Short term outcome after left atrial appendage occlusion with the AMPLATZER Amulet and WATCHMAN device: results from the ORIGINAL registry (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure)

Background

Various randomized multicenter studies have shown that percutaneous left atrial appendage closure (LAAC) is not inferior in stroke prevention compared to vitamin K antagonists (VKA) and can be performed safely and effectively.

Aims

The prospective multicenter ORIGINAL registry in the Free State of Saxony (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure) investigated the efficiency and safety of LAAC with Watchman or Amulet device in a real word setting. A special focus was put on the influence of LAAC frequency on periprocedural efficiency and safety.

Methods and results

The total of 482 consecutive patients (Abbott Amulet N = 93 and Boston Scientific Watchman N = 389) were included in the periinterventional analyses. After 6 weeks, 353 patients completed the first follow-up including transoesophageal echocardiography (TEE) (73.2%). Successful LAAC could be performed in more than 94%. The complication rate does not significantly differ between device types (p = 0.92) according to Fischer test and comprised 2.2% in the Amulet and 2.3% in the Watchman group. The kind of device and the frequency of LAAC per study center had no influence on the success and complication rates. Device related thrombus could be revealed more frequently in the Watchman group (4.5%) than in the Amulet group (1.4%) but this difference is still not significant in Fisher test (p = 0.14). Same conclusion can be made about residual leakage 1.1% versus 0% [not significant in Fisher test (p = 0.26)]. Dual antiplatelet therapy followed the intervention in 64% and 22% of patients were discharged under a combination of an anticoagulant (VKA/DOAC/Heparin) and one antiplatelet agent.

Conclusions

The ORIGINAL registry supports the thesis from large, randomized trials that LAAC can be performed with a very high procedural success rate in the everyday clinical routine irrespective of the used LAA device (Watchman or Amulet). The postprocedural antithrombotic strategy differs widely among the participating centers.

Trial registration Name of the registry: "saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure", Trial registration number: DRKS00023803; Date of registration: 15/12/2020 'Retrospectively registered'; URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023803.

P3711Impact of peri-device leakage after interventional occlusion of the left atrial appendage: Results from the ORIGINAL registry (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure)

Background

Oral anticoagulation for prophylaxis of central and peripheral embolisation is limited in its use in patients with atrial fibrillation (AF) and bleeding events. As an alternative to anticoagulation, the interventional closure of the left atrial appendage (LAAO) is available. A common clinical dilemma is the treatment of patients with potential peri-device leakage following LAA occlusion. The specific definition of the severity of the leak and the long-term clinical implications have not yet been sufficiently investigated.

Methods

The multi-centre ORIGINAL registry was initiated 2014. The aim of this registry is to analyze the safety and efficacy of the procedure in patients with a high risk of bleeding in everyday clinical practice and to evaluate hemorrhagic and thromboemb. events in the long term follow-up. Patients with an indication for LAA occl. were included in the registry after informed consent. The impl., follow-up and anticoagulation regimens are performed according to the standard of the participating centers. 521 patients with AF underwent an implantation of an LAA closure device between Jul. 2014 and Nov. 2018. A mean follow-up of 463 days could be reached in 386 patients.

Results

The periprocedural complication rate was 3.8% of which 5 patients experienced pericardial effusion (successful treatment with pericardial puncture or surgical), 2 patients had periprocedural stroke and 1 patient suffered from air embolism. In 27 patients a peri-device flow due to incomplete occlusion was detected by TEE (5.4% of the implantations). The size ranged between 1 and 8 mm (mean 2.28 mm (SD=2.11)). The eccentricity index (EI) of the LAA in these patients was 1.22 (SD 0.17), and thus the LAA rather oval, while those LAA without leakage tend to be more circular (EI 1.08 with SD=0.17). 2 of the patients with leakage (7.4%) experienced stroke or peripheral embolism, respectively. The annual risk for stroke/TIA/peripheral embolism of these patients was 5.84%, the annual risk of the patients without leakage was 2.04%. Patients with a leakage >6 mm were treated with rivaroxaban in full therapeutic dosage. One patient underwent an additional procedure.

Conclusion

The evaluation and management of para-device leakage after an interventional LAA occlusion represents a challenge. Currently, limited data are available on the optimal strategy. Those data indicate that residual peri-device flow into the LAA after percutaneous closure with the Watchman device represents no cause for alarm. However, our data suggest, that patients with peridevice leak might be at a higher risk of thromboembolic events. Furthermore, it could be shown, that these patients had rather oval ostium of the LAA, while those LAA without leakage tend to be more circular. This implicates the importance of advanced imaging methods, such as 3D-TEE, which are capable to precisely determine the size of the LAA and the degree of its circularity.

Acknowledgement/Funding

None

284Outcomes after left atrial appendage occlusion with AMPLATZER Amulet and WATCHMAN device: Results from the ORIGINAL registry (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure)

Aims

Left atrial appendage occlusion (LAAO) is a therapeutic option for patients with non-valvular atrial fibrillation (NVAF) and high risk of bleeding. This study reports outcomes of patients enrolled in the prospective multicentre, investigator initiated real life registry in the Free State of Saxony (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure).

Methods and results

Data of all consecutive 521 patients (64.7% adult males, 35.3% adult females, mean age: 75.1 (SD 7.9) years with non-valvular atrial fibrillation undergoing interventional left atrial appendage occlusion procedure in the ORIGINAL prospective registry were analysed. The CHA2DS2-VASc and HAS-BLED scores were 4.3 (SD 1.5) and 3.7 (SD 1.1), respectively. 78.9% of the patients had a history of bleeding. 89.3% of the patients were considered as non-eligible for long term oral anticoagulation. A left atrial appendage occlusion device was successfully implanted in 97.5% of cases. A mean follow-up of 463 days could be reached in 386 patients. Among these, the distribution of the follow-up length reached was as follows: 1 year 205, 2 years 118, 3 years 65 and 4 years 17 patients. In the follow-up the annual frequency of stroke was very low (0.4%), which resulted in the 4.98% absolute risk reduction in the amount of thromboembolic strokes, which would have been expected according to the calculated CHA2DS2-VASc score in the hypothetic group not receiving any anticoagulant therapy. The occurrence of major and minor bleeding in the follow-up was 1.55% and 3.37% respectively.

Conclusions

In this prospective multicentre study we included the patients who are at high risk of stroke and bleeding. The annual ischemic stroke rate was 0.4%, the LAA could be sealed in 97.5%. Six months after the LAA closure only 3.63% of all patients were further on treated using oral anticoagulation. Considering the stroke reduction rates, the implantation of an LAAO device proves to be effective and safe in the clinical routine in the studied population.

Acknowledgement/Funding

None

Angioplasty of the internal thoracic artery bypass-graft an alternative to reoperation

BACKGROUND

This review presents an overview of interventional revascularization procedures of the internal thoracic artery after prior implantation as a coronary-artery bypass graft.

METHODS

Our search was concentrated on the MEDLINE-database to identify all articles on internal thoracic artery-graft-angioplasties and reoperation after internal thoracic artery bypass grafting published between 1968 and 2000.

RESULTS

Surgical revascularization and reoperation were reported in five papers including a total of 785 patients. The overall mortality of these patients was 4.2%. The presence of a patent internal thoracic artery-graft at the time of reoperation was not a risk factor for higher morbidity and mortality. Revascularization with percutaneous transluminal coronary angioplasty of the internal thoracic artery or the native left anterior descending artery via the internal thoracic artery-graft used as a conduit was performed in 327 patients. The primary success rate was 87%, the angiographically assessed rate of restenosis was 30% and the rate of complications approximately 1%.

CONCLUSIONS

In spite of technical problems the percutaneous transluminal coronary angioplasty in or via internal thoracic artery-graft presents a safe and feasible option to be recognized before a potential reoperation.

[Interventional therapy after failed fibrinolysis in acute myocardial infarct. Acute and long-term outcome of referral for rescue balloon angioplasty]

BACKGROUND

The results from studies of coronary angioplasty after failed thrombolysis (rescue-PTCA) in acute myocardial infarction are contradictory. Long-term results were not presented till now. Therefore we analyzed the data from our registry of those patients whose acute and long-term results were available.

PATIENTS AND METHODS

Data of 49 patients were analyzed who had been admitted for rescue-PTCA from other hospitals. Thrombolysis had to be started < 6 hours (mean 2.7 hours) from onset of symptoms. Rescue-PTCA had to be completed within < 24 hours (mean 10.5 hours). 37 patients received streptokinase, seven rt-PA, three urokinase and two prourokinase. Electrocardiographic and clinical criteria were used to define failure of thrombolysis. The data of the acute results were from a prospective registry and the long-term results came from clinical follow-up visits and a questionnaire sent to the patients.

RESULTS

Mean age of the patients was 48.5 years (38-78 years), 45 male, nine patients in cardiogenic shock (18%), infarct related artery (IRA): RCA 22x, LAD 21x, LCX 5x, CABG 1x, single vessel disease 27x, multiple vessel disease 22x. Acute results: Initial IRA-TIMI flow 0 in 28 patients, 1 in twelve patients, 2 in 9 patients; after rescue-PTCA TIMI flow 1 in one patient, 2 in two patients, 3 in 46 patients (procedural success 94%). Hospital mortality 8.2% (four patients), all in cardiogenic shock. Early reocclusion rate 10%. Bleeding complications 14%, no fatal complications. Long-term results: Observation period 2.5 years in 42 patients (0.5-6.5 years). Three more deaths. Total mortality 14% (7/49). Angiographic follow-up: Ejection fraction initially 50%; 53% after 3 months. Repeat revascularization in 43% (15/35): Re-PTCA in 8/35, surgery in 6/35 patients, 1x transplantation. 80% of the patients were free from angina or heart failure.

CONCLUSIONS

Rescue-PTCA in acute myocardial infarction has a high procedural success rate with a low hospital mortality. It is the treatment of choice for patients in cardiogenic shock. Transportation to an interventional center is safe. The reintervention rate is comparably high. The long-term results are good.

Dobutamine stress echocardiography

Dobutamine is a synthetic catecholamine with predominant beta-stimulation. Its half-life is approximately 2 min. The positive chronotropic and inotropic effects of dobutamine induce myocardial ischaemia if significant coronary artery obstruction is present. Regional ischaemia produces regional wall motion abnormalities which can be detected by echocardiography. Most dobutamine stress protocols start at an infusion rate of 5 micrograms.kg-1.min-1 and increase to a peak dose of 40 or 50 micrograms.kg-1.min-1; to further increase heart rate, a bolus injection of 0.25-1.0 mg atropine is added. Test endpoints are the detection of new wall motion abnormalities, the occurrence of severe complications or achievement of the target heart rate. Viable myocardial regions have a positive inotropic reserve, which can be stimulated by dobutamine and detected by echocardiography. Indications for the use of dobutamine stress echocardiography are to prove stress-inducible myocardial ischaemia and to detect myocardial viability. The test should only be performed for the detection of stress-induced myocardial ischaemia if patients are unable to undergo exercise echocardiography, or if patients fail to reach their required test level in exercise echocardiography.

Arbutamine stress echocardiography

Arbutamine, a new potent non-selective beta-adrenoceptor agonist with mild alpha 1-sympathomimetic activity, has been developed specifically for pharmacological stress testing. The drug acts like physical exercise, increasing both heart rate and myocardial contractility. Sensitivity, specificity and accuracy in detecting significant stenotic coronary artery disease are 76%, 96%, and 82%, respectively, again similar to those of exercise echocardiography. The drug is delivered by a computerized drug delivery and monitoring device (GenESA) which adjusts the infusion rate according to the patient's heart rate data feedback. The drug is generally well tolerated and has an acceptable safety profile. This article describes recent clinical experience with arbutamine and presents preliminary results of a multicentre multinational study which evaluates the clinical utility and safety of the GenESA system in diagnosing coronary artery disease.

Stress echocardiography: personnel and technical equipment

In recent years, stress echocardiography has gained broad acceptance as a non-invasive method for the diagnosis of coronary artery disease. Facing different protocols, dosages and instrumentation, official guidelines for the performance, standardization and quality control of stress echocardiograms are needed; however, so far they are not available. This paper recommends the type of personnel and technical equipment needed for stress echocardiography laboratories, based on experience gained during more than 2000 stress echocardiographic procedures. To perform stress echocardiography, a cardiologist and a technical assistant--both well trained over a large number of tests--should be involved. The laboratory must have basic equipment such as a 12-lead ECG, blood pressure monitoring capacity, a treadmill or bicycle for ergometry, a precision intravenous delivery system for pharmacological stress testing as well as an adequate echo table; additionally, emergency equipment is mandatory. The ultrasound machine should contain transducers with high 2-D resolution; most important is a digital image acquisition system which facilitates performance and interpretation through side-by-side display of synchronized rest and stress images. Finally, there is a need for proper patient preparation and the obtaining of informed consent.

Detection of myocardial viability using stress echocardiography

Asynergic myocardial regions in patients with coronary artery disease can be viable. They may have the ability to improve their function after restoring coronary blood flow. Asynergic but viable myocardial regions have a positive inotropic reserve which can be stimulated by catecholamines. Because echocardiography is an established method for evaluating regional left ventricular function, it has the potential to detect the inotropic response of asynergic myocardial regions. In the clinical setting, prediction of left ventricular functional improvement after revascularization is particularly important. Dobutamine stress echocardiography is the most frequently used stress echocardiographic test for detection of myocardial viability. Dobutamine is infused at low rates of 2.5 to 20 micrograms.kg-1.min-1 to detect myocardial viability. This paper reports on the sensitivity and specificity of the method for the detection of viability and its usefulness for prediction of left ventricular functional improvement after revascularization.

-Value of activated blood coagulation time in monitoring anticoagulation during coronary angioplasty-

Accurate heparin anticoagulation assessment is important to prevent complications (hemorrhage, thrombotic coronary occlusion) during and after coronary angioplasty (PTCA). Paired ACT-, aPTT- and prothrombin time (PT) measurements have not been studied after PTCA using a high dose heparin management. For that reason we analyzed in 150 consecutive patients (115 m., 35 f., 61 +/- 10 y.) immediately after PTCA and at the time of arterial sheath removal aPTT-(Neothromtin, Behring), PT- (Thromborel S, Behring) and ACT-(HR-ACT, HemoTec) values after application of 20,000 U of heparin (5,000 U intravenous, 15,000 U intracoronary) followed by a heparin-infusion (15,000-25,000 U/24 h). Immediately after PTCA in all patients a aPTT above the upper limit of >180 s was found. The average postprocedural ACT was 330 +/- 82 s. Only 9 patients showed an ACT below 200 s. All coronary reocclusions (n = 3) immediately after PTCA occurred in this group. Arterial sheaths were removed 13 +/- 3 h after PTCA. The incidence of minor peripheral bleeding complications at that time was 21% and was related to the anticoagulation level. Major bleeding complications requiring transfusion were noted in only one case. Our findings suggest that after high dose heparinization for PTCA the ACT test provides a reliable and broad range for the assessment of heparin anticoagulation. In contrast to the aPTT the ACT is ideally suited to determine the dosage of heparin infusion and the time of arterial sheath removal after PTCA. ACT measurements are superior to aPTT measurements in heparin anticoagulation assessment during and direct after PTCA.