Progress in the study and treatment of peri-device leak after left atrial appendage closure

For patients with atrial fibrillation with an increased risk of stroke and contraindications to long-term anticoagulation,percutaneous left atrial appendage closure(LAAC)has become an important alternative to long-term oral anticoagulation.Incomplete closure of the LAAC during the procedure leads to faster blood flow in the interstitial space around the device,resulting in peri-device leak(PDL),which is not uncommon.Studies are still inconclusive in determining the incidence,long-term safety,and management of PDL.Therefore,this article reviewed the progress made in the research and treatment of PDL after LAAC.

One-stop strategy for treatment of atrial fibrillation:feasibility and safety of combining catheter ablation and left atrial appendage closure in a single procedure

Background:Catheter ablation is effective in restoring sinus rhythm and left atrial appendage closure(LAAC)is increasingly used for stroke prevention in patients with atrial fibrillation(AF).We aimed to observe the feasibility and safety of performing AF ablation and LAAC in a single(one-stop)procedure.Methods:Consecutive AF patients who underwent the combined procedure of AF ablation and LAAC with WATCHMAN device between March 2017 and September 2018 were prospectively enrolled.Baseline and intra-procedural parameters were evaluated.Three-month and subsequent 1-year follow-up were performed in all and earlier-enrolled subjects,respectively.Results:A total of 178 AF patients(94 males,68.9±8.1 years)underwent the one-stop procedure with CHA2DS2-VASc score 3.3±1.5 and HAS-BLED score 1.6±1.0,respectively.Pulmonary vein isolation was achieved in all patients while additional linear ablation was applied if the operator deemed necessary,yielding immediate ablation success rate of 98.9%(176/178).In the subsequent LAAC,satisfactory seal(residual leak<5 mm)was achieved in all patients.One stroke and four cardiac perforations occurred peri-operatively.At 3-month follow-up,sinus rhythm and satisfactory seal were maintained in 153/178(86.0%)and 178/178(100%)patients,respectively.One stroke and one delayed cardiac tamponade occurred,while no device-related thrombus or device migration was observed.During the 1-year follow-up for the earlier enrolled subjects,52/72(72.2%)of the patients maintained sinus rhythm.There was no stroke or systemic embolism observed.Conclusion:Combining catheter ablation and LAAC in a single procedure can be successfully and safely performed in non-valvular AF patients of Chinese population.

Management of cerebral amyloid angiopathy and atrial fibrillation:We are still far from precision medicine

The use of anticoagulation therapy could prove to be controversial when trying to balance ischemic stroke and intracranial bleeding risks in patients with concurrent cerebral amyloid angiopathy(CAA)and atrial fibrillation(AF).In fact,CAA is an age-related cerebral vasculopathy that predisposes patients to intracerebral hemorrhage.Nevertheless,many AF patients require oral systemic dose-adjusted warfarin,direct oral anticoagulants(such as factor Xa inhibitors)or direct thrombin inhibitors to control often associated with cardioembolic stroke risk.The prevalence of both CAA and AF is expected to rise,due to the aging of the population.This clinical dilemma is becoming increasingly common.In patients with coexisting AF and CAA,the risks/benefits profile of anticoagulant therapy must be assessed for each patient individually due to the lack of a clear-cut consensus with regard to its risks in scientific literature.This review aims to provide an overview of the management of patients with concomitant AF and CAA and proposes the implementation of a risk-based decision-making algorithm.

Efficacy and Safety of the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Chinese Patients with Nonvalvular Atrial Fibrillation： A Single-center, Prospective, Observational Study

Background： In patients with nonvalvular atrial fibrillation （NVAF）, embolic stroke is thought to be associated with left atrial appendage （LAA） thrombi. The WATCHMAN LAA Occlusion Device has been shown to be noninferior to conventional oral anticoagulation with warfarin for stroke prevention in patients with NVAF. This study aimed to evaluate the procedural feasibility, safety and 12-month outcomes of the WATCHMAN LAA Occlusion Device in NVAF patients with high risk for stroke in China. Methods： The clinical data of 106 NVAF patients, who were consecutively underwent LAA closure with the WATCHMAN Device between April 2014 and May 2015, were collected. Patients were followed up at 1,3, 6, and 12 months after discharge. A transesophageal echocardiograph was performed at 45 days after implantation and repeated in case of an unexpected event during the follow-up period. Results： This study included 106 NVAF patients with a mean age of 64.2 ± 8.6 years （ranging from 50 to 88 years）, and the mean CHA,DS,-VASc score of all patients was 3.6 ± 1.6 （ranging from 2 to 9）. Among those 106 NVAF patients, 100 （94.3%） patients were implanted with the device successfully. The procedural success rate was 94.3% （100/106）, and the occlusion rate was 100.0% （100/100）. There were one tamponade, one ischemic stroke, and eight minor pericardial effusions during hospitalization. During 12-month follow-up period, two patients developed a tbrombus layer on the device that resolved with additional anticoagulation： one with visible device-thrombus experienced transient ischemic stroke, and one had a hemorrhagic stroke. There were no deaths in this study. The overall survival rate was 100.0%, and nonmajor adverse event rate was 95.0% （95/100）. In this study, the expected annual rate ofischemic stroke risk in these patients according to the CHA2DS2-VASc score was 4.0%, while the observed ischemic stroke rate was 2.0% per year. Conclusions： LAA closure with the WATCHMAN Device was feasible, efficient, and safe for NVAF to prevent the accidence of stroke in Chinese patients. During the 12-month follow-up period, the observed ischemic stroke rate （2.0% per year） in our study was lower than the predicted annual stroke risk （4.0%） using the CHA2DS：-VASc score.