Left atrial appendage occluder detachment treated with transthoracic ultrasound combined with digital subtraction angiography guided catcher:A case report

BACKGROUND There are very few cases of cardiac occluder detachment,and it is rare to completely remove the occluder using interventional methods without undergoing thoracotomy surgery after detachment.This case innovatively used ultrasound guidance combined with digital subtraction angiography(DSA)to completely remove the occluder,accumulating some experience.CASE SUMMARY The patient underwent left atrial appendage occlusion surgery in our hospital due to atrial fibrillation.After the surgery,the occluder fell off and became free in the left ventricle,which is very dangerous.We innovatively used ultrasound guidance,combined with DSA,and interventional surgery to successfully capture the free occluder using a catcher,completely remove it,and then re implant a new left atrial appendage occluder.After the surgery,the patient recovered very well.CONCLUSION The size selection of the occluder is slightly conservative,and the shape of the left atrial appendage opening is irregular.

Relationship of inflammatory indices with left atrial appendage thrombus or spontaneous echo contrast in patients with atrial fibrillation

BACKGROUND Inflammatory indices derived from complete blood tests have been reported to be associated with poor outcomes in patients with atrial fibrillation(AF).The data about the relationship between inflammatory indices and left atrial appendage thrombus(LAAT)or dense spontaneous echo contrast(SEC)are limited.AIM To explore the value of inflammatory indices for predicting the presence of LAAT or dense SEC in nonvalvular AF patients.METHODS A total of 406 patients with nonvalvular AF who underwent transesophageal echocardiography were included and divided into two groups based on the presence(study group)or absence(control group)of LAAT or dense SEC.Inflammatory indices,including the neutrophil-to-lymphocyte ratio(NLR),platelet–tolymphocyte ratio(PLR),and lymphocyte-to-monocyte ratio(LMR),were calculated from complete blood analysis.The associations of inflammatory indices RESULTS LAAT and dense SEC were detected in 11(2.7%)and 42(10.3%)patients,respectively.The PLR only showed an association with LAAT/dense SEC in the univariate model.Elevated NLR(odds ratio[OR]=1.48,95%confidence interval[CI]:1.11-1.98,P=0.007)and reduced LMR(OR=0.59,95%CI:0.41-0.83,P=0.003)were found to be independent risk factors for the presence of LAAT/dense SEC.The areas under the NLR and LMR curves for predicting LAAT/dense SEC were 0.73(95%CI:0.66-0.80,P<0.001)and 0.73(95%CI:0.65-0.81,P<0.001),respectively,while the cutoff values were 2.8(sensitivity:69.8%;specificity:64.0%)and 2.4(sensitivity:71.7%;specificity:60.6%),respectively.CONCLUSION Increased NLR and decreased LMR may predict LAAT/dense SEC in patients with nonvalvular AF.

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.

Surgical left atrial appendage occlusion during cardiac surgery： A systematic review and meta-analysis

AIM To evaluate the safety and efficacy of surgical left atrial appendage occlusion(s-LAAO) during concomitant cardiac surgery.METHODS We performed a comprehensive literature search through May 31 st 2018 for all eligible studies comparing s-LAAO vs no occlusion in patients undergoing cardiac surgery. Clinical outcomes during follow-up included: embolic events, stroke, all-cause mortality, atrial fibrillation(AF), reoperation for bleeding and postoperative complications. We further stratified the analysis based on propensity matched studies and AF predominance.RESULTS Twelve studies(n = 40107) met the inclusion criteria.s-LAAO was associated with lower risk of embolic events(OR: 0.63, 95%CI: 0.53-0.76; P < 0.001) and stroke(OR: 0.68, 95%CI: 0.57-0.82; P < 0.0001).Stratified analysis demonstrated this association was more prominent in the AF predominant strata. There was no significant difference in the incidence risk of allcause mortality, AF, and reoperation for bleeding and postoperative complications.CONCLUSION Concomitant s-LAAO during cardiac surgery was associated with lower risk of follow-up thromboembolic events and stroke, especially in those with AF without significant increase in adverse events. Further randomized trials to evaluate long-term benefits of s-LAAO are warranted.

Percutaneous left atrial appendage closure:Technical aspects and prevention of periprocedural complications with the watchman device

Transcatheter closure of the left atrial appendage has been developed as an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation, and as a primary therapy for patients with contraindications to chronic oral anticoagulation. The promise of this new intervention compared with warfarin has been supported by several, small studies and two pivotal randomized trial with the Watchman Device. The results regarding risk reduction for stroke have been favourable although acute complications were not infrequent. Procedural complications, which are mainly related to transseptal puncture and device implantation, include air embolism, pericardial effusions/tamponade and device embolization. Knowledge of nature, management and prevention of complications should minimize the risk of complications and allow transcatheter left atrial appendage closure to emerge as a therapeutic option for patients with atrial fibrillation at risk for cardioembolic stroke.

Left atrial appendage occlusion: A better alternative to anticoagulation?

Non-valvular atrial fibrillation is associated with a significantly increased risk of embolic stroke due to blood clot forming predominantly in the left atrial appendage(LAA). Preventive measures to avoid embolic events are permanent administration of anticoagulants or surgical closure of the LAA. Various clinical trials provide evidence about safety, effectiveness and therapeutic success of LAA occlusion using various cardiac occluder devices. The use of such implants for interventional closure of the LAA is likely to become a valuable alternative for stroke prevention, especially in patients with contraindication for oral anticoagulation as safety, clinical benefit and cost-effectiveness of LAA occlusion has recently been demonstrated.

Left atrial appendage aneurysm: A case report

BACKGROUND An aneurysm of the left atrial appendage is one of the rare but potentially hazardous heart defects.The risk of lethal complications grows with its size.To date,about 150 cases of this defect have been described in the literature.We present a case of left atrial appendage aneurysm with the deformation of the mitral valve and the left main coronary and circumflex artery,which required mitral valve annuloplasty and bifurcation stenting.CASE SUMMARY A 58-year-old man presented to our hospital complaining of shortness of breath,general weakness,dizziness during physical exertion,and fatigue.Based on the results of echocardiography,an aneurysm of the left atrium was suspected.A free-breathing real-time cine magnetic resonance imaging with electrocardiograph synchronization confirmed the diagnosis of left atrial appendage aneurysm.The patient underwent an aneurysmectomy via a median sternotomy with cardiopulmonary bypass.Intraoperative transesophageal echocardiography revealed relative mitral insufficiency that was corrected with an annuloplasty ring.Intraoperative coronary angiogram showed impaired blood flow in the left main coronary and circumflex artery and 60%stenosis.For this reason,bifurcation stenting was performed.The patient had an uneventful postoperative clinical course and was discharged from the hospital on the 10th day in a satisfactory condition.CONCLUSION Left atrial appendage aneurysm is a rare and dangerous heart pathology that requires surgery to prevent related complications.

Delayed cardiac tamponade after simultaneous transcatheter atrial septal defect closure and left atrial appendage closure device implantation: a particular case report

Percutaneous left atrial appendage(LAA)occlusion evolved as an alternative treatment to the patients who are contraindicated or cannot tolerate oral anticoagulants with nonvalvular atrial fibrillation(AF)at risk of stroke or systemic embolism.[1]Abnormal hemodynamic changes in elder atrial septal defect(ASD)patients cause remodeling of the left atrium,which eventually leads to right heart failure.[2]As the ASDs elderly are associated with a higher incidence of AF,simultaneous transcatheter ASD and LAA closure has become a new effective therapeutic strategy.However,only a limited number of articles involving cardiac tamponade complications have been published in the literature.What’s more,previous studies involving early hemodynamically irrelevant pericardial effusion after the procedure attribute to multiple repositioning attempts of LAA occluder or delivery sheath injured the atrial wall.

Simultaneous Transcatheter Closure of the Left Atrial Appendage and Congenital Interatrial Communication Closure

Background:Left atrial appendage closure(LAAC)with simultaneous interventional occlusion therapy for congenital interatrial communication has become a new focus of patients with nonvalvular atrial fibrillation.Little is known about the results of mid-and long-term results.Objective:The aim of this study was to evaluate the midand long-term safety and effectiveness of simultaneous transcatheter closure of the left atrial appendage(LAA)and congenital interatrial communication closure in atrial fibrillation(AF)patients.Methods:From Jan 2016 to June 2017,27 patients with AF were treated with simultaneous transcatheter closure of the LAA and atrial septal defect(ASD,n=22),patent foramen ovale(PFO,n=5).Results:The perioperative closure success rate was 96.3%,except for cardiac tamponade occurred in one ASD patient.During the median 37.6-month follow-up period,no cases of cerebrovascular or peripheral vascular embolism,bleeding,infective endocarditis or thrombosis along the occluders were observed.Of the 21 patients with NYHA Class III,nineteen had significant improvements to NYHA Classes I or II,and 81.5%of patients were free from major or minor adverse events during midand long-term follow-up.Conclusions:Simultaneous closure of the LAA and congenital interatrial communication closure is a viable option for patients with nonvalvular atrial fibrillation who are at risk of stroke or systemic embolism,and it is effective and yields excellent mid-and long-term results.

Left atrial appendage occlusion in a mirror-image dextrocardia:A case report and review of literature

BACKGROUND In mirror-image dextrocardia,the anterior-posterior position of the cardiac chambers and great vessels is maintained,but the left-right orientation of the abdominal organs is reversed.The abnormal anatomy of the heart poses surgical challenges and problems in dealing with surgical risk and monitoring complications.There are few reports on closure of the left atrial appendage(LAA)in dextrocardia and no reports on the application of enhanced recovery after surgery(ERAS)following LAA occlusion(LAAO)procedures.CASE SUMMARY The objective for this case was to ensure perioperative safety and accelerate postoperative recovery from LAAO in a patient with mirror-image dextrocardia.ERAS was guided by the theory and practice of nursing care.Atrial fibrillation was diagnosed in a 77-year-old male patient,in whom LAAO was performed.The 2019 guidelines for perioperative care after cardiac surgery recommend that the clinical nursing procedures for patients with LAAO should be optimized to reduce the incidence of perioperative complications and ensure patient safety.Music therapy can be used throughout perioperative treatment and nursing to improve the anxiety symptoms of patients.CONCLUSION The procedure was uneventful and proceeded without complications.Anxiety symptoms were improved.

Evaluation of left atrial remodelling following percutaneous left atrial appendage closure

Atrial fibrillation prevalence is increasing with age, reaching up to 5% of patients older than 65 years, and is associated with 20%-30% of stroke episodes in that population.

Cryoballoon pulmonary vein isolation and left atrial appendage occlusion prior to atrial septal defect closure: A case report

BACKGROUND In patients who suffer from both atrial fibrillation(AF)and atrial septal defect(ASD),cryoballoon pulmonary vein isolation(PVI),sequential left atrial appendage(LAA)occlusion and ASD closure could be a strategy for effective prevention of stroke and right heart failure.CASE SUMMARY A 65-year-old man was admitted to our institution due to recurrent episodes of palpitations and shortness of breath for 2 years,which had been worsening over the last 48 h.He had a history of AF,ASD,coronary heart disease with stent implantation and diabetes.Physical and laboratory examinations showed no abnormalities.The score of CHA2DS2VASc was 3,and HAS-BLED was 1.Echocardiography revealed a 25-mm secundum ASD.Pulmonary vein(PV)and LAA anatomy were assessed by cardiac computed tomography.PV mapping with 10-pole Lasso catheter was performed following ablation of all four PVs with complete PVI.Following the cryoballoon PVI,the patient underwent LAA occlusion under transesophageal echocardiographic monitoring.Lastly,a 34-mm JIYI ASD occlude device was implanted.A follow-up transesophageal echocardiography at 3 mo showed proper position of both devices and neither thrombi nor leakage was found.CONCLUSION Sequential cryoballoon PVI and LAA occlusion prior to ASD closure can be performed safely in AF patients with ASD.

Left atrial appendage in acute coronary syndromes: small but not insignificant

In this issue of Journal of Geriatric Cardiology, Dr.Piotrowski and colleagues explored the function of the left atrial appendage (LAA)-a small, blind-ended structure of the heart which has been often ignored by cardiologists.

Non-electrocardiography-gated dual-energy cardiac CT angiography for assessment of left atrial appendage thrombus

Objective:To explore the diagnosis value of a low dose,dual-energy cardiac computed tomography angiography(CTA)with non-electrocardiography-gated(non-ECG-gated)in detecting left atrial appendage(IAA)thrombus.Methods:Consecutive patients with atrial fibrillation who underwent cardiac CTA protocol(dual-energy scan for arterial phase and conventional scan for delayed phase)were prospectively enrolled.LAA lesions were proved by clinical comprehensive diagnosis,the final study included 18 cases with LAA thrombus and 48 cases with circulatory stasis.Quantitative parameters derived from dual-energy images were measured for the LAA lesions,including the conventional CT attenuation value(CT value),iodine concentration(IC),normalized iodine concentration(NIC),effective atomic number values(Zeff)and energy spectrum curve slope(Slope).The differences between LAA thrombus group and circulatory stasis group were compared by independent sample t-test or Wilcoxon rank sum test regarding to the normality test.The diagnosis performance of the dual-energy parameters was assessed using receiver operating characteristic(ROC)curve analysis and area under curve(AUC).Results:All the dual-energy parameters were demonstrated significantly difference between LAA thrombus and circulatory stasis group(P<0.05),and showed better diagnostic performance than the conventional CT value.ROC analysis revealed IC was the most predictive parameter with AUC equal to 0.836.The radiation dose in the arterial phase was(2.640.66)mSv.Conclusion:Dual-energy CTA scanning shows convincing diagnostic performance in detecting left atrial appendage thrombus with lower radiation dose,and may help reduce the need for delayed phase scan.

Current Status of Left Atrial Appendage Thrombus with Atrial Fibrillation

Cardiac thrombus in patients with atrial fibrillation (AF) is most commonly found in the left atrial appendage (LAA). The incidence of LAA thrombus ranges from 1.2% to 22.6%, with the vast variation in incidence attributed to the patient’s condition. The effective rate of anticoagulation for thrombus dissolution therapy is only 50%-60%, and long-term anticoagulation treatment increases the risk of bleeding. Direct percutaneous LAA closure in AF patients with LAA thrombus in a suitable location is another alternative treatment option. LAA resection with cardiac surgery is also an effective treatment. This review presents the development of the incidence, diagnosis, and treatment of thrombus in LAA.

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.

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.

Left atrial appendage morphology in patients with atrial fibrillation in China： implications for stroke risk assessment from a single center study

Background The left atrial appendage （LAA） is thought to be the main source of thrombi in patients with atrial fibrillation （AF）. The purpose of this study was to describe the LAA orifice diameter, LAA length, and morphologic type of the LAA in Chinese patients with AF as well as to evaluate whether these LAA parameters are associated with a history of stroke in patients with AF from a single center in China. Methods The study population consisted of 219 consecutive patients with drug-refractory, symptomatic paroxysmal, or persistent AF scheduled to undergo radiofrequency catheter ablation in our single center. All patients underwent extensive clinical assessment and multidetector computed tomography to fully explore the anatomy of the LAA. Results Of the 219 patients who underwent catheter ablation procedures, chicken wing LAA morphology was found in 114 patients （52.2%）, windsock in 52 （23.9%）, cauliflower in 29 （13.0%）, and cactus in 24 （10.9%）. Compared with the windsock LAA morphology, cactus had a larger left atrial diameter （（42.40±3.68） and （37.91±4.32） mm, P=-0.005） and LAA orifice diameter （（27.38±3.70） and （24.14±3.58） mm, P=0.048）. The LAA length was significantly larger in the chicken wing morphology than in the windsock （（37.50±6.74） and （31.33±3.92） ram, P=0.015） and cauliflower morphologies （（37.50±6.74） and （31.33±3.92） mm, P=-0.015）. According to their medical records, 26 patients （11.9%） had suffered a prior stroke. Compared with patients who had no history of stroke, the prior-stroke patients were older （62.04±8.07 and 58.24±9,24, P=-0.047） and there were fewer patients with chicken wing （23.1% and 59.1%, P=-0.001） and more patients with cauliflower （26.9% and 9.8%, P=-0.046）. Multivariate Logistic regression analysis demonstrated that age （odds ratio （OR） 1.26; 95% confidence interval （CI） 1.08-1.47; P=0.003）, non-chicken wing morphology （OR 5.82; 95% CI 1.61- 21.03; P=-0.007）, and LAA orifice diameter （OR 1.25; 95% CI 1.05-1.49; P=0.014） were independent predictors of stroke after adjusting for all parameters that emerged as potential confounders with univariate analysis. Conclusion LAA analysis can potentially be used to inform guidance on the implication for stroke risk assessment.

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.

Assessment of the morphology and mechanical function of the left atrial appendage by real-time three-dimensional transesophageal echocardiography

Background The left atrial appendage （LAA） is an important source of thrombus formation. We investigated the feasibility of the recently developed real-time three-dimensional transesophageal echocardiography （RT3D-TEE） method in assessment of the morphology and function of the LAA. Methods Ninety-six consecutive patients （58 males with a mean age of （43.4±12.5） years） who were referred for 2-dimensional （2D） transesophageal echocardiography （TEE） underwent additional RT3D-TEE. LAA morphology was visualized in multiple views. Orifice size, depth, volumes and ejection fraction （EF） of the LAA, were measured. Results All the patients underwent RT3D-TEE examination without complications. Ninety-two patients （95.8%） had adequate images for visualization and quantitative analysis of the LAA. The LAA exhibited great variability with respect to relative dimensions and morphology. LAA orifice area was （3.8±1.2） cm^2 with a diameter of （2.4±0.9） cm x （1.4±0.6） cm. The mean depth of the LAA was （2.9±0.7） cm. End-diastolic volume （EDV-LAA）, end-systolic volume （ESV-LAA） and EF of the LAA were （6.2±3.7） ml, （4.1±2.8） ml, and 0.35±0.16, respectively. EDV-LAA, ESV-LAA and the orifice area of the LAA in patients with atrial fibrillation （AF） were larger than those without AF, whereas the EF was smaller in the AF patients. Conclusions Defining LAA morphology and quantitative analysis of the size and function of the LAA with superior quality and resolution of images using RT3D-TEE is feasible. This technique may be an ideal tool for guidance of the LAA occlusion procedure. Determination of LAA volumes and volume-derived EF by RT3D-TEE provides new insights into the analysis of LAA function.