824 Eligibility for Percutaneous Left Atrial Appendage (LAA) Closure: A Retrospective Study of Patients With Atrial Fibrillation With Haemorrhagic Events

Abstract Background/Introduction Left atrial appendage (LAA) occlusion is an effective strategy for thromboembolism prevention in patients with atrial fibrillation (AF), and the novel methods of occlusion is various. The acute thrombosis after percutaneous LAA occlusion devices has been recently reported, but thrombus formation after surgical LAA occlusion is still unclear. Purpose This study aimed to analyse the incidence and prognosis of thrombus formation on closure stump line in patients with AF who underwent surgical LAA occlusion. Methods This study retrospectively analised the data from patients treated with two methods of surgical LAA closure, resection or clipping, from January 2014 to November 2018. Results A total of 187 consecutive patients with AF underwent surgical LAA closure (31 clipping and 156 stapler resection). 170 patients (91%) underwent cardiac CT for LAA imaging on postoperative day 2. The incidence of acute procedure-related thrombus formation in full cohort was 19% (35 cases). The incidence of acute thrombus in patients with clipping and resection was 19% and 16%, respectively (Fisher's exact test, p=0.8). All of 35 patients who had thrombus on LAA closure stump line underwent cardiac CT again 3 months after the primary CT. In all patients with secondary cardiac CT, thrombus on LAA closure stump line disappeared. No symptomatic thromboembolism occurred during the follow-up from operation to secondary CT scan. Conclusion(s) Thrombus formation on stump after surgical LAA closure may often occur on acute phase. The optimal LAA imaging and anti-coagulation therapy after surgical LAA occlusion will prevent patients with acute thrombus from thromboembolism.

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Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984520960116 ◽

2020 ◽

Vol 15 (6) ◽

pp. 541-546

Author(s):

Marco Franciulli ◽

Giuseppe De Martino ◽

Mariateresa Librera ◽

Ahmed Desoky ◽

Antonio Mariniello ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Oral Anticoagulants ◽

Bleeding Risk ◽

Atrial Appendage ◽

Nonvalvular Atrial Fibrillation ◽

High Bleeding Risk ◽

Laa Closure

Objective In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. Methods From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. Results Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. Conclusions In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

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Left Atrial Appendage Morphology With The Progression of Atrial Fibrillation

10.21203/rs.3.rs-757374/v2 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Fumi Yokohama ◽

Norihisa Toh ◽

Koji Nakagawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Therapeutic Strategy ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Volume Index ◽

Determining The Indication ◽

Device Size ◽

Laa Closure

Abstract Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 340 patients (mean age: 65 ± 15 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 105), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth, greater LAA lobes, and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (r = 0.37, p < 0.01) and the duration of continuous AF (r = 0.30, p < 0.01), but not with age or the period from the onset of AF. In conclusion, LAA size, which is the determinant for selecting device size of transcatheter LAA closure, was increased with the progression of AF. Our findings have potential implications for therapeutic strategy of transcatheter LAA closure.

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Percutaneous left atrial appendage closure in a patient with haemophilia and atrial fibrillation: a case report

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytz124 ◽

2019 ◽

Vol 3 (3) ◽

Cited By ~ 1

Author(s):

Ümit Güray ◽

Ahmet Korkmaz ◽

Havva Tuğba Gürsoy ◽

Özgül Uçar Elalmış

Keyword(s):

Atrial Fibrillation ◽

Oral Anticoagulation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Anticoagulation Therapy ◽

Atrial Appendage ◽

Clotting Factor ◽

Bleeding Disorders ◽

Oral Anticoagulation Therapy ◽

Laa Closure

Abstract Background Atrial fibrillation (AF) is the most common cardiac arrhythmia and is a major cause of embolic stroke. In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. Left atrial appendage (LAA) closure is an emerging option in AF patients who are not eligible for oral anticoagulation therapy because of contraindications or high bleeding risk. Case summary A 67-year-old man with permanent AF and haemophilia was referred for further evaluation of our cardiology clinic by his primary haematologist. The CHA2DS2-VASc score was estimated to be 3 and the HAS-BLED score was 3. Due to high risk of bleeding, we decided to perform percutaneous LAA closure instead of oral anticoagulation. Pre-procedural cardiac computerized tomography angiography and transoesophageal echocardiography were performed for measurements of LAA dimensions and exclude LAA thrombus. Percutaneous LAA occlusion was performed using a 28-mm AmplatzerTM AmuletTM device. The final result was excellent without significant residual leak, pericardial effusion, and embolic complication. Clopidogrel 75 mg/day and aspirin 81 mg/day for 1 month with adequate FVIII prophylaxis and then only aspirin 81 mg/day for 2 months were recommended. No antiplatelet was given after 3 months. The patient did not report any thrombotic or haemorrhagic adverse events and there were no complications related to implanted device after 1 year of follow-up. Discussion In patients with hereditary bleeding disorders such as haemophilia, management of AF particularly anticoagulation can be quite challenging. In this report, we present a case of percutaneous LAA occlusion using AmplatzerTM AmuletTM device in a patient who has haemophilia and permanent AF. LAA closure has the potential to be more cost effective as compared to oral anticoagulation therapy due to lesser necessity of clotting factor infusion.

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Second and fourth generation Cryoballoon based left atrial appendage isolation for the treatment of persistent atrial fibrillation

EP Europace ◽

10.1093/europace/euab116.056 ◽

2021 ◽

Vol 23 (Supplement_3) ◽

Author(s):

CH Heeger ◽

RMS Meyer-Saraei ◽

TF Fink ◽

VS Sciacca ◽

JV Vogler ◽

...

Keyword(s):

Atrial Fibrillation ◽

Phrenic Nerve ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

High Rate ◽

Fourth Generation ◽

Phrenic Nerve Palsy ◽

Increased Risk ◽

Laa Closure

Abstract Funding Acknowledgements Type of funding sources: None. Background Although pulmonary vein isolation (PVI) is an effective treatment strategy for patients with paroxysmal atrial fibrillation (AF), it is associated with limited success rates in patients with persistent AF (PersAF). In this context the left atrial appendage (LAA) was recently identified as a target of catheter ablation especially in PVI non-responders. Although effective, this strategy may cause electromechanical dissociation and was therefore assumed to be associated with an increased risk of thromboembolism despite oral anticoagulation (OAC). Since RF based LAAI showed increased rates of thromboembolism and stable LAAI is difficult to achieve in some cases, Cryoballoon-based LAAI might offer a valuable option to achieve safe and durable LAAI. Recently the fourth generation cryoballoon was introduced. Additionally, the 40% shorter tip potentially increases the safety profile as well as efficacy of CB-based LAAI. Objective To assess safety and efficacy on CB2 vs CB4 based LAAI. Methods Cryoballoon based PVI and LAAI was performed in 20 patients with PersAF and long-standing PersAF. The first 10 consecutive patients were treated by the second-generation cryoballoon (CB2) the last 10 patients were treated by the CB4. LAAI was performed by utilizing a bonus freeze protocol (freezing time 300 seconds + another 300 seconds after LAAI). Results Stable LAAI was achieved after a mean of 2.6+/- 1.7 cryoballoon applications with a mean minimal temperature of -52+/-6 °C. Unless one phrenic nerve palsy (5.6%) of the left phrenic nerve no further periprocedural complications occurred. Successful LAAI was performed in 19/20 (95%). TEE after 6 weeks detected LAA thrombus in 3/10 (30%) patients (CB2 group) and 3/10 patients (30%) (CB4 group), p = 0.99. Successful LAA-closure was performed in 16/20 patients (80%) after a mean of 75+/-59 days. The LAA was durable isolated in 8/9 patients (89%, CB2) and 6/8 patients (75%, CB4), p = 0.56). AF recurrence after 6 weeks was 1/10 (10%, CB2) and 3/9 (33%, CB4), p = 0.26. Conclusions Here we used – to our knowledge – for the first time a CB4 for LAAI, followed by a combined check for LAAI and LAA-closure after 6 weeks, compared to the CB2. LAAI was successfully isolated by both cryo-balloons in the majority of patients. Hence the use of newest cryo-balloon generation for LAAI seems a safe and successful procedure compared to earlier balloon generations. However, a relatively high rate of LAA-Thrombus was detected after LAAI. Therefore, LAA closure is mandatory in this population.

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Reduced Incidence of Thromboembolic Events after Surgical Closure of Left Atrial Appendage in Patients with Atrial Fibrillation

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000231 ◽

2016 ◽

Vol 11 (1) ◽

pp. 24-30 ◽

Cited By ~ 3

Author(s):

Manuel Wilbring ◽

Friedrich Jung ◽

Christoph Weber ◽

Klaus Matschke ◽

Michael Knaut

Keyword(s):

Atrial Fibrillation ◽

Cardiac Surgery ◽

Left Atrial ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Thromboembolic Events ◽

Surgical Ablation ◽

Closure Group ◽

Laa Closure

Objective Most of the detected thrombi in patients with atrial fibrillation (AF) can be found in the left atrial appendage (LAA). Interventional LAA closure recently proved to be noninferior to warfarin therapy. Whether these results can be fully translated into surgical LAA closure remains unclear. Corresponding data are still lacking. The present observational study evaluated the impact of surgical LAA closure in patients with AF undergoing cardiac surgery on postoperative thromboembolic events. Methods A prospective registry enrolled 398 patients with permanent AF undergoing cardiac surgery. Concomitant procedures were isolated surgical ablation (group I, n = 71), isolated LAA closure (group II, n = 44), and combined surgical ablation and LAA closure (group III, n = 196). The control group consisted of 87 patients without concomitant surgical ablation or LAA closure. One-year follow-up was completed in all patients. End points were thromboembolic events and death from any cause. Results Clinical baseline characteristics were comparable among the groups. General hospital mortality was 5.5% and likewise differed not significantly. Postoperatively, mean (SD) CHAD2S2-VASc score of 3.5 (1.3) differed not significantly among the groups, indicating comparable thromboembolic risk. Follow-up referred to all hospital survivors (n = 376). Herein, overall incidence of thromboembolic events was 9.8% (n = 37), with an associated mortality of 41.0%. Patients with LAA closure alone or in combination with surgical ablation had a significantly reduced incidence of thromboembolic events (6.6% vs 20.5%, P < 0.01) and consecutively improved survival after 1 year of follow-up (7.0% vs 17.1%, P < 0.01). Conclusions Left atrial appendage closure alone or in combination with surgical ablation was associated with a significantly reduced rate of thromboembolic events and consecutively improved survival after 1 year of follow-up.

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Left Atrial Appendage Morphology With the Progression of Atrial Fibrillation

10.21203/rs.3.rs-757374/v1 ◽

2021 ◽

Author(s):

Yoichi Takaya ◽

Rie Nakayama ◽

Fumi Yokohama ◽

Norihisa Toh ◽

Koji Nakagawa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Transesophageal Echocardiography ◽

Left Atrial ◽

Therapeutic Strategy ◽

Left Atrial Appendage ◽

Atrial Appendage ◽

Volume Index ◽

Determining The Indication ◽

Device Size ◽

Laa Closure

Abstract Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 340 patients (mean age: 65 ± 15 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 105), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth, greater LAA lobes, and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (R = 0.37, P < 0.01) and the duration of continuous AF (R = 0.30, P < 0.01), but not with age or the period from the onset of AF. LAA size, which is the determinant for selecting device size of transcatheter LAA closure, was increased with the progression of AF. Our findings have potential implications for therapeutic strategy of transcatheter LAA closure.

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Percutaneous left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation

Future Neurology ◽

10.2217/fnl-2020-0001 ◽

2020 ◽

Vol 15 (3) ◽

pp. FNL48

Author(s):

Hans-Christoph Diener ◽

Ulf Landmesser

Keyword(s):

Atrial Fibrillation ◽

High Risk ◽

Stroke Prevention ◽

Left Atrial ◽

Left Atrial Appendage ◽

Oral Anticoagulants ◽

Atrial Appendage ◽

Bleeding Complications ◽

Randomized Studies ◽

Laa Closure

Patients with atrial fibrillation (AF) have a fivefold higher risk of stroke than persons in sinus rhythm. Effective stroke prevention is achieved with oral anticoagulants such as vitamin K antagonists or nonvitamin K oral anticoagulants. An alternative for stroke prevention in patients with AF is the closure of the left atrial appendage (LAA) with a percutaneously applied closure system. The two large randomized studies PROTECT-AF and PREVAIL failed to show superiority of LAA closure over anticoagulation in patients with AF. Meta-analyses of studies and registries, however, suggest that LAA closure has particular advantages with regard to the reduction of severe bleeding complications. Currently, several prospective randomized studies are being conducted in different patient populations to evaluate the benefit of LAA closure in comparison to standard of care. Currently, LAA closure is recommended in patients after intracranial hemorrhage, with advanced renal failure, after severe gastrointestinal bleeding, in patients with a high risk of recurrent ischemic stroke and elderly patients with high risk of bleeding and falling.

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Totally Endoscopic Robotic Left Atrial Appendage Closure Demonstrates High Success Rate

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000330 ◽

2017 ◽

Vol 12 (1) ◽

pp. 46-49 ◽

Cited By ~ 6

Author(s):

Alison F. Ward ◽

Robert M. Applebaum ◽

Nana Toyoda ◽

Ans Fakiha ◽

Peter J. Neuburger ◽

...

Keyword(s):

Atrial Fibrillation ◽

Left Atrial ◽

Left Atrial Appendage ◽

Suture Line ◽

Atrial Appendage ◽

Success Rates ◽

Left Atrial Appendage Occlusion ◽

Mitral Repair ◽

Incomplete Closure ◽

Laa Closure

Objective In patients with atrial fibrillation, 90% of embolic strokes originate from the left atrial appendage (LAA). Successful exclusion of the LAA is associated with a lower stroke rate in patients with atrial fibrillation. Surgical oversewing of the LAA is often incomplete when evaluated with transesophageal echocardiogram (TEE). External closure techniques of suturing and stapling have also demonstrated high failure rates with persistent flow and large stumps. We hypothesized that the precise visualization of a robotic LAA closure (RLAAC) would result in superior closure rates. Methods Before robotic mitral repair, patients underwent RLAAC; the base of the LAA was oversewn using a running 4–0 polytetrafluoroethylene suture in two layers. Postoperatively, the LAA was interrogated in multiple TEE views. Incomplete closure was defined as any flow across the LAA suture line or a residual stump of greater than 1 cm. Results Seventy-nine consecutive patients underwent RLAAC; no injuries occurred. On postrepair TEE, 73 of 79 patients had LAAs visualized well enough to thoroughly evaluate. Successful ligation was confirmed in 64 (87.7%) of 73 patients. Seven patients (9.6%) had small jet flow into the LAA; no residual stumps were noted. Two patients (2.7%) had undetermined flow. Conclusions We have demonstrated excellent success with RLAAC; we postulate that this may be due to improved intracardiac visualization. Robotic LAA closure was more successful (87.7%) than previously reported results from the Left Atrial Appendage Occlusion Study for suture exclusion (45.5%) and staple closure (72.7%). With success rates equivalent to transcatheter device closures, RLAAC should be considered for robotic mitral valve surgical patients.

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Post-angiography Retention of the Contrast Agent in the Left Atrial Appendage Is Associated With Risk of Cardioembolic Stroke in Patients With Atrial Fibrillation: A Retrospective Study

Frontiers in Cardiovascular Medicine ◽

10.3389/fcvm.2021.753949 ◽

2021 ◽

Vol 8 ◽

Author(s):

Ping Fang ◽

Youquan Wei ◽

Jinfeng Wang ◽

Xianghai Wang ◽

Hao Yang

Keyword(s):

Atrial Fibrillation ◽

Retrospective Study ◽

Contrast Agent ◽

Left Atrial ◽

Left Atrial Appendage ◽

Relative Proportion ◽

Multivariate Logistic Regression Analysis ◽

Atrial Appendage ◽

Cardioembolic Stroke ◽

Stroke Group

Background: Atrial fibrillation (AF) represents an important risk factor for cardioembolic stroke, and most atrial thrombi originate from the left atrial appendage (LAA). Although the CHA2DS2-VASc score is widely used to estimate the risk of cardioembolic stroke in AF patients, yet greatly affected by many factors. This study was undertaken to determine the association between contrast agent retention in LAA after LAA angiography and risks of cardioembolic stroke in patients with AF.Methods: This is a retrospective study. The demographic and clinical data of AF patients undergone left atrial appendage occlusion (LAAO) with or without catheter radiofrequency ablation were retrospectively analyzed. The patients were classified into either stroke or non-stroke group by the history with cardioembolic stroke or transient ischemic attack (TIA).Results: Sixty-two consecutive patients undergone LAAO were finally included, in whom 31 AF patients had a history of cardioembolic stroke or TIA (one TIA), and significantly higher CHA2DS2-VASc score (4.2 ± 1.4 vs. 3.3 ± 1.3; P = 0.006) as well as incidence of contrast agent retention in LAA (n = 20 vs. n = 7; P = 0.001) compared to the patients in non-stroke group. In addition, the relative proportion of distinctive morphological types of LAA was significantly different between groups (P < 0.001). Multivariate logistic regression analysis showed that higher CHA2DS2-VASc scores (OR = 1.7, 95% CI: 1.0–3.0, P = 0.046) and LAA contrast agent retention (OR = 5.1, 95% CI: 1.1–23.9, P = 0.002) were associated with increased risks of cardioembolic stroke. The patients with Windsock type LAA (OR = 7.8, 95% CI: 1.1–57.2, P = 0.044) and Cauliflower LAA (OR = 20.2, 95% CI: 3.2–125.5, P = 0.001) were more prone to cardioembolic stroke compared to those with Chicken Wing type LAA.Conclusion: Left atrial appendage contrast agent retention after LAA angiography is associated with the risks of cardioembolic stroke in patients with AF, and cardioembolic stroke is more seen in AF patients with Windsock or Cauliflower type LAA.

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