Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Pulmonary vein perforation into the respiratory tract with systemic air embolism: a rare complication of left atrial appendage closure

BACKGROUND

Pulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with systemic air embolism during left atrial appendage closure (LAAC).

CASE PRESENTATION

A 77-year-old man with persistent nonvalvular atrial fibrillation was referred for percutaneous LAAC under local anaesthesia (CHA2DS2-VASc score of 4, HAS-BLED score of 3, and prior ischaemic stroke). During the procedure, after delivering a super-stiff guidewire into the left superior pulmonary vein (LSPV), the patient suddenly developed a severe cough with haemoptysis upon advancement of a delivery sheath along the guidewire. Fluoroscopy showed signs of blood entering the left main bronchus, and fast transthoracic echocardiography revealed bubbles in the left heart without pericardial effusion. The procedure was terminated because of a major complication indicated by the repeated haemoptysis and headache, and haemostatic drugs were immediately administered. Subsequent chest computed tomography angiography (CTA) revealed a filling defect in the LSPV branches and bubbles in the aorta. The patient was transferred to the critical care unit for haemostasis and antibacterial treatment. Transthoracic echocardiography later that day showed no bubbles in the heart. The headache and haemoptysis significantly abated the following day. The bubbles in the aorta disappeared on chest CTA 7 days later.

CONCLUSIONS

Interventional cardiologists should pay attention to anatomical variations of the pulmonary vein, which are associated with a high risk of complications of pulmonary vein perforation during LAAC. Preoperative CTA examination and intraoperative transoesophageal echocardiography might be helpful to avoid this complication.

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study

INTRODUCTION

Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA₂DS₂-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile.

METHODS AND ANALYSIS

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well.

ETHICS AND DISSEMINATION

Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05144958.

Imaging risk features for device related pulmonary artery injury after left atrial appendage closure with Amplatzer™ Amulet™ device

OBJECTIVES

This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC).

BACKGROUND

Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC.

METHODS

In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected.

RESULTS

In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (<1.5 mm) for the stabilizing wires to cause risk for DR-PAI, configuration called ''cuddling lobe orientation''. On CT measurements middle lobe-PA distance was 4.7 mm (IQR = 2.7-9.5), with close proximity in 4 (4%) patients, and distal lobe-PA distance was 3.2 mm (IQR = 1.8-7.2 mm), with close proximity in 17 (17%) patients. Stabilizing wires were pointing toward PA in 47 patients (47%) with median wire-to-PA distance 5.7 mm (IQR = 3.6-8.5 mm). ''Cuddling'' was found in 2 (2%) patients and resulted in shorter wires-to-PA distance vs no ''cuddling'' group (2.3 vs 5.8 mm p <.01). At 2.9 ± 1.0 yrs of follow-up, the two patients with ''cuddling lobe orientation'' on post-LAAC CT scan developed late cardiac tamponades (p <.001). One of those required surgery, which confirmed DR-PAI.

CONCLUSIONS

''Cuddling lobe orientation'' of Amulet device with the PA was associated with short wires-to-PA distance and late pericardial effusions, including DR-PAI. Hence, such device-to-PA configuration should be avoided.

Late presentation of left atrial appendage erosion and perforation by an Amplatzer™ Amulet™ closure device: a case report

Background

Percutaneous left atrial appendage (LAA) closure may reduce the risk of cardioembolic stroke in patients with non-valvular atrial fibrillation. Given the prophylactic nature of the procedure, identifying and managing complications are paramount.

Case summary

A 73-year-old man presented 14 months after percutaneous LAA closure with syncope and acute pericardial tamponade which required surgical exploration and haemostasis; the most temporally remote account of this complication albeit amongst very few case reports. Tissue erosion by the Amplatzer™ Amulet™ LAA closure device (Abbott, Plymouth, MN, USA) was noted at two separate anatomical locations, corresponding to the device disc and lobe, which has not been described previously.

Discussion

This case report highlights the anatomical relationship between the LAA and its surrounding structures, and the importance of recognizing the risk of late device erosion.

Late Presentation of Pulmonary Artery-Left Atrial Appendage Fistula Formation After Left Atrial Appendage Device Closure

Atrial fibrillation is the most common arrhythmia in clinical practice with indication for anticoagulation in those patients whose annual risk for thromboembolism is >2%. Left atrial appendage closure is growing as an alternative to anticoagulation. We present a case of pulmonary artery-left atrial appendage fistula seen after left atrial appendage closure. (Level of Difficulty: Intermediate.)

Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices

Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.

Left Atrial Appendage Transcatheter Occlusion with AMPLATZER™ Amulet™ Device: Real Life Data with Mid-Term Follow-Up Results

Background

Left atrial appendage (LAA) occlusion is an alternative therapy for atrial fibrillation patients who have high embolic risk and contraindications to anticoagulant therapy.

Objective

To evaluate the feasibility, safety, and mid-term outcomes of percutaneous LAA occlusion, including device-related thrombosis.

Methods

Sixty consecutive patients who had undergone percutaneous LAA occlusion with AMPLATZER™ Amulet™ device from September 2015 to March 2018 were enrolled. Patients were followed for 21 ± 15 months (median - 20 months, interquartile range - 9 to 27 months). The postprocedural assessment was done at the 1^st, 6^th, and 12^th month. Patients were clinically evaluated, and transesophageal echocardiography was performed at each visit. We evaluated the condition of normality of variables using the Kolmogorov-Smirnov test. P-values < 0.05 were statistically significant.

Results

The most common indication for the procedure was major bleeding with anticoagulants (n: 53, 88.3%). The procedure was completed successfully in 59 (98.3%) patients. Periprocedural mortality was observed in one patient. Postprocedural antiplatelet treatment was planned as dual or single antiplatelet therapy or low-dose anticoagulant therapy in 52 (88.1%), 2 (3.4%), and 5 (8.5%) patients, respectively. We found no clinically significant cerebrovascular events, device-related thrombus, or embolization in any patient during the follow-up. Two (3.4 %) patients presented significant peri-device leak (>3 mm) at the 1^st month evaluation, which disappeared at the 12^th month follow-up.

Conclusion

We concluded that LAA occlusion using the Amulet™ LAA occluder can be performed with high procedural success and acceptable outcomes.

Relation of left atrial appendage closure devices to topographic neighboring structures using standardized imaging by cardiac computed tomography angiography

Background

Although left atrial appendage (LAA) anatomy and topographic relations are well understood, little is known about the impairment of neighboring structures (NBS) by an implanted left atrial appendage closure (LAAC) device. This prospective longitudinal observational study for the first time describes distances of implanted LAA closure (LAAC) devices to NBS using a standardized imaging protocol of cardiac computed tomography angiography (cCTA).

Hypothesis

cCTA imaging is an eligible tool for post‐implantation evaluation of LAAC devices and their relation to neighboring structures.

Methods

cCTA data sets of consecutive patients 6 months after successful LAAC were acquired on a third generation dual‐source CT 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 measure the distances to NBS in relation to LAA morphology and implanted LAAC devices.

Results

A total of 48 patients (median age 80 years, 25% female) were included. Left upper pulmonary vein and circumflex artery were generally closest to occlusion devices (median 2.9 and 2.8 mm, respectively). AMPLATZER AMULET devices were closer to the mitral valve annulus than WATCHMAN devices (6.6 mm (inter quartile range [IQR] 4.9‐8.6) vs 10.9 mm (IQR 7.4‐14.0), P = 0.001). Distances to the left upper pulmonary vein were affected by LAA morphology, with cauliflower type having the closest proximity (1.7 mm [IQR 1.0‐3.4], P = 0.048).

Conclusion

A standardized cCTA imaging protocol is an eligible tool to accurately measure distances to NBS. Left upper pulmonary vein and circumflex artery are closest to LAAC devices and could thus be most prone to impairment.

Delayed presentation of pulmonary artery perforation by an Amulet left atrial appendage closure device

Left atrial appendage occlusion (LAAO) devices offer stroke prevention in atrial fibrillation for patients intolerant of anticoagulation. Device placement leading to bleeding and cardiac tamponade have been reported periprocedurally but delayed presentations have not been reported in the literature. We present the case of an Amulet LAAO device causing erosion and bleeding from the main pulmonary artery that presented with cardiac tamponade 6 months after device placement. The pulmonary artery defect was repaired primarily and buttressed with a pericardial patch with good result.

Long-term invasive follow-up of the everolimus-eluting bioresorbable vascular scaffold: five-year results of multiple invasive imaging modalities

AIMS

Invasive imaging modalities have shown restoration of vasomotion, prevention of restenosis and, most importantly, increase in lumen area between six months and two years after first-generation everolimus-eluting bioresorbable vascular scaffold (Absorb BVS) implantation. Our aim was to assess whether these positive findings were sustained in the long term.

METHODS AND RESULTS

Patients included in the ABSORB cohort A from the Thoraxcenter Rotterdam cohort underwent coronary catheterisation including angiography, intravascular ultrasound (IVUS), virtual histology, optical coherence tomography (OCT) and vasomotion testing at five years. Eight out of 16 patients underwent catheterisation and scaffold assessment with multiple imaging modalities. A trend towards an increase in minimum luminal diameter was observed between two and five years by angiography (1.95±0.37 mm vs. 2.14±0.38 mm; p=0.09). IVUS data showed an increase in mean lumen area at five years (6.96±1.13 mm2) compared to six months (6.17±0.74 mm2; p=0.06) and two years (6.56±1.16 mm2; p=0.12), primarily due to a persistent reduction in plaque area size between six months and five years (9.17±1.86 mm2 vs. 7.57±1.63 mm2; p=0.03). The necrotic core area was reduced at five years compared to post-procedural results. In OCT, an increase in mean and minimal luminal area was observed. Moreover, no scaffold struts could be identified and a smooth endoluminal lining was observed. The scaffolded coronary segment did not show signs of endothelial dysfunction with acetylcholine testing.

CONCLUSIONS

At five years, the Absorb BVS is no longer discernible by any invasive imaging method and endothelial function is restored. Late luminal enlargement persists up to five years of follow-up without adaptive vessel remodelling.

Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion

Percutaneous left atrial appendage (LAA) closure is a routinely performed method to reduce the risk of stroke in patients suffering from atrial fibrillation, when an oral anticoagulation is no longer indicated due to relevant bleeding complications. Currently, the Amplatzer Amulet and the Watchman system are two equally used systems. While there is an acute success rate of more than 95 per cent for this intervention, several minor and major complications such as pericardial effusions, air embolism, vascular lesions in proximity to the heart or even death can occur. Here, we report two cases of very rare fatal outcomes in percutaneous LAA occlusion. Eight hours after deployment of an Amplatzer Amulet a patient died, after the pulmonary trunk was perforated by a hook of the occluder device causing pericardial tamponade. In the second case during final radiological position control of the deployed Watchman occluder air was injected accidentally. The patient immediately died due to coronary air embolism. Forensic autopsies are necessary to solve the cause and manner of death, to evaluate and develop medical devices and to rule out medical malpractice. Thus, a close collaboration of legal medicine and the various cardiologic departments is proposed.

Left atrial appendage and pulmonary artery anatomic relationship by cardiac-gated computed tomography: Implications for late pulmonary artery perforation by left atrial appendage closure devices

BACKGROUND

Delayed pulmonary artery (PA) perforation and tamponade caused by implantable left atrial appendage (LAA) closure devices has been reported in patients with close proximity between these structures. The LAA and PA anatomic relationship (LAA-PAar) has not been analyzed systematically.

OBJECTIVE

The purpose of this study was to identify LAA-PAar variants potentially susceptible to this complication using cardiac-gated computed tomography angiography.

METHODS

We studied 100 consecutive patients with atrial fibrillation undergoing cardiac-gated computed tomography angiography of the left atrium. The LAA-PAar was classified into 3 types on the basis of the location, length, and thickness of the segment of contact between the PA and/or its branches and the LAA: type 1, no contact; type 2, contact involving the proximal LAA (defined as the proximal 15 mm extending into the LAA from its ostium, or the LAA proximal to the first major bend arising <15 mm from the ostium); and type 3, contact limited to the distal LAA.

RESULTS

LAA-PAar types 1, 2, and 3 were present in 7 (7%), 28 (28%), and 65 (65%) patients, respectively. For LAA-PAar type 2, the mean contact segment thickness and length were 0.6 ± 0.3 and 18.1 ± 10.6 mm, respectively. For LAA-PAar type 3, the distance between the LAA orifice and the segment of contact was <30 mm in 52 patients (80%).

CONCLUSION

In this series, the LAA came in direct contact with the main PA in the majority of patients. Contact involved the proximal LAA (where the fixation components of most LAA closure devices are positioned) in 28% of patients, posing potential vulnerability to PA perforation.

Preclinical assessment of a modified Occlutech left atrial appendage closure device in a canine model

BACKGROUND

LAA occlusion has a similar stroke prevention efficacy compared to anticoagulation treatment for non-valvular atrial fibrillation.

OBJECTIVE

The objective of this study was to assess the feasibility and safety of a modified Occlutech® left atrial appendage (LAA) closure device in a canine model.

METHODS

The device was implanted in 10 dogs (33±1kg) using fluoroscopy and transesophageal echocardiography (TEE) guidance. The modified Occlutech® LAA occlusion device was compared with the current version, the Watchman device, and the Amplazter cardiac plug (ACP). LAA occlusion and anchoring to the LAA were evaluated. All dogs were assessed using angiography, TEE, and a gross anatomy examination.

RESULTS

The 10 LAA occlusion devices were to be implanted into 10 dogs (5 modified Occlutech devices, 3 current version of Occlutech devices, 1 Watchman, and 1 ACP). LAA implantation was not performed in one dog due to transeptal puncture failure. The three current version of Occlutech devices were embolized immediately after implantation, so three modified devices of the same size were implanted securely without embolization. The mean implant size was 20.1±2.0mm. The devices chosen were a mean of 23.3±10.6% larger than the measured landing zone diameters. Post-implant angiography and TEE revealed well-positioned devices without pericardial effusion or impingement on surrounding structures.

CONCLUSIONS

The results of this acute animal study suggested that a modified Occlutech® LAA occlusion device was feasible and had greater anchoring performance in canines. Additional large clinical studies are needed to evaluate safety and efficacy.

Delayed Pulmonary Artery Perforation With Left Atrial Appendage Occluder Hooks

We describe a case of delayed pulmonary artery perforation with the anchoring hooks of the Amplazer Cardiac Plug (ACP) (St Jude Medical, MN), which occurred 17 days after its proper and uncomplicated implantation. The patient was successfully treated with a surgical procedure. Technologic improvement of the ACP anchoring system seems to be most rational solution necessary to eliminate the risk of the adverse event described here.

Optimization Of Stroke Prophylaxis Strategies In Nonvalvular AF -Drugs, Devices Or Both?

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].

Periprocedural intracardiac echocardiography for left atrial appendage closure: a dual-center experience

OBJECTIVES

This dual-center study sought to demonstrate the utility and safety of intracardiac echocardiography (ICE) in providing adequate imaging guidance as an alternative to transesophageal echocardiography (TEE) during Amplatzer Cardiac Plug device implantation.

BACKGROUND

Over 90% of intracardiac thrombi in atrial fibrillation originate from the left atrial appendage (LAA). Patients with contraindications to anticoagulation are potential candidates for LAA percutaneous occlusion. TEE is typically used to guide implantation.

METHODS

ICE-guided percutaneous LAA closure was performed in 121 patients to evaluate the following tasks typically achieved by TEE: assessment of the LAA dimension for device sizing; guidance of transseptal puncture; verification of the delivery sheath position; confirmation of location and stability of the device before and after release and continuous monitoring to detect procedural complications. In 51 consecutive patients, we compared the measurements obtained by ICE and fluoroscopy to choose the size of the device.

RESULTS

The device was successfully implanted in 117 patients, yielding a technical success rate of 96.7%. Procedural success was achieved in 113 cases (93.4%). Four major adverse events (3 cardiac tamponades and 1 in-hospital transient ischemic attack) occurred. There was significant correlation in the measurements for device sizing assessed by angiography and ICE (r = 0.94, p < 0.0001).

CONCLUSIONS

ICE imaging was able to perform the tasks typically provided by TEE during implantation of the Amplatzer Cardiac Plug device for LAA occlusion. Therefore, we provide evidence that the use of ICE offered accurate measurements of LAA dimension in order to select the correct device sizes.

Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update

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.

Left Atrial Appendage Closure for Stroke Prevention: Emerging Technologies

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.