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Duan F, Li H, Zhou C, Li H, Tao J, Kang W, Yu M, Zheng Z. Novel sizing role of 3D transesophageal echocardiography in a novel left atrial appendage clip device for patients undergoing video-assisted atrial fibrillation ablation: a cohort study. Quant Imaging Med Surg 2024; 14:1335-1347. [PMID: 38415171 PMCID: PMC10895130 DOI: 10.21037/qims-23-900] [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: 06/20/2023] [Accepted: 11/24/2023] [Indexed: 02/29/2024]
Abstract
Background Three-dimensional (3D) transesophageal echocardiography (TEE) has been successfully used in the sizing of left atrial appendage (LAA) occlusion devices, but its use has not yet been studied in LAA clip devices. We sought to develop and validate the novel use of 3D-TEE sizing in a novel LAA clip device for atrial fibrillation (AF) patients undergoing video-assisted thoracic surgery (VATS) ablation. Methods Consecutive patients with isolated AF undergoing LAA clipping or excision during VATS ablation were included in the study between June 2021 and September 2022 at Fuwai Hospital. The patients underwent 3D-TEE examinations preoperatively and postoperatively. The VATS length, LAA clip effective length, and LAA excision margin length were recorded. A correlation analysis, intraclass correlation coefficient (ICC) analysis, and Bland-Altman plot analysis were conducted to examine the TEE parameters, VATS length, LAA clip effective length, and LAA excision margin length. Results In total, 26 AF patients undergoing LAA clipping and 15 undergoing LAA excision were included in the study. In the LAA clipping group, in which the Atriclip size served as the control, the 3D-TEE with volumetric measurement (the perimeter-derived maximum orifice diameter) (R=0.938; ICC =0.934; Bland-Altman plot variability, 3.85%) showed the best sizing efficacy for the LAA clip device among the 3D-TEE with multiplanar reformatting sizing (the perimeter-derived maximum orifice diameter) (R=0.808; ICC =0.772; Bland-Altman plot variability, 3.85%), VATS sizing (R=0.851; ICC =0.756; Bland-Altman plot variability, 11.54%), and VATS plus 0.5-cm sizing (R=0.851; ICC =0.775; Bland-Altman plot variability, 11.54%) measurements (all P<0.001). In addition, for the distribution of matched sizing in the LAA clip group, 3D-TEE with volumetric measurement sizing (20/26) had a higher proportion than 3D-TEE with multiplanar reformatting sizing (11/26, P=0.011), VATS sizing (9/26, P=0.002), and VATS plus 0.5-cm sizing (14/26, P=0.08). Using the LAA excision margin length as the control, the mean difference in the LAA diameter was 1.17 cm [95% confidence interval (CI): 0.71-1.62 cm , P<0.001] in the maximum orifice diameter of two-dimensional-TEE, 0.15 cm (95% CI: -0.32 to 0.61 cm , P=0.523) in the perimeter-derived 3D multiplanar reformatting (the maximum orifice diameter), and 0.03 cm (95% CI: -0.47 to 0.53, P=0.901) in the perimeter-derived 3D volumetric (3DV) measurement (the maximum orifice diameter), and the related Pearson correlation coefficients for these modalities were 0.760 (P=0.001), 0.843 (P<0.001), and 0.963 (P<0.001), respectively. Conclusions Our study showed that 3D-TEE might be employed in the sizing of a novel LAA clip device using the VATS approach in patients with AF. The 3DV measurement (the perimeter-derived maximum orifice diameter) was superior to the VATS measurement. These findings might also apply to LAA VATS excision patients with AF.
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Affiliation(s)
- Fujian Duan
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Li
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chenghui Zhou
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haojie Li
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jia Tao
- Department of Echocardiography, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenying Kang
- Department of Anesthesiology, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Minggang Yu
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Rufa M, Göbel N, Franke UFW. Surgical atrial appendage closure: time for a randomized study. Herzschrittmacherther Elektrophysiol 2022; 33:386-390. [PMID: 36178509 DOI: 10.1007/s00399-022-00903-6] [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: 07/11/2022] [Accepted: 09/11/2022] [Indexed: 06/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and is assumed to affect more than 30 million people worldwide. Studies report that the left atrial appendage (LAA) plays an important role in thrombus formation and is considered the embolic source in 90% of affected patients with non-valvular and 57% with valvular AF. Oral anticoagulants have been the standard of care for stroke prevention in patients with AF for decades. However, bleeding complications and noncompliance are barriers to effective embolic protection. Therefore, as an alternative to conventional anti-thrombotic therapy, surgical LAA occlusion, which may lead to a reduced risk of thromboembolism, has received increasing attention. However, the procedure can be associated with additional risks such as prolonged operation time, damage to the circumflex coronary artery, and incomplete LAA occlusion. This review discusses some of the observational studies that have examined the impact of LAA occlusion on stroke, the LAAOS III (Left Atrial Appendage Occlusion Study) trial, which provided definitive evidence for the benefit of surgical LAA occlusion on ischemic stroke, which surgical methods are safe and effective for LAA occlusion, and whether oral anticoagulation can be stopped after surgical removal of the LAA.
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Affiliation(s)
- Magdalena Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany.
| | - Nora Göbel
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
| | - Ulrich F W Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital Stuttgart, Auerbachstraße 110, 70376, Stuttgart, Germany
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Bakir NH, Khiabani AJ, MacGregor RM, Kelly MO, Sinn LA, Schuessler RB, Maniar HS, Melby SJ, Helwani MA, Damiano RJ. Concomitant surgical ablation for atrial fibrillation is associated with increased risk of acute kidney injury but improved late survival. J Thorac Cardiovasc Surg 2022; 164:1847-1857.e3. [PMID: 33653608 PMCID: PMC8608247 DOI: 10.1016/j.jtcvs.2021.01.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) after cardiac surgery remains a common complication that has been associated with increased morbidity and mortality. This study implemented Kidney Disease Improving Global Outcomes criteria to evaluate renal outcomes after concomitant surgical ablation for atrial fibrillation. METHODS Patients with a history of atrial fibrillation who underwent elective cardiac surgery at our institution from 2008 to 2018 were retrospectively reviewed. Those with preoperative renal dysfunction were excluded. Patients were classified as those who underwent concomitant Cox-Maze IV (CMP-IV) (n = 376) or no surgical ablation (n = 498). Nearest neighbor 1:1 propensity matching was conducted on fourteen covariates. AKI was evaluated by mixed effects logistic regression analysis. Long-term survival was evaluated by proportional hazards regression. RESULTS Propensity matching yielded 308 patients in each group (n = 616). All preoperative variables were similar between groups. The concomitant CMP-IV group had a greater incidence of AKI: 32% (n = 99) versus 16% (n = 49), P < .001. After accounting for bypass time and nonablation operations on mixed effects analysis, concomitant CMP-IV was associated with increased risk of AKI (odds ratio, 1.89; confidence interval, 1.12-3.18; P = .017). While AKI was associated with decreased late survival (P < .001), patients who received a concomitant CMP-IV maintained superior 7-year survival to patients who received no ablation (P < .001). No patients required permanent dialysis. CONCLUSIONS Concomitant CMP-IV was independently associated with increased risk of AKI in the acute postoperative period. However, the long-term risks of AKI were offset by the significant survival benefit of CMP-IV. Concerns regarding new-onset renal dysfunction should not prohibit recommendation of this procedure in appropriate patients.
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Affiliation(s)
- Nadia H. Bakir
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ali J. Khiabani
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Robert M. MacGregor
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Meghan O. Kelly
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Laurie A. Sinn
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Richard B. Schuessler
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Hersh S. Maniar
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Spencer J. Melby
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Mohammad A. Helwani
- Department of Anesthesiology, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Ralph J. Damiano
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, Missouri,Corresponding Author: Ralph J. Damiano, Jr., MD, Washington University School of Medicine, Barnes-Jewish Hospital, Department of Surgery, Division of Cardiothoracic Surgery, Campus Box 8234, 660 S. Euclid Ave., St. Louis, MO 63110, Phone: 314-362-7327, Fax: 314-361-8706,
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Prasad RM, Saleh Y, Al-Abcha A, Abdelkarim O, Abdelfattah OM, Abdelnabi M, Almaghraby A, Elwany M, DeBruyn E, Abela GS. Left atrial appendage closure during cardiac surgery for atrial fibrillation: A meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:26-36. [PMID: 34801420 DOI: 10.1016/j.carrev.2021.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) during cardiac surgery in atrial fibrillation (AF) patients has been investigated in multiple studies with variable safety and efficacy results. METHODS A comprehensive review was performed of all studies comparing LAAC and placebo arm during cardiac surgery in AF patients. A random-effect model was used to calculate risk ratios, mean differences, and 95% confidence intervals. RESULTS Five randomized controlled trials and 22 observational studies were included with a total of 540,111 patients. The LAAC group had significantly decreased postoperative stroke/embolic events as compared to the no LAAC group with all cardiac surgeries (3.74% vs 4.88%, p = 0.0002), isolated valvular surgery (1.95% vs 4.48%, p = 0.002). However, CABG insignificantly favored the LAAC group for stroke/embolic events (6.72% vs 8.30%, p = 0.07). There was no difference between both groups in all-cause mortality in the perioperative period (p = 0.42), but was significantly lower in the LAAC arm after two years (14.1% vs 18.3%, p = 0.02). There was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time between both groups (p = 0.53 and p = 0.45). The bypass and the cross-clamp time were longer in the LAAC group (4 and 9 min, respectively). CONCLUSION In AF patients, LAAC during cardiac surgery had a decreased risk of stroke and long-term all-cause mortality. Additionally, there was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time.
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Affiliation(s)
- Rohan Madhu Prasad
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA.
| | - Yehia Saleh
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Abdullah Al-Abcha
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Ola Abdelkarim
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Omar M Abdelfattah
- Department of Internal Medicine, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
| | - Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Science Center, Lubbock, Texas, USA
| | | | - Mostafa Elwany
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Elise DeBruyn
- College of Medicine, University of Illinois, Chicago, IL, USA
| | - George S Abela
- Department of Cardiology, Michigan State University, East Lansing, MI, USA
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