Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the U.S. transcatheter LAA ligation consortium.

BACKGROUND: Transcatheter left atrial appendage (LAA) ligation may represent an alternative to oral anticoagulation for stroke prevention in atrial fibrillation. OBJECTIVES: This study sought to assess the early safety and efficacy of transcatheter ligation of the LAA for stroke prevention in atrial fibrillation. METHODS: This was a retrospective, multicenter study of consecutive patients undergoing LAA ligation with the Lariat device at 8 U.S. sites. The primary endpoint was procedural success, defined as device success (suture deployment and <5 mm leak by post-procedure transesophageal echocardiography), and no major complication at discharge (death, myocardial infarction, stroke, Bleeding Academic Research Consortium bleeding type 3 or greater, or cardiac surgery). Post-discharge management was per operator discretion. RESULTS: A total of 154 patients were enrolled. Median CHADS2 score (congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism [doubled]) was 3 (interquartile range: 2 to 4). Device success was 94%, and procedural success was 86%. A major complication occurred in 15 patients (9.7%). There were 14 major bleeds (9.1%), driven by the need for transfusion (4.5%). Significant pericardial effusion occurred in 16 patients (10.4%). Follow-up was available in 134 patients at a median of 112 days (interquartile range: 50 to 270 days): Death, myocardial infarction, or stroke occurred in 4 patients (2.9%). Among 63 patients with acute closure and transesophageal echocardiography follow-up, there were 3 thrombi (4.8%) and 13 (20%) with residual leak. CONCLUSIONS: In this initial multicenter experience of LAA ligation with the Lariat device, the rate of acute closure was high, but procedural success was limited by bleeding. A prospective randomized trial is required to adequately define clinical efficacy, optimal post-procedure medical therapy, and the effect of operator experience on procedural safety.

The annular fat stripe as a fluoroscopic guide to anatomic sites during diagnostic and interventional electrophysiology studies.

Few radiographic landmarks are visible during electrophysiology procedures to aid in catheter positioning other than the catheters themselves. In the 35 degrees -45 degrees RAO projection, a linear radio-opacity corresponding to the rings of fat surrounding both annuli can be easily identified. This "fat stripe" can serve as a useful landmark for several important anatomic sites. Intracardiac catheters positioned left of (posterior) the fat stripe lie within an atrial cavity while those positioned to the right (anterior) lie within a ventricular cavity. The superior third of the stripe corresponds to the region of the right and left atrial appendages while the inferior end identifies the site of the coronary sinus os. The middle third serves as a reference for the fast AV nodal pathway and compact AV node. The region corresponding to the slow AV nodal pathway superimposes on the lower third of the fat stripe. Electrophysiological recordings from catheters positioned along the fat stripe always exhibit both an atrial and ventricular component consistent with an annular recording, whether the catheter is septal or free wall in its location. Coronary sinus os engagement and catheterization can be simplified by using the fat stripe as an anatomic guide. In addition to facilitating catheter positioning for evaluating normal AV conduction, the fat stripe can serve as an excellent guide for targeting the majority of structures intended for ablation because of their annular location. These include the compact AV node, the slow AV nodal pathway, the subeustachian isthmus and any accessory pathway. Good ablation catheter tip contact with annular structures is confirmed by observing its movement in unison with the fat stripe.