scholarly journals Results of the Thoracoscopic Radiofrequency Epicardial Ablation with a Bipolar Electrode During Longstanding Persistent form of Atrial Fibrillation

2020 ◽  
Vol 159 ◽  
pp. 08007
Author(s):  
Rustem Tuleutaev ◽  
Alibek Oshakbayev ◽  
Kuat Abzaliyev ◽  
Baurzhan Rakishev ◽  
Symbat Abzaliyeva
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Bipolar Electrode ◽  
Epicardial Ablation ◽  
Input And Output ◽  
Mean Size ◽  
The Mean ◽  
Β Blockers

Thoracoscopic ablation using the ‘box lesion’ technique was performed using a bipolar radio frequency clamp. A total of 48 patients, including 38 men and 10 women, mean age 58 years (range 33 74). The mean duration of AF was 4 yrs (range 1.5 months 21), the mean size of the atrium 4.15 ± 0.9 cm (2.9-8.8 cm), mean LVEF was 57.7% (39 -73%). Mitral regurgitation of 1-2 degrees was present in 14 patients, EDV LV 147.7 ml (81-224). Primary catheter ablation was performed in 22 patients, where 5 of them (22,7%) were performed repeatedly. Resection of the left atrial appendage (LAA) during the operation was performed in 44 patients (91%). Input and output block was achieved in all patients. In the postoperative period, all patients were administered supporting antiarrhythmic therapy with amiodarone and β-blockers, anticoagulant therapy with warfarin or PLA for 6-12 months. The effectiveness of treatment was monitored by a cardiomonitor Reveal XT in the period 1, 3, 6, 12, 24 months after surgery, the mean follow-up length was 498 ± 19 days. Sinus rhythm was restored during surgery in all patients and remained until discharge.

scholarly journals Comparison of Left Atrial Appendage Occlusion versus Non-Vitamin-K Antagonist Oral Anticoagulation in High-Risk Atrial Fibrillation: An Update

2021 ◽  
Vol 8 (6) ◽  
pp. 69
Author(s):  
Shaojie Chen ◽  
K. R. Julian Chun ◽  
Zhiyu Ling ◽  
Shaowen Liu ◽  
Lin Zhu ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
High Risk ◽  
Vitamin K ◽  
Major Bleeding ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Vitamin K Antagonists ◽  
Left Atrial Appendage Occlusion ◽  
The Mean

Transcatheter left atrial appendage occlusion (LAAO) is non-inferior to vitamin K antagonists (VKAs) in preventing thromboembolic events in atrial fibrillation (AF). Non-vitamin K antagonists (NOACs) have an improved safety profile over VKAs; however, evidence regarding their effect on cardiovascular and neurological outcomes relative to LAAO is limited. Up-to-date randomized trials or propensity-score-matched data comparing LAAO vs. NOACs in high-risk patients with AF were pooled in our study. A total of 2849 AF patients (LAAO: 1368, NOACs: 1481, mean age: 75 ± 7.5 yrs, 63.5% male) were enrolled. The mean CHA2DS2-VASc score was 4.3 ± 1.7, and the mean HAS-BLED score was 3.4 ± 1.2. The baseline characteristics were comparable between the two groups. In the LAAO group, the success rate of device implantation was 98.8%. During a mean follow-up of 2 years, as compared with NOACs, LAAO was associated with a significant reduction of ISTH major bleeding (p = 0.0002). There were no significant differences in terms of ischemic stroke (p = 0.61), ischemic stroke/thromboembolism (p = 0.63), ISTH major and clinically relevant minor bleeding (p = 0.73), cardiovascular death (p = 0.63), and all-cause mortality (p = 0.71). There was a trend toward reduction of combined major cardiovascular and neurological endpoints in the LAAO group (OR: 0.84, 95% CI: 0.64–1.11, p = 0.12). In conclusion, for high-risk AF patients, LAAO is associated with a significant reduction of ISTH major bleeding without increased ischemic events, as compared to “contemporary NOACs”. The present data show the superior role of LAAO over NOACs among high-risk AF patients in terms of reduction of major bleeding; however, more randomized controlled trials are warranted.

scholarly journals A novel individualized strategy for cryoballoon catheter ablation in patients with paroxysmal atrial fibrillation

2019 ◽  
Author(s):  
Jun Ding ◽  
Jing Xu ◽  
Wei Ma ◽  
Bingwei Chen ◽  
Peigen Yang ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Dwell Time ◽  
Pulmonary Veins ◽  
Group Versus ◽  
Conventional Group ◽  
Optimal Dosage ◽  
Total Procedure Time ◽  
The Mean

Abstract Background : The optimal dosage for cryoablation of atrial fibrillation (Cryo-AF) is still unknown. To evaluate the efficacy of an individualized freeze duration, we compared the clinical outcome of patients treated with a time-to-pulmonary vein isolation (TT-PVI) or temperature-guided ablation protocol to the outcome of patients treated with a conventional ablation protocol. Methods: A total of 164 consecutive patients were included in the study. One method employed was a conventional dosing protocol (at least 2 applications of 180 seconds each)(the Cryo-AF Conventional group n=84), and the second method had a shorter protocol that was based on the TT-PVI or achievement of -40°C within 60 seconds (the Cryo-AF Dosing group n=80). Results: We treated 656 pulmonary veins (PVs) with 1420 cryotherapy applications. The mean number of applications per patient was 8.7±0.8, with no difference between groups (Cryo-AF Conventional , 8.7±0.8 versus Cryo-AF Dosing ,8.6±0.8; P =0.359). The Cryo-AF Dosing group required significantly less total cryotherapy application time (990.60±137.77versus 1501.58±89.60 seconds; P <0.001) and left atrial dwell time (69.91±6.91 versus 86.48±7.03 minutes; P <0.001) than the Cryo-AF Conventional group. Additionally, the Cryo-AF Dosing group required significantly less total procedure time (95.03±6.50 versus 112.43±7.11 minutes; P <0.001). We observed acute ATP-induced or spontaneous vein electric reconnections in 13 veins (1.98%) after 20 minutes. The reconnection rates between the Cryo-AF Conventional and Cryo-AF Dosing groups were similar in that 2.98% and 0.94% of the initially isolated veins were reconnected, respectively, ( P =0.061). There was no difference in the recurrence rate of free atrial arrhythmia after a 1-year follow-up, which were 78.75% in the Cryo-AF Dosing group versus 78.57% in the Cryo-AF Conventional group ( P =0.978). Conclusion: A novel Cryo-AF dosing protocol guided by temperature or the TT-PVI can be used to individualize an ablation strategy. This new protocol can lead to a significant reduction in duration of the procedure, the cryoenergy dosage and the left atrial dwell time. The procedure had equal safety and similar acute and 1-year follow-up outcomes compared to the conventional approach.

scholarly journals Impact of atrial fibrillation pattern on left atrial appendage closure: insights from the prospective LAARGE registry

EP Europace ◽  
2021 ◽  
Vol 23 (Supplement_3) ◽  
Author(s):  
S Kany ◽  
J Brachmann ◽  
T Lewalter ◽  
I Akin ◽  
H Sievert ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Systemic Embolism ◽  
Long Term Outcomes ◽  
Left Atrial Appendage Closure ◽  
History Of ◽  
One Year

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): Stiftung für Herzinfarkforschung Background  Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death compared with paroxysmal AF (PAF). This study investigates the procedural safety and long-term outcomes of left atrial appendage closure (LAAC) in patients with different forms of AF. Methods  Comparison of procedural details and long-term outcomes in patients (pts) with PAF against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC in Germany (LAARGE).  Results  A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. NPAF consisted of 31.6% patients with persistent AF and 68.4% with longstanding persistent AF or permanent AF. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The PAF group had significantly less history of heart failure (19.0% vs 33.0%, p &lt; 0.001) while the current median LVEF was similar (60% vs 60%, p = 0.26). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), but no difference in the HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was observed. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77) in both groups. In the three-month echo follow-up, device-related thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak &gt;5 mm (0.0% vs 7.1%, p= 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95%-CI: 1.02-2.72). Conclusion  Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE of patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality and combined outcome of death, stroke and systemic embolism.

Abstract 14990: Pulmonary Vein Stenosis After Epicardial Atrial Fibrillation Ablation and Epicardial Left Atrial Appendage Occlusion: A Diagnostic Dilemma and Challenges in Management

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Moghniuddin Mohammed ◽  
Nachiket Apte ◽  
Mohammed Ansari ◽  
Amit Noheria ◽  
Seth Sheldon ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Pulmonary Vein ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Atrial Appendage ◽  
Maze Procedure ◽  
Pulmonary Vein Stenosis ◽  
Epicardial Ablation ◽  
Left Atrial Appendage Occlusion ◽  
Vein Stenosis

Background: Pulmonary vein stenosis is a dreaded complication of endocardial atrial fibrillation (AF) ablation but rare after epicardial ablation and has not been reported after epicardial left atrial appendage occlusion (LAAO). Case: A 55-year-old male was referred to our tertiary hospital for management of left superior pulmonary vein (LSPV) stenosis causing dyspnea on exertion. About 2 years prior to presentation, he underwent quadruple coronary artery bypass grafting for non-ST elevation myocardial infarction along with modified Cox-Maze procedure with pulmonary vein and posterior wall isolation as well as epicardial LAAO with AtriClip for history of paroxysmal AF. At our institute, V/Q scan showed ventilation-perfusion mismatch and absent perfusion of the left upper lobe (Figure 1A). Cardiac CT showed persistent LSPV occlusion (Figure 1B). TEE showed atrial appendage occluded with a clip and no flow was observed from LSPV (Figure 1C). After multidisciplinary discussion between cardiology and cardiothoracic surgery teams, surgical approach to remove the AtriClip was deemed futile as it was placed 2 years ago and less likely to result in resolution of stenosis. Thus, an endovascular approach was attempted with left atrial and pulmonary vein angiography showing LSPV to be 100% occluded (Figure 1D). Pulmonary vein recanalization was attempted but was not successful. Conclusion: Our case highlights the importance of recognition of PVS as a possible complication after epicardial LAAO as early intervention can improve patient outcomes. PVS has been previously described with Maze procedure but that patient was successfully treated with catheter-balloon angioplasty. Given 100% occlusion and difficulty with recanalization makes epicardial ablation a less likely cause of occlusion in our case. More careful application of Atriclip protocols might be necessary to prevent this potential complication.

scholarly journals Spontaneously occluded left atrial appendage in a patient with atrial fibrillation and stroke: a case report

2020 ◽  
Vol 4 (2) ◽  
pp. 1-4
Author(s):  
Andreas Bugge Tinggaard ◽  
Kasper Korsholm ◽  
Jesper Møller Jensen ◽  
Jens Erik Nielsen-Kudsk
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Transoesophageal Echocardiography ◽  
Similar Efficacy ◽  
Cardiovascular Death ◽  
Atrial Appendage ◽  
Left Atrial Appendage Occlusion ◽  
All Cause Mortality

Abstract Background  The left atrial appendage (LAA) is the main source of thromboembolism in atrial fibrillation (AF). Transcatheter closure is non-inferior to warfarin therapy in preventing stroke. Case summary  A patient with two consecutive strokes associated with AF was referred for transcatheter LAA occlusion (LAAO). Preprocedural cardiac CT and transoesophageal echocardiography demonstrated a spontaneously occluded LAA with a smooth left atrial surface, with stationary results at 6- and 12-month imaging follow-up. Warfarin was discontinued, and life-long aspirin instigated. Discussion  Left atrial appendage occlusion has shown non-inferiority to warfarin for prevention of stroke, cardiovascular death, and all-cause mortality. No benefits from anticoagulation have been demonstrated in patients with embolic stroke of undetermined source. In the present case, we observed that the LAA was occluded and, therefore, treated with aspirin monotherapy assuming similar efficacy as transcatheter LAAO.

Epicardial Surgical Ligation of the Left Atrial Appendage is Safe, Reproducible, and Effective by Transesophageal Echocardiographic Follow-up

2013 ◽  
Vol 8 (5) ◽  
pp. 371-375 ◽  
Author(s):  
Alex Zapolanski ◽  
Christopher K. Johnson ◽  
Omid Dardashti ◽  
Ryan M. O'Keefe ◽  
Nancy Rioux ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Perioperative Complications ◽  
Low Cost ◽  
Color Doppler ◽  
Color Doppler Imaging ◽  
Atrial Appendage ◽  
Doppler Imaging

Objective The left atrial appendage (LAA) is the source of 90% of thrombi in patients with atrial fibrillation. Our double LAA ligation (LLAA) technique was shown to be 96% successful in a small study. However, the outcomes of these patients have yet to be compared with a set of nonligated patients. Methods From 2005 to 2012, a total of 808 patients received LAA using our double ligation technique using both a polydioxanone (PDS) II endosnare and a running 4-0 Prolene pledgeted suture. The 30-day outcomes of these patients were compared with that of nonligated patients. Fifty-six of the ligated patients had a postoperative transesophageal echocardiography (TEE). An echocardiographer reviewed the follow-up TEEs for LAA remnant and/or residual flow into the LAA using color Doppler imaging. The patients with LAA flow and/or remnant depth of 1 cm or greater were deemed to have an unsuccessful exclusion. Results The ligated group had a trend of less postoperative atrial fibrillation (19.4% vs 22.9%, P = 0.07) and an overall significantly lower in-hospital mortality (0.7% vs 3.0%, P < 0.001) and lower 30-day mortality (0.7% vs 3.4%, P < 0.0001). The LAA was successfully excluded in 53 (94.7%) of the 56 patients with TEE. Conclusions Double LAA ligation correlates with lower rates of in-hospital and 30-day mortality. This advantage comes without an increase in perioperative complications. This technique can easily be performed off or on pump, is very reproducible, and comes at a very low cost compared with LAA occlusion devices. Stroke has a multifactorial etiology; successful LLAA removes one potential source of thrombi perioperatively and in the long-term.

Initial Experience with Minimally Invasive Surgical Exclusion of the Left Atrial Appendage with an Epicardial Clip

2017 ◽  
Vol 12 (1) ◽  
pp. 28-32 ◽  
Author(s):  
Nathan E. Smith ◽  
Jeevan Joseph ◽  
John Morgan ◽  
Saqib Masroor
Keyword(s):  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Minimally Invasive ◽  
Left Atrial ◽  
Left Atrial Appendage ◽  
Intercostal Space ◽  
Atrial Appendage ◽  
Maze Procedure ◽  
Initial Experience ◽  
The Mean

Objective Atrial fibrillation (AF) is the primary cardiac abnormality associated with ischemic stroke. Atrial fibrillation affects 2.7 million people with a stroke rate of 3.5% per year. Most of the emboli in patients with nonvalvular AF originate in the left atrial appendage (LAA). Surgical exclusion of the LAA decreases the yearly risk of stroke to 0.7% when combined with a Maze procedure. Traditional oversewing the LAA from inside the left atrium is associated with a significant number of recanalizations of LAA. An alternate technique is epicardial clipping, which has been approved through sternotomy for permanent exclusion of LAA. We present our initial experience of epicardial clipping of the LAA using a minimally invasive approach. Methods Between May 2012 and December 2015, a total of 24 consecutive patients underwent minimally invasive, echo-guided epicardial clipping. Indications for the procedure were persistent (n = 12) or paroxysmal (n = 12) AF in patients who could not tolerate full anticoagulation because of a combination of gastrointestinal bleeding (n = 7), hemorrhagic stroke (n = 5), ischemic stroke (n = 5), intramuscular bleeding (n = 3), falls (n = 2), urinary tract bleeding (n = 2), subdural hematoma (n = 1), traumatic aortic intramural hematoma (n = 1), and lifestyle and career practices inconsistent with anticoagulation (n = 1). The clipping was performed through three 5-mm ports in the left seventh intercostal space (n = 22) or a 5-cm incision in the fifth intercostal space (n = 2). Echocardiography was performed to exclude the presence of LAA thrombus and to confirm exclusion of LAA before final deployment of the clip. Results The mean age was 73.6 years. The mean CHA2DS2VASC score was 4.7 and the mean HAS-BLED score was 3.8. The mean postoperative length of stay was 6.4 days. One patient died of stroke-related complications 10 days after successful clipping, and two patients required thoracentesis to drain recurrent pleural effusions. All patients had successful exclusion of LAA defined as residual sac of less than 1 cm. Conclusions Isolated epicardial left atrial clipping is a safe treatment option in high-risk patients with AF. Long-term success in preventing stroke is still to be determined, but short-term results are very encouraging.

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