Pulmonary artery perforation and coronary air embolism-two fatal outcomes in percutaneous left atrial appendage occlusion

Pulmonary Artery Injury Following Endocardial Left Atrial Appendage Occlusion: The Known and Unknown

BACKGROUND

Left atrial appendage closure (LAAC) is frequent alternative for stroke prophylaxis in patients for whom oral anticoagulation is contraindicated. Pulmonary artery injury (PAI) is a feared yet rare complication of endocardial LAAC, but its surrounding literature is scarce.

OBJECTIVES

The aim of the current study was to review prior PAI published reports and the U.S. Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database to understand evidence and mechanisms of PAI after LAAC.

METHODS

A systematic review was conducted of the literature and MAUDE database for previously reported cases of PAI, and cases were reviewed for patient characteristics and outcomes. In addition, we identify risks and review our strategies to avoid this injury.

RESULTS

Thirty-six cases (16 case reports and 20 MAUDE reports) of PAI were found. These patients had a mean age of 73.6 ± 8.2 years with a median CHA2DS2VASC score of 5 (Q1-Q3: 3-6). Most commonly, LAAC associated with PAI involved a dual-seal (75%) followed by lobular occlusive devices (19.4%); the device was unspecified in 2.8% of cases. PAI commonly presented postprocedurally, either within the first 24 hours (50%) or beyond (38.9%), with cardiac tamponade (61.1%) or cardiac arrest (19.4%). Overall, 52.8% required surgery with or without antecedent pericardiocentesis, and 16.7% were managed with pericardiocentesis. PAI was associated with a high mortality rate (ie, 33.3%). Unfortunately, no specific cardiac imaging or procedural details to predict PAI were noted in the reports.

CONCLUSIONS

Presentation of PAI after LAAC can occur immediately following the procedure or be delayed. Thus, the threshold for suspicion, especially with rapid and hemodynamically significant pericardial effusion, after LAAC should be low.

The Future of LAAC-In 5, 10, and 20 Years

Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation. Finally, we consider how to make the procedure safer and more effective.

The Future of LAAC-In 5, 10, and 20 Years

Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation. Finally, we consider how to make the procedure safer and more effective.

2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation

The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).

Pulmonary artery pressure is associated with mid-term major adverse cardiovascular events and postprocedure pericardial effusion in atrial fibrillation patients undergoing left atrial appendage occlusion

Background

Patients with nonvalvular atrial fibrillation (NVAF) undergoing left atrial appendage occlusion (LAAO) are at high risk of stroke or bleeding. However, risk factors for their adverse cardiovascular events remain largely unknown. Pulmonary hypertension has been shown to be related to poor prognosis in many heart diseases. In this study, we determined whether elevated pulmonary artery systolic pressure (PASP) is associated with postprocedure adverse events and major adverse cardiovascular events (MACE) in these patients.

Methods

From June 2017 and December 2019, 530 consecutive patients with NAVF at high risk of stroke or bleeding who undergone LAAO were retrospectively enrolled in our study. The preprocecure PASP was obtained by transthoracic echocardiography using the simplified Bernoulli's equation. Patients were followed-up through clinic visits or over the phone at discharge at 1-3 months, 6 months, and annually thereafter. The median follow-up time was 12 months, and clinical data were analyzed. MACE was defined as myocardial infarction, definite heart failure, stroke, or all-cause death. The outcome of postprocedure pericardial effusion included in-hospital pericardial effusion and pericardial effusion detected after discharge.

Results

Univariate analyses indicated that patients who had MACE tended to have elevated PASP (P=0.005). After dividing the cohort according to the cut-off value of PASP, Kaplan-Meier curves indicated that patients with PASP ≥39.5 mmHg had a higher risk of MACE (P=0.007) and heart failure hospitalization (P=0.005) compared to patients whose PASP <39.5 mmHg. Cox regression analysis showed that PASP was a predominant risk factor of MACE (HR =2.337, 95% CI, 1.207-4.526, P=0.012) and heart failure hospitalization (HR =3.701, 95% CI, 1.118-12.251, P=0.032). Furthermore, the PASP cut-off added incremental discriminatory capacity to the MACE risk model of this cohort. In addition, logistic regression showed that PASP had as a significant association with postprocedure pericardial effusion (OR =1.061, P=0.032).

Conclusions

Elevated PASP was associated with postprocedure pericardial effusion and mid-term MACEs in patients with atrial fibrillation (AF) undergoing LAAO.

Imaging risk features for device related pulmonary artery injury after left atrial appendage closure with Amplatzer™ Amulet™ device

OBJECTIVES

This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC).

BACKGROUND

Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC.

METHODS

In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected.

RESULTS

In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (<1.5 mm) for the stabilizing wires to cause risk for DR-PAI, configuration called ''cuddling lobe orientation''. On CT measurements middle lobe-PA distance was 4.7 mm (IQR = 2.7-9.5), with close proximity in 4 (4%) patients, and distal lobe-PA distance was 3.2 mm (IQR = 1.8-7.2 mm), with close proximity in 17 (17%) patients. Stabilizing wires were pointing toward PA in 47 patients (47%) with median wire-to-PA distance 5.7 mm (IQR = 3.6-8.5 mm). ''Cuddling'' was found in 2 (2%) patients and resulted in shorter wires-to-PA distance vs no ''cuddling'' group (2.3 vs 5.8 mm p <.01). At 2.9 ± 1.0 yrs of follow-up, the two patients with ''cuddling lobe orientation'' on post-LAAC CT scan developed late cardiac tamponades (p <.001). One of those required surgery, which confirmed DR-PAI.

CONCLUSIONS

''Cuddling lobe orientation'' of Amulet device with the PA was associated with short wires-to-PA distance and late pericardial effusions, including DR-PAI. Hence, such device-to-PA configuration should be avoided.

Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices

Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.

Pulmonary artery perforation caused by a left atrial appendage closure device

We describe a female patient who received hybrid catheter intervention and occlusion of the patent ductus arteriosus (PDA) and left atrial appendage (LAA). Four hours after the procedure, pericardial tamponade suddenly occurred. Surgical exploration of the heart found that a fixation hook of the WATCHMAN device, had protruded through the LAA wall and tore the dilated pulmonary artery (PA). This is the first case report to describe PA perforation caused by barbs of the WATCHMAN device, and more attention should be paid to the relationship between the LAA and its adjacent structures before LAA closure.

A case report of a late left atrial appendage perforation 4 months after occluder implant: reason for or caused by a resuscitation?

Background

Atrial fibrillation (AF) is a common disease and can lead to cardioembolic stroke. Stroke prevention according to the CHA₂DS₂VASc score is achieved via oral anticoagulation. In recent years, interventional occlusion of the left atrial appendage (LAA) has become a common alternative. Besides showing non-inferiority in large trials compared with warfarin interventional LAA occlusion can lead to serious adverse events with most of them occurring peri-interventionally.

Case summary

A 75-year-old man with AF and recurrent gastrointestinal bleedings was referred for an interventional closure of the LAA. The intervention was successful with an ABBOTT^® Amulet device. Four months later, the patient had to be resuscitated. Return of spontaneous circulation occurred after 10 min. On hospital arrival, echocardiography revealed a pericardial tamponade and 2 L of blood were drained. A coronary angiogram revealed a lesion with active leakage of contrast agent in the proximal circumflex artery. The patient was transferred to the cardiac surgery department immediately. Intra-operatively a perforation of the tissue at the basis of the LAA close to the left main coronary artery was discovered. The occluder was excised and the LAA was closed by endocardial sutures.

Discussion

In this report, we review the literature concerning interventional LAA occlusion and the reported cases of LAA perforation. Retrospectively, it remains unclear whether the perforation caused the resuscitation or was induced by it. To our knowledge, this is the first reported case of a laceration of a coronary artery by an occlusion device.

Photorealistic imaging of left atrial appendage occlusion/exclusion

Recent improvements in 3D TEE post processing rendering techniques referred to as TrueVue (Philips Medical Systems, Andover, MA, USA). It allows for novel photorealistic imaging of cardiac structures including left atrial appendage (LAA) and its closure devices. Here we present TrueVue images of the LAA prior to and after LAA exclusion/occlusion using various percutaneous and surgical techniques. TrueVue may improve delineation of LAA anatomy prior to occlusion as well as visualization of occluder device position within the LAA.

In-hospital mortality of patients with atrial arrhythmias: insights from the German-wide Helios hospital network of 161 502 patients and 34 025 arrhythmia-related procedures

Aims

Atrial fibrillation (AFib) and atrial flutter (AFlut) are common arrhythmias with increased use of invasive procedures. A steady re-evaluation of relevant safety endpoints is recommended and both quality management and pay-for-performance programs are evolving. Therefore, the aims of this study were (i) to investigate and report overall in-hospital mortality and mortality of invasive arrhythmia-related procedures and (ii) to identify mortality predictors in a German-wide hospital network.

Methods and results

Administrative data provided by 78 Helios hospitals between 2010 and 2017 were examined using International Statistical Classification of Diseases and Related Health Problems- and Operations and Procedures-codes to identify patients with AFib or AFlut as main discharge diagnosis or secondary diagnosis combined with invasive arrhythmia-related interventions. In 161 502 patients, in-hospital mortality was 0.6% with a significant decrease from 0.75% to 0.5% (P < 0.01) during the observational period. In multivariable analysis, age [odds ratio (OR) 2.69, 95% confidence interval (CI) 2.36-3.05; P < 0.01], high centre volume (OR 0.57, 95% CI 0.50-0.65; P < 0.01), emergency hospital admission (OR 1.57, 95% CI 1.38-1.79; P < 0.01), and Charlson Comorbidity Index (CCI, OR 4.95, 95% CI 4.50-5.44; P < 0.01) were found as independent predictors of in-hospital mortality. Mortality rates were 0.05% for left atrial catheter ablation (CA, n = 21 744), 0.3% for right atrial CA (n = 9972), and 0.56% for implantation of a left atrial appendage occluder (n = 2309), respectively.

Conclusion

We analysed for the first time in-hospital mortality rates of patients with atrial arrhythmias in a German-wide, multi-centre administrative dataset. This allows feasible, comparable, and up-to-date performance measurement of clinically important endpoints in a real-world setting which may contribute to quality management programs and towards value-based healthcare.