Imaging Integration to Localize and Protect the Left Coronary Artery in Patients Undergoing LAAEI

Cryoballoon ablation of non-PV triggers in persistent atrial fibrillation

Cryoballoon-based catheter ablation has emerged as an efficacious and safe therapeutic intervention for patients with paroxysmal atrial fibrillation (PAF). PAF is primarily associated with the triggers in the pulmonary vein (PV). However, persistent atrial fibrillation (PeAF) is a complex condition that involves changes in the atrial substrate and the presence of non-PV triggers. Therefore, a comprehensive treatment approach is necessary for patients with PeAF. Utilizing a 3D electroanatomical map, the radiofrequency-based ablation technique adeptly identifies and targets the atrial substrate and non-PV triggers. On the other hand, the cryoballoon-based AF ablation was initially designed for PV isolation. However, its single-shot feature makes it a great choice for electrophysiologists looking to address non-PV triggers. It is possible to target the left atrial appendage (LAA), superior vena cava (SVC), left atrial roof, and posterior wall using the apparatus's unique configuration and ablation abilities. This review focuses on the increasing literature regarding cryoballoon-based methods for non-PV trigger ablation. Specifically, it delves into the technical procedures used to isolate the LAA, SVC, and ablate the left atrial roof and posterior wall.

Strategies for managing left main trunk compression by left atrial appendage clip: a case report

Background

Closure of the left atrial appendage (LAA) using a clip in at-risk patients reduces stroke risk. The rate of LAA closure procedures is increasing worldwide; however, complications have been reported, with coronary compression being one possible lethal complication associated with the anatomical structures around the LAA.

Case summary

A 75-year-old man presented with a diagnosis of a φ50 mm saccular thoracic aortic aneurysm. He had a history of chronic atrial fibrillation and functional tricuspid regurgitation. We performed total arch replacement with an open stent graft, tricuspid ring annuloplasty, left atrium Maze procedure, left atrial plication, and LAA closure using a LAA clip. The blood pressure of the patient dropped after closing the pericardium post-operatively. Coronary artery angiography (CAG) confirmed 90% stenosis at the left coronary main trunk (LMT) origin. Percutaneous coronary intervention (PCI) was performed, and the haemodynamics settled.

Discussion

The distance from the anterior wall of the LAA ostium to the LMT can be a risk for AtriClip-induced LMT compression. A different surgical strategy, such as internal sutures or surgical stapler for LAA closure, should be considered under such a condition. Selecting an appropriately sized AtriClip is essential while using the clip, placing it close to the orifice, and visually checking for compression after insertion to prevent LMT stenosis. When LMT compression by the clip was confirmed, levelling the endocardial adipose tissue with the LAA landing zone, cutting and removing the clip or coronary artery bypass grafting during operation, and PCI during CAG should be considered.

Efficacy and safety of left atrial appendage electrical isolation during catheter ablation of atrial fibrillation: an updated meta-analysis

AIMS

Left atrial appendage electrical isolation (LAAEI) has been shown to improve freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal atrial fibrillation (AF). The aim of this study is to investigate the long-term efficacy and safety outcomes of LAAEI in patients with non-paroxysmal AF undergoing catheter ablation.

METHODS AND RESULTS

A systematic review of Medline, Cochrane, and Embase was performed for clinical studies evaluating the benefit of LAAEI in non-paroxysmal AF. Nine studies with a total of 2336 patients were included (mean age: 65 ± 9 years, 63% male). All studies included patients with persistent AF, long-standing persistent AF, or both. At a mean follow-up of 40.5 months, patients who underwent LAAEI had significantly higher freedom from all-atrial arrhythmia recurrence than patients who underwent standard ablation alone [69.3% vs. 46.4%; risk ratio (RR) 0.54; 95% confidence interval (CI) 0.42-0.69; P < 0.0001]. A 46% relative risk reduction and 22.9% absolute risk reduction in atrial-arrhythmia recurrence was noted with LAAEI. Rates of cerebral thromboembolism were not significantly different between the two groups (LAAEI 3% vs. standard ablation 1.6%, respectively; RR 1.76; 95% CI 0.61-5.04; P = 0.29). Furthermore, there was no significant difference in the acute procedural complication rates between the two groups (LAAEI 4% vs. standard ablation 3%, respectively; RR 1.29; 95% CI 0.83-2.02; P = 0.26).

CONCLUSION

At long-term follow-up, LAAEI led to a significantly higher improvement in freedom from all-atrial arrhythmia recurrence in patients with non-paroxysmal AF, when compared to standard ablation alone. Importantly, this benefit was achieved without an increased risk of acute procedural complications or cerebral thromboembolic events.

Long-Term Outcomes of Left Atrial Appendage Electrical Isolation in Patients With Nonparoxysmal Atrial Fibrillation

Background:

Left atrial appendage electrical isolation (LAAEI) has been proposed for the treatment of nonparoxysmal atrial fibrillation (AF). The long-term clinical outcomes of this approach remain unclear. The objective of our study was to investigate the incremental benefit and safety of LAAEI in patients undergoing catheter ablation for nonparoxysmal AF.

Methods:

Propensity score-matched analysis was performed using a prospective registry database from 2010 to 2014. All patients in the LAAEI group were matched based on baseline characteristics, echocardiographic parameters, and procedural ablation techniques.

Results:

We identified 1842 patients who underwent catheter ablation for nonparoxysmal AF. Propensity score matching yielded 1092 patients, 546 patients with LAAEI, and 546 patients without LAAEI. At 5-year follow-up, overall freedom from all-atrial arrhythmia recurrence, off-antiarrhythmic drugs, in patients who underwent LAAEI was 68.9% versus 50.2% in those who underwent standard ablation alone ( P <0.001). Acute complication rates were similar between groups (LAAEI 1.3% versus non-LAAEI 0.73%, P =0.36). At 5-year follow-up, 382 (70%) patients in the LAAEI group remained on oral anticoagulation versus 217 (39.7%) in the non-LAAEI group. At 5-year follow-up, thromboembolic events occurred in 15/546 (2.75%) in the LAAEI group and 4/546 (0.73%) in the non-LAAEI group ( P =0.01). No thromboembolic events occurred in either group on-oral anticoagulation. In patients who were off-oral anticoagulation, at 5-year follow-up, thromboembolic events occurred in 15/164 (9.1%) in the LAAEI group and 4/329 (1.2%) in the non-LAAEI group ( P <0.001).

Conclusions:

At 5-year follow-up, LAAEI was associated with significantly higher freedom from all-atrial arrhythmia recurrence in patients with persistent and long-standing persistent AF without increasing acute procedural complication rate. In patients off-oral anticoagulation, there appears to be a higher risk of thromboembolic events in the LAAEI group.