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

Objective: Catheter ablation combined with left atrial appendage closure (LAAC) has emerged as a promising strategy for atrial fibrillation (AF) patients at high risk for stroke or with contraindications for oral anticoagulants (OACs). But the evidence for the long-term safety and efficacy of a combined procedure using cryoballoon ablation (CBA) with LAAC is still insufficient.

Methods: From October 2015 to December 2017, a total of 76 consecutive non-valvular, drug-refractory AF patients who underwent a combined procedure of CBA and LAAC are included. Peri- and post-procedural safety and efficacy were evaluated through scheduled follow-ups and transesophageal echocardiography (TEE).

Results: A total of 74 patients (97.4%) underwent the combined procedure and achieved instant pulmonary vein isolation and satisfactory LAAC. With a mean follow-up time of 23.7 ± 11.0 months, the recurrence of atrial arrhythmia was recorded in 35 patients (48.0%). In addition, a survival analysis shows a non-significant higher recurrence in persistent AF (p = 0.48). The overall OAC withdrawal rate was 97.2%, and one patient (1.4%) had a lethal hemorrhagic stroke while on single antiplatelet therapy. For safety concerns, the overall mortality was 2.7%, which resulted from one case of myocardial infarction on OAC and one hemorrhagic stroke, as mentioned. No other major hemorrhagic events occurred. Among the 72 patients (94.7%) who underwent TEE, one patient (1.4%) had device-related thrombosis and one patient (1.4%) had prominent residual flow (over 3 mm). Both were prescribed long-term OACs without severe complications occurring.

Conclusions: Combining CBA with LAAC in a single procedure achieved considerable long-term safety and efficacy, providing a promising strategy for AF management.

Percutaneous left atrial appendage closure-An alternative strategy for anticoagulation in atrial fibrillation and hereditary hemorrhagic telangiectasia?

Many patients with hereditary hemorrhagic telangiectasia (HHT) are unable to sustain oral anticoagulation (OAC) because of severe epistaxis, gastrointestinal (GI) bleeding and the risk of life-threatening bleeding from cerebral arteriovenous malformations (CAVMs) or pulmonary arteriovenous malformations (PAVMs). In patients with atrial fibrillation (AF), most thromboembolic complications arise from the left atrial appendage (LAA) and percutaneous transcatheter LAA closure proved to be non-inferior to OAC at mid-term follow-up. We report our experience with LAA closure in HHT with a follow-up of 12 months. Percutaneous LAA closure was performed in five patients with both HHT and high thromboembolic risk AF (CHA2DS2-VASc score ≥2) without peri-procedural complications. At 3 months no thromboembolic event occurred. After 12 months one patient had a transient ischemic attack while another patient had recurrence of stroke, this latter patient had a significant stenosis of the carotid artery and an incomplete closure of the LAA without any signs of thrombus on echocardiogram. Both patients had a non-treatable pulmonary right-to-left shunt (RLS). Percutaneous closure of the LAA may provide an alternative strategy to long-term OAC therapy in HHT patients with AF induced high stroke risk and intolerance for OAC.

Left atrial appendage closure for thromboembolism prevention in patients with atrial fibrillation: advances and perspectives

Atrial fibrillation (AF) is a frequent cause of stroke. More than 90% of thrombi were found in the left atrial appendage (LAA) in non-valvular AF. Transcatheter LAA closure has been developed as a novel approach to reduce the risk of stroke in patients with AF over the last decade. In this article, we review the recent advances and propose the possible challenges regarding the LAA closure for thromboembolism prevention in patients with AF.