Contemporary left atrial appendage management during adult cardiac surgery

Robotic-assisted biatrial Cox-maze ablation for atrial fibrillation

Left Atrial Reduction Plasty: A Novel Technique

Commentary: The appendage strikes back: The last surgeon

Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

PERCUTANEOUS LEFT ATRIAL APPENDAGE OCCLUSION : INITIAL EXPERIENCE WITH THE ARTICULATED ULTRASEPT LAA OCCLUDERTM

Background In the recent ESC/EACTS guidelines, left atrial appendage (LAA) occlusion or exclusion in patients undergoing (thoracoscopic) atrial fibrillation (AF) ablation surgery is recommended. The Watchman device (WD, Boston Scientific, Minnesota) has proved to reduce the risk of thromboembolic events by closing of the LAA, yet no data exist on WD implantation during surgical AF ablation. The objective is to determine if WD implantation is safe and feasible in a hybrid AF ablation setting (i.e., combination of thoracoscopic epicardial surgical and endocardial catheter ablation) and could become subject of further testing to serve as a bail-out in cases in which surgical LAA occlusion methods cannot be applied, due to, for example, severe adhesions. Methods In this prospective, single center, pilot study, 10 consecutive patients undergoing a hybrid ablation qualifying for LAA exclusion (CHA2DS2-VASc ≥ 1) were included. At the end of the hybrid ablation, the LAA was occluded endocardially using the WD. The feasibility endpoint was successful implantation. The safety endpoint concerned major complications. Results One patient was excluded and replaced because the LAA was insufficiently visible on transesophageal echocardiography. In 10/11 patients, device delivery was successful (mean time: 35 minutes). No major complications occurred. Transesophageal echocardiography after 6 weeks and 6 months showed successful occlusion of the LAA without significant peridevice flow. Conclusion Implantation of the WD seems to be feasible and safe in the setting of hybrid AF ablation and could be an alternative to epicardial occlusion in surgical AF ablation procedures. Larger studies are required to confirm these findings. This trial is registered with NCT02471131.

Malignant left atrial appendage morphology and embolization risk in atrial fibrillation

To the Editor: With great interest we read the article by Onalan et al about left atrial appendage (LAA) exclusion for stroke prevention in nonrheumatic atrial fibrillation (AF).1 We share the author’s concerns about the hazards of this procedure and would like to emphasize additional arguments. There is no evidence that thromboembolism in AF exclusively derives from LAA thrombi detected by transesophageal echocardiography. The prevalences (4% to 21%) of LAA-thrombi were found in studies of acutely sick patients, patients before cardioversion, cardiac surgery or after recent embolism. Contrarily, when prospectively investigating clinically stable outpatients with AF and no recent embolism by transesophageal echocardiography, the prevalence of LAA thrombi was only …

Objective To evaluate the role of real-time three-dimensional transesophageal echocardiography(RT-3D TEE) in left atrial appendage (LAA) occlusion. Methods Consecutive 10 atrial fibrillation (AF) patients (CHADS2≥2) with high risk bleeding underwent LAA occlusion under the guidance of TEE. The LAA orifice shape and characteristics of lobes were assessed, the size of LAA with RT-3D TEE wee measured before closer implanation, and the position of the LAA occlusion device were evaluated by RT-3D TEE.The correlational analysis between LAA diameter and occluder size was conducted. Results Among 10 patients, the test results revealed 8 cases with complete LAA occlusion and 1 case with incomplete occlusion, and 1 case with failed occlusion. Five cases showed approximate round LAA ostium, and the other 5 showed approximate oval ostium. The average number of LAA lobes were 2.2±0.7. LAA ostium long diameter were larger by 3D TEE compared with 2D TEE[(21.8±5.1)mm vs (20.8±4.1)mm], and ostium short diameter were smaller by 3D TEE compared with 2D TEE[(16.1±3.0)mm vs (17.0±2.6)mm], however there were no significant differences between 2D and 3D TEE measurements, and the mean ostium diameter and LAA depth were comparable between two methods. LAA ostium long diameter, short diameter, average diameter and LAA depth assessed by 3D TEE and 2D TEE showed good correlation with occluder diameter (3D TEE: r=0.719, 0.690, 0.791, 0.711, and P=0.029, 0.040, 0.011, 0.032, respectively; 2D TEE: r=0.887, 0.894, 0.932, 0.896, and P=0.001, 0.001, 0.000, 0.000, respectively). LAA occlusion device position assessed by RT-3D: 6 cases with appropriate position, acceptable position with 2 cases, and 1 case with malposition. Conclusions RT-3D TEE can play important role in evaluating the morphology of LAA, accurately judging LAA ostium shape and size and position of the occlusion device. Key words: Echocardiography, transesophageal; Echocardiography, real-time three-dimensional; Left atrial appendage; Occlusion

Funding Acknowledgements Type of funding sources: None. Background Percutaneous endocardial left atrial appendage (LAA) occlusion (LAAO) in non-valvular atrial fibrillation (AF) seems comparable to anticoagulation therapy (OAC) as regards thromboembolic risk reduction with a possible additional decrease in major bleeding. LAAO is currently limited to patients with contraindications to OAC, due to its high costs and procedural risks, but better pre-procedural planning and operative techniques might improve the outcome widening practical indications. Computational fluid dynamics (CFD) represents a valuable non-invasive approach to estimate physiologically significant hemodynamic parameters in a complex fluid dynamics system. It might provide a helpful in silico simulation of blood flow patterns within the LA and LAA by using 3D patient-specific models, allowing LAAO planning and effects prediction. Purpose This study’s aim was to simulate the fluid dynamics effects of LAAO in AF patients to predict patient-specific hemodynamic changes caused by applying the two most popular devices. Methods LAAO was simulated on the 3D LA anatomical models obtained from CT data in 5 AF patients, considering the device specific shape. CFD simulations in AF condition were performed both on the whole LA model and on the models with the LAAO performed with the two devices. Significant fluid dynamics indices (blood velocity, vortex structures, LAA ostium velocity, LA blood stasis) were computed to evaluate the changes in the flow patterns after LAAO in relation to the thrombogenic risk. Results Overall we found a more effective washout within the LA after LAAO, in terms of a different spatial distribution of velocities (see figure for a qualitative evaluation of LA blood flow velocity in one patient: (A) model with LA and LAA; models after LAAO applying the Amulet (B) and the Watchman (C) device) and vortex structures (after LAAO, they were decreased in number and increased in size). Moreover, a higher velocity at the mitral valve and at the LAA ostium (peak velocity: 12-17 cm/s in the models with LAA, 40-60 cm/s in LAAO_A and 35-65 in LAAO_W) was detected together with a slightly improved washout effect in terms of blood stasis with the Watchman device (stasis: 3.1-5.7% in the models with LAA, 1.9-4.1% in LAAO_A, 1.7-3.7% in LAAO_W). Conclusions A workflow for simulating the fluid dynamics effects of endocardial LAAO in AF was developed and tested. CFD provides a valuable tool to quantify hemodynamic changes after LAAO and assess thrombogenic risk in patient-specific LA and LAA. Our preliminary results suggest that endocardial LAAO favourably affects blood fluid dynamics in the LA. Abstract figure

Key Findings▪Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative strategy to oral anticoagulants in selected patients with atrial fibrillation.▪The landmark trials comparing LAA occlusion to an oral anticoagulation strategy enrolled patients with no apparent contraindications to the use of warfarin.▪LAA occlusion has limited head-to-head comparison against the direct-acting oral anticoagulants.▪Observational data to date have generally shown specific adverse events after LAA occlusion in specific subgroups of patients (women, patients with kidney disease and heart failure, patients belonging to racial/ethnic subgroups and with advanced age), but further large-scale studies are necessary to elucidate reasons for increased adverse events associated with LAA occlusion in these subgroups of patients before recommending this modality as first-line therapy in all patient groups. ▪Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative strategy to oral anticoagulants in selected patients with atrial fibrillation.▪The landmark trials comparing LAA occlusion to an oral anticoagulation strategy enrolled patients with no apparent contraindications to the use of warfarin.▪LAA occlusion has limited head-to-head comparison against the direct-acting oral anticoagulants.▪Observational data to date have generally shown specific adverse events after LAA occlusion in specific subgroups of patients (women, patients with kidney disease and heart failure, patients belonging to racial/ethnic subgroups and with advanced age), but further large-scale studies are necessary to elucidate reasons for increased adverse events associated with LAA occlusion in these subgroups of patients before recommending this modality as first-line therapy in all patient groups.

ORAL PRESENTATION

Commentary: Are the atrial fibrillation ablation guidelines wrong?

Commentary: Making it look like open cardiac surgery and better

POSTER PRESENTATIONS