Left Atrial Appendage Occlusion In Patients Research Articles

Abstract 11688: Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Cancer

Introduction: Prevention of stroke in patients with atrial fibrillation and cancer is challenging as patients are at increased bleeding and thrombotic risk. Left atrial appendage occlusion (LAAO) has evolved as a promising strategy for stroke prevention with protentional to reduce bleeding risk, though no data exists on its efficacy in patients with cancer. Hypothesis: LAAO is a safe and effective strategy for reducing stroke and bleeding risk in cancer patients with atrial fibrillation. Methods: We retrospectively reviewed all patients with nonvalvular atrial fibrillation who underwent LAAO at all Mayo Clinic sites from 2017-2020 and identified those who had undergone prior or current treatment for cancer. Baseline demographics, malignancy history, atrial fibrillation parameters, procedural success/complications, stroke and bleeding incidence and major adverse cardiac events were ascertained. Results: 55 patients were included in the study; 44 (80.0%) were male and mean age was 79.0 ± 6.1 years. Most common primary malignancies included prostate cancer (29.1%), oropharyngeal cancer (12.7%), and melanoma (10.9%) with 15 (27.3%) having metastatic disease and 14 (25.5%) patients having active malignancy at device implant. Mean CHA2DS2-Vasc score was 4.9 ± 1.3, with 47 (85.5%) patients having a prior bleeding event. Acute procedural success was achieved in all patients with 30-day complications including 4 (7.3%) with vascular access site bleeding, 1 (1.8%) with pericarditis and 1 (1.8%) with a seizure. At a follow up of 1.8 ± 1.1 years, ischemic stroke occurred in 2 (3.6%) patients with bleeding complications in 5 (9.1%) patients. Device related complications occurred in 6 (10.9%) patients with 4 (7.3%) with device thrombosis and 2 (3.6%) with a peri-device leak. Death occurred in 14 (25.5%) patients most commonly due to malignancy progression (9.1%) and infection (7.3%). Conclusions: In our study cohort, LAAO in patients with cancer was achieved with excellent procedural success and offered reasonable reduction in stroke and bleeding risk. Mortality was high likely due to the age of the patients studied, underlying malignancy and comorbidities. Further studies are needed to investigate the prevalence of device thrombosis in cancer patients.

Abstract 9424: Single versus Dual Antiplatelet Therapy for Stroke Prevention Following Left Atrial Appendage Occlusion in Patients With High Bleeding Risk

Introduction: The optimal antiplatelet therapy following Left atrial appendage occlusion (LAAO) in atrial fibrillation patients who are not candidates for long-term oral anticoagulation therapy (OAC) is subject to debate. Hypothesis: Is single antiplatelet therapy (SAPT) safe and effective when compared to dual antiplatelet therapy (DAPT) in patients with high bleeding risk? Methods: We conducted a comprehensive search for all studies that compared the use of SAPT with DAPT following LAAO for patients in whom OAC is deemed highly risky or contraindicated. The outcomes of our study were device-related thrombosis (DRT), stroke and systemic embolization (SSE), and major bleeding (MB). The risk ratio (RR) with 95% confidence intervals (CIs) are presented as summary statistics and were calculated using a random-effects model. Results: A total of 15 observational studies with 3231 patients (SAPT, n=1036; DAPT, n=2195; 64.5% men; median follow-up duration 12 months; mean age 74.7±8.5 years; CHA2DS2-VASc score 4.3±1.6; HASBLED score 3.2±1.2) were included. For DRT, data were available from 10 studies (2910 patients); there was no difference between SAPT and DAPT groups (2.6% vs. 2.3%; RR: 1.41; 95%CI: 0.77-2.59; P=0.26; I 2 :0%). For SSE (8 studies, 959 patients); although numerically more events were observed in the SAPT group, there was no statistical difference between the two groups in the pooled analysis (2.9% vs. 1.5%; RR: 5.43; 95%CI: 0.74-39.81; P=0.1; I 2 :78%). Finally, for MB (8 studies, 1818 patients); although numerically more events were observed in the DAPT group, there was no statistical difference between the two arms (2.3% vs. 3.2%; RR: 1.90; 95%CI: 0.46-7.87; P=0.37; I 2 :72%). Conclusions: Our study showed comparable safety and efficacy profiles for SAPT and DAPT after LAAO. Adequately powered randomized studies determining the optimal antithrombotic therapy in the first weeks after LAAO are warranted in patients at high risk for bleeding.

Routine left atrial appendage occlusion in patients undergoing cardiac surgery: a narrative review.

New evidence suggests a greater prevalence of protracted postoperative atrial fibrillation (POAF) than previously recognized. The left atrial appendage (LAA) is the most common source of embolism in patients with nonvalvular atrial fibrillation. In this review, we ask whether there is evidence to support routine LAA occlusion (LAAO) in patients without preexisting atrial fibrillation undergoing cardiac surgery. Overall, available studies are small, inconsistent and have varying proportions of patients with and without preexisting atrial fibrillation. There is considerable discrepancy with respect to the efficacy of LAAO in reducing the risk of POAF-related stroke. Only one study reported a lower rate of stroke in the LAAO group compared with no LAAO. Two studies included a subgroup analysis of patients that developed POAF and report a significantly higher rate of stroke in patients that developed POAF and did not undergo LAAO. There are three clinical trials ongoing that are investigating prophylactic LAAO in patients undergoing cardiac surgery: ATLAS, LAA-CLOSURE and LAACS-2. There is currently insufficient evidence to recommend routine addition of LAAO to lower the risk of postoperative stroke. Ongoing clinical trials will provide important insight into the role of routine LAAO in all patients undergoing cardiac surgery.

Comparing the adverse outcomes of left atrial appendage occlusion in patients with diabetes

Abstract Introduction In patients with atrial fibrillation, it is estimated that greater than 90 percent of left atrial thrombi are located in the left atrial appendage. Multiple percutaneously implanted devices have been approved worldwide for left atrial appendage occlusion (LAAO) to reduce stroke risk in patients not suitable for long-term oral anticoagulation. Device implantation has been associated with a high success rate and low risk for peri-procedural complications. However, as the prevalence of diabetes continues to rise, there is a considerable need to establish peri-procedural risk in these patients. Purpose This study aimed to evaluate and compare the in-hospital outcomes of LAAO in patients with and without diabetes. Methods We performed a retrospective cross-sectional analysis using the 2018 National Inpatient Sample. All patients aged 18 years and older with atrial fibrillation and LAAO-related hospitalizations were included in this study. To mitigate selection bias and control for patient and institutional imbalances, propensity scoring method was used to select matched sample between patients with diabetes and patients without diabetes. The scoring was based on a multivariate logistic regression model accounting for age, gender, race, hospital type, hospital region, hospital teaching status, median household income, and medical comorbidities. Using an 8-to-1-digit match, we paired each admission in the diabetes group with one admission without diabetes. Results We identified a total of 3572 patients admitted for LAAO; 1298 of these patients had comorbid diabetes. Diabetics did not have a higher risk of in-hospital mortality with LAAO (0.2% vs 0.3%, p=0.620). The risk for 17 out of the 18 identified peri-procedural complications was similar in patients with and without diabetes. However, diabetes was associated with an increased risk of acute kidney injury (Adjusted OR 1.75; 95% CI 1.05–2.93, p=0.03). Interestingly, 0 endocarditis events were captured in both groups, indicating that this complication is only seen in long-term follow-up and had a peri-procedural risk of 0%. Conclusion As the use of implantable LAAO devices increases worldwide, clinicians should be cognizant of the increased risk for peri-procedural acute kidney injury in diabetics. Patients with diabetes often have diabetes-induced chronic kidney disease with susceptibility to acute injury. Therefore, volume status should be closely monitored in the peri-procedural period to mitigate further damage to the kidneys in these patients. Funding Acknowledgement Type of funding sources: None. Characteristics of the matched cohortOutcomes in the matched cohort

Concomitant left atrial appendage occlusion in patients undergoing cardiac surgery.

The Left Atrial Appendage Occlusion Study (LAAOS III) was a multicenter, randomized controlled trial that included patients undergoing cardiac surgery who also had atrial fibrillation. The trial recruited 4811 participants, of which 2400 patients were randomized to undergo left atrial appendage (LAA) occlusion surgery, while 2411 participants had isolated cardiac surgery. The aim of the study was to determine whether concomitant occlusion of the LAA prevents ischemic stroke or systemic embolism. The study also evaluated the efficacy and safety of concomitant LAA occlusion in patients undergoing cardiac surgery. The number of ischemic strokes or systemic embolisms was significantly lower in the LAA occlusion group [114 (4.8%) vs. 68 (7.0%)] compared to the no-occlusion surgery group. There was also no increase in hospital length of stay or hospitalization for heart failure. It is expected that based on the findings of the LAAOS III study, the recommendations for concomitant LAA occlusion will be upgraded from the current class IIB to class I.

Percutaneous left atrial appendage occlusion.

To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device. The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval. In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

Feasibility of Left Atrial Appendage Closure in Atrial Fibrillation Patients with a History of Intracranial Bleeding: A Systematic Review of Observational Studies.

Background Left atrial appendage occlusion (LAAO) is performed in patients with nonvalvular atrial fibrillation to reduce the risk of ischemic stroke. The patients with a history of intracranial hemorrhage were excluded from the pioneer randomized controlled trials. The purpose of this systemic review was to evaluate the data from observational studies reporting the efficacy and safety of LAAO in patients with a history of intracranial hemorrhage. Methods Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science Core Collection, Scopus, Global Index Medicus, and ClinicalTrials.gov data sources were utilized for data collection. Results A total of 12 studies met the inclusion criteria that included seven retrospective observational and five prospective observational studies. A total of seven hundred and twenty-seven patients with a history of intracranial hemorrhage underwent percutaneous left atrial appendage occlusion. There were 11 events of recurrent intracranial hemorrhage, 12 ischemic strokes, 4 transient ischemic attacks, and 26 all-cause deaths. The duration of follow-up varied from 3 months to 3.6 years in the included studies. Conclusion Left atrial appendage occlusion can potentially be an effective and relatively safe treatment option to reduce the risk of ischemic stroke in selected patients with nonvalvular atrial fibrillation patients and history of intracranial hemorrhage. Future prospective randomized trials are needed to validate this approach.

Percutaneous left atrial appendage closure, a safe alternative to anticoagulation for patients with nonvalvular atrial fibrillation and end-stage renal disease on hemodialysis: A single center experience.

The evidence about the effectiveness and safety of oral anticoagulation in patients on hemodialysis is conflicting and scarce. Percutaneous left atrial appendage occlusion (LAAO) has demonstrated to be a valid alternative therapeutic option for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). The aim of this study is to present the outcomes of percutaneous LAAO in patients with end-stage renal disease (ESRD) on hemodialysis and NVAF in our center. We conducteda retrospective review of clinical records, demographics, LAAO procedure, complications, and outcomes of patients with NVAF and ESRD on hemodialysis who underwent a percutaneous LAAO in our center between January 2017 and January 2019. In the period of the study, eight patients with ESRD on hemodialysis underwent a percutaneous LAAO in our center. The overall mean age was 67.5years (range 56-81; SD±7.2). All patients had permanent NVAF. The total mean dialysis duration was 8.49years (range 0.83-14.8; SD±6.2). The mean CHA2DS2-VASc and HAS-BLED scores were high (4.75 [SD±1.16] and 4.62 [SD±0.91], respectively). All patients had history of a major hemorrhagic event (BARC Score ≥3). Most patients (n=6) showed left ventricular hypertrophy, and the average LVEF was 54% (SD±6.5). All devices were implanted successfully. Postprocedural antithrombotic regimen prescribed was based on antiplatelet therapy. No deaths, cardioembolic events, or major bleeding (according to the BARC scale) were reported during a mean follow-up of 14.24months (SD±9.44). Percutaneous LAAO could be of particular interest in patients with NVAF and CKD in hemodialysis. Further studies will be necessary to confirm this hypothesis.

Cierre de orejuela izquierda en pacientes mayores de 85 años: seguridad y eficacia del registro EWOLUTION

Introduction and objectivesElderly patients with atrial fibrillation are at greater risk of both cardioembolic events and major bleeding than younger patients. Left atrial appendage occlusion (LAAO) could be an attractive alternative for these patients, but there are limited data on outcomes with LAAO in patients ≥ 85 years old. The aim of the present study was to assess the safety and efficacy of LAAO in patients ≥ 85 years old. MethodsA total of 1025 patients included in the EWOLUTION registry who underwent LAAO were analyzed and 84 patients ≥ 85 years old were identified and compared with the younger cohort. ResultsPatients ≥ 85 years old had higher estimated stroke and hemorrhagic risks than younger patients (CHA2DS2-VASc: 5.2±1.2 vs 4.4±1.6, P <.0001; HAS-BLED: 2.7±1.1 vs 2.3±1.2; P=.003; ≥ 85 years vs <85 years). Procedural success was high and similar in both groups (98.8% vs 98.5%; P=.99). There were no differences in 7-day device- or procedure-related adverse event rates (2.6% in ≥ 85 years vs 3.1% in <85 years; P=.80). Despite the higher baseline stroke risk, there was no difference at follow-up between the groups in the annualized stroke rate (0.8/100 patient-years in ≥ 85 years vs 1.3/100 patient-years in <85 years; P=.649). ConclusionsLAAO in patients ≥ 85 years is safe and effective even though these patients are at high risk for embolic and hemorrhagic events. LAAO may be a reasonable alternative to oral anticoagulation in these patients.

Reduction in risk of stroke and bleeding after left atrial appendage closure with LARIAT device in patients with increased risk of stroke and bleeding: Long term results.

Left atrial appendage occlusion (LAAO) offers an alternative to oral anticoagulation (OAC) for patients with atrial fibrillation (AF). The aim of this study was to present long-term clinical outcomes of LAAO in patients with a high risk of stroke and thromboembolic events (CHA2 DS2 -VAS-score ≥ 2) and bleeding (HAS-BLED score ≥ 2). A prospective, single-center study was performed in 120 patients who were screened for LAAO with the LARIAT. Out of these 89 patients were underwent LARIAT placement, were 57 had high risk of thromboembolic and bleeding risk (LAA group). Control Group consisted of patients and 31 who screened out from the LARIAT and did not undergo LAAO. The mean CHA2 DS2 -VAS-score was 3.6 ± 1.5 versus 3.1 ± 1.2 and HAS-BLED score was 3.6 ± 1 versus 3 ± 1 compare LAA group versus control group. There were no thromboembolic events in the LAA group. In the control group thromboembolic events were observed in 9.6% (P = 0.017). Annual mortality rate was 1.8% in LAA group and 3.2% in control group (P < 0.05). Estimated bleeding risk reduction in LAA group was 62.2%. Long-term data confirmed that left atrial appendage closure with the LARIAT device is an effective and safe treatment in nonvalvular AF patients with high risk of stroke and bleeding.

Thromboembolic events and need for anticoagulation therapy following left atrial appendage occlusion in patients with electrical isolation of the appendage.

Electrical isolation of the left atrial appendage (LAA) is an important adjunctive ablation strategy in patients with nonparoxysmal atrial fibrillation (AF). Patients who have impaired LAA contractility following isolation may require long-term oral anticoagulant (OAC) therapy irrespective of their CHADS2 -VASc score. Percutaneous LAA occlusion (LAAO) is a potential alternative to life-long OAC therapy. We aimed to assess the rate of OAC discontinuation and thromboembolic (TE) events following percutaneous LAAO in patients who underwent LAA electrical isolation (LAAI). This is a retrospective two-center study of patients who underwent percutaneous LAAO following LAAI. Patients with at least 3-monthfollow-up were included in the study. The antithrombotic therapy and TE events at the time of the last follow-up were noted. The LAA was successfully occluded in 162 (with Watchman device in 140 [86.4%] and Lariat in 22 [13.6%]). A total of 32 patients had leaks detected on the 45-day transesophageal echocardiogram (TEE); 21 (15%) Watchman and 11 (50%) Lariat cases (P = 0.0001). Two (one Watchman and one Lariat) of the 32 leaks were more than 5 mm. After the 45-day TEE, 150 (92.6%) patients were off-OAC. No TE events were reported in the 150 patients who stopped the anticoagulants. Four (2.47%) patients experienced stroke following the LAAO (three Watchman and one Lariat) procedure while on-OAC, two of which were fatal. At the median follow-up of 18.5 months, 159 (98.15%) patients were off-anticoagulant. Up to 98% of patients with LAAI could safely discontinue OAC after undergoing the appendage closure procedure.

Left atrial appendage occlusion for stroke prevention in diabetes mellitus patients with atrial fibrillation: Long-term results.

Concomitant diabetes mellitus (DM) in atrial fibrillation (AF) may increase the risk of thromboembolism. Left atrial appendage occlusion (LAAO) is an alternative treatment in AF patients in whom antithrombotic therapy is ineffective or contraindicated. The aim of this study was to evaluate the long-term efficacy of LAAO in DM patients with AF. A retrospective study was conducted in 139 patients who had undergone LAAO and were categorized into two groups: 28 patients with DM and 111 patients without DM. Overall, the follow-up period was 530 patient-years. Mean CHADS2 and CHA2 DS2 -VASc scores were higher in patients with than without DM (2.6 vs 1.7 [P < 0.001] and 3.5 vs 2.8 [P = 0.056], respectively). There were no significant differences between the two groups in terms of HAS-BLED scores and other patient factors (sex, age, heart failure, hypertension, previous stroke or transient ischemic attack, peripheral vascular disease) that may increase the risk of thromboembolism based on CHA2 DS2 -VASc. The mean follow-up period was 51.6 and 50 months in patients with DM and without DM, respectively. Comparing patients with and without DM, there were no significant differences in thromboembolic events (4% vs 1.9%), severe bleeding (0% vs 3.1%), or mortality (4% vs 5.9%). The estimated reductions in thromboembolic and bleeding risk were 77% and 100%, respectively, for patients with DM, compared with 85% and 62%, respectively, for patients without DM. The present study indicates that LAAO in AF patients with DM has similar safety endpoints and long-term efficacy as LAAO in patients without DM.

The Efficacy and Safety of the WATCHMAN Device in LAA Occlusion in Patients with Non-Valvular Atrial Fibrillation Contraindicated to Oral Anticoagulation: A Focused Review.

The standard treatment for stroke risk patients with non-valvular atrial fibrillation (NVAF) is the use of oral anticoagulants (OACs). However, a substantial number of patients have relative or absolute contraindications to OACs due to concerns of major bleeding risk and other adverse effects while using oral anticoagulation therapy. Recently, occurrences of exclusion of the left atrial appendage (LAA) in patients with contraindication to anticoagulation therapy are widely expanding worldwide, causing major contentious discussions. The LAA is the commonest place of thrombus formation; therefore, the concept of LAA occlusion in reducing stroke and other embolic events in NVAF patients is very important. The current understanding of the available evidence on efficacy and safety of LAA closure (LAAC) with the Watchman device in patients contraindicated to OACs is the major aim of this focused review. After reviewing a significant body of literature, a world experience with no randomized trials, it is suggested that Watchman device implantation is effective and safe in high-risk patients with NVAF contraindicated to OACs therapy.

Interventional and surgical occlusion of the left atrial appendage

With a steadily increasing prevalence, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide and an independent risk factor for stroke caused by thromboembolic events. The left atrial appendage (LAA) is the primary source of thromboemboli in patients with nonvalvular AF who have a stroke. Novel strategies (such as mechanical and nonpharmacological intervention) targeting the LAA in patients with AF for stroke prevention have become a major focus during the past decade. Some devices for percutaneous LAA occlusion are supported by robust clinical data obtained from randomized trials or large registries, and are a valid alternative to pharmacological stroke prevention. However, the incidence of periprocedural complications and the presence of device-related thrombi or residual LAA leaks, whose long-term clinical implications are still unknown, are limiting factors in wider acceptability of these techniques. In this Review, we discuss the available techniques for LAA occlusion in patients with nonvalvular AF at high risk of stroke. We describe the pharmacological and mechanical approaches to LAA occlusion, and provide the current clinical evidence for various strategies. We particularly focus on the current management of the LAA, and discuss the challenges and future implications of the available approaches to LAA occlusion.

Establishment and assessment of an LAA occlusion preoperative simulation system based on 3D transesophageal echocardiography and 3D printing

Objective To create an left atrial appendage(LAA) occlusion preoperative simulation system by three dimensional transesophageal echocardiography(3DTEE) and three dimensional printing(3DP), and simulate the process of LAA occlusion including the selection and deployment of devices, leaks around devices and the compression rate of the devices in vitro. Methods Fifteen cases of LAA occlusion in patients with atrial fibrillation were selected in this study. Preoperative and intraoperative TEE was performed to acquire the volume data of LAA. Replicas of LAAs were created by 3DP. Then the simulation system was created by 3DTEE and the models. The models were scanned by 3DTEE to evaluate the accuracy of models, leaks around devices and the compression rate of the devices.The results were compared with intraoperative measurements. Results 3DP models of 15 patients were created based on the 3DTEE data. There was no significant difference in the values of measurements between models and cases in vivo by 3DTEE and there were agreements between these two methods. The compression rate of devices was higher in models than in case (P=0.04). Compression rate in models correlated with that in cases (r=0.949, P<0.01). Four cases were observed with leaks in 3DP models and 6 cases were observed with leaks intraoperatively, the Kappa value of agreement was 0.706. Conclusions Preoperative exercise and evaluation of LAA occlusion can be acquired by the preoperative simulation system based on 3DTEE and 3DP, which can be an important supplement for preoperative preparation. Key words: Echocardiography, transesophageal, three-dimensional; Three-dimensional printing; Left atrial appendage

Safety of Percutaneous Left Atrial Appendage Occlusion in Patients with Atrial Fibrillation after Acute Coronary Syndrome: A Single Center Experience

Aims: In patients with atrial fibrillation (AF) and indication to Dual Antiplatelet Therapy (DAPT) for Acute Coronary Syndrome (ACS), triple therapy is recommended. However, this issue is still largely debated. Percutaneous Left Atrial Appendage (LAA) occlusion may represent an alternative therapeutic approach in this subset of patients, as it could lead to a reduction in the incidence of bleeding. Nevertheless, due to lack of clinical evidence, this approach does not represent the gold standard treatment for these patients. The objective of this study is to evaluate the safety of percutaneous LAA occlusion in patients with Atrial Fibrillation and indication of concomitant DAPT for ACS. Methods and Results: Fifteen AF-patients with indications to anticoagulant and DAPT after ACS underwent LAA occlusion with Amplatzer Cardiac Plug (ACP) or Amulet ACP (St. Jude) from October 2014 to May 2016. Procedural success was achieved in 14/15 patients, while in 1 patient a clinically non-relevant pericardial effusion was registered before the trans-septal puncture, without implantation of the device. No peri-procedural death, major bleeding and dislocation or thrombi of the device were recorded. During a median follow-up of 182 days (interquartile range [IQR]: 169 to 183 days), one peri-procedural minor bleeding and two non cardiovascular death were described. Conclusions: LAA occlusion represents a relatively safe procedure for patients with atrial fibrillation and the need of DAPT due to ACS. Randomized trials should be designed to evaluate the efficacy and safety of this procedure in this clinical setting.

Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation.

Pulmonary veins (PVs) isolation is the cornerstone of atrial fibrillation (AF) ablation and can be achieved either by conventional radiofrequency ablation or by cryoenergy. Left atrial appendage (LAA) closure has been proposed as alternative treatment to vitamin K antagonists (VKA). We aimed to evaluate the feasibility of combining cryoballoon (CB) ablation and LAA occlusion in patients with AF and a high thromboembolic risk or contraindication to antithrombotic therapy. Thirty-five patients (28 males, 74 ± 2 years) underwent CB ablation. Left atrial appendage occlusion was carried out by using two occluder devices (Amplatz Cardiac Plug, ACP, St. Jude Medical, MN, USA, in 25 patients; Watchman, Boston Scientific, MA, USA, in 10 patients). Thirty patients (86%) had previous stroke/TIA episodes, 6 patients (17%) had major bleeding while on VKA therapy, and 7 patients (20%) had inherited bleeding disorders. Over the follow-up (24 ± 12 months), atrial arrhythmias recurred in 10 (28%) patients. Thirty patients (86%) had complete sealing; 5 patients (14%) showed a residual flow (<5 mm) at first transoesophageal echocardiography (TEE) check, while at 1-year TEE residual flow was detected in 3 patients. In 13 patients (37%), VKA therapy was immediately discontinued. Six patients (17%) received novel oral anticoagulants treatment and then discontinued 3 months thereafter. No device-related complications or clinical thromboembolic events occurred. Combined CB ablation and LAA closure using different devices appears to be feasible in patients with non-valvular AF associated with high risk of stroke or contraindication to antithrombotic treatment.

Extending percutaneous left atrial appendage closure indications using the AMPLATZER™ Cardiac Plug device in patients with persistent left atrial appendage thrombus: The thrombus trapping technique

Percutaneous left atrial appendage (LAA) closure has emerged as an alternative therapeutic option for the prevention of embolic stroke in high-risk patients with non-valvular atrial fibrillation. The presence of thrombus in the LAA is currently a contraindication to the procedure. To describe a modified LAA closure technique that allows a safe procedure in patients with LAA thrombus. Between May 2013 and October 2014, LAA closure was performed in three patients with LAA thrombus (mean age 73.6±14 years; two men), using a modified technique that avoids manipulation of catheters or angiography in the LAA. Two patients had persistent thrombus despite appropriate antithrombotic therapy, while the other patient had a contraindication to systemic anticoagulation. The procedure was successful using the modified implantation technique in all patients. The implanted device was the AMPLATZER™ Cardiac Plug (St. Jude Medical, Minneapolis, MN, USA) in one patient and the Amulet™ (St. Jude Medical, Minneapolis, MN, USA) in two patients. No periprocedural complications occurred. After a mean follow-up of 8±2 months, no deaths or late complications were observed. Thrombus trapping is a feasible and effective technique for performing LAA occlusion in patients with thrombus within the LAA. This modification of the implantation technique may allow LAA closure indications to be extended to include patients with LAA thrombus, who were formerly considered unsuitable.

Real World Outcomes of Left Atrial Appendage Occlusion.

Percutaneous left atrial appendage occlusion (LAAO) is a device-based therapy for the prevention of stroke in patients with non-valvular atrial fibrillation (AF). Recently, the Watchman device (Boston Scientific, St Paul, MN, US) was approved in the US by the Food and Drug Administration (FDA) based on the results of two randomised clinical trials that evaluated LAAO in patients eligible for oral anticoagulation (OAC) therapy. However, in real-word clinical practice LAAO is typically offered to patients ineligible for OAC therapy, as they appear to have limited treatment options and consequently worse prognosis. Although LAAO has shown favourable clinical outcomes in OAC-ineligible patients in single or multicentre observational studies, these results need to be confirmed in randomised clinical trials.

Leaving no hole unclosed: left atrial appendage occlusion in patients having closure of patent foramen ovale or atrial septal defect.

To report procedural outcome of sequential occlusion of the left atrial appendage (LAA) and an interatrial septal communication and discuss possible indications. There are some patients who may have indications for both closure of patent foramen ovale (PFO) or atrial septal defect (ASD), as well as closure of the LAA. The optimal procedural strategy is not known. A retrospective review of LAA and PFO/ASD cases at our center was performed. Demographic, echocardiographic, and procedural data were recorded. Closure of LAA and then PFO/ASD (Group I: 11 patients), closure of both in the same setting (Group II: 3 patients), and closure of the PFO/ASD and then the LAA (Group III: 3 patients) was performed in a total of 17 patients. Average age was 63.5 ± 9.8 years. Most patients were hypertensive with prior cerebrovascular event in 52.9% of patients. Procedural success was 100%. Procedural adverse events were 2 episodes of tamponade (in Group I after first LAA procedure) treated with pericardiocentesis and 1 access-site hematoma (Group II) treated conservatively. Sequential (staged or during the same procedure) closure of the LAA and interatrial communications can be performed safely in a carefully selected patient population. This is also the first known report of LAA occlusion in patients with prior septal closure devices.