Endocardial Closure Research Articles

Impacts of Left Atrial Appendage Treatments on Mitral Valve Diseases during Surgical Ablations.

Left atrial appendages (LAAs) play an important role in regulating left atrial function, and much evidence supports the possibility that changes in left atrial structure may cause or worsen mitral regurgitation. This study intended to investigate the outcomes of patients with mitral regurgitation who underwent left atrial appendage closure (resection or endocardial closure) during isolated surgical ablations. Patients with mild or moderate mitral regurgitation who received isolated surgical ablations for atrial fibrillation (AF) in our center from 2013 to 2022 were referred. During follow-up, each clinical visit was composed of medical interrogation, a 24 h Holter, and echocardiographic evaluation. Death, atrial fibrillation, worsening of mitral regurgitation, and stroke were evaluated as outcomes. Freedom from outcomes whose results were adjusted by inverse probability of treatment weighting for causal effects after acquiring propensity scores. A total of 456 patients were enrolled in this study. During a median follow-up of 48 months, 30 deaths and 11 cases of stroke were observed. After adjustments, no significant differences in terms of death or stroke were observed among the three groups. Patients who underwent resection or endocardial closure during surgical ablations had a higher risk of mitral regurgitation worsening during follow-up (p 0.05). During the whole follow-up, patients who underwent left atrial appendage interventions showed significantly larger left atrial and mitral annular diameters, as well as lower tethering height than those who had left atrial appendage preserved (all p 0.05). Mitral regurgitation was more likely to get worse when patients with fundamental mitral diseases underwent LAA interventions during isolated surgical AF ablations. In the absence of LAA, the dilation of the left atrium and mitral annulus may ultimately lead to worsening of regurgitation.

Left Atrial Appendage Closure with Watchman vs Amulet Devices: Similarities and Differences.

Left atrial appendage closure (LAAC) has shown to be non-inferior to oral anticoagulation (OAC) for non-valvular atrial fibrillation (AF). LAAC is now becoming a leading method for stroke prophylaxis in patients who have atrial fibrillation and are unable to tolerate OAC. There are currently two FDA-approved endocardial closure devices, namely, the Watchman FLX and Amplatzer Amulet. Current data highlights that both devices offer similar efficacy and safety for LAAC. While the two devices differ in terms of intraprocedural complication rates, they offer similar short- to long-term outcomes in regard to peri-device leaks, device-related thrombosis, and mortality. With similar risk and safety profiles, both devices are indicated for patients who are unable to tolerate OAC. Newer clinical studies are directed to establish the efficacy of both devices as the primary method for stroke prevention in AF as an alternate to OAC.

Feasibility of the AtriClip Pro Left Atrium Appendage Elimination Device via the Transverse Sinus in Minimally Invasive Mitral Valve Surgery.

BackgroundAchieving external access to and manual occlusion of the left atrial appendage (LAA) during minimally invasive mitral valve surgery (MIMVS) through a small right thoracotomy is difficult. Occlusion of the LAA using an epicardial closure device seems quite useful compared to other surgical techniques.MethodsFourteen patients with atrial fibrillation underwent MIMVS with concomitant surgical occlusion of the LAA using double-layered endocardial closure stitches (n=6, endocardial suture group) or the AtriClip Pro closure device (n=8, AtriClip group) at our institution. The primary safety endpoint was any device-related adverse event, and the primary efficacy endpoint was successful complete occlusion of blood flow into the LAA as assessed by transthoracic echocardiography at hospital discharge. The primary efficacy endpoint for stroke reduction was the occurrence of ischemic or hemorrhagic neurologic events.ResultsAll patients underwent LAA occlusion as scheduled. The cardiopulmonary bypass and aortic cross-clamp times in the endocardial suture group and the AtriClip group were 202±39 and 128±41 minutes, and 213±53 and 136±44 minutes, respectively (p=0.68, p=0.73). No patients in either group experienced any device-related serious adverse events, incomplete LAA occlusion, early postoperative stroke, or neurologic complication.ConclusionEpicardial LAA occlusion using the AtriClip Pro during MIMVS in patients with mitral valve disease and atrial fibrillation is a simple, safe, and effective adjunctive procedure.

Long-Term Follow-Up of Pediatric Patients After Congenital Coronary Artery Fistula Closure.

The surgical closure of congenital coronary artery fistulas (CAF) is associated with excellent immediate outcomes. Few studies have investigated the long-term prognosis in patients who have undergone surgery for the closure of CAF or differentiated among types of CAF or types of surgical procedures. In this study, we performed clinical examinations and computed tomography angiography (CTA) to characterize outcomes after CAF closure in pediatric patients. The medical records of 79 pediatric patients who underwent surgical closure of CAF were retrospectively reviewed. The median age of the patients included in the study at the time of surgery was 3.4years (range 0.2 to 15.3years). The patients had been followed up for 11years (range 1 to 17years) with electrocardiography, echocardiography, and coronary CTA. There were 67 medium-to-large CAF and 12 small CAF. Twenty-six (32.9%) CAF arose from the branch coronary artery (proximal type); the others arose from the parent coronary artery (distal type). The surgical procedure included endocardial closure in 16 cases, epicardial distal ligation in 51 cases, epicardial proximal and distal ligation in 12 cases. There was no instance of perioperative death among the cases included in the study. Twenty-eight patients were treated with antiplatelet medication postoperatively. No patient required re-operation during the follow-up period. Coronary thrombi were detected in 27 patients (34.2%). There was no instance of myocardial ischemia related to thrombosis. Among the patients with thrombosis, 26 had medium-to-large CAF (96.3%), and 23 had distal-type CAF (85.2%). Average age at surgery was higher among the patients with thrombosis than among the patients without thrombosis (7.4years vs. 3.3years, t = 5.509, P = 0.000). Among the patients with distal-type CAF, thrombosis was more common among the patients treated with ligation than treated with endocardial closure (41.5% vs. 16.7%, χ2 = 3.742, P = 0.043). There was no difference in risk for thrombosis between the patients who did vs. did not receive antiplatelet therapy (P = 0.436). The most common complication after CAF closure was thrombosis. Increased risk for thrombosis was associated with large fistulae, distal-type CAF, and older age at presentation. Antiplatelet treatment did not appear to decrease the risk of thrombosis. Among patients with distal-type CAF, risk for thrombosis was lower among patients treated with endocardial closure, compared with patients treated with epicardial ligation.

Left Atrial Appendage Closure: Technical Considerations of Endocardial Closure.

Left atrial appendage closure (LAAC) is a safe and effective therapy for the prevention of stroke in patients with nonvalvular atrial fibrillation and high bleeding risk with oral anticoagulants. Multimodality imaging with transesophageal echocardiography and computed tomography angiography to define the anatomy and its implications on endocardial exclusion is becoming increasingly important. The only LAAC device currently approved for clinical use in the United States is the WATCHMAN device. Systematic assessment of the transseptal crossing site, left atrial appendage anatomy, adequate device size selection, and device postdeployment evaluation is essential for the safety and efficacy of the procedure.

Management Techniques of Coronary Fistulae

Coronary fistulae are rare anomalies that present in both children and adults. The majority are congenital in origin and require intervention to treat or prevent complications. While transcatheter closure of coronary fistula is possible, surgical management can be performed with low mortality and morbidity. A number of surgical techniques exist including epicardial closure, endocardial closure, and transcoronary closure of the fistula with or without the use of cardiopulmonary bypass. Herein we describe the surgical techniques of coronary fistula repair.

Surgical Management of Left Circumflex Coronary Artery Fistula: A 25-Year Single-Center Experience in 29 Patients

Left circumflex coronary artery (LCX) fistula is rare, and surgical experience is limited. We report our experience with 29 patients with LCX fistula during a 25-year period in terms of clinical features, pathology, surgical procedure, and late outcomes. Between June 1988 and July 2013, 29 patients (19 males, 10 females; median age, 10 years) with LCX fistula were treated surgically and followed up. Preoperative diagnosis was made echocardiographically in 29 patients and angiographically in 17. The fistula drained into the right atrium in 12, the right ventricle in 8, left atrium and left ventricle, each in 3, main pulmonary artery in 2, and coronary sinus in 1. Surgical procedure included endocardial closure in 17 patients, epicardial closure in 5, endocardial and epicardial closure in 2, suture ligation in 1, and off-pump suture ligation in 4. Postoperative anticoagulation was prescribed for at least 6 months. There were no operative deaths. Complications included residual shunt in 2 patients, and LCX thrombosis, pneumothorax, hemoglobinuria, and wound infection, each in 1 patient. At the latest follow-up extending to 25 years (mean, 10.1±4.6 years), 17 patients were asymptomatic and in New York Heart Association functional class I, 4 in II and 2 in III. Residual shunt, myocardial infarction, and right atrial thrombosis occurred, each in 1 patient. Surgical repair of LCX fistula is safe and effective, with low risks and favorable late outcomes. Our experience implies the necessity for postoperative anticoagulation therapy to achieve good long-term outcomes.

Hybrid ablation of long standing persistent atrial fibrillation utilizing minimally invasive surgical and endocardial catheter approach: one year results

Introduction: Unfortunately the efficacy of catheter ablation of long standing persisting atrial fibrillation (LSPAF) remains poor even after multiple ablation procedures. With a novel hybrid ablation strategy with combined epicardial and endocardial approach high short term success rates were demonstrated. The objective of this study was to evaluate safety and efficacy outcomes one year after hybrid ablation. Methods: 25 consecutive patients (pts) (2 female, age 52±1 years, LA size 46±1 x 62±1 mm with LSPAF were included. The epicardial ablation was first performed via an endoscopic subxyphoid access utilizing Numeris® Coagulation Device, nContact Surgical Inc. It was secondly followed during the same day by conventional endocardial ablation utilizing EnSite NavX Velocity™ system, SJM Inc. During the endocardial procedure voltage mapping was performed and detected gaps were closed. Esophageal temperature was continuously monitored. Pts were prospectively followed at 1, 2, 3 months with 48 h holter ECG and every 3 months thereafter. Pts free of AF after 3 months underwent implantation of loop event recorder, Reveal™, Medtronic Inc. Results: AF was persisting since 55±9 months and 20±2 months after last cardioversion attempted. 9 pts (36%) have already undergone repeated AF catheter ablations. All pts were highly symptomatic with EHRA class 4. The mean duration of epi- and endocardial procedure were 134±6 min. and 193±13 min. respectively, utilizing 32±3 min. of the fluoroscopy time (37±11 Gy/cm2). In first 5 pts endocardial voltage mapping has shown incomplete posterior box lesions with necessity of endocardial closure. After the modification of the initial epicardial ablation scheme complete posterior box lesions were achieved in 20 pts. Endocardial closure of anterolateral and septal gaps with additional application of anterior roof lines led also to complete isolation of the whole roof region and all PVs. After this step 5 pts converted primary into SR and 10 into atrial tachycardia. After the application of anterior mitral valve lines another 5 of these 10 pts converted into SR. Electrical cardioversion was performed in 15 pts. 7 pts developed a postpericardiotomy syndrome, which was managed conservatively. One pt has developed bleeding from the transdiaphragmal access site, which required surgical revision. After a median follow up of 329 (IQR 187-509) days 21 (84%) pts were free of AF without AADs. Conclusions: A hybrid ablation of LSPAF in pts with severe atrial enlargement represents a feasible treatment option with high mid-term success rates. Further evaluation of long-term results is required.