1
|
Grossi S, Bianchi F, Blandino A, Pintor C, Tomasello A, Mabritto B, Musumeci G. Combination of percutaneous left appendage epicardial ligation and endo-epicardial atrial fibrillation ablation. Front Cardiovasc Med 2023; 10:1224924. [PMID: 37876773 PMCID: PMC10590910 DOI: 10.3389/fcvm.2023.1224924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/11/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Atrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure. Methods and results We describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.All procedures were concluded without complications.At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred. Conclusion The combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.
Collapse
Affiliation(s)
- Stefano Grossi
- Cardiology Department, AO Ordine Mauriziano, Turin, Italy
| | | | | | - Chiara Pintor
- Biosense Webster Italy, Johnson&Johnson MedTech Italy, Pomezia (RM), Italy
| | | | | | | |
Collapse
|
2
|
Mantini C, Corradi F, Ricci F, Jensen B, Tana C, Di Mascio V, Mastrodicasa D, Bucciarelli B, Procaccini L, Saba L, Marco Tana, Cademartiri F, De Caterina R. A highly-detailed anatomical study of left atrial auricle as revealed by in-vivo computed tomography. Heliyon 2023; 9:e20575. [PMID: 37842578 PMCID: PMC10568352 DOI: 10.1016/j.heliyon.2023.e20575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 09/19/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
The left atrial auricle (LAA) is the main source of intracardiac thrombi, which contribute significantly to the total number of stroke cases. It is also considered a major site of origin for atrial fibrillation in patients undergoing ablation procedures. The LAA is known to have a high degree of morphological variability, with shape and structure identified as important contributors to thrombus formation. A detailed understanding of LAA form, dimension, and function is crucial for radiologists, cardiologists, and cardiac surgeons. This review describes the normal anatomy of the LAA as visualized through multiple imaging techniques such as computed tomography (CT), magnetic resonance imaging (MRI), and echocardiography. Special emphasis is devoted to a discussion on how the morphological characteristics of the LAA are closely related to the likelihood of developing LAA thrombi, including insights into LAA embryology.
Collapse
Affiliation(s)
- Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
- Department of Clinical Sciences, Lund University, Malmö, Sweden
| | - Bjarke Jensen
- Department of Medical Biology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centres, Amsterdam, the Netherlands
| | - Claudio Tana
- Geriatrics Clinic, SS. Annunziata Hospital of Chieti, 66100, Chieti, Italy
| | - Valeria Di Mascio
- Department of Neuroscience, Imaging and Clinical Sciences, “G. D'Annunzio” University, Chieti, Italy
| | | | - Benedetta Bucciarelli
- Department of Pediatrics, Politechnic University of Marche, G. Salesi Children's Hospital, Ancona, Italy
| | | | - Luca Saba
- Department of Radiology, University Hospital of Cagliari, Cagliari, Italy
| | - Marco Tana
- Internal Medicine Unit and Department of Vascular Medicine and Cardiovascular Ultrasound, SS. Annunziata Hospital of Chieti, Italy
| | | | - Raffaele De Caterina
- Cardiology, University of Pisa and University Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant’Angelo-Pescara, Italy
| |
Collapse
|
3
|
Bhuta S, Cao C, Pieper JA, Tong MS, Varghese J, Han Y, Harfi TT, Simonetti OP, Augostini RS, Kalbfleisch SJ, Savona SJ, Okabe T, Afzal MR, Hummel JD, Daoud EG, Houmsse M. Cardiac magnetic resonance imaging for left atrial appendage closure planning. Pacing Clin Electrophysiol 2023; 46:745-751. [PMID: 37221927 DOI: 10.1111/pace.14713] [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: 03/18/2023] [Revised: 04/25/2023] [Accepted: 05/02/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. METHODS This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland-Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. RESULTS 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p = .229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p = .177), morphology (p = .422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland-Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR-TEE bias 0.7 mm, 95% CI [-1.1, 2.4], p = .420), but LAA depth was significantly larger with CMR versus TEE (CMR-TEE bias 7.4 mm, 95% CI [1.6, 13.2], p = .015). CONCLUSIONS CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable.
Collapse
Affiliation(s)
- Sapan Bhuta
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Carolyn Cao
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Justin A Pieper
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew S Tong
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Juliet Varghese
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yuchi Han
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Thura T Harfi
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Orlando P Simonetti
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Toshimasa Okabe
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
4
|
Badhwar V, Scott Rankin J, Lee R, McCarthy PM, Wei LM. Contemporary left atrial appendage management during adult cardiac surgery. J Thorac Cardiovasc Surg 2023; 165:1398-1404. [PMID: 35307219 DOI: 10.1016/j.jtcvs.2022.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/23/2022] [Accepted: 02/07/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
| | - J Scott Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | - Richard Lee
- Division of Cardiothoracic Surgery, Medical College of Georgia, Augusta University, Augusta, Ga
| | | | - Lawrence M Wei
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| |
Collapse
|
5
|
Narasimhan B, Aedma SK, Bhatia K, Garg J, Kanuri SH, Turagam MK, Lakkireddy D. Current practice and future prospects in left atrial appendage occlusion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1236-1252. [PMID: 34085712 DOI: 10.1111/pace.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/30/2021] [Accepted: 05/30/2021] [Indexed: 01/31/2023]
Abstract
The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.
Collapse
Affiliation(s)
- Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | | | - Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | - Jalaj Garg
- Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | |
Collapse
|