techniques and lower complication rates, LAA-occlusion might develop to a real alternative to anticoagulation therapy, at least for vitamin-K-antagonists. There are no data available so far in comparison with new oral anticoagulants. Further studies are needed to compare device therapy with new oral anticoagulants.
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Urena M, Rodés-Cabau J, Freixa X, Saw J, Webb JG, Freeman M, Horlick E, Osten M, Chan A, Marquis JF, Champagne J, Ibrahim R. Percutaneous left atrial appendage closure with the AMPLATZER cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy. J Am Coll Cardiol 2013; 62:96-102. [PMID: 23665098 DOI: 10.1016/j.jacc.2013.02.089] [Citation(s) in RCA: 217] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 02/06/2013] [Accepted: 02/14/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate the results associated with left atrial appendage closure (LAAC) with the AMPLATZER Cardiac Plug (ACP) (St. Jude Medical, Minneapolis, Minnesota) in patients with nonvalvular atrial fibrillation and absolute contraindications to anticoagulation therapy. BACKGROUND Few data exist on the late outcomes after LAAC in patients with absolute contraindications to warfarin. METHODS A total of 52 patients with nonvalvular atrial fibrillation underwent LAAC with the ACP device in 7 Canadian centers. Most patients received short-term (1 to 3 months) dual-antiplatelet therapy after the procedure and single-antiplatelet therapy thereafter. A transesophageal echocardiography was performed in 74% of patients at the 6-month follow-up. No patient was lost to follow-up (≥ 12 months in all patients). RESULTS The mean age and median (interquartile range) CHADS2 score were 74 ± 8 years and 3 (2 to 4), respectively. The procedure was successful in 98.1% of the patients, and the main complications were device embolization (1.9%) and pericardial effusion (1.9%), with no cases of periprocedural stroke. At a mean follow-up of 20 ± 5 months, the rates of death, stroke, systemic embolism, pericardial effusion, and major bleeding were 5.8%, 1.9%, 0%, 1.9%, and 1.9%, respectively. The presence of mild peridevice leak was observed in 16.2% of patients at the 6-month follow-up as evaluated by transesophageal echocardiography. There were no cases of device thrombosis. CONCLUSIONS In patients with nonvalvular atrial fibrillation at high risk of cardioembolic events and absolute contraindications to anticoagulation, LAAC using the ACP device followed by dual-/single-antiplatelet therapy was associated with a low rate of embolic and bleeding events after a mean follow-up of 20 months. No cases of severe residual leak or device thrombosis were observed at the 6-month follow-up.
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Affiliation(s)
- Marina Urena
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | | | | | - Jacqueline Saw
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - John G Webb
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - Eric Horlick
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Mark Osten
- Toronto General Hospital, Toronto, Ontario, Canada
| | - Albert Chan
- Royal Columbian Hospital, Vancouver, British Columbia, Canada
| | | | - Jean Champagne
- Quebec Heart & Lung Institute, Quebec City, Quebec, Canada
| | - Réda Ibrahim
- Montreal Heart Institute, Montreal, Quebec, Canada.
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Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol 2013; 61:2551-6. [PMID: 23583249 DOI: 10.1016/j.jacc.2013.03.035] [Citation(s) in RCA: 535] [Impact Index Per Article: 48.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 03/13/2013] [Accepted: 03/19/2013] [Indexed: 12/30/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the safety and efficacy of left atrial appendage (LAA) closure in nonvalvular atrial fibrillation (AF) patients ineligible for warfarin therapy. BACKGROUND The PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial demonstrated that LAA closure with the Watchman device (Boston Scientific, Natick, Massachusetts) was noninferior to warfarin therapy. However, the PROTECT AF trial only included patients who were candidates for warfarin, and even patients randomly assigned to the LAA closure arm received concomitant warfarin for 6 weeks after Watchman implantation. METHODS A multicenter, prospective, nonrandomized study was conducted of LAA closure with the Watchman device in 150 patients with nonvalvular AF and CHADS₂ (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ≥1, who were considered ineligible for warfarin. The primary efficacy endpoint was the combined events of ischemic stroke, hemorrhagic stroke, systemic embolism, and cardiovascular/unexplained death. RESULTS The mean CHADS₂ score and CHA₂DS₂-VASc (CHADS₂ score plus 2 points for age ≥75 years and 1 point for vascular disease, age 65 to 74 years, or female sex) score were 2.8 ± 1.2 and 4.4 ± 1.7, respectively. History of hemorrhagic/bleeding tendencies (93%) was the most common reason for warfarin ineligibility. Mean duration of follow-up was 14.4 ± 8.6 months. Serious procedure- or device-related safety events occurred in 8.7% of patients (13 of 150 patients). All-cause stroke or systemic embolism occurred in 4 patients (2.3% per year): ischemic stroke in 3 patients (1.7% per year) and hemorrhagic stroke in 1 patient (0.6% per year). This ischemic stroke rate was less than that expected (7.3% per year) based on the CHADS₂ scores of the patient cohort. CONCLUSIONS LAA closure with the Watchman device can be safely performed without a warfarin transition, and is a reasonable alternative to consider for patients at high risk for stroke but with contraindications to systemic oral anticoagulation. (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology [ASAP]; NCT00851578).
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Nietlispach F, Gloekler S, Krause R, Shakir S, Schmid M, Khattab AA, Wenaweser P, Windecker S, Meier B. Amplatzer left atrial appendage occlusion: single center 10-year experience. Catheter Cardiovasc Interv 2013; 82:283-9. [PMID: 23412815 DOI: 10.1002/ccd.24872] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Revised: 01/04/2013] [Accepted: 02/09/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To report a 10-year single center experience with Amplatzer devices for left atrial appendage (LAA) occlusion. BACKGROUND Intermediate-term outcome data following LAA occlusion are scarce. METHODS Short- and intermediate-term outcomes of patients who underwent LAA occlusion were assessed. All procedures were performed under local aesthesia without transesophageal echocardiography. Patients were discharged on acetylsalicylic acid and clopidogrel for 1-6 months. RESULTS LAA occlusion was attempted in 152 patients (105 males, age 72 ± 10 years, CHA2 DS2 -Vasc-score 3.4 ± 1.7, HAS-BLED-score 2.4 ± 1.2). Nondedicated devices were used in 32 patients (21%, ND group) and dedicated Amplatzer Cardiac Plugs were used in 120 patients (79%, ACP group). A patent foramen ovale or atrial septal defect was used for left atrial access and closed at the end of LAA occlusion in 40 patients. The short-term safety endpoints (procedural complications, bleeds) occurred in 15 (9.8%) and the efficacy endpoints (death, stroke, systemic embolization) in 0 patients. Device embolization occurred more frequently in the ND as compared to the ACP group (5 patients or 12% vs. 2 patients or 2%). Mean intermediate-term follow up of the study population was 32 months (range 1-120). Late deaths occurred in 15 patients (5 cardiovascular, 7 noncardiac, 3 unexplained). Neurologic events occurred in 2, peripheral embolism in 1, and major bleeding in 4 patients. The composite efficacy and safety endpoint occurred in 7% and 12% of patients. CONCLUSION LAA closure may be a good alternative to oral anticoagulation. This hypothesis needs to be tested in a randomized clinical trial to ensure that all potential biases of this observational study are accounted for.
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Swaans MJ, Alipour A, Rensing BJWM, Post MC, Boersma LVA. Catheter ablation in combination with left atrial appendage closure for atrial fibrillation. J Vis Exp 2013:e3818. [PMID: 23486416 DOI: 10.3791/3818] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope. Patients with AF have a five-fold higher risk of stroke. Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64%. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug. The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers. CA is a well-established treatment for AF symptoms, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy. Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes). This device received the Conformité Européenne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy. Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding or other warfarin-associated problems. The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.
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Affiliation(s)
- Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, The Netherlands.
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Khattab AA, Meier B. Transcatheter left atrial appendage closure for stroke prevention among atrial fibrillation patients. Expert Rev Cardiovasc Ther 2013; 10:819-21. [PMID: 22908912 DOI: 10.1586/erc.12.70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Walker DT, Humphries JA, Phillips KP. Combined Catheter Ablation for Atrial Fibrillation and Watchman ® Left Atrial Appendage Occlusion Procedures: A Single Centre Experience. J Atr Fibrillation 2012; 5:687. [PMID: 28496779 DOI: 10.4022/jafib.687] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2012] [Revised: 09/17/2012] [Accepted: 09/21/2012] [Indexed: 11/10/2022]
Abstract
Background Patients with atrial fibrillation (AF) may be interested in undergoing concomitant interventions of left atrial catheter ablation and device occlusion of the left atrial appendage (LAA). We report on the feasibility and outcome of combined procedures in a single centre case series. Methods Twenty-six patients underwent either first time or redo pulmonary vein isolation (PVI) procedures followed by successful implant of a Watchman® device. Results All procedures were uncomplicated with a mean case time of 233 ± 38 minutes. Maximal LAA orifice dimension was smaller in 3 of 26 patients post PVI (range 1mm) than on the pre-procedural transoesophageal echocardiogram (TOE). A new peri-device leak of maximum 3mm was noted in 5 of 26 patients at 6 week follow-up TOE, but resolved in 4 by the 6 month follow-up. Conclusion Combined procedures for catheter ablation for AF and Watchman® LAA implant appear to be feasible and safe with satisfactory occlusion of the LAA maintained at follow-up.
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Affiliation(s)
- Daniel T Walker
- St Jude Medical, 17 Orion Rd, Lane Cove, NSW, Australia 2066
| | - Julie A Humphries
- Greenslopes Private Hospital, Newdegate St, Greenslopes, QLD, Australia 4120
| | - Karen P Phillips
- Greenslopes Private Hospital, Newdegate St, Greenslopes, QLD, Australia 4120
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Affiliation(s)
- Vivek Iyer
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, NY, USA
| | - Harsimran S. Singh
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, NY, USA
| | - James A. Reiffel
- Department of Medicine, Division of Cardiology, Columbia University Medical Center, NY, USA
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