Abstract
Aim. To assess procedural and long-term efficacy and safety of two alternative methods for appendage closure, conscious sedation with standard transoesophageal echo and procedure guided by rotational angiography. Background. Demand for appendage closure is increasing, and a reasonable time-response should be given to nonvalvular atrial fibrillation patients not suitable to receive anticoagulation. General anesthesia and the need for an anesthesiologist are limiting factors to improve procedure availability; it is time to introduce simpler approaches. Methods. Single center experience in appendage closure during 9 years, using three different procedural approaches: general anesthesia with echo guidance, conscious sedation with echo guidance, and rotational angiography guidance. Conscious sedation and rotational angiography-guided procedures were performed in the absence of an anesthesiologist. Procedural characteristics and follow-up events were recorded. Results. 260 consecutive appendage closure procedures were reviewed: 155 were performed under general anesthesia (59.6%), 71 were performed with conscious sedation (27.3%), and 34 were rotational angiography guided (13.1%). Device success rate for procedures guided by rotational angiography was significantly lower than that for general anesthesia and conscious sedation (91.2% versus 100% versus 98.6%, p = 0.001 ) because there was a greater need to recapture and change device size. However, final procedural success was high and without difference between approaches (98.8% versus 97.2% versus 100%, for general anesthesia, conscious sedation, and rotational angiography, respectively); with a median follow-up of 17 months (CI 95% 13–23 month) (637.9 patients-year), there was no difference among approaches for thromboembolic (1.3 versus 1.8 versus 1.8) and major bleeding events (3.2 versus 2.8 versus 1.8), respectively. Conclusions. Appendage closure performed, either with conscious sedation with echo guidance or rotational angiography guided, is feasible, with no difference in procedural success and follow-up events compared with general anesthesia and without the limitation of the need for an anesthesiologist on-site.
Highlights
Left atrial appendage closure (LAAC) is the second most commonly performed structural procedure in Spain [1], 921 interventions in 2019
As LAAC becomes more frequently used in our daily practice, there is a greater need to improve its availability, so that we may reduce the time at the risk of ischemic stroke or severe bleeding in patients with nonvalvular atrial fibrillation and contraindication for oral anticoagulation
It is generally assumed that general anesthesia is one of the most limiting factors for LAAC availability as it requires the presence of an anesthesiologist
Summary
Left atrial appendage closure (LAAC) is the second most commonly performed structural procedure in Spain [1], 921 interventions in 2019. As LAAC becomes more frequently used in our daily practice, there is a greater need to improve its availability, so that we may reduce the time at the risk of ischemic stroke or severe bleeding in patients with nonvalvular atrial fibrillation and contraindication for oral anticoagulation. Journal of Interventional Cardiology echocardiography (TOE) examination. It results in greater patient comfort and improved procedural safety. It is generally assumed that general anesthesia is one of the most limiting factors for LAAC availability as it requires the presence of an anesthesiologist. In an attempt to avoid the need for general anesthesia and to facilitate the performance of LAAC, other procedural approaches such as micro-TOE probe with conscious sedation [3], intracardiac echo [4], and even 3D computed tomography fusion images [5] have been described. Computed tomography studies are usually acquired at a different time and under different hemodynamic conditions than LAAC procedure
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