Clinical observation of iatrogenic atrial septal defect after atrial septal puncture during atrial fibrillation intervention surgery / 中国医师杂志

Objective:To observe the occurrence and closure of iatrogenic atrial septal defect (IASD) after left atrial appendage occlusion (LAAo) and atrial fibrillation cryoballoon ablation (CBA), and to identify potential factors that may affect the occurrence of IASD.Methods:A total of 383 patients who underwent successful LAAo surgery in the Department of Cardiology at the Nanjing Hospital Affiliated to Nanjing Medical University from June 7, 2016 to December 2, 2020, and atrial fibrillation CBA surgery from December 29, 2016 to September 10, 2020 were retrospectively selected. Patients were followed up with echocardiography at 1 month, 3 months, 6 months, 1 year, and>1 year after surgery to determine the occurrence of IASD. The incidence of IASD between the two groups was compared, and clinical data between the two groups with and without IASD were analyzed to identify the relevant factors for the occurrence of IASD.Results:One month after CBA surgery for atrial fibrillation [73.8%(138/187) vs 47.9%(67/140), P<0.001], 3 months [39.0%(57/146) vs 13.6%(16/118), P<0.001], 6 months [17.7%(22/124) vs 3.6%(4/110), P=0.001], 1 year [11.8%(15/127) vs 1.8%(2/112), P=0.003], and one year later [9.8%(13/133) vs 0.9%(1/116), P=0.002], the incidence of IASD was significantly higher than those in LAAo. Compared with the non IASD group, the IASD group had a lower proportion of males [59.0%(121/205) vs 83.6%(102/122), P<0.001], and a higher proportion of paroxysmal atrial fibrillation [61.5%(126/205) vs 45.9%(56/122), P=0.006]. Logistic regression analysis found a significant correlation between women and CBA with postoperative IASD. Conclusions:Compared with LAAo, the incidence of IASD after CBA for atrial fibrillation is higher, and some IASD persist for more than 1 year after surgery. Women are significantly associated with IASD.

Cierre percutáneo de orejuela en paciente con antecedente de cierre percutáneo de comunicación interauricular / Left atrial appendage closure in a patient with prior atrial septal defect occlusion

Resumen La fibrilación auricular es la arritmia más prevalente en la práctica clínica, y se asocia con una morbimortalidad significativa, la cual, en parte, se explica por el riesgo de fenómenos embólicos. En la actualidad, el uso de anticoagulantes es el estándar de manejo en aquellos pacientes con riesgo embólico significativo (dado por un puntaje ≥ 2 en la escala CHA2DS2Vasc). Sin embargo, algunos pacientes tienen contraindicaciones que impiden recibir este tipo de tratamiento a largo plazo, en cuyo caso se considera el cierre percutáneo de la orejuela como medida para la disminución del riesgo de embolia. Al requerir una punción transeptal, la presencia de dispositivos de cierre de defectos del septo interauricular dificulta el procedimiento de manera significativa. Se presenta el caso de una paciente con contraindicación absoluta para recibir anticoagulantes debido a sangrado gastrointestinal y antecedente de cierre percutáneo de comunicación interauricular sometida a cierre percutáneo de orejuela como alternativa terapéutica a la anticoagulación.

Abstract Atrial fibrillation is the most prevalent arrythmia in clinical practice, associated with a significant morbimortality explained, in part, by the high risk of embolic phenomena. The use of anticoagulation is the standard of care in those patients with increased embolic risk (given by a score ≥ 2 in the CHA2DS2Vasc scale). However, some patients have contraindications to receiving this treatment long-term, in which case percutaneous left atrial appendage occlusion can be considered as a means of decreasing their embolic risk. Because the procedure requires transeptal puncture, the presence of devices for atrial septal defect closure can difficult the technique. We present the case of a patient with absolute contraindication to anticoagulation therapy given gastrointestinal bleeding, with history of percutaneous closure of interauricular communication, who was treated with percutaneous left atrial appendage occlusion as an alternative to oral anticoagulants.

Efficacy of Watchman occlusion of the left atrial appendage in patients ≥85 years with atrial fibrillation / 中华老年医学杂志

Objective:To analyze the safety and efficacy of left atrial appendage closure(LAAC)with Watchman in patients ≥85 years with atrial fibrillation(AF).Methods:515 elderly patients with atrial fibrillation, including 73 patients aged 85 years or older(85~91), who had undergone Watchman LAAC at Zhoupu Hospital affiliated to Shanghai Health Medical College from August 2016 to December 2020, were retrospectively analyzed.Of those ≥85 years, 44(60.3%)with transesophageal echocardiography records were assigned to the elderly group.Fifty-three patients aged 60 to 65 were selected as the control group.Differences in baseline data, intraoperative conditions, antithrombotic treatment plans and 1-year follow-up prognosis were compared between the two groups.Results:Compared with the control group, there was no difference in AF types, history of ischemic stroke/transient ischaemic attack(all P>0.05), but there were higher incidences of coronary heart disease and renal insufficiency, more severe heart failure, higher CHA 2DS 2-VASC(6.0±1.5 vs.3.6±1.5), HAS-BLED(3.2±1.2 vs.2.3±1.3)scores( t values were 7.682 and 3.871, respectively, P<0.05), and a lower one-stop surgery rate(6 cases or 13.6% vs. 27 cases or 50.9%, χ2=10.517, P<0.05)in the advanced age group.There was no difference in the diameter of the Watchman device, rate of device replacement, compression percentage and residual flow between the two groups during the perioperative period.The incidences of device-related thrombosis were 4.5%(2/44)and 3.8%(2/53)for the advanced age group and the control group, respectively, but the difference was not statistically significant( P>0.05). During the 12-month follow-up, there were no cases of ischemic stroke or intracerebral hemorrhage.Three died of heart failure and 1 died of cancer. Conclusions:LAAC with Watchman is safe and effective for patients over 85 years with AF, but the decision on the procedure should be based on careful assessment of patients' cardiac and renal function and general health.

Clinical analysis of left atrial appendage occlusion for stroke prevention in elderly patients with atrial fibrillation / 中华内科杂志

To evaluate the efficacy and safety of left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF) over 75 years. A total of 82 patients with AF who underwent LAAO successfully in Beijing Anzhen Hospital from March 2014 to March 2019 were divided into two groups according to age: the elderly group (aged>75 years) and the young group (aged ≤75 years). Risk of perioperative complications and incidence of ischemic stroke and major bleeding during follow-up were retrospectively analyzed. The results showed that there were no significant differences in procedure-related ischemic stroke(0 vs.1.6%, P=0.768) and major bleeding (0 vs.1.6%, P=0.768) during perioperative period between the two groups. No complications as death or pericardial tamponade occurred in the two group. During a (25.9±15.9) months period of followed up, ischemic stroke event rate was 3.6/100 person-years in the elderly group and 4.9/100 person-years in the young group, respectively. Major bleeding event rate was 2.5/100 person-years in the elderly group and 0/100 person-years in the young group, respectively. Compared with the expected ones, the relative risk reduction (RRR) of stroke in the elderly group was more profound than that in the young group (32.0% vs. 25.0%), while the risk of major bleeding in the young group was significantly lower than that in the elderly group (RRR 100% vs. 56.9%). Therefore, LAAO might be suitable for stroke prevention in the elderly AF patients.

oncurrent surgical left atrial appendage occlusion should become routine procedure in cardiac surgery for atrial fibrillation patients — Commentary on LAAOS Ⅲ / 中国胸心血管外科临床杂志

@#Left atrial appendage occlusion is a common procedure for patients with atrial fibrillation history when they underwent cardiac surgery. Before the LAAOS Ⅲ research results, this operation has been lacking strong evidence-based support. LAAOS Ⅲ is a prospective, double-blind, international multicenter, randomized blinded trial. According to the results of LAAOS Ⅲ, the left atrial appendage occlusion can reduce the risk of stroke and systemic embolism. This article will perform detailed interpretation of LAAOS Ⅲ research.

CT Image-based Surgery Assist System for Left Atrial Appendage Occlusion / 中国医疗器械杂志

At present, the standard left atrial appendage occlusion procedure mainly involves two-dimensional imaging methods such as X-ray fluoroscopy and transesophageal echocardiography to guide the operation, which will lead to underestimation of the three dimensional structure of the left atrial appendage and the surrounding tissue, thus adversely affects the surgery. To solve this problem, a surgery assist system for left atrial appendage occlusion based on preoperative cardiac CT images is developed. The proposed system realizes the left atrial appendage parameter measurement based on cardiac CT image, and realizes the calculation of optimal delivery sheath trajectory and three-dimensional simulation of the delivery sheath movement on the basis of a novel delivery sheath trajectory model. The system is expected to provide precise guidance for left atrial appendage occlusion, improve the success rate and safety of the operation, and at the same time help reduce the difficulty of learning the operation, and facilitate the promotion of left atrial appendage occlusion.

Cierre percutáneo de orejuela izquierda con dispositivo LAmbre / Percutaneous closure of the left atrial appendage using the LAmbre device

Abstract Atrial fibrillation (AF) is an increasing health care problem associated with thromboembolic risk about 5% per year, with high mortality and morbidity when associated to stroke. Oral anticoagulants (OAC) are the treatment of choice for preventing ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF). However, these drugs are associated with an increased risk of serious complications such an intracranial hemorrhage (ICH). In this context percutaneous closure of the left atrial appendage (LAA) is an effective therapeutic alternative to OACs, with an increasing success rate. Novel devices might allow or facilitate the procedure in some anatomically and technically complicated cases. Two patients with a complex morphology of the LAA, in which the LAmbre (Lifetech Scientific [Shenzhen] Co. Ltd.) device was implanted with good technical and clinical results are presented.

Cost-effective analysis of LAAC and oral anticoagulants in the prevention of stroke in patients with atrial fibrillation / 中国实用内科杂志

OBJECTIVE: To study the cost-effectiveness of left atrial appendage occlusion(LAAC), rivaroxaban and warfarin in the prevention of stroke in patients with atrial fibrillation, in order to explore the most appropriate economical medication model. METHODS: A total of 156 NVAF patients treated in the First Affiliated Hospital of Dalian Medical University from July2016 to June 2018 were studied; they were divided into group A(LAAC), group B(rivaroxaban)and group C(warfarin)by random digital method.Markov model was used to analyze the drug economy of three methods to prevent stroke in patients with atrial fibrillation within one year, and sensitivity analysis was conducted to verify the stability of the results. RESULTS: The total cost of treatment in group C was significantly lower than that in the other two groups, while in group A it was significantly higher than in the other two groups, with statistical significance(P<0.05). ICER(A vs. B)was 91242.31 yuan/QALY,ICER(B vs. C)was 96706.25 yuan/QALY, and ICER(A vs. C)was 93323.81 yuan/QALY. So the drug economy of group A was better than that of the other two groups, and group B was better than group C. When the sensitive indicators selected changed, there was still a statistical difference in the total cost among the three groups(P<0.05), which indicated that the results of this study were credible. CONCLUSION: Compared with warfarin and rivaroxaban, LAAC may have more pharmacoeco-nomic effects on preventing stroke in patients with atrial fibrillation, but further studies with large sample sizes and longer follow-up cycles are needed.

Application value of real-time three-dimensional transesophageal echocardiography in percutaneous left atrial appendage occlusion in patients with non-valvular atrial fibrillation / 中国医学影像技术

Objective: To investigate the value of real-time three-dimensional transesophageal echocardiography (RT-3D-TEE) in percutaneous left atrial appendage (LAA) transcatheter occlusion (PLAATO) in patients with non-valvular atrial fibrillation. Methods: Totally 62 patients with non-valvular atrial fibrillation who underwent PLAATO were examined with two-dimensional transesophageal echocardiography (2D-TEE), RT-3D-TEE and cardioangiography (CAG). The maximum diameter, minimum diameter and depth of LAA were measured and compared respectively. According to the maximum diameter of LAA measured with RT-3D-TEE, occluder with appropriate type was selected, and LAA occlusion was performed under the guidance of RT-3D-TEE and CAG. Follow-up was conducted after operation. Results: Occlusion was successfully performed in all 62 patients, the success rate was 100%, and the compression rate was (19.78±6.92)%. No serious complications occurred during the operation and follow-up period. There was significant difference of the maximum diameter of LAA measured with 2D-TEE, RT-3D-TEE and CAG (P=0.029). The maximum diameter of LAA measured with RT-3D-TEE was higher than that measured with 2D-TEE, while lower than that measured with CAG. There was no significant difference of the minimum diameter nor depth of LAA measured with 2D-TEE, RT-3D-TEE and CAG (both P>0.05). The maximum diameter of LAA measured with CAG (r=0.925), RT-3D-TEE (r=0.841) and 2D-TEE (r=0.716) were positively correlated with the size of occluder (all P≤0.001). Conclusion: RT-3D-TEE can be used for preoperative screening, intraoperative guidance and post-operative follow-up of PLAATO for non-valvular atrial fibrillation, which may accurately describe the shape of LAA and evaluate the effect of occlusion.

Role of transesophageal echocardiography during left atrial appendage occlusion device closure in a patient with non-valvular atrial fibrillation and angiodysplasia of the colon

Atrial fibrillation is the most common arrhythmia associated with significant mortality and morbidity secondary to thrombo-embolism. To prevent this thrombo-embolism oral anticoagulation therapy is the recommended treatment. In patients with contraindications to oral anticoagulation therapy, percutaneous left atrial appendage occlusion device is indicated. TEE is essential to guide in all the stages of LAA device deployment. Right from pre-procedure screening, to guiding during deployment, to rule out any complications and post-procedure surveillance and monitoring long term outcomes.