Image fusion of integrating fluoroscopy into 3D computed tomography in guidance of left atrial appendage closure

Left atrial appendage closure guided by fusion of 3D computational modelling on real-time fluoroscopy: A multicenter experience

BACKGROUND

Patient-specific 3-dimensional (3D) computational modelling offers a tailored approach with promising results, but experience using digital-twin fusion on real-time fluoroscopy to guide left atrial appendage closure (LAAC) is unreported.

OBJECTIVES

To assess whether LAAC guided by fusion of a 3D computational model on real-time fluoroscopy is safe and effective.

METHODS

We included retrospectively through a multicenter registry all consecutive patients with non-valvular atrial fibrillation (AF) who underwent LAAC guided by artificial intelligence (AI)-enabled computer simulations (FEops, Gent, Belgium) fusion with real-time fluoroscopy. Operators selected the appropriate device size and position in relation to the LAA using FEops HEARTguide™, and a digital twin was provided for image fusion. The primary efficacy endpoint was successful LAAC with the use of a single device, without moderate or greater peri-device leak and/or device related thrombus (DRT) on follow-up imaging. The primary safety endpoint was a composite of major procedural complications including tamponade, stroke, systemic embolism, major bleeding, and device embolization.

RESULTS

A total of 106 patients underwent LAAC with an Amulet™ or Watchman FLX™ device using CT-model-fluoroscopy fusion imaging. Device implantation was successful in 100 % of cases. The primary efficacy endpoint was met in 82 patients (89 %). A single-device deployment LAAC procedure was observed in 49 cases (46 %). The primary safety endpoint occurred in 2 patients (1.9 %). After a median follow-up of 405 days, two patients suffered an ischemic stroke and four expired.

CONCLUSIONS

Fusion of a CT-based 3D computational model on real-time fluoroscopy is a safe and effective approach that may optimize transcatheter LAAC outcomes.

Multi-network approach for image segmentation in non-contrast enhanced cardiac 3D MRI of arrhythmic patients

Left atrial appendage (LAA) is the source of thrombi formation in more than 90% of strokes in patients with nonvalvular atrial fibrillation. Catheter-based LAA occlusion is being increasingly applied as a treatment strategy to prevent stroke. Anatomical complexity of LAA makes percutaneous occlusion commonly performed under transesophageal echocardiography (TEE) and X-ray (XR) guidance especially challenging. Image fusion techniques integrating 3D anatomical models derived from pre-procedural imaging into the live XR fluoroscopy can be applied to guide each step of the LAA closure. Cardiac magnetic resonance (CMR) imaging gains in importance for radiation-free evaluation of cardiac morphology as alternative to gold-standard TEE or computed tomography angiography (CTA). Manual delineation of cardiac structures from non-contrast enhanced CMR is, however, labor-intensive, tedious, and challenging due to the rather low contrast. Additionally, arrhythmia often impairs the image quality in ECG synchronized acquisitions causing blurring and motion artifacts. Thus, for cardiac segmentation in arrhythmic patients, there is a strong need for an automated image segmentation method. Deep learning-based methods have shown great promise in medical image analysis achieving superior performance in various imaging modalities and different clinical applications. Fully-convolutional neural networks (CNNs), especially U-Net, have become the method of choice for cardiac segmentation. In this paper, we propose an approach for automatic segmentation of cardiac structures from non-contrast enhanced CMR images of arrhythmic patients based on CNNs implemented in a multi-stage pipeline. Two-stage implementation allows subdividing the task into localization of the relevant cardiac structures and segmentation of these structures from the cropped sub-regions obtained from previous step leading to efficient and effective way of automated cardiac segmentation.

Impact of cardiac and respiratory motion on the 3D accuracy of image-guided interventions on monoplane systems

PURPOSE

Image-guided intervention (IGI) systems have the potential to increase the efficiency in interventional cardiology but face limitations from motion. Even though motion compensation approaches have been proposed, the resulting accuracy has rarely been quantified using in vivo data. The purpose of this study is to investigate the potential benefit of motion-compensation in IGS systems.

METHODS

Patients scheduled for left atrial appendage closure (LAAc) underwent pre- and postprocedural non-contrast-enhanced cardiac magnetic resonance imaging (CMR). According to the clinical standard, the final position of the occluder device was routinely documented using x-ray fluoroscopy (XR). The accuracy of the IGI system was assessed retrospectively based on the distance of the 3D device marker location derived from the periprocedural XR data and the respective location as identified in the postprocedural CMR data.

RESULTS

The assessment of the motion-compensation depending accuracy was possible based on the patient data. With motion synchronization, the measured accuracy of the IGI system resulted similar to the estimated accuracy, with almost negligible distances of the device marker positions identified in CMR and XR. Neglection of the cardiac and/or respiratory phase significantly increased the mean distances, with respiratory motion mainly reducing the accuracy with rather low impact on the precision, whereas cardiac motion decreased the accuracy and the precision of the image guidance.

CONCLUSIONS

In the presented work, the accuracy of the IGI system could be assessed based on in vivo data. Motion consideration clearly showed the potential to increase the accuracy in IGI systems. Where the general decrease in accuracy in non-motion-synchronized data did not come unexpected, a clear difference between cardiac and respiratory motion-induced errors was observed for LAAc data. Since sedation and intervention location close to the large vessels likely impacts the respiratory motion contribution, an intervention-specific accuracy analysis may be useful for other interventions.

Real-time 3D-3D image fusion of CTA/CBCT roadmap fluoroscopy in the transcatheter mitral intervention

Absence of periprocedural visualization of three-dimensional (3D) left heart anatomy and its surrounding structures in fluoroscopy may reduce the rate of successful transcatheter mitral valve repair. We proposed a multimodal imaging strategy based on 3D computed tomography (CT) angiography and 3D cone beam CT fusion images, which enabled real-time visual inspection of 3D cardiac structures on fluoroscopy, to optimize transcatheter mitral intervention. This new image fusion technology, together with standard transesophageal echocardiography guidance, improved the efficiency and safety of the procedure, and could be considered as a new workflow for transcatheter mitral valve intervention.

MRI-based training model for left atrial appendage closure

PURPOSE

Percutaneous closure of the left atrial appendage (LAA) reduces the risk of embolic stroke in patients with atrial fibrillation. Thereby, the optimal transseptal puncture (TSP) site differs due to the highly variable anatomical shape of the LAA, which is rarely considered in existing training models. Based on non-contrast-enhanced magnetic resonance imaging (MRI) volumes, we propose a training model for LAA closure with interchangeable and patient-specific LAA enabling LAA-specific identification of the TSP site best suited.

METHODS

Based on patient-specific MRI data, silicone models of the LAAs were produced using a 3D-printed cast model. In addition, an MRI-derived 3D-printed base model was set up, including the right and left atrium with predefined passages in the septum, mimicking multiple TSP sites. The various silicone models and a tube mimicking venous access were connected to the base model. Empirical use of the model allowed the demonstration of its usability.

RESULTS

Patient-specific silicone models of the LAA could be generated from all LAA patient MRI datasets. The influence of various combinations regarding TSP sites and LAA shapes could be demonstrated as well as the technical functionality of the occluder system. Via the attached tube mimicking the venous access, the correct handling of the deployment catheter even in case of not optimal puncture site could be practiced.

CONCLUSION

The proposed contrast-agent and radiation-free MRI-based training model for percutaneous LAA closure enables the pre-interventional assessment of the influence of the TSP site on the access of patient-specific LAA shapes. A straightforward replication of this work is measured by using clinically available imaging protocols and a widespread 3D printer technique to build the model.

Efficacy of 3D-multidetector computed tomography and fluoroscopy fusion for percutaneous left atrial appendage occlusion procedures

INTRODUCTION

We studied the impact of the use of three-dimensional multidetector computed tomography (3D-MDCT) and fluoroscopy fusion on percutaneous left atrial appendage occlusion (LAAO) procedures in relation to procedure time, contrast volume, fluoroscopy time, and total radiation.

METHODS

This was a single-center, prospective, single-blinded, randomized control trial. Patients meeting criteria for LAAO were randomized to undergo LAAO with the WATCHMAN FLXTM device with and without 3D-MDCT-fluoroscopy fusion guidance using a prespecified protocol using computed tomography angiography for WATCHMAN FLXTM sizing, moderate sedation, and intracardiac echocardiography for procedural guidance.

RESULTS

Overall, 59 participants were randomly assigned to the fusion (n = 33) or no fusion (n = 26) groups. The median (interquartile range) age was 79 (75-83) years, 24 (41%) were female, and 55 (93%) were Caucasian. The median CHA2 DS2 VASc and HASBLED scores were 5 (4-6) and 3 (3-4), respectively. At the time of the study, 51 (53%) patients were on a direct acting oral anticoagulant. There were no significant differences between the fusion and no fusion groups in procedure time (52.4 ± 15.4 vs. 56.8 ± 19.5 min, p = .36), mean contrast volume used (33.8 ± 12.0 vs. 29.6 ± 11.5 mls, p = .19), mean fluoroscopy time (31.3 ± 9.9 vs. 28.9 ± 8.7 min, p = .32), mean radiation dose (1177 ± 969 vs. 1091 ± 692 mGy, p = .70), and radiation dose product curve (23.9 ± 20.5 vs. 35.0 ± 49.1 Gy cm2 , p = .29). There was no periprosthetic leak in the two groups in the immediate 1-month postprocedure follow-up periods.

CONCLUSIONS

There was no significant difference with and without 3D-MDCT-fluoroscopy fusion in procedure time, contrast volume use, radiation dose, and radiation dose product.

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.

Cardiac magnetic resonance imaging for preprocedural planning of percutaneous left atrial appendage closure

Introduction

Percutaneous closure of the left atrial appendage (LAA) facilitates stroke prevention in patients with atrial fibrillation. Optimal device selection and positioning are often challenging due to highly variable LAA shape and dimension and thus require accurate assessment of the respective anatomy. Transesophageal echocardiography (TEE) and x-ray fluoroscopy (XR) represent the gold standard imaging techniques. However, device underestimation has frequently been observed. Assessment based on 3-dimensional computer tomography (CTA) has been reported as more accurate but increases radiation and contrast agent burden. In this study, the use of non-contrast-enhanced cardiac magnetic resonance imaging (CMR) to support preprocedural planning for LAA closure (LAAc) was investigated.

Methods

CMR was performed in thirteen patients prior to LAAc. Based on the 3-dimensional CMR image data, the dimensions of the LAA were quantified and optimal C-arm angulations were determined and compared to periprocedural data. Quantitative figures used for evaluation of the technique comprised the maximum diameter, the diameter derived from perimeter and the area of the landing zone of the LAA.

Results

Perimeter- and area-based diameters derived from preprocedural CMR showed excellent congruency compared to those measured periprocedurally by XR, whereas the respective maximum diameter resulted in significant overestimation (p < 0.05). Compared to TEE assessment, CMR-derived diameters resulted in significantly larger dimensions (p < 0.05). The deviation of the maximum diameter to the diameters measured by XR and TEE correlated well with the ovality of the LAA. C-arm angulations used during the procedures were in agreement with those determined by CMR in case of circular LAA.

Discussion

This small pilot study demonstrates the potential of non-contrast-enhanced CMR to support preprocedural planning of LAAc. Diameter measurements based on LAA area and perimeter correlated well with the actual device selection parameters. CMR-derived determination of landing zones facilitated accurate C-arm angulation for optimal device positioning.

Pre-cath Laboratory Planning for Left Atrial Appendage Occlusion - Optional or Essential?

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging. Furthermore, incorporation of computational modeling and artificial intelligence (AI) may yield promise. For optimal patient-centric procedural success, we advocate for standardized preprocedural imaging planning by physicians within the Heart Team as an essential part of LAAO.

[Contribution of CT-scan fusion imaging for interventional cardiology]

Fusion imaging is developing fast, allowing improvements in interventional cardiology procedures workup and guidance. Computed-tomography (CT) scan and fluoroscopy fusion guidance used in procedures such as left appendage occlusion or perivalvular leak closure permit prediction and simulation of the appropriatedevice, as well as implantation guidance. In the era of tailored medicine, CT/fluoroscopy fusion imaging guidance is an interesting tool for individualizing and adapting the devices implanted to each patient, as well as improving the outcomes and safety of each procedure.

The Chinese Experience of Imaging in Cardiac Intervention: A Bird's Eye Review

Recent scientific and technological advances have greatly contributed to the development of medical imaging that could enable specific functions. It has become the primary focus of cardiac intervention in preoperative assessment, intraoperative guidance, and postoperative follow-up. This review provides a contemporary overview of the Chinese experience of imaging in cardiac intervention in recent years.

The year 2021 in the European Heart Journal—Cardiovascular Imaging: Part I

The European Heart Journal—Cardiovascular Imaging was introduced in 2012 and has during these 10 years become one of the leading multimodality cardiovascular imaging journals. The journal is currently ranked as Number 19 among all cardiovascular journals. It has an impressive impact factor of 9.130 and our journal is well established as one of the top cardiovascular journals. The most important studies published in our Journal in 2021 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease.

Computed tomography angiography/magnetic resonance imaging-based preprocedural planning and guidance in the interventional treatment of structural heart disease

Preprocedural planning and periprocedural guidance based on image fusion are widely established techniques supporting the interventional treatment of structural heart disease. However, these two techniques are typically used independently. Previous works have already demonstrated the benefits of integrating planning details into image fusion but are limited to a few applications and the availability of the proprietary tools used. We propose a vendor-independent approach to integrate planning details into periprocedural image fusion facilitating guidance during interventional treatment. In this work, we demonstrate the feasibility of integrating planning details derived from computer tomography and magnetic resonance imaging into periprocedural image fusion with open-source and commercially established tools. The integration of preprocedural planning details into periprocedural image fusion has the potential to support safe and efficient interventional treatment of structural heart disease.

Left Atrial Appendage Occlusion: Current Stroke Prevention Strategies and a Shift Toward Data-Driven, Patient-Specific Approaches

The left atrial appendage (LAA) is a complex structure with unknown physiologic function protruding from the main body of the left atrium. In patients with atrial fibrillation, the left atrium does not contract effectively. Insufficient atrial and LAA contractility predisposes the LAA morphology to hemostasis and thrombus formation, leading to an increased risk of cardioembolic events. Oral anticoagulation therapies are the mainstay of stroke prevention options for patients; however, not all patients are candidates for long-term oral anticoagulation. Percutaneous occlusion devices are an attractive alternative to long-term anticoagulation therapy, although they are not without limitations, such as peri-implant leakage and device-related thrombosis. Although efforts have been made to reduce these risks, significant interpatient heterogeneity inevitably yields some degree of device-anatomy mismatch that is difficult to resolve using current devices and can ultimately lead to insufficient occlusion and poor patient outcomes. In this state-of-the-art review, we evaluated the anatomy of the LAA as well as the current pathophysiologic understanding and stroke prevention strategies used in the management of the risk of stroke associated with atrial fibrillation. We highlighted recent advances in computed tomography imaging, preprocedural planning, computational modeling, and novel additive manufacturing techniques, which represent the tools needed for a paradigm shift toward patient-centric LAA occlusion. Together, we envisage that these techniques will facilitate a pipeline from the imaging of patient anatomy to patient-specific computational and bench-top models that enable customized, data-driven approaches for LAA occlusion that are engineered specifically to meet each patient's unique needs.

Deep learning-based framework for motion-compensated image fusion in catheterization procedures

OBJECTIVE

Augmenting X-ray (XR) fluoroscopy with 3D anatomic overlays is an essential technique to improve the guidance of the catheterization procedures. Unfortunately, cardiac and respiratory motion compromises the augmented fluoroscopy. Motion compensation methods can be applied to update the overlay of a static model with regard to respiratory and cardiac motion. We investigate the feasibility of motion detection between two fluoroscopic frames by applying a convolutional neural network (CNN). Its integration in the existing open-source software framework 3D-XGuide is demonstrated, such extending its functionality to automatic motion detection and compensation.

METHODS

The CNN is trained on reference data generated from tracking of the rapid pacing catheter tip by applying template matching with normalized cross-correlation (CC). The developed CNN motion compensation model is packaged in a standalone web service, allowing for independent use via a REST API. For testing and demonstration purposes, we have extended the functionality of 3D-XGuide navigation framework by an additional motion compensation module, which uses the displacement predictions of the standalone CNN model service for motion compensation of the static 3D model overlay. We provide the source code on GitHub under BSD license.

RESULTS

The performance of the CNN motion compensation model was evaluated on a total of 1690 fluoroscopic image pairs from ten clinical datasets. The CNN model-based motion compensation method clearly overperformed the tracking of the rapid pacing catheter tip with CC with prediction frame rates suitable for live application in the clinical setting.

CONCLUSION

A novel CNN model-based method for automatic motion compensation during fusion of 3D anatomic models with XR fluoroscopy is introduced and its integration with a real software application demonstrated. Automatic motion extraction from 2D XR images using a CNN model appears as a substantial improvement for reliable augmentation during catheter interventions.

Pre-cath Laboratory Planning for Left Atrial Appendage Occlusion - Optional or Essential?

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging. Furthermore, incorporation of computational modeling and artificial intelligence (AI) may yield promise. For optimal patient-centric procedural success, we advocate for standardized preprocedural imaging planning by physicians within the Heart Team as an essential part of LAAO.

Left Atrial Appendage Closure for Primary and Secondary Stroke Prevention in Patients With Hypertrophic Cardiomyopathy and Atrial Fibrillation: A Pilot Study

Background: The aim of this study was to investigate the efficacy of left atrial appendage closure (LAAC) for primary and secondary stroke prevention in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF).

Methods: This pilot study enrolled 36 patients with HCM and AF who underwent LAAC between April 2017 and December 2019, of whom 22 were for primary stroke prevention and 14 were for secondary prevention.

Results: The patients enrolled in this study had non-obstructive (86.1%) or mild obstructive (13.9%) HCM. Patients in the Secondary Prevention Group had higher CHA2DS2-VASc scores (5.1 ± 1.4 vs. 2.6 ± 1.6, P < 0.001) and higher HAS-BLED scores (2.8 ± 1.0 vs. 1.5 ± 0.9, P < 0.001) compared with those in the Primary Prevention Group. Successful closure with satisfactory seals (residual leak ≤ 5 mm) was achieved in all patients, with complete occlusion in 86.4% of the Primary Prevention Group and 92.9% of the Secondary Prevention Group. Procedural-related complications included one pericardial effusion and one groin hematoma. One device-related thrombus was identified in the Secondary Prevention Group and resolved after anticoagulation. During a mean follow-up time of 28.4 months, one bleeding event was recorded. There were no thromboembolic events or deaths in either group, with 97.2% of the patients achieving freedom from anticoagulation therapy.

Conclusions: Initial results suggest that LAAC can be a safe and feasible alternative for primary and secondary stroke prevention in selected patients with HCM and AF. Further studies with larger samples are required.

Value of detecting peri-device leak and incomplete endothelialization by cardiac CT angiography in atrial fibrillation patients post Watchman LAAC combined with radiofrequency ablation

Objectives

To explore the value of detecting the peri‐device leak (PDL) and device endothelialization after left atrial appendage closure (LAAC) by cardiac computed tomography (CT) in patients with atrial fibrillation (AF), who underwent Watchman LAAC combined with radiofrequency ablation of atrial fibrillation (AFCA).

Methods

Patients with symptomatic drug‐refractory atrial fibrillation at high risk of stroke (CHA₂DS₂‐VASc Score ≥ 2), who underwent Watchman LAAC combined with AFCA in our center from March 2017 to December 2018 were enrolled. Maximum diameter of LAA orifice was determined by preoperative CCTA. A standardized view of Watchman device was obtained by postoperative CCTA multiplannar reconstruction to evaluate the PDL and device endothelialization.

Results

Approximately 84 patients post successful LAAC and AFCA were enrolled in this study. The satisfactory LAA occlusion rate was 100%. There was no death, bleeding, stroke, and device‐related thrombus (DRT) events. At 6‐month postprocedure, CCTA images evidenced complete endothelialization in 44 patients (no contrast enhancement in LAA); contrast enhancement in LAA and visible PDL in 33 patients; contrast enhancement in LAA but without PDL in seven patients (incomplete device endothelialization). Maximum diameter of LAA orifice could independently predict the occurrence of PDL (odds ratio, 1.31; 95% confidence interval, 1.11–1.55; p = .002), sensitivity was 69.7% and specificity was 80.4% with the cutoff value of maximum diameter of LAA orifice more than 28.2 mm on predicting PDL.

Conclusions

CCTA is feasible to evaluate PDL and device endothelialization after LAAC. The maximum diameter of LAA orifice derived from CT can independently predict the occurrence of post‐LAAC PDL.

Left atrial appendage occlusion in COVID-19 times

The coronavirus disease 2019 pandemic is having a major impact on healthcare systems worldwide. Several months after the COVID-19 outbreak, waiting lists of non-urgent structural heart (SH) interventions continue to increase. Limitations in terms of ICU beds and anesthesiology represent a major limitation to conduct non-urgent SH interventions and are a valid reason to move towards less invasive approaches. The field of left atrial appendage occlusion (LAAO) reflects this challenging situation perfectly. The aim of this paper is to describe the possibilities for pre-procedural LAA assessment, performance of the LAAO procedure and post-procedural surveillance in these challenging times.

Combined Therapy of Catheter Ablation and Left Atrial Appendage Closure for Patients with Atrial Fibrillation: A Case-Control Study

Aim

The feasibility and safety of performing the combined procedure of catheter ablation (CA) and left atrial appendage closure (LAAC) for atrial fibrillation (AF) have been reported by observational studies without controls. The aim of this study was to compare the procedural and long-term outcomes of combined procedures with isolated CA or LAAC.

Methods and Results

This study included patients who underwent combined CA and LAAC (combined group), CA alone (CA-only group), or LAAC alone (LAAC-only group). Propensity score matching was used to select controls from the CA-only and LAAC-only groups. Each group contained 76 subjects. The procedures were successfully performed in all the patients. Procedure-related complications of the combined group included one pericardial effusion and two groin haematomas, which did not differ significantly with those of the CA-only group (3.9% vs. 2.6%, P=0.650) or the LAAC-only group (3.9% vs. 2.6%, P=0.650), respectively. The AF-free rate of the combined group was comparable with that of the CA-only group after a mean of 2 years follow-up (67.1% vs. 69.7%, P=0.727). Compared with the LAAC-only group, the combined group achieved similar complete occlusion rate at implant (94.7% vs. 93.4%) and at 45 days (82.9% vs. 85.5%). At the end of follow-up, ischemic stroke and bleeding events of the combined group were low (3.9%) and were comparable with those of the CA-only group (5.3%) and the LAAC-only group (2.6%).

Conclusions

The combination of AF-CA and LAAC is safe and efficacious compared with single procedures alone.