Two-Year Outcome From Combining Cryoballoon Ablation and Left Atrial Appendage Closure: CLACBAC Study

Combined Catheter Ablation and Left Atrial Appendage Occlusion in Atrial Fibrillation: From Data to Clinical Reality

PURPOSE

Atrial fibrillation (AF) requires treatment that focuses on two main goals: symptom control and prevention of thromboembolic events. Catheter ablation and left atrial appendage occlusion (LAAO) constitute two well-established treatment methods in selected patients that accomplish these two goals correspondingly. Recently, there is increasing interest in performing the two procedures concomitantly in a so-called "combined" or "one-stop" procedure. This review aims to summarize the current data on the combined procedure, from the rationale and the techniques to its clinical efficacy, indications and future directions.

METHODS

An extensive search has been conducted using the MEDLINE/PubMed database to identify the relevant studies.

RESULTS

The reported success rates of the combined procedure are very high and frequently reach 100% when performed by experienced operators. The periprocedural and follow-up complications are low, the procedure is cost-effective, while there is significant stroke, bleeding and arrhythmia incidence reduction that does not seem to be undermined by interference between the two interventions. There are also a few indications that the one-stop procedure has a positive effect on left atrial mechanical function as it has been correlated with left atrial reverse remodeling. On the other hand, some studies suggest possible increase in peri-device leaks (PDLs), compared with LAAO alone, which could in turn negatively affect the clinical outcomes. Most available studies are small and observational, with a lack of randomized controlled trials.

CONCLUSION

Catheter ablation and left atrial appendage occlusion can be safely and effectively combined in a cost-effective single procedure in carefully selected patients.

Comparison of prognosis and analysis of related risk factors among three different left atrial appendage occlusion procedures in patients with atrial fibrillation

Background

Left atrial appendage occlusion (LAAO) serves as an alternative to oral anticoagulation (OAC) for atrial fibrillation (AF) patients at high risk of bleeding. The aim of this study was to compare the peri-procedural safety, complete or incomplete occlusion, the incidence of the peri-device leak (PDL), and device-related thrombosis (DRT) among LAAO, cryoballoon ablation (CBA) combined with LAAO, and radiofrequency catheter ablation (RFCA) combined with LAAO and to explore the risk factors of PDL and incomplete occlusion.

Methods

382 patients with non-valvular AF who underwent either LAAO alone (n = 117), CBA combined with LAAO (n = 125), or RFCA combined with LAAO (n = 140) were included in the retrospective study. The study assessed peri-procedural complications and imaging results (3 months post-procedure). Multivariable logistic regression was employed to identify risk factors for incomplete occlusion and PDL.

Results

Peri-procedural complication rates were low among all groups, with 2.9% in the RFCA combined with the LAAO group. In contrast, the LAAO alone and CBA combined with LAAO groups reported no major complications (p = 0.347). At the 3-month follow-up, the incidence of DRT was 1.7% in the LAAO group, 2.4% in the CBA combined with the LAAO group, and 2.1% in the RFCA combined with the LAAO group (p = 0.930). Complete occlusion rates were comparable among the groups: 64.8% for CBA combined with LAAO, 62.4% for LAAO alone, and 60.7% for RFCA combined with LAAO (p = 0.794). PDL occurred in 33.3% of LAAO-alone patients, 34.4% of CBA combined with LAAO patients, and 38.6% of RFCA combined with LAAO patients (p = 0.644). Multivariable analysis identified persistent AF and serum creatinine (SCr) as independent predictors of PDL and incomplete occlusion.

Conclusion

Peri-procedural complications, complete occlusion, PDL, and DRT rates were similar across the three treatment strategies. Persistent AF and SCr were significant risk factors for incomplete occlusion and PDL. These findings highlight the importance of individualized treatment strategies based on patient-specific risk factors for optimizing outcomes.

Safety and Efficacy of Cryoballoon Pulmonary Vein Isolation and Left Atrial Appendage Closure Combined Procedure and Half-Dose Rivaroxaban After Operation in Elderly Patients with Atrial Fibrillation

Background

To investigate the safety and effectiveness of cryo-balloon pulmonary vein isolation (PVI) and left atrial appendage closure (LAAC) combined procedure and half-dose rivaroxaban after operation in elderly patients with atrial fibrillation (AF).

Patients and Methods

A total of 203 AF patients presented for cryo-balloon PVI, and LAAC combined procedure was included from 2019 to 2021. Postoperative patients were anticoagulated with rivaroxaban with/without clopidogrel for 60 days, with oral rivaroxaban of 10 mg in the elderly group and 20 mg in the non-elderly group. Patients with AF ≥80 and <80 years were considered elderly and non-elderly groups, respectively. Scheduled follow-ups and transesophageal echocardiography were used to assess peri- and post-procedural safety and effectiveness.

Results

A total of 203 patients underwent the combined procedure, 83 in the elderly and 120 in the non-elderly groups. All patients successfully obtained PVI and satisfactory LAAC. During the perioperative period, one patient had puncture complications in the elderly group and one with thrombosis in the non-elderly group. Oral rivaroxaban was administered to 83.2% and 75% of patients in the elderly and non-elderly groups, respectively, and rivaroxaban was combined with clopidogrel anticoagulation in the remaining patients. The annual rates of composite clinical events were 8.4% and 9.2% in the elderly and non-elderly groups, respectively, with no statistically significant difference. Patients in both groups had complete sealing, and there was no displacement of devices, death and peripheral arterial thrombosis. Recurrence of AF occurred in 25 and 32 patients in the elderly and non-elderly groups, respectively, with no statistically significant difference. Besides, the two groups had no statistically significant difference in cerebral infarction/transient ischemic attack and device-related thrombosis (p > 0.05).

Conclusion

This study suggests that cryo-balloon PVI and LAAC combined procedure and half-dose rivaroxaban after the operation is safe and effective in treating elderly patients with AF.

Guiding atrial fibrillation ablation combined with left atrial appendage occlusion procedure by fluoroscopy with or without transesophageal echocardiography achieved comparable outcomes

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia and can be treated with catheter ablation (CA) combined with left atrial appendage occlusion (LAAO). The study is designed to compare the safety and efficacy of guiding the combined procedure by digital subtraction angiography (DSA) with or without transesophageal echocardiography (TEE).

METHODS

From February 2019 to December 2020, 138 patients with nonvalvular AF who underwent CA combined with LAAO procedure were consecutively included, and two cohorts were built according to intraprocedural guidance (DSA or DSA with TEE). Periprocedural and follow-up outcomes were compared with investigate the feasibility and safety between the two cohorts.

RESULTS

71 patients and 67 patients were included in the DSA cohort and TEE cohort, respectively. Age and gender were comparable, despite the TEE cohort having a higher proportion of persistent AF (37 [55.2%] vs. 26 [36.6%]) and hemorrhage history (9 [13.4%] vs. 0). The procedure time of the DSA cohort was significantly reduced (95.7 ± 27.6 vs. 108.9 ± 30.3 min, p = .018), with a nonsignificant longer fluoroscopic time (15.2 ± 5.4 vs. 14.4 ± 7.1 min, p = .074). And the overall incidence of peri-procedural complications was similar between cohorts. After an average of 24 months of clinical follow-up, only three patients in the TEE cohort had ≤3 mm residual flow (p = .62). Kaplan-Meier estimates showed nonsignificant differences between the cohorts for freedom from atrial arrhythmia (log-rank p = .964) and major adverse cardiovascular events (log-rank p = .502).

CONCLUSIONS

Compared with DSA and TEE guidance, DSA-guided combined procedure could shorten the procedural time, while achieving similar periprocedural and long-term feasibility and safety.

Left atrial appendage occlusion combined with cryoballoon or radiofrequency ablation: One-year follow-up comparison

Background

A one-stop procedure involving catheter ablation and left atrial appendage occlusion (LAAO) is an option for high-risk atrial fibrillation patients. Few studies have reported the efficacy and safety of cryoballoon ablation (CBA) combined with LAAO, and no studies have compared the combination of LAAO with CBA or radiofrequency ablation (RFA).

Methods

A total of 112 patients were enrolled in the present study; 45 patients received CBA combined with LAAO (group 1), and 67 patients received RFA combined with LAAO (group 2). Patient follow-up was performed for 1 year to detect peri-device leaks (PDLs) and safety outcomes (defined as a composite of peri-procedural and follow-up adverse events).

Results

The number of PDLs at the median 59 days follow-up was comparable between the two groups (33.3% in group 1 vs. 37.3% in group 2, p = 0.693). Safety outcomes were also comparable between the two groups (6.7% in group 1 vs. 7.5% in group 2, p = 1.000). Multivariable regression showed that PDLs risk and safety outcomes were all similar between the two groups. Subgroup analysis of PDLs indicated no significant differences. Follow-up safety outcomes were related to anticoagulant medication, and patients without PDLs were more likely to discontinue antithrombotic therapy. The total procedure and ablation times were all significantly shorter for group 1.

Conclusion

When compared with left atrial appendage occlusion combined with radiofrequency, left atrial appendage occlusion combined with cryoballoon ablation has the same risk of peri-device leaks and safety outcomes, but the procedure time was significantly reduced.

Patients With Larger Left Atrial Appendage Orifice Presented Worse Prognosis Contributed by Acute Heart Failure After Left Atrial Appendage Closure

Background Left atrial appendage (LAA) closure (LAAC) could prevent stroke in patients with atrial fibrillation. However, LAAC may impair the compliance of the left atrium and result in poor prognosis. This study aimed to comparatively evaluate the prognosis of LAAC among patients with different sizes of LAA orifice. Methods and Results Three hundred two consecutive patients who underwent successful LAAC were included and divided into 4 groups based on LAA orifice size that was measured using transesophageal echocardiography. Clinical outcomes including thromboembolic events, major cardiocerebrovascular adverse events, and acute heart failure (AHF) were compared among 4 quartile groups and between propensity-score matched groups of large and small LAAs. Through follow-up of 39.6±8.4 months, survival of thromboembolic events was similar. Survival of major cardiocerebrovascular adverse events was significantly lower in the group with the largest LAA orifice (log-rank P<0.001), including a higher incidence of AHF with New York Heart Association class III to IV (21.4%, log-rank P=0.009). A large LAA orifice (by cutoff) could predict major cardiocerebrovascular adverse events (hazard ratio, 3.749 [95% CI, 2.074-6.779]) in most patients, except for subgroups of those aged <65 years, with paroxysmal atrial fibrillation, and/or with failed rhythm/rate control. Further compared with a propensity-score matched small-LAA group, the large-LAA orifice group still presented worse survival of AHF with New York Heart Association class III to IV (log-rank P=0.010). Conclusions Patients with a larger LAA orifice presented a worse prognosis after LAAC, including a higher incidence of AHF. A large LAA orifice could predict a post-LAAC AHF event in most patients, except for young patients, patients with paroxysmal atrial fibrillation, and/or with failed rhythm/rate control. Registration URL: clinicaltrials.gov; Unique identifier: NCT04185142.

Hospital outcomes of patients receiving catheter ablation of atrial fibrillation, left atrial appendage closure, or both

BACKGROUND

Catheter ablation (CA) and left atrial appendage closure (LAAC) require transseptal access; combining both in a single procedure may have advantages. However, the safety of this approach has not been extensively studied. The objective of this study was to compare in hospital outcomes among patients receiving CA, LAAC, and combination of both treatments on the same day.

METHODS

We conducted a retrospective cohort analysis of the National Inpatient Sample database. The primary outcome was the presence of major adverse cardiovascular and cerebrovascular events (MACCE) during index hospitalization. Secondary outcomes included stroke, pericardial effusion, pericardiocentesis, and bleeding.

RESULTS

A total of 69,285 hospitalizations with AF were included in the analysis, of which 71.7% received LAAC, 27.8% received CA, and 0.5% received combination of both treatments on the same day. MACEE (OR, 1.63; 95% CI, 0.39-6.70), stroke (OR, 2.98; 95% CI, 0.55-16.01), pericardial effusion (OR, 0.33; 95% CI, 0.07-1.41), pericardiocentesis (OR, 1.00; 95% CI, 0.25-3.86), and bleeding (OR, 3.25; 95% CI, 0.87-12.07) did not differ significantly between CA and combination treatment. Similarly, MACCE (OR, 1.11; 95% CI, 0.28-4.41), stroke (OR, 1.03; 95% CI, 0.24-4.35), pericardial effusion (OR, 0.45; 95% CI, 0.11-1.90), pericardiocentesis (OR, 0.63; 95% CI, 0.14-2.83), and bleeding (OR, 2.04; 95% CI, 0.65-6.39) did not differ significantly between LAAC and combination treatment.

CONCLUSIONS

The combined approach is infrequently used in clinical practice (< 1%). However, major life-threatening adverse events did not differ between CA and LAAC when performed in isolation or combined in a single procedural stage on the same day.

Concomitant transcatheter occlusion versus thoracoscopic surgical clipping for left atrial appendage in patients undergoing ablation for atrial fibrillation: A meta-analysis

Background

Both catheter left atrial appendage occlusion combined with ablation (COA) and thoracoscopic surgical left atrial appendage clipping combined with ablation (TCA) have shown favorable outcomes in management of patients with atrial fibrillation (AFib). However, studies comparing the endpoints of both techniques are still lacking. Herein, a meta-analysis of safety and efficacy outcomes of COA versus TCA was performed in patients with AFib.

Methods

Pubmed, Embase, Cochrane, and Web of Science databases were searched for retrieving potential publications. The primary outcome was the incidence of stroke during follow-up period of at least 12 months. Secondary outcomes were acute success rate of complete left atrial appendage (LAA) closure by COA or TCA, postprocedural mortality and complications, and all-cause mortality during follow-up period of at least 12 months.

Results

19 studies of COA containing 1,504 patients and 6 studies of TCA with 454 patients were eligible for analysis. No significant difference in stroke and all-cause mortality was found in patients undergoing COA versus TCA after at least a 12-month follow-up (stroke: p = 0.504; all-cause mortality: p = 0.611). COA group had a higher acute success rate compared with TCA group (p = 0.001). COA placed the patients at a higher risk of hemorrhage during the postprocedural period compared with TCA (p = 0.023). A similar risk of other postprocedural complications (stroke/transient ischemic attack and pericardial effusion) and mortality was found in the COA group in comparison with TCA group (p>0.05).

Conclusion

This meta-analysis showed that COA and TCA did not differ in stroke prevention and all-cause mortality in patients with AFib after a follow-up of at least 12 months. Postprocedural complications and mortality were almost comparable between the two groups. In the near future, high-quality randomized controlled trials exploring the optimal surgical strategies for AFib and endpoints of different procedures are warranted.

Systematic review registration

[https://www.crd.york.ac.uk/PROSPERO/], identifier [CRD42022325497].

Experience of Combined Procedure during Percutaneous LAA Closure

Introduction: Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulants (OAC) in patients with non-valvular atrial fibrillation (AF) and contraindication to long-term OAC. Combined strategy with percutaneous LAAC at the same time of other cardiac structural or electrophysiological procedures has emerged as an alternative to a staged strategy. Aim: To describe our experience with combined LAAC procedures using Watchman™ devices. Methods: All patients with combined LAAC procedures using Watchman™ (WN) devices performed from 2016 to 2021 were included. The primary safety endpoint was a composite of periprocedural complications and adverse events during the follow-up. The primary efficacy endpoint included strokes, systemic embolisms, major bleeding and cardiovascular death. Results: From 2016, among 160 patients who underwent LAAC using WN devices, 19 underwent a combined strategy: 7 transcatheter edge-to-edge mitral valve repair (TEMVR) (37%), 6 typical atrial flutter ablation (31%), 2 leadless pacemaker (LP) implantation (10%) and 4 AF ablation (22%). The WN device was successfully implanted in 98% and 100% of cases for single and combined LAAC procedures, respectively (p = 0.63). Median follow-up was 13 months (IQR 25/75 3/24). Device-related complications occurred in 6 out of 141 patients (4%) who underwent single LAAC and in no (0/19) patient in the combined LAAC procedure (p = ns). The procedural-related complications did not differ significantly between groups (5% vs. 10%, respectively, in the single and combined group, p = 0.1). Conclusion: Combined procedure using the Watchman™ devices and one other structural or electrophysiological procedure appears safe and effective. Larger series are needed to confirm these results.

Effect of catheter ablation combined with left appendage occlusion for non-valvular atrial fibrillation: a meta-analysis

Objective

To estimate the effect of catheter ablation combined with left appendage occlusion in the treatment of non-valvular atrial fibrillation (NVAF) by a method of meta-analysis.

Methods

Pubmed, Embase, and Cochrane Library were searched for the studies about catheter ablation combined with left appendage occlusion in treating NVAF. The data analysis was performed using R 4.0.5 software. The retrieval time was from inception to May 12, 2021.

Results

A total of 18 published studies were identified in the meta-analysis, including 1385 participants. During the perioperative period of catheter ablation combined with left appendage occlusion in treating NVAF, the pooled incidences of pericardial effusion, major or minor bleeding events, and residual flow documented were 0.5%(95%CI 0.0002–0.0099), 1.42%(95% CI 0.00–0.04), 7.24%(95% CI 0.0447–0.0975), respectively. During the follow-up, the incidences of all-cause mortality, embolism events, and bleeding events were 0.32%(95%CI 0.0000–0.0071), 1.29%(95%CI 0.0037–0.0222), 2.07%(95% CI 0.0075–0.0339), respectively. In the follow-up period of the transesophageal echocardiography, the most complication was residual flow event with an incident rate of 10.80%(95% CI 0.054–0.1620). The maximum occurrence probability of residual flow events was 17.92% (95% CI 0.1133–0.2452). Moreover, the incident rate of NVAF recurrence was 29.23% (95% CI 0.2222–0.3623).

Conclusion

The meta-analysis suggests that the “one-stop” procedure is effective for those patients undergoing NVAF. However, Patients with more residual blood flow have a higher incidence of bleeding complications. More studies are warranted to verify the safety and efficacy of catheter ablation combined with left appendage occlusion in terms of the “one-stop” procedure.

Current evidence on the safety and efficacy of combined atrial fibrillation ablation and left atrial appendage closure

PURPOSE OF REVIEW

Combined atrial fibrillation (AF) ablation and left atrial (LA) appendage (LAA) closure (LAAC) has been practiced for management of both the symptoms and the high stroke risk of AF. The purpose of this review is to review recent evidence regarding the combined procedure.

RECENT FINDINGS

Newly acquired long-term data of combined AF ablation and LAAC supplied satisfactory evidence on the safety and efficacy of the combined procedure. Studies also showed LA structural remodeling following combined procedure was mainly affected by sinus rhythm status post catheter ablation, not by LAAC. A cost-effectiveness study revealed that combined procedure was a cost-effective therapeutic option in symptomatic AF patients with high stroke and bleeding risk. Due to recent evidence of high incidences of LAA thrombus formation after LAA electrical isolation (LAAEI) and benefit of LAAC after LAAEI, an extended combined procedure of standard AF ablation plus LAAEI and LAAC was considered as a potential therapeutic option for persistent AF patients with high stroke risk.

SUMMARY

In conclusion, combined AF ablation and LAAC serve as a promising option for patients with symptomatic AF and high risk of stroke and/or bleeding.

Exclusion of left atrial appendage: effects beyond thromboembolic prevention

PURPOSE OF REVIEW

This review aims to summarize the nonthromboembolic prevention effects of left atrial appendage exclusion (LAAE).

RECENT FINDINGS

Left atrial appendage (LAA) secretes multiple hormones; regulates blood volume and pressure; and generates trigger activities. Exclusion of the LAA by different techniques may lead to downstream effects including changes in blood pressure and cardiac performance, improvement of outcome of atrial fibrillation (AF) ablation, and alteration of metabolism.

SUMMARY

LAAE procedures not only prevent thromboembolic events in patients with AF, but rather may bring additional benefits or side-effect to patients undergoing LAAE.