Incidence and Temporal Evolution of Delayed Peridevice Leak After Left Atrial Appendage Closure.

BACKGROUND: Peridevice leak (PDL) following left atrial appendage closure (LAAC) portends adverse outcomes. OBJECTIVE: To assess the incidence, predictors, clinical implications, and temporal evolution of PDL following LAAC. METHODS: This single-center retrospective study included all patients who underwent LAAC with Watchman FLX and had no PDL detected at implant. The primary endpoint was incidence of new PDL at initial imaging. The composite secondary endpoint included continued oral anticoagulation after initial imaging, device-related thrombus, stroke or transient ischemic attack, major bleeding, and need for PDL closure at longest follow-up. Temporal evolution of PDL was assessed in patients with available surveillance imaging. RESULTS: Among 355 patients who completed imaging at 47 (IQR 6) days, 139 (39%) had a new PDL with a mean leak size of 3.2±1.4 [median 3.0 (IQR 2.0), and range 1.0-9.0 mm]. Multiple deployment attempts and larger device size were positive predictors of PDL, while increased contrast volume administration was a negative predictor of PDL. The composite secondary endpoint occurred in 42 (30%) and 33 (15%) patients with and without PDL respectively (p<0.001). Among the 139 patients with PDL, 43 (31%) had surveillance imaging where leak size regressed from 3.7±1.8mm at 46 (IQR 7) days to 1.7±2.0mm at 189 (IQR 127) days (p<0.001). The leak size regressed in 33 (77%), remained stable in 4 (9%), and progressed in 6 (14%) cases. CONCLUSION: Despite design improvements, LAAC with Watchman FLX demonstrates significant incidence of PDL with meaningful clinical implications. Regardless of initial size, most leaks regressed over time.

Direct current cardioversion practices following percutaneous left atrial appendage closure.

INTRODUCTION: Among patients with non-valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear. OBJECTIVE: The purpose of this study is to evaluate the real-world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre- and post-DCCV in patients with AF status post percutaneous LAAC. METHODS: This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre-DCCV, OAC use pre- and post-DCCV, incidence of left atrial thrombus (LAT) or device-related thrombus (DRT), incidence of peri-device leak (PDL), and DCCV-related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days. RESULTS: A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as "non-guideline based" due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV-related complications within 30 days. DISCUSSION: There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.

Cardiac magnetic resonance imaging for left atrial appendage closure planning.

BACKGROUND: Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. METHODS: This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland-Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. RESULTS: 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p = .229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p = .177), morphology (p = .422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland-Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR-TEE bias 0.7 mm, 95% CI [-1.1, 2.4], p = .420), but LAA depth was significantly larger with CMR versus TEE (CMR-TEE bias 7.4 mm, 95% CI [1.6, 13.2], p = .015). CONCLUSIONS: CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable.

Remede Systems: Transvenous Pacing of the Phrenic Nerve.

The remede System (ZOLL Medical, Minnetonka, MN; Fig 1), which was approved by the Food and Drug Administration in October of 2017, is a transvenous device that stimulates the phrenic nerve for the treatment of central sleep apnea, which is often associated with heart failure and atrial fibrillation. Given the similarity in implantation procedure to pacemakers and implantable cardioverter/defibrillators, the remede System implantation often occurs in the electrophysiology laboratory. Despite the transvenous nature and close proximity to cardiac structures on radiographic imaging, the remede System does not have any cardiac pacing function/antiarrhythmia therapies, and it is important for an anesthesiologist to be able to recognize and manage such a device if they were to come across one preoperatively.

Floppy mitral valve/mitral valve prolapse and sudden cardiac death.

It is well appreciated today that sudden cardiac death (SCD) occurs in patients with floppy mitral valve (FMV)/mitral valve prolapse (MVP) without significant mitral regurgitation . Data from studies most likely represent a heterogeneous population and probably underestimate the true incidence of SCD in this group of patients. SCD in patients with FMV/MVP occurs mostly in young individuals without comorbidities. Over the last decade, the phenotypic expression of patients with FMV/MVP at risk for SCD (bileaflet prolapse, redundant mitral leaflets, symptomatic young women) have been defined, possible pathophysiologic mechanisms leading to SCD have been proposed, and appropriate steps to prevent the catastrophic event, though in evolution, have been suggested. In this review, state-of-the-art knowledge related to SCD in patients with FMV/MVP is summarized.

Aveir Leadless Pacemaker: Novel Technology With New Anesthetic Implications.

The Aveir VR Leadless Pacemaker (Abbott, Chicago, IL) recently was approved by the US Food and Drug Administration, and joined the Micra (Medtronic, Minneapolis, MN) transcatheter pacing system in the realm of nontransvenous cardiovascular implantable devices. The Aveir VR offers design improvements over its predecessor, the Nanostim (St. Jude Medical). There are recommendations for the perioperative management of conventional transvenous pacemakers, but leadless pacemakers add a new layer of consideration. Although there have been prior documented experiences with the Micra device, there are enough differences between the Aveir VR and the Micra that it is important to understand what makes the Aveir VR unique if an anesthesiologist were to come across one preoperatively.

A 10 J shock impedance in sinus rhythm correlates with a 65 J defibrillation impedance during subcutaneous defibrillator implantation using an intermuscular technique.

INTRODUCTION: Defibrillation testing (DT) is recommended during the subcutaneous defibrillator (S-ICD) placement. We sought to compare 10 J shock impedance in sinus rhythm (SR) with 65 J defibrillation impedance and evaluate device position on a postimplant chest X-ray (CXR) using an intermuscular (IM) technique. METHODS: Consecutive S-ICD implantations between 12/2019 and 12/2020 at The Ohio State University were reviewed. All implantations were performed using a two-incision IM technique. Standard DT with 65 J shock and 10 J shock in SR were performed unless contraindicated. The PRAETORIAN score was calculated based on CXR. RESULTS: A total of 37 patients (age: 47.2 ± 15.8 years old, male: n = 26 [70.3%], body mass index: 30.1 ± 6.7 kg/m2 ) underwent IM S-ICD implantation, and of those, 27 (73%) underwent both 65 J shock and 10 J shock in SR. The coefficient of determination (R2 ) between 10 J shock impedance and 65 J shock impedance was 0.84. The mean of an impedance difference was 1.6 ± 4.8 Ω (minimum - 11 and maximum 8). Postimplant CXR was available for 33 out of 37 patients (89.2%). The PRAETORIAN score was less than 90 in all patients and the mean score was 32.7 ± 8.8. CONCLUSION: We demonstrated that 10 J shock impedance in SR correlated well with 65 J defibrillation impedance during IM S-ICD implantation. An IM implantation technique provides excellent generator location on postimplant CXR. The IM technique combined with 10 J shock in SR may be sufficient to predict and ensure the defibrillation efficacy of the S-ICD.