1
|
Yoshimura K, Mengyan W, Kume S, Kurokawa T, Miyamoto S, Mizukami Y, Ono K. Detection and identification of factors in the atrium responsible for blood pressure regulation in patients with hypertension. Heart Vessels 2024; 39:464-474. [PMID: 38451262 PMCID: PMC11006736 DOI: 10.1007/s00380-024-02362-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 01/17/2024] [Indexed: 03/08/2024]
Abstract
Resection of the left atrial appendage reportedly improves blood pressure in patients with hypertension. This study aimed to validate the transcriptional profiles of atrial genes responsible for blood pressure regulation in patients with hypertension as well as to identify the molecular mechanisms in rat biological systems. RNA sequencing data of left atrial appendages from patients with (n = 6) and without (n = 6) hypertension were subjected to unsupervised principal component analysis (PCA). Reduction of blood pressure was reflected by third and ninth principal components PC3 and PC9, and that eighteen transcripts, including endothelin-1, were revealed by PCA-based pathway analysis. Resection of the left atrial appendage in hypertensive rats improved their blood pressure accompanied by a decrease in serum endothelin-1 concentration. Expression of the endothelin-1 gene in the atrium and atrial appendectomy could play roles in blood pressure regulation in humans and rats.
Collapse
Affiliation(s)
- Kenshi Yoshimura
- Department of Pathophysiology, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
- Department of Cardiovascular Surgery, Oita University School of Medicine, Oita University, Yufu, Oita, Japan
| | - Wei Mengyan
- Department of Pathophysiology, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Shinichiro Kume
- Department of Pathophysiology, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tatsuki Kurokawa
- Department of Pathophysiology, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University School of Medicine, Oita University, Yufu, Oita, Japan
| | - Yoichi Mizukami
- Institute of Gene Research, Yamaguchi University Science Research Center, Ube, Yamaguchi, Japan
| | - Katsushige Ono
- Department of Pathophysiology, Oita University School of Medicine, 1-1 Idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan.
| |
Collapse
|
2
|
Lakkireddy DR, Wilber DJ, Mittal S, Tschopp D, Ellis CR, Rasekh A, Hounshell T, Evonich R, Chandhok S, Berger RD, Horton R, Hoskins MH, Calkins H, Yakubov SJ, Simons P, Saville BR, Lee RJ. Pulmonary Vein Isolation With or Without Left Atrial Appendage Ligation in Atrial Fibrillation: The aMAZE Randomized Clinical Trial. JAMA 2024; 331:1099-1108. [PMID: 38563835 PMCID: PMC10988350 DOI: 10.1001/jama.2024.3026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 02/21/2024] [Indexed: 04/04/2024]
Abstract
Importance Left atrial appendage elimination may improve catheter ablation outcomes for atrial fibrillation. Objective To assess the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to catheter pulmonary vein isolation for nonparoxysmal atrial fibrillation. Design, Setting, and Participants This multicenter, prospective, open-label, randomized clinical trial evaluated the safety and effectiveness of percutaneous left atrial appendage ligation adjunctive to planned pulmonary vein isolation for nonparoxysmal atrial fibrillation present for less than 3 years. Eligible patients were randomized in a 2:1 ratio to undergo left atrial appendage ligation and pulmonary vein isolation or pulmonary vein isolation alone. Use of a 2:1 randomization ratio was intended to provide more device experience and safety data. Patients were enrolled from October 2015 to December 2019 at 53 US sites, with the final follow-up visit on April 21, 2021. Interventions Left atrial appendage ligation plus pulmonary vein isolation compared with pulmonary vein isolation alone. Main Outcomes and Measures A bayesian adaptive analysis was used for primary end points. Primary effectiveness was freedom from documented atrial arrythmias of greater than 30 seconds duration 12 months after undergoing pulmonary vein isolation. Rhythm was assessed by Holter monitoring at 6 and 12 months after pulmonary vein isolation, symptomatic event monitoring, or any electrocardiographic tracing obtained through 12 months after pulmonary vein isolation. Primary safety was a composite of predefined serious adverse events compared with a prespecified 10% performance goal 30 days after the procedure. Left atrial appendage closure was evaluated through 12 months after pulmonary vein isolation. Results Overall, 404 patients were randomized to undergo left atrial appendage ligation plus pulmonary vein isolation and 206 were randomized to undergo pulmonary vein isolation alone. Primary effectiveness was 64.3% with left atrial appendage ligation and pulmonary vein isolation and 59.9% with pulmonary vein isolation only (difference, 4.3% [bayesian 95% credible interval, -4.2% to 13.2%]; posterior superiority probability, 0.835), which did not meet the statistical criterion to establish superiority (0.977). Primary safety was met, with a 30-day serious adverse event rate of 3.4% (bayesian 95% credible interval, 2.0% to 5.0%; posterior probability, 1.0) which was less than the prespecified threshold of 10%. At 12 months after pulmonary vein isolation, complete left atrial appendage closure (0 mm residual communication) was observed in 84% of patients and less than or equal to 5 mm residual communication was observed in 99% of patients. Conclusions and Relevance Percutaneous left atrial appendage ligation adjunctive to pulmonary vein isolation did not meet prespecified efficacy criteria for freedom from atrial arrhythmias at 12 months compared with pulmonary vein isolation alone for patients with nonparoxysmal atrial fibrillation, but met prespecified safety criteria and demonstrated high rates of closure at 12 months. Trial Registration ClinicalTrials.gov Identifier: NCT02513797.
Collapse
Affiliation(s)
| | - David J Wilber
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | | | | | | | | | | | | | - Sheetal Chandhok
- Bryn Mawr Medical Specialists Association, Bryn Mawr, Pennsylvania
| | | | | | | | | | | | | | | | - Randall J Lee
- AtriCure, Inc, Mason, Ohio
- University of California, San Francisco
| |
Collapse
|
3
|
Brahier MS, Friedman DJ, Bahnson TD, Piccini JP. Repeat catheter ablation for atrial fibrillation. Heart Rhythm 2024; 21:471-483. [PMID: 38101500 DOI: 10.1016/j.hrthm.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 12/08/2023] [Indexed: 12/17/2023]
Abstract
Catheter ablation of atrial fibrillation (AF) is an established therapy that reduces AF burden, improves quality of life, and reduces the risks of cardiovascular outcomes. Although there are clear guidelines for the application of de novo catheter ablation, there is less evidence to guide recommendations for repeat catheter ablation in patients who experience recurrent AF. In this review, we examine the rationale for repeat ablation, mechanisms of recurrence, patient selection, optimal timing, and procedural strategies. We discuss additional important considerations, including treatment of comorbidities and risk factors, risk of complications, and effectiveness. Mechanisms of recurrent AF are often due to non-pulmonary vein (non-PV) triggers; however, there is insufficient evidence supporting the routine use of empiric lesion sets during repeat ablation. The emergence of pulsed field ablation may alter the safety and effectiveness of de novo and repeat ablation. Extrapolation of data from randomized trials of de novo ablation does not optimally inform efficacy in cases of redo ablation. Additional large, randomized controlled trials are needed to address important clinical questions regarding procedural strategies and timing of repeat ablation.
Collapse
Affiliation(s)
- Mark S Brahier
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel J Friedman
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Tristram D Bahnson
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina
| | - Jonathan P Piccini
- Electrophysiology Section, Duke Heart Center, Duke University Hospital & Duke Clinical Research Institute, Durham, North Carolina.
| |
Collapse
|
4
|
Hassouna S, Osmancik P. Catheter ablation for non-paroxysmal atrial fibrillation. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2024; 168:1-14. [PMID: 38230517 DOI: 10.5507/bp.2023.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 12/20/2023] [Indexed: 01/18/2024] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia is associated with increased morbidity and mortality. The higher mortality is due to the risk of heart failure and cardioembolic events. This in-depth review focuses on the strategies and efficacy of catheter ablation for non-paroxysmal atrial fibrillation. The main medical databases were searched for contemporary studies on catheter ablation for non-paroxysmal AF. Catheter ablation is currently proven to be the most effective treatment for AF and consists of pulmonary vein isolation as the cornerstone plus additional ablations. In terms of SR maintenance, it is less effective in non-paroxysmal AF than in paroxysmal patients. but the clinical benefit in non-paroxysmal patients is substantially higher. Since pulmonary vein isolation is ineffective, a variety of techniques have been developed, e.g. linear ablations, ablation of complex atrial fractionated electrograms, etc. Another paradox consists in the technique of catheter ablation. Despite promising results in early observation studies, further randomized studies have not confirmed the initial enthusiasm. Recently, a new approach, pulsed-field ablation, appears promising. This is an in-depth summary of current technologies and techniques for the ablation of non-paroxysmal AF. We discuss the benefits, risks and implications in the treatment of patients with non-paroxysmal AF.
Collapse
Affiliation(s)
- Sabri Hassouna
- Department of Cardiology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Prague, Czech Republic
| |
Collapse
|
5
|
Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
Collapse
Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| |
Collapse
|
6
|
Niu J, Zhang M, Liu P, Hua C, Zhong G. Research progress on predicting atrial fibrillation recurrence after radiofrequency ablation based on electrocardiogram-related parameters. J Electrocardiol 2023; 81:146-152. [PMID: 37708737 DOI: 10.1016/j.jelectrocard.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 08/18/2023] [Accepted: 08/28/2023] [Indexed: 09/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia. It is associated with increased stroke risks, thromboembolism, and other complications, which are great life and economic burdens for patients. In recent years, with the maturity of percutaneous catheter radiofrequency ablation (RFA) technology, it has become a first-line therapy for AF. However, some patients still experience AF recurrence (AFR) after RFA, which can cause serious consequences. Therefore, it is critical to identify appropriate parameters that are predictive of prognosis and to be able to translate the parameters easily into the clinical setting. Here, we reviewed possible predicting indicators for AFR, focusing on all the electrocardiogram indicators, such as P wave duration, PR interval and so on. It may provide valuable information for guiding clinical works.
Collapse
Affiliation(s)
- Jiayin Niu
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Min Zhang
- Research Ward, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Pengfei Liu
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Cuncun Hua
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Guangzhen Zhong
- Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China; Research Ward, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
7
|
Sylvester CB, Patel V, Ghanta RK, Loor G. Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery. Cardiovasc Drugs Ther 2023; 37:1011-1019. [PMID: 36550349 DOI: 10.1007/s10557-022-07415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.
Collapse
Affiliation(s)
- Christopher B Sylvester
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Vivek Patel
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA.
| |
Collapse
|
8
|
Schutgens RE, Jimenez-Yuste V, Escobar M, Falanga A, Gigante B, Klamroth R, Lassila R, Leebeek FW, Makris M, Owaidah T, Sholzberg M, Tiede A, Werring DJ, van der Worp HB, Windyga J, Castaman G. Antithrombotic Treatment in Patients With Hemophilia: an EHA-ISTH-EAHAD-ESO Clinical Practice Guidance. Hemasphere 2023; 7:e900. [PMID: 37304933 PMCID: PMC10256340 DOI: 10.1097/hs9.0000000000000900] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 06/13/2023] Open
Abstract
Cardiovascular disease is an emerging medical issue in patients with hemophilia (PWH) and its prevalence is increasing up to 15% in PWH in the United States. Atrial fibrillation, acute and chronic coronary syndromes, venous thromboembolism, and cerebral thrombosis are frequent thrombotic or prothrombotic situations, which require a careful approach to fine-tune the delicate balance between thrombosis and hemostasis in PWH when using both procoagulant and anticoagulant treatments. Generally, PWH could be considered as being naturally anticoagulated when clotting factors are <20 IU/dL, but specific recommendations in patients with very low levels according to the different clinical situations are lacking and mainly based on the anecdotal series. For PWH with baseline clotting factor levels >20 IU/dL in need for any form of antithrombotic therapy, usually treatment without additional clotting factor prophylaxis could be used, but careful monitoring for bleeding is recommended. For antiplatelet treatment, this threshold could be lower with single-antiplatelet agent, but again factor level should be at least 20 IU/dL for dual antiplatelet treatment. In this complex growing scenario, the European Hematology Association in collaboration with the International Society on Thrombosis and Haemostasis, the European Association for Hemophilia and Allied Disorders, the European Stroke Organization, and a representative of the European Society of Cardiology Working Group on Thrombosis has produced this current guidance document to provide clinical practice recommendations for health care providers who care for PWH.
Collapse
Affiliation(s)
- Roger E.G. Schutgens
- Center for Benign Hematology, Thrombosis and Hemostasis, Van Creveldkliniek University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Victor Jimenez-Yuste
- Hematology Department, La Paz University Hospital, Autonoma University, Madrid, Spain
| | - Miguel Escobar
- University of Texas Health Science Center at Houston, TX, USA
| | - Anna Falanga
- University of Milano Bicocca, School of Medicine, Monza, Italy
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Bruna Gigante
- Division of Cardiovascular Medicine, Department of Medicine, Karolinska Institutet, Solna, Sweden
- Department of Clinical Science, Danderyd Hospital, Karolinska institutet, Stockholm, Sweden
| | - Robert Klamroth
- Department of Internal Medicine Angiology and Coagulation Disorders at the Vivantes Klinikum im Friedrichshain, Berlin, Germany
- Institute of Experimental Hematology and Transfusion Medicine, University Hospital Bonn, Medical Faculty, University of Bonn, Germany
| | - Riitta Lassila
- Department of Hematology, Coagulation Disorders Unit, and Research Program Unit in Systems Oncology Oncosys, Medical Faculty, University of Helsinki, Finland
| | - Frank W.G. Leebeek
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, The Netherlands
| | - Michael Makris
- Haemophilia and Thrombosis Centre, University of Sheffield, United Kingdom
| | - Tarek Owaidah
- King Faisal Specialist Hospital and Research Centre, Alfaisal University, Riyadh, Saudi Arabia
| | - Michelle Sholzberg
- Division of Hematology-Oncology, Departments of Medicine, and Laboratory Medicine and Pathobiology, St. Michael’s Hospital, Li Ka Shing Knowledge Institute, University of Toronto, Canada
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Germany
| | - David J. Werring
- Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, London, United Kingdom
| | | | - Jerzy Windyga
- Department of Hemostasis Disorders and Internal Medicine, Laboratory of Hemostasis and Metabolic Diseases, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Giancarlo Castaman
- Center for Bleeding Disorders and Coagulation, Department of Oncology, Careggi University Hospital, Florence, Italy
| |
Collapse
|
9
|
Pasupula DK, Siddappa Malleshappa SK, Munir MB, Bhat AG, Anandaraj A, Jakkoju A, Spooner M, Koranne K, Hsu JC, Olshansky B, Camm AJ. Combined atrial fibrillation ablation and left atrial appendage occlusion procedure in the United States: a propensity score matched analysis from 2016-2019 national readmission database. Europace 2022; 25:390-399. [PMID: 36350997 PMCID: PMC9935040 DOI: 10.1093/europace/euac181] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS The safety and feasibility of combining percutaneous catheter ablation (CA) for atrial fibrillation with left atrial appendage occlusion (LAAO) as a single procedure in the USA have not been investigated. We analyzed the US National Readmission Database (NRD) to investigate the incidence of combined LAAO + CA and compare major adverse cardiovascular events (MACEs) with matched LAAO-only and CA-only patients. METHODS AND RESULTS In this retrospective study from NRD data, we identified patients undergoing combined LAAO and CA procedures on the same day in the USA from 2016 to 2019. A 1:1 propensity score match was performed to identify patients undergoing LAAO-only and CA-only procedures. The number of LAAO + CA procedures increased from 28 (2016) to 119 (2019). LAAO + CA patients (n = 375, mean age 74 ± 9.2 years, 53.4% were males) had non-significant higher MACE (8.1%) when compared with LAAO-only (n = 407, 5.3%) or CA-only patients (n = 406, 7.4%), which was primarily driven by higher rate of pericardial effusion (4.3%). All-cause 30-day readmission rates among LAAO + CA patients (10.7%) were similar when compared with LAAO-only (12.7%) or CA-only (17.5%) patients. The most frequent primary reason for readmissions among LAAO + CA and LAAO-only cohorts was heart failure (24.6 and 31.5%, respectively), while among the CA-only cohort, it was paroxysmal atrial fibrillation (25.7%). CONCLUSION We report an 63% annual growth (from 28 procedures) in combined LAAO and CA procedures in the USA. There were no significant difference in MACE and all-cause 30-day readmission rates among LAAO + CA patients compared with matched LAAO-only or CA-only patients.
Collapse
Affiliation(s)
| | - Sudeep K Siddappa Malleshappa
- Division of Haematology-Oncology, Department of Internal Medicine, UMass Chan-Baystate, 759 Chestnut St, Springfield, MA 01199, USA
| | - Muhammad B Munir
- Division of Cardiology, Department of Internal Medicine, University of California Davis, 4150 V Street, Suite 3100, Sacramento, CA 95817, USA
| | - Anusha Ganapati Bhat
- Department of Cardiology, Department of Internal Medicine, University of Maryland, 620 W Lexington St, Baltimore, MD 21201, USA
| | - Antony Anandaraj
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Avaneesh Jakkoju
- Division of Cardiology, Cardiovascular Institute of South, 441 Heymann Blvd, Lafayette, LA 70503, USA
| | - Michael Spooner
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Ketan Koranne
- Division of Cardiovascular Disease, Department of Internal Medicine, MercyOne North Iowa Medical Center, 1000 4th St SW, Mason City, IA 50401, USA
| | - Jonathan C Hsu
- Division of Cardiology, Department of Internal Medicine, University of California San Diego, 9500 Gilman Dr. La Jolla, CA 92093, USA
| | - Brian Olshansky
- Department of Cardiology, University of Iowa, 200 Hawkins Dr, Iowa City, IA 52242, USA
| | - A John Camm
- Division of Cardiology, St George's University of London, Cranmer Terrace, London SW17 0RE, UK
| |
Collapse
|
10
|
Bregasi A, Freeman JV, Curtis JP, Akar JG, Ortiz-Leon XA, Maia JH, Higgins AY, Matthews RV, Sinusas AJ, McNamara RL, Sugeng L, Lin BA. Abnormal left atrial body stiffness is predicted by appendage size: impact of appendage occlusion on left atrial mechanics assessed by pressure-volume analysis. Am J Physiol Heart Circ Physiol 2022; 323:H559-H568. [PMID: 35960632 PMCID: PMC9576173 DOI: 10.1152/ajpheart.00083.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Atrial cardiomyopathy has been recognized as having important consequences for cardiac performance and clinical outcomes. The pathophysiological role of the left atrial (LA) appendage and the effect of percutaneous left atrial appendage occlusion (LAAO) upon LA mechanics is incompletely understood. We evaluated if changes in LA stiffness due to endocardial LAAO can be detected by LA pressure-volume (PV) analysis and whether stiffness parameters are associated with baseline characteristics. Patients undergoing percutaneous endocardial LAAO (n = 25) were studied using a novel PV analysis using near-simultaneous three-dimensional LA volume measurements by transesophageal echocardiography (TEE) and direct invasive LA pressure measurements. LA stiffness (dP/dV, change in pressure with change in volume) was calculated before and after LAAO. Overall LA stiffness significantly increased after LAAO compared with baseline (median, 0.41-0.64 mmHg/mL; P ≪ 0.001). LA body stiffness after LAAO correlated with baseline LA appendage size by indexed maximum depth (Spearman's rank correlation coefficient Rs = 0.61; P < 0.01). LA stiffness change showed an even stronger correlation with baseline LA appendage size by indexed maximum depth (Rs = 0.70; P < 0.001). We found that overall LA stiffness increases after endocardial LAAO. Baseline LA appendage size correlates with the magnitude of increase and LA body stiffness. These findings document alteration of LA mechanics after endocardial LAAO and suggest that the LA appendage modulates overall LA compliance.NEW & NOTEWORTHY Our study documents a correlation of LA appendage remodeling with the degree of chronically abnormal LA body stiffness. In addition, we found that LA appendage size was the baseline parameter that best correlated with the magnitude of a further increase in overall LA stiffness after appendage occlusion. These findings offer insights about the LA appendage and LA mechanics that are relevant to patients at risk for adverse atrial remodeling, especially candidates for LA appendage occlusion.
Collapse
Affiliation(s)
- Alda Bregasi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph G Akar
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Julia H Maia
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Angela Y Higgins
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ray V Matthews
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Albert J Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut
- Department of Biomedical Engineering, Yale University School of Engineering and Applied Science, New Haven, Connecticut
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Ben A Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Keck School of Medicine of University of Southern California, Los Angeles, California
| |
Collapse
|
11
|
Bartus K, Elbey MA, Kanuri SH, Lee R, Litwinowicz R, Natorska J, Zabczyk M, Bartus M, Kapelak B, Malecki MT, Lakkireddy D. Metabolic Effects of the Left Atrial Appendage Exclusion (THE HEART HORMONE STUDY). J Cardiovasc Electrophysiol 2022; 33:2064-2071. [PMID: 35771566 DOI: 10.1111/jce.15604] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 05/07/2022] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The effect of epicardial LAA occlusion therapy on lipid and glucose metabolism in AF patients over the long term follow up is unclear. METHODS In a single-center prospective observational study, 60 patients with longstanding persistent AF with cardiovascular risk factors had undergone an epicardial exclusion procedure. Anthropometric parameters and glucose, glycated hemoglobin (HbA1c), insulin, leptin, adiponectin, free fatty acids, beta-hydroxybutyrate, and total cholesterol levels were evaluated on fasting at baseline before the procedure and compared with levels at 24 hours, 7 days, 1 month, 3 months, 6 months, and 24 months follow the procedure. RESULTS The mean age of the patients was 67.5 ± 8.1. Insulin levels significantly increased at 7 days, 1 month, 3 months, 6 months, 12 months, and 24 months follow-up. The leptin levels showed a significant increase in 6 months, 12 months, and 24 months when compared to baseline. Whereas the adiponectin levels showed a significant decrease at 3 months, 6 months, 12 months, and 24 months when compared to baseline levels. In patients with the epicardial procedure, when compared to baseline, glucose, glycated hemoglobin, total cholesterol, and beta-hydroxybutyrate levels did not show any significant changes at baseline and 24 months follow up. CONCLUSION The epicardial exclusion ligation in AF patients was associated with significant changes in insulin, leptin, and adiponectin over long follow up. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul Hospital, Krakow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Mehmet A Elbey
- Cardiology EP Clinic Fellow, Kansas City Heart Rhythm Institute (KCHRI), Overland Park, KS, USA
| | - Sri Harsha Kanuri
- Cardiology EP Clinic Fellow, Kansas City Heart Rhythm Institute (KCHRI), Overland Park, KS, USA
| | - Randall Lee
- Department of Cardiac Electrophysiology, University of California San Francisco, USA
| | - Radoslaw Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul Hospital, Krakow, Poland
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Michal Zabczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Bartus
- Department of Pharmacology, Jagiellonian University Medical College, Krakow, Poland
| | - Boguslaw Kapelak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, Medical College, John Paul Hospital, Krakow, Poland.,Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Maciej T Malecki
- Department of Metabolic Diseases, Medical College, Jagiellonian University, Krakow, Poland
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute, Overland Park, Kansas, USA.,University of Missouri - Columbia, USA
| |
Collapse
|
12
|
Chang TY, Lin CY, Lin YJ, Wu CI, Chang SL, Lo LW, Hu YF, Chung FP, Tuan TC, Chao TF, Liao JN, Kuo L, Liu CM, Chen SA. Long-term Outcome of Patients with Long-standing Persistent Atrial Fibrillation undergoing Ablation Guided by a Novel High-Density Panoramic Mapping System - A Propensity Score Matching Study. Heart Rhythm O2 2022; 3:269-278. [PMID: 35734294 PMCID: PMC9207729 DOI: 10.1016/j.hroo.2022.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background Catheter ablation is a current therapeutic approach for atrial fibrillation (AF). However, its efficacy for long-standing persistent AF remains suboptimal. Objective The purpose of this study was to test the hypothesis that a panoramic mapping system (CARTOFINDER, Biosense Webster) can guide pulmonary vein (PV) isolation and additional potential AF drivers. Methods A total of 76 patients with nonparoxysmal AF referred for ablation guided by a novel high-density panoramic mapping system with CARTOFINDER were prospectively enrolled. Of this cohort, 40 patients (52.6%) had long-standing persistent AF (CARTOFINDER group). We then retrospectively screened the patients with long-standing persistent AF undergoing conventional PV isolation and elimination of non-PV triggers during the contemporary period (conventional group). They were matched at a 1:2 ratio (40 patients in group 1 received ablation guided by CARTOFINDER; 80 patients in group 2 receiving conventional PV isolation and elimination of non-PV triggers). Results During follow-up, patients in group 1 had a lower recurrence AF rate than those in group 2 (P = .040). There was no difference in recurrence of atrial flutter (P = .996) and atrial tachycardia (P = .525). In Cox proportional hazards regression analysis, AF duration and PV isolation along with AF driver ablation using a panoramic mapping system with CARTOFINDER both were independent predictors of recurrent AF after catheter ablation of long-standing persistent AF. Conclusion Identification of the potential drivers in long-standing AF is crucial. Compared with conventional PV isolation and elimination of non-PV triggers, ablation guided by a high-density panoramic mapping system (CARTOFINDER) might have a better outcome in patients with long-standing persistent AF.
Collapse
Affiliation(s)
- Ting-Yung Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | - Chin-Yu Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yenn-Jiang Lin
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Address reprint requests and correspondence: Dr Yenn-Jiang Lin, Division of Cardiology, Internal Medicine Department, Taipei Veterans General Hospital, No. 201, Section 2, Shipai Road, Beitou District, Taipei, Taiwan 112.
| | - Cheng-I Wu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Lin Chang
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Li-Wei Lo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yu-Feng Hu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Fa-Po Chung
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ta-Chuan Tuan
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tze-Fan Chao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jo-Nan Liao
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ling Kuo
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chih-Min Liu
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shih-Ann Chen
- Heart Rhythm Center, Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Division of Cardiology, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan
| |
Collapse
|
13
|
Hoff SJ. Evaluation and Interventional Management of Cardiac Dysrhythmias. Surg Clin North Am 2022. [DOI: 10.1016/j.suc.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
14
|
Romero J, Gabr M, Patel K, Briceno D, Diaz JC, Alviz I, Trivedi C, Mohanty S, Polanco D, Della Rocca DG, Lakkireddy D, Natale A, Di Biase L. Efficacy and safety of left atrial appendage electrical isolation during catheter ablation of atrial fibrillation: an updated meta-analysis. Europace 2021; 23:226-237. [PMID: 33324978 DOI: 10.1093/europace/euaa266] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/16/2020] [Indexed: 11/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Mohamed Gabr
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Kavisha Patel
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - David Briceno
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Isabella Alviz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Dalvert Polanco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Bronx, New York, USA
| |
Collapse
|
15
|
Sabzwari SRA, Mehta NA, Garg L, Racharla L, Kurtz E, Afzal MR, Turagam MK, Lakkireddy D. Safety and efficacy of left atrial appendage closure using an epicardial suture snaring device: Systematic review and current status. J Cardiovasc Electrophysiol 2021; 32:2189-2198. [PMID: 34164881 DOI: 10.1111/jce.15132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The LARIAT epicardial suture snaring device has been fraught with technical challenges and procedural complications. Over time, technique modification and improved operator experience have helped overcome many of these challenges. METHODS AND RESULTS: Studies reporting left atrial appendage epicardial closure over a 12-year period from 2009 to 2020 were evaluated. The primary efficacy outcome evaluated was left atrial appendage closure with residual flow ≤1 mm. Safety outcomes evaluated were periprocedural and long term complications after device placement. Nine studies consisting of 1430 patients were included in this analysis, of which 1386 (97%) underwent successful device placement. The mean age was 69.3 years, with a mean CHADS2 -VASC score of 3.78. Primary efficacy end point was achieved in 95.8% patients immediately after device placement, and in 92.8% patients on long term follow-up. Early procedural complications consisted of pericardial effusion 5.6%, cardiac perforation 2.7%, pericarditis 2.6%, and need for open heart surgery 1.5%. Long term complications consisted of all-cause mortality 2.3%, stroke 1.5%, and left atrial appendage thrombus 2.3%. Reduced complications were noted using micropuncture needles (2.20% vs. 10.14%; p < .0001), a longer duration pericardial drainage, and use of anti-inflammatory medications (1.58% vs. 8.4%). Oral anticoagulation use decreased from 44.7% to 22.9% post device implantation, and to 8.5% on last clinical follow up. CONCLUSIONS The LARIAT device is effective in epicardial closure of the left atrial appendage. Improvement in device techniques such as use of micropuncture needle, prophylactic colchicine, and maintenance of a pericardial drain have helped improve safety over time.
Collapse
Affiliation(s)
| | - Nikhil A Mehta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Lohit Garg
- Department of Electrophysiology, Hospital of the University of Pennsylvania, Pennsylvania, USA
| | - Lekha Racharla
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Emilee Kurtz
- Department of Internal Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Muhammad R Afzal
- Department of Electrophysiology, Ohio State University, Columbus, Ohio, USA
| | - Mohit K Turagam
- Department of Electrophysiology, The Mount Sinai Hospital, New York City, New York, USA
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Overland Park Regional Medical Center, Overland Park, Kansas, USA
| |
Collapse
|
16
|
Murtaza G, Yarlagadda B, Akella K, Della Rocca DG, Gopinathannair R, Natale A, Lakkireddy D. Role of the Left Atrial Appendage in Systemic Homeostasis, Arrhythmogenesis, and Beyond. Card Electrophysiol Clin 2021; 12:21-28. [PMID: 32067644 DOI: 10.1016/j.ccep.2019.11.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The left atrial appendage (LAA) affects body homeostasis via atrial natriuretic peptide and the renin-angiotensin-aldosterone system and plays an important role in atrial compliance. Approximately 90% of clots in nonvalvular atrial fibrillation (AF) are formed in the LAA. AF is the most common sustained cardiac arrhythmia and is frequently associated with stroke. Because anticoagulation for stroke prophylaxis carries a higher bleeding risk, LAA closure via epicardial and endocardial approaches has gained popularity and is being increasingly pursued for arrhythmogenic, homeostatic, and stroke-reduction benefits. This review discusses the homeostatic role of the LAA and its involvement in arrhythmogenesis and thrombus formation.
Collapse
Affiliation(s)
- Ghulam Murtaza
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Bharath Yarlagadda
- Division of Cardiology, Department of Internal Medicine, MSC10-5550, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Krishna Akella
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Rakesh Gopinathannair
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA.
| |
Collapse
|
17
|
Narasimhan B, Aedma SK, Bhatia K, Garg J, Kanuri SH, Turagam MK, Lakkireddy D. Current practice and future prospects in left atrial appendage occlusion. Pacing Clin Electrophysiol 2021; 44:1236-1252. [PMID: 34085712 DOI: 10.1111/pace.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/30/2021] [Accepted: 05/30/2021] [Indexed: 01/31/2023]
Abstract
The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.
Collapse
Affiliation(s)
- Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | | | - Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | - Jalaj Garg
- Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | |
Collapse
|
18
|
Gopinathannair R, Chen LY, Chung MK, Cornwell WK, Furie KL, Lakkireddy DR, Marrouche NF, Natale A, Olshansky B, Joglar JA. Managing Atrial Fibrillation in Patients With Heart Failure and Reduced Ejection Fraction: A Scientific Statement From the American Heart Association. Circ Arrhythm Electrophysiol 2021; 14:HAE0000000000000078. [PMID: 34129347 DOI: 10.1161/hae.0000000000000078] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation and heart failure with reduced ejection fraction are increasing in prevalence worldwide. Atrial fibrillation can precipitate and can be a consequence of heart failure with reduced ejection fraction and cardiomyopathy. Atrial fibrillation and heart failure, when present together, are associated with worse outcomes. Together, these 2 conditions increase the risk of stroke, requiring oral anticoagulation in many or left atrial appendage closure in some. Medical management for rate and rhythm control of atrial fibrillation in heart failure remain hampered by variable success, intolerance, and adverse effects. In multiple randomized clinical trials in recent years, catheter ablation for atrial fibrillation in patients with heart failure and reduced ejection fraction has shown superiority in improving survival, quality of life, and ventricular function and reducing heart failure hospitalizations compared with antiarrhythmic drugs and rate control therapies. This has resulted in a paradigm shift in management toward nonpharmacological rhythm control of atrial fibrillation in heart failure with reduced ejection fraction. The primary objective of this American Heart Association scientific statement is to review the available evidence on the epidemiology and pathophysiology of atrial fibrillation in relation to heart failure and to provide guidance on the latest advances in pharmacological and nonpharmacological management of atrial fibrillation in patients with heart failure and reduced ejection fraction. The writing committee's consensus on the implications for clinical practice, gaps in knowledge, and directions for future research are highlighted.
Collapse
|
19
|
Lellouche N, Arrouasse R, Ternacle J, Gallet R, Hermida JS, Hamon D, Juliard JM, Pasquie JL, Dhanjal T, Teiger E, Le Corvoisier P. Atrial fibrillation evolution and rhythm control strategy following left appendage closure: new insights from the prospective FLAAC registry. BMC Cardiovasc Disord 2021; 21:227. [PMID: 33941095 PMCID: PMC8091509 DOI: 10.1186/s12872-021-01994-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) closure is an alternative to oral anticoagulation (OAC) for atrial fibrillation (AF) patients with high thromboembolism risk, particularly with contraindications to OAC. The LAA itself could possess proarrhythmogenic properties. As patients undergoing LAA closure could be candidates for cardioversion or ablation, we aimed to evaluate AF disease progression following LAA closure and the outcome of patients undergoing a rhythm control strategy after the procedure. METHODS The prospective multicenter French Nationwide Observational LAA Closure Registry (FLAAC) comprises 33 French interventional cardiology departments. Patients were included if they fulfilled the following criteria: history of non-valvular AF, successful LAA closure and long-term ECG follow-up. RESULTS A total of 331 patients with successful LAA closure were enrolled in the study. Patients mean age was 75.4 ± 0.5 years. The study population was characterized by a high thromboembolic risk (CHA2DS2-VASc score: 4.5 ± 0.1) and frequent comorbidities. The median follow-up was 11.9 months. One hundred and nineteen (36.0%) patients were in sinus rhythm (SR) at baseline. Among SR patients, documented AF was observed in 16 (13.4%) patients whereas 15 (7.1%) patients in AF at baseline restored SR, at the end of follow up. Finally, only 13 patients (4%) underwent procedures to restore SR without complications during the follow-up. CONCLUSIONS The vast majority of patients undergoing LAA closure have the same AF status at baseline and one year after the index procedure. During the follow-up, a very small proportion (4%) of our population underwent procedures to restore SR without complications whatever the post-procedural antithrombotic strategy was.
Collapse
Affiliation(s)
- Nicolas Lellouche
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France. .,AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.
| | | | - Julien Ternacle
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Romain Gallet
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | | | - David Hamon
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Jean-Michel Juliard
- Department of Cardiology, Bichat Hospital, APHP, University Paris VII, DHU FIRE, Sorbonne Paris-Cité, INSERM U-1148, Paris, France
| | - Jean-Luc Pasquie
- Montpellier University Hospital, CNRS UMR9214-Inserm U1046-PHYMEDEXP, Montpellier, France
| | - Tarvinder Dhanjal
- Department of Electrophysiology, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Emmanuel Teiger
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Philippe Le Corvoisier
- Inserm, CIC 1430, Henri Mondor University Hospital, Creteil, France.,Inserm, U955 team 3, Henri Mondor University Hospital, Creteil, France
| |
Collapse
|
20
|
Garg J, Lakkireddy D. Simultaneous appendage ligation and atrial ablation - is it worth the risk? Indian Pacing Electrophysiol J 2021; 21:80-1. [PMID: 33712110 DOI: 10.1016/j.ipej.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
|
21
|
Nentwich K, Ene E, Halbfass P, Berkowitz A, Sonne K, Kerber S, Lee R, Deneke T. Concomitant epicardial left atrial appendage ligation and left atrial ablation of atrial fibrillation: Safety, feasibility and outcome. Indian Pacing Electrophysiol J 2021; 21:75-79. [PMID: 33460777 PMCID: PMC7952894 DOI: 10.1016/j.ipej.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction We present initial results of patients undergoing a combined procedure of epicardial LAA ligation in addition to left atrial ablation for AF. Methods 9 patients were included for additional use of LARIAT as an individual treatment approach for AF. First an epicardial LAA ligation was performed, in the same procedure left atrial ablations consisting of PVI and additional substrate based modifying ablations were performed. Follow–up at 3 months and 12 months was performed. Results There was only 1 minor procedural complication (11%) involving epicardial bleeding and 2 late adverse events of pericardial tamponade and stroke. At the final follow-up (median 20 months) 7 patients were in stable sinus rhythm (78%) and 2 pts had reduced AF burden. Conclusion Concomitant epicardial LAA ligation and ablation is feasible in selected patients with a reasonable risk profile. More prospective data are required to validate the safety and efficacy.
Collapse
Affiliation(s)
- Karin Nentwich
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany.
| | - Elena Ene
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Philipp Halbfass
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Arthur Berkowitz
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Kai Sonne
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Sebastian Kerber
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Randall Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, 500 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Thomas Deneke
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| |
Collapse
|
22
|
Abstract
PURPOSE The left atrial appendage (LAA) is believed to be a source for thrombus formation and an ancillary structure involved in the initiation and maintenance of atrial fibrillation (AF). LAA ligation has been proposed as adjunctive therapy for the treatment of AF. This study will determine the feasibility of a percutaneous epicardial approach for LAA ligation. METHODS The pericardium of 5 dogs was accessed via percutaneous subxyphoid approach. A 20F epicardial cannula was inserted into the pericardial space and contrast-injected to visualize the LAA. Under fluoroscopic guidance, a suction cup catheter was inserted and attached to the LAA. A 12F snare device was inserted over the vacuum cup to ligate the LAA. The closure of the LAA was verified with LA angiography, in the first 2 dogs, and ICE in all 5 animals. All animals were sacrificed for post hoc assessment of LAA closure. RESULTS All 5 dogs underwent successful epicardial suture ligation of the LAA. In the first 2 dogs, LA angiography demonstrated complete closure of the LAA. All dogs underwent gross examination of the LAA. Post hoc assessment was notable for a small well-circumscribed hematoma on the LAA, consistent with point of suction cup attachment, as well as complete closure of the entire LAA. No laceration or perforation was noted on the LAA. CONCLUSIONS Exclusion of the LAA via a novel percutaneous epicardial-only approach was successful without complications. This demonstrates the feasibility of this technique in an animal model, and may provide an effective approach for epicardial-only LAA exclusion in humans.
Collapse
Affiliation(s)
- José M Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Randall J Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA.
- , San Francisco, USA.
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW In patients with atrial fibrillation who are unable to take novel oral anticoagulants for stroke prophylaxis due to bleeding risk or other contraindications, left atrial appendage (LAA) occlusion and exclusion devices have shown benefit. In this review, we highlight the risks and benefits associated with LAA removal. RECENT FINDINGS LAA, once considered a vestigial organ, has been shown to have physiological, anatomical, and arrhythmogenic properties. Device-related complications such as pericardial effusion, device embolization, device-related thrombus, while uncommon, are still present. With increased operator experience related to appendage occlusion, overall procedural complications have declined. Further refinements in device technology will help decrease complications. While benefits of appendage removal are plenty, procedural complications need to be weighed into the equation when making decisions regarding LAA occlusion.
Collapse
Affiliation(s)
- Ghulam Murtaza
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Urooge Boda
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Mohit K Turagam
- Department of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Krishna Akella
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA.
| |
Collapse
|
24
|
Zheng Y, Rao CF, Chen SP, He L, Hou JF, Zheng Z. Surgical left atrial appendage occlusion in patients with atrial fibrillation undergoing mechanical heart valve replacement. Chin Med J (Engl) 2020; 133:1891-1899. [PMID: 32826451 PMCID: PMC7462216 DOI: 10.1097/cm9.0000000000000967] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Surgical left atrial appendage occlusion (SLAAO) may be associated with a lower risk of thromboembolism in patients with atrial fibrillation undergoing cardiac surgery. However, evidence regarding the effectiveness of SLAAO in patients undergoing mechanical heart valve replacement (MHVR) is lacking. Therefore, we aimed to evaluate the association between SLAAO and the cardiovascular outcomes in patients with atrial fibrillation undergoing MHVR. METHODS We retrospectively analyzed data for 497 patients with atrial fibrillation; 27.6% of the patients underwent SLAAO, and the remainder of the patients did not (No-SLAAO group). The primary outcome was a composite of ischemic stroke, systemic embolism, and all-cause mortality. Cumulative event-free survival rates were estimated using Kaplan-Meier curves, and we performed multivariate Cox analyses to evaluate the association between SLAAO and outcomes. We used one-to-one propensity score matching to balance patients' baseline characteristics, and analyzed 120 matching pairs. RESULTS Five patients died within 30 days postoperatively, and there were no significant differences between the two groups regarding in-hospital complications (all P > 0.05). After a median follow-up of 14 months, 14 primary events occurred. Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome (log-rank P = 0.830), hemorrhagic events (log-rank P = 0.870), and the secondary outcome (log-rank P = 0.730), between the two groups. Multivariable Cox proportional hazards regression analysis showed no association between SLAAO and any outcome (all P > 0.05). After propensity score matching, cardiopulmonary bypass time and aortic cross-clamp time, and the postoperative length of stay were significantly longer in the SLAAO group (all P < 0.05); results were similar to the unadjusted analyses. CONCLUSIONS Concomitant SLAAO and MHVR was associated with longer length of stay, and cardiopulmonary bypass time and aortic cross-clamp time, but was not associated with additional protective effects against thromboembolic events and mortality during the 14-month follow-up.
Collapse
Affiliation(s)
- Ye Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chen-Fei Rao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Si-Peng Chen
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Li He
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-Feng Hou
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| |
Collapse
|
25
|
Wintgens LIS, Maarse M, Swaans MJ, Rensing BJWM, Van Dijk VF, Boersma LVA. The WATCHMAN left atrial appendage closure device for patients with atrial fibrillation: current status and future perspectives. Expert Rev Med Devices 2020; 17:615-626. [PMID: 32543911 DOI: 10.1080/17434440.2020.1781615] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Atrial fibrillation (AF) is associated with an increased risk of stroke. Stroke prevention with oral anticoagulation (OAC) is recommended in AF patients at increased risk of stroke. The left atrial appendage (LAA) is the main source of thrombus formation in AF patients. The WATCHMAN percutaneous LAA closure (LAAC) device may serve as an alternative to OAC overcoming disadvantages including the risk of (major) bleeding. AREAS COVERED This review will focus on LAAC with the Watchman device for stroke prevention in AF patients. Current status, available literature, clinical safety and efficacy will be summarized. Furthermore, the future perspectives of Watchman will be discussed. EXPERT OPINION LAAC with Watchman appears a promising, safe, and effective alternative to OAC. Ongoing and future studies to consolidate the position of Watchman should focus on comparative safety and efficacy of different LAAC devices, patient selection, various post-procedural antithrombotic regimens, head-to-head comparisons with NOAC, better understanding of device-related thrombus, and the role of the LAA in the propagation of non-valvular AF. This research may attribute to a paradigm shift in which LAAC no longer serves as a 'last resort' treatment for AF patients ineligible for OAC but may serve as a second-line or even first-line treatment option for AF patients.
Collapse
Affiliation(s)
| | - Moniek Maarse
- St. Antonius Hospital, Heartcenter , Nieuwegein, The Netherlands
| | - Martin J Swaans
- St. Antonius Hospital, Heartcenter , Nieuwegein, The Netherlands
| | | | | | - Lucas V A Boersma
- St. Antonius Hospital, Heartcenter , Nieuwegein, The Netherlands.,Department Cardiology, AMC Amsterdam , Amsterdam, The Netherlands
| |
Collapse
|
26
|
Tian X, Zhang XJ, Yuan YF, Li CY, Zhou LX, Gao BL. Morphological and functional parameters of left atrial appendage play a greater role in atrial fibrillation relapse after radiofrequency ablation. Sci Rep 2020; 10:8072. [PMID: 32415245 DOI: 10.1038/s41598-020-65056-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 04/26/2020] [Indexed: 11/18/2022] Open
Abstract
This study was to quantitatively investigate the role of morphological and functional parameters of the left atrium (LA) and left atrial appendage (LAA) with 256-slice spiral computed tomography (CT) in the recurrence of atrial fibrillation (AF) after radiofrequency ablation (RFA). Eighty-three patients with AF who underwent RFA for the first time were divided into the recurrence (n = 27) and non-recurrence (n = 56) groups. All patients underwent a 256-slice spiral CT examination before the operation. The clinical data and quantitative measurement of the morphology and functional parameters of the LA and LAA were analyzed, including the maximal and minimal volume, ejection fraction and volume, and volume strain of LAA and LA (LAAVmax, LAAVmin, LAAEF, LAAEV, and LAA-VS, LAVmax, LAVmin, LAEF, LAEV and LA-VS, respectively). The CHA2DS2-VASc score and the proportion of patients with heart failure were significantly (P < 0.05) higher in the recurrence than non-recurrence group. The LAAVmax, LAAVmin, LAVmax, LAVmin, LAAV and LAV were all significantly greater in the recurrence than non-recurrence group (P < 0.05), and the perimeter, major and minor axes of LAA orifice and LAA depth were also significantly greater in the recurrence than non-recurrence group. The LAAEF, LAEF and LAA-VS were significantly (P < 0.05) lower in the recurrence than non-recurrence group (P < 0.05). Heart failure, CHA2DS2-VASC score, LAEF, LAV, LAAEF and LAA-VS were univariately significant (P < 0.05) risk factors for AF recurrence after ablation. Multivariate analysis revealed LAAEF (HR: 0.790, 95% CI: 0.657–0.950, P = 0.012) and LAAV (HR: 1.160, 95% CI: 1.095–1.229, P <0.001) to be two significant independent predictors of recurrence. ROC curve analysis showed that LAAEF <44.68% had the highest predictive value for recurrence after radiofrequency ablation, with the sensitivity of 90% and specificity of 67.4%, whereas LAA volume >9.25 ml had the highest predictive value for AF recurrence after RFA, with the sensitivity of 85.2% and specificity of 67.9%. In conclusion, the volume of left atrium, volume and morphology of left atrial appendage have all significantly increased while the ejection fraction and volume strain of left atrium and left atrial appendage have both significantly decreased in recurrence than in non-recurrence after radiofrequency ablation. The ejection fraction and volume of left atrial appendage are significant independent predictors of atrial fibrillation recurrence after radiofrequency ablation.
Collapse
|
27
|
Kharbanda RK, van Schaagen FRN, Bogers AJJC, de Groot NMS. Persistence and Distortion of Electrical Activity in the LAA 5 Years After Endovascular Occlusion. JACC Case Rep 2020; 2:583-7. [PMID: 34317298 DOI: 10.1016/j.jaccas.2019.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/13/2019] [Accepted: 12/19/2019] [Indexed: 11/25/2022]
Abstract
This is the first report demonstrating persistence and distortion of electrical activity in the left atrial appendage 5 years after endovascular occlusion with a Watchman device. Electrical conduction is impaired providing an arrhythmogenic substrate for atrial tachyarrhythmias. Localized inflammation may result in structural and electrical remodeling in these patients. (Level of Difficulty: Intermediate.)
Collapse
|
28
|
|
29
|
Akella K, Yarlagadda B, Murtaza G, Della Rocca DG, Gopinathannair R, Natale A, Lakkireddy D. Epicardial versus Endocardial Closure: Is One Better than the Other? Card Electrophysiol Clin 2020; 12:97-108. [PMID: 32067652 DOI: 10.1016/j.ccep.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Left atrial appendage occlusion is an evolving technology with demonstrable benefits of stroke prophylaxis in patients with atrial fibrillation unsuitable for anticoagulation. This has resulted in the development of a plethora of transcatheter devices to achieve epicardial exclusion and endocardial occlusion. In this review, the authors summarize the differences in technique, target patient population, outcomes, and complication profiles of endocardial and epicardial techniques.
Collapse
Affiliation(s)
- Krishna Akella
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Bharath Yarlagadda
- Department of Cardiology, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Ghulam Murtaza
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Rakesh Gopinathannair
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA.
| |
Collapse
|
30
|
Abstract
Left atrial appendage exclusion is efficacious for stroke prophylaxis in patients with atrial fibrillation. Surgical excision provides reliable left atrial appendage exclusion, whereas surgical occlusion does not. Specifically, 2-layer internal suture ligation has a high failure rate. Left atrial appendage exclusion concomitant to another cardiac surgical procedure is indicated in patients with atrial fibrillation but not in patients without baseline atrial fibrillation. Studies currently underway will further define the role of concomitant surgical left atrial appendage exclusion, especially for the population without baseline atrial fibrillation but at high risk of developing postoperative atrial fibrillation.
Collapse
Affiliation(s)
- James R Edgerton
- Department of Epidemiology, Baylor Scott and White Health, PO Box 190667, Dallas, TX 75219, USA.
| |
Collapse
|
31
|
Gussak G, Pfenniger A, Wren L, Gilani M, Zhang W, Yoo S, Johnson DA, Burrell A, Benefield B, Knight G, Knight BP, Passman R, Goldberger JJ, Aistrup G, Wasserstrom JA, Shiferaw Y, Arora R. Region-specific parasympathetic nerve remodeling in the left atrium contributes to creation of a vulnerable substrate for atrial fibrillation. JCI Insight 2019; 4:130532. [PMID: 31503549 DOI: 10.1172/jci.insight.130532] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 08/27/2019] [Indexed: 12/27/2022] Open
Abstract
Atrial fibrillation (AF) is the most common heart rhythm disorder and a major cause of stroke. Unfortunately, current therapies for AF are suboptimal, largely because the molecular mechanisms underlying AF are poorly understood. Since the autonomic nervous system is thought to increase vulnerability to AF, we used a rapid atrial pacing (RAP) canine model to investigate the anatomic and electrophysiological characteristics of autonomic remodeling in different regions of the left atrium. RAP led to marked hypertrophy of parent nerve bundles in the posterior left atrium (PLA), resulting in a global increase in parasympathetic and sympathetic innervation throughout the left atrium. Parasympathetic fibers were more heterogeneously distributed in the PLA when compared with other left atrial regions; this led to greater fractionation and disorganization of AF electrograms in the PLA. Computational modeling revealed that heterogeneously distributed parasympathetic activity exacerbates sympathetic substrate for wave break and reentry. We further discovered that levels of nerve growth factor (NGF) were greatest in the left atrial appendage (LAA), where AF was most organized. Preferential NGF release by the LAA - likely a direct function of frequency and regularity of atrial stimulation - may have important implications for creation of a vulnerable AF substrate.
Collapse
Affiliation(s)
- Georg Gussak
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Anna Pfenniger
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lisa Wren
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Mehul Gilani
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Wenwei Zhang
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Shin Yoo
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - David A Johnson
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amy Burrell
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brandon Benefield
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gabriel Knight
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Bradley P Knight
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rod Passman
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Gary Aistrup
- Masonic Medical Research Institute, Utica, New York, USA
| | - J Andrew Wasserstrom
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Yohannes Shiferaw
- Department of Physics, California State University, Northridge, California, USA
| | - Rishi Arora
- Feinberg Cardiovascular and Renal Research Institute, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| |
Collapse
|
32
|
Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
Collapse
Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| |
Collapse
|
33
|
Abstract
Introduction: Pulmonary vein isolation (PVI), by catheter ablation, represents the current treatment for drug-resistant atrial fibrillation (AF). Nowadays cryoballoon (CB) is a recognized ablation method in patients with atrial fibrillation, mainly due to its ease of use, leading to reproducible and fast procedures. This novel single shot technology literally revolutionized the approach to AF ablation. Areas covered: The historical development of the cryoballoon, ablation techniques and new approaches beyond the ordinary PVI and complications are summarized here. Expert opinion: Although cryoballoon ablation has greatly standardized the approach to PVI a few critical points still need to be clarified scientifically in order to further uniform this procedure in cath labs worldwide. Duration and dosage of the cryoapplication is undoubtedly a topic of great interest.
Collapse
Affiliation(s)
- Thiago Guimarães Osório
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Hugo-Enrique Coutiño
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Pedro Brugada
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Gian-Battista Chierchia
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| | - Carlo De Asmundis
- Heart Rhythm Management Centre, Postgraduate course in Cardiac Electrophysiology and Pacing, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel , Brussels , Belgium
| |
Collapse
|
34
|
Bordignon S, Chen S, Perrotta L, Bologna F, Nagase T, Konstantinou A, Weise F, Fuernkranz A, Schmidt B, Chun JKR. Durability of cryoballoon left atrial appendage isolation: Acute and invasive remapping electrophysiological findings. Pacing Clin Electrophysiol 2019; 42:646-654. [DOI: 10.1111/pace.13690] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/11/2019] [Accepted: 02/20/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Stefano Bordignon
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Laura Perrotta
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Fabrizio Bologna
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Takahiko Nagase
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Athanasios Konstantinou
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Felix Weise
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | | | - Boris Schmidt
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| | - Julian K. R. Chun
- Cardioangiologisches Centrum BethanienAgaplesion Markus‐Krankenhaus Frankfurt am Main Germany
| |
Collapse
|
35
|
Turner JL, Marrouche N. The Next 10 Years in Atrial Fibrillation. US Cardiology Review 2019. [DOI: 10.15420/usc.2018.21.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Predicting future advancements in arrhythmia management – specifically AF – with any certainty is impossible. The clinical approach to AF has changed markedly since the turn of the century in ways that could never have been foreseen, but the current methods of identification and treatment remain far from perfect. Over the next decade we expect significant continued progress in AF management. However, if asked to forecast the future, we consider it wise to predict advancements in the nearer term. We believe there will be widespread expansion in digital health and mobile devices, altering the way we detect and monitor the arrhythmia. We expect substantial growth in advanced MRI to aid in early detection, evaluation, and possibly non-invasive treatment of AF substrate. We imagine there will be increasing focus on individual populations to identify at-risk groups and personalize early management. We also anticipate improvement in anticoagulation employment and left atrial appendage modification. Finally, recognizing the benefit of improvement in modifiable risk factors such as mandatory tobacco cessation and weight loss in obese patients, we predict that reimbursement will be dependent on successfully addressing modifiable risk. For now, several questions remain unanswered, and while no one can predict the next 10 years in AF, there is, without doubt, an abundance of opportunity.
Collapse
Affiliation(s)
- Jeffrey L Turner
- Comprehensive Arrhythmia and Research Management Center, University of Utah School of Medicine, Salt Lake City, UT
| | - Nassir Marrouche
- Comprehensive Arrhythmia and Research Management Center, University of Utah School of Medicine, Salt Lake City, UT
| |
Collapse
|
36
|
Abstract
Atrial fibrillation is common in patients with congestive heart failure (CHF). Due to reduced left atrial appendage (LAA) emptying velocities and increased sludge formation, a higher rate of stroke and embolism are seen with CHF. Up to 50% of CHF patients are inadequately covered for stroke protection with anticoagulation, and, even while on therapy, CHF patients are at risk for failure to clear LAA or left ventricular (LV) thrombus. Device-based LAA closure (LAAC) alternatives exist. Following intracardiac device closure, an increased rate of device-related thrombus is seen in heart failure patients, which warrants further study to optimize LAAC benefits.
Collapse
Affiliation(s)
- Christopher R Ellis
- Left Atrial Appendage Program, Vanderbilt University Medical Center, 5414 Medical Center East, 1211 21st Avenue South, Nashville, TN 37232-8802, USA.
| | | |
Collapse
|
37
|
Ojo A, Yandrapalli S, Veseli G, Karim M, Aronow WS, Sharma M, Frishman WH, Naidu SS, Jacobson JT, Iwai S. Left Atrial Appendage Occlusion in the Management of Stroke in Patients With Atrial Fibrillation. Cardiol Rev 2020; 28:42-51. [PMID: 30520738 DOI: 10.1097/CRD.0000000000000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
Collapse
|
38
|
|
39
|
Di Biase L, Natale A, Romero J. Thrombogenic and Arrhythmogenic Roles of the Left Atrial Appendage in Atrial Fibrillation: Clinical Implications. Circulation 2018; 138:2036-50. [DOI: 10.1161/circulationaha.118.034187] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
40
|
AlTurki A, Huynh T, Dawas A, AlTurki H, Joza J, Healey JS, Essebag V. Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta-analysis. J Arrhythm 2018; 34:478-484. [PMID: 30327692 PMCID: PMC6174377 DOI: 10.1002/joa3.12095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Revised: 06/17/2018] [Accepted: 06/19/2018] [Indexed: 11/10/2022] Open
Abstract
A significant proportion of patients' experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random-effects meta-analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow-up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10-0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25-0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long-term risk of stroke.
Collapse
Affiliation(s)
- Ahmed AlTurki
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Thao Huynh
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Ahmed Dawas
- Faculty of MedicineMcGill UniversityMontrealQuebecCanada
| | | | - Jacqueline Joza
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
| | - Jeff S. Healey
- Population Health Research InstituteHamiltonOntarioCanada
| | - Vidal Essebag
- Division of CardiologyMcGill University Health CenterMontrealQuebecCanada
- Hôpital Sacré‐Coeur de MontréalMontrealQuebecCanada
| |
Collapse
|
41
|
Abstract
The thrombus formed within the LAA is responsible for the vast (about 90%) majority of strokes. Anticoagulation, although effective therapy for stroke prevention is not feasible in a significant minority of patients due to various reasons. Two percutaenous LAA exclusion techniques have been developed in an effort to decrease risk for stroke: endocardial closure/plugging of the LAA (Watchman, Amplatzer devices) and epicardial LAA ligation (LARIAT). The aim of this study is to review the trial data to date for the LARIAT device. The LARIAT suture has been used in more than 4500 patients with high success of LAA complete closure (92-100%), mostly in the patients unable to take anticoagulation and in a small minority as antiarrhythmic option. The LARIAT technique has evolved with a change in pericardial access method that resulted in dramatic improvement of safety. LAA closure performance with LARIAT system seems to be similar to Watchman device, with small leaks during follow-up in 6-24% of the cases, which do not to correlate with thrombo-embolic events. LAA has been proven to play an important triggering role in patients with persistent atrial fibrillation. Small studies had shown that LAA ligation with LARIAT could terminate persistent atrial fibrillation and possible improve ablation success. Ongoing aMAZE randomized trial is studying if LAA ligaiton using LARIAT suture leads to improved atrial fibrillation ablation success. Available data suggests that LAA closure using LARIAT epicardial suture is a good alternative for stroke risk reduction in patients who are unable to be on anticoagulation therapy. LARIAT system might improve success of AF ablation for patients with persistent and long persistent AF, pending the results of the ongoing aMAZE trial.
Collapse
Affiliation(s)
- Dan Musat
- Valley Health System of NY and NJ, Paramus, NJ
| | | |
Collapse
|
42
|
Affiliation(s)
- Jorge Romero
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - David F Briceño
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Michael Grushko
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | - Ilir Maraj
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York
| | | | - Luigi Di Biase
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, New York.,Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas.,Department of Biomedical Engineering, University of Texas, Austin, Texas.,Department of Cardiology, University of Foggia, Foggia, Italy
| |
Collapse
|
43
|
Fink T, Schlüter M, Tilz RR, Heeger CH, Lemes C, Maurer T, Reissmann B, Rottner L, Santoro F, Mathew S, Rillig A, Ouyang F, Kuck KH, Metzner A. Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience. Clin Res Cardiol 2018; 107:1139-1147. [DOI: 10.1007/s00392-018-1288-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
|
44
|
Dar T, Afzal MR, Yarlagadda B, Kutty S, Shang Q, Gunda S, Samanta A, Thummaluru J, Arukala KS, Kanmanthareddy A, Reddy M, Atkins D, Bommana S, Dawn B, Lakkireddy D. Mechanical function of the left atrium is improved with epicardial ligation of the left atrial appendage: Insights from the LAFIT-LARIAT Registry. Heart Rhythm 2018; 15:955-959. [PMID: 29477973 DOI: 10.1016/j.hrthm.2018.02.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Left atrial (LA) strain (ε) and ε rate (SR) analysis by 2-dimensional speckle tracking echocardiography is a novel method for functional assessment of the LA. OBJECTIVE The purpose of this study was to determine the impact of left atrial appendage (LAA) exclusion by Lariat epicardial ligation on mechanical function of the LA by performing ε and SR analysis before and after the procedure. METHODS A total of 66 patients who underwent successful LAA exclusion were included in the study. Of these 66 patients, 32 had adequate paired data for ε and SR analysis. SR during ventricular systole (LA-SRs) represents LA reservoir function, and SR during early ventricular diastole (LA-SRe) represents LA conduit function. ε and SR were determined from apical 4- and 2-chamber views using the electrocardiographic QRS as a reference point. LA volume index as surrogate for LA remodeling was measured from apical views. RESULTS Mean patient age was 70 ± 9.2 years. LAA ligation resulted in improved reservoir function (LA-SRs: pre 0.72, confidence interval [CI] 0.63-0.83 vs post 0.81, CI 0.73-0.98; P = .043) and conduit function (LA-SRe: pre 0.74, CI 0.67-0.99 vs post 0.89, CI 0.82-1.07; P = .025). LA volume index improved significantly with the Lariat (pre 35.4, CI 29.4-37.2 vs post 29.2, CI 28.2-35.9; P <.023). CONCLUSION LAA exclusion seems to improve mechanical function of the LA and results in reverse LA remodeling.
Collapse
Affiliation(s)
- Tawseef Dar
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Muhammad R Afzal
- Division of Cardiovascular Diseases, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bharath Yarlagadda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Shelby Kutty
- Division of Pediatric Cardiology, University of Nebraska Medical Center and Children's Hospital & Medical Center, Omaha, Nebraska
| | - Quanliang Shang
- Division of Pediatric Cardiology, University of Nebraska Medical Center and Children's Hospital & Medical Center, Omaha, Nebraska
| | - Sampath Gunda
- Division of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Anweshan Samanta
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Jahnavi Thummaluru
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Kedareeshwar S Arukala
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Arun Kanmanthareddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Madhu Reddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Sudharani Bommana
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Buddhadeb Dawn
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, Kansas
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute (KCHRI) and Research Foundation, Overland Park Regional Medical Center, HCA MidWest, Overland Park, Kansas.
| |
Collapse
|
45
|
McBride DA, Markman TM, Liang JJ, Santangeli P. Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF. US Cardiology Review 2018. [DOI: 10.15420/usc.2018.6.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.
Collapse
|
46
|
Turagam M, Atkins D, Earnest M, Lee R, Nath J, Ferrell R, Bartus K, Badhwar N, Rasekh A, Cheng J, Di Biase L, Natale A, Wilber D, Lakkireddy D. Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry. J Cardiovasc Electrophysiol 2017; 28:1433-1442. [DOI: 10.1111/jce.13343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mohit Turagam
- Division of Cardiovascular Medicine; University of Missouri Hospital and Clinics; Columbia MO USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Randall Lee
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Jayant Nath
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Ryan Ferrell
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | | | - Nitish Badhwar
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Abdi Rasekh
- Baylor St. Luke's Medical Center; Houston TX USA
| | - Jie Cheng
- Texas Heart Institute; Houston TX USA
| | - Luigi Di Biase
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - Andrea Natale
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| |
Collapse
|
47
|
Abstract
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the clinical setting affecting nearly 6 million people in United States and the numbers are only expected to rise as the population continues to age. Broadly it is classified into paroxysmal, persistent and longstanding persistent AF. Electrical, structural and autonomic remodeling are some of the diverse pathophysiological mechanisms that contribute to the persistence of AF. Our review article emphasizes particularly on long standing persistent atrial fibrillation (LSPAF) aspect of the disease which poses a great challenge for electrophysiologists. While pulmonary vein isolation (PVI) has been established as a successful ablation strategy for paroxysmal AF, same cannot be said for LSPAF owing to its long duration, complexity of mechanisms, multiple triggers and substrate sites that are responsible for its perpetuation. The article explains different approaches currently being adopted to achieve freedom from atrial arrhythmias. These mainly include ablation techniques chiefly targeting complex fractionated atrial electrograms (CFAE), rotors, linear lesions, scars and even considering hybrid approaches in a few cases while exploring the role of delayed enhancement magnetic resonance imaging (deMRI) in the pre-procedural planning to improve the overall short and long term outcomes of catheter ablation.
Collapse
Affiliation(s)
- Behram P Mody
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Anoshia Raza
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Jason Jacobson
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Sei Iwai
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Daniel Frenkel
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Rhadames Rojas
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| |
Collapse
|
48
|
Bajwa RJ, Kovell L, Resar JR, Arbab-Zadeh A, Mandal K, Calkins H, Berger RD. Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. Clin Cardiol 2017; 40:825-831. [PMID: 28750152 DOI: 10.1002/clc.22764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 01/23/2023] Open
Abstract
Atrial fibrillation (AF) is a commonly sustained atrial arrhythmia with associated morbidity and mortality. AF is associated with increased risk of thromboembolism and stroke, requiring use of anticoagulation. Anticoagulation decreases the risk of stroke but is associated with a higher risk of bleeding, necessitating discontinuation in some patients. The left atrial appendage is the likely source of thrombus in the majority of patients with AF. This has led to the development of left atrial appendage occlusion as a means to reduce stroke risk in patients who have a contraindication to long-term anticoagulation. Multiple implantable devices have surfaced in the last few years, with some promising prospects. The main purpose of this review is to highlight the indications and use of these devices for left atrial appendage occlusion.
Collapse
Affiliation(s)
- Rizma Jalees Bajwa
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lara Kovell
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Armin Arbab-Zadeh
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaushik Mandal
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| |
Collapse
|
49
|
Kuck K, Böcker D, Chun J, Deneke T, Hindricks G, Hoffmann E, Piorkowski C, Willems S. Qualitätskriterien zur Durchführung der Katheterablation von Vorhofflimmern: Positionspapier der Deutschen Gesellschaft für Kardiologie. Kardiologe 2017; 11:161-82. [DOI: 10.1007/s12181-017-0146-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
|
50
|
|