Search

Introduction: Over the past decade, left atrial appendage occlusion (LAAO) has emerged as an established alternative to oral anticoagulation for patients diagnosed with atrial fibrillation (AF). The LARIAT device stands as the sole available epicardial system for complete percutaneous left atrial appendage (LAA) closure. Aim: To present the extended outcomes (spanning over 9 years of observation) in patients with AF who underwent epicardial LAAO. The presented results constitute the longest observation in world literature. Material and methods: A prospective, single-center study was conducted on 121 patients undergoing LAAO with the LARIAT system. Incidence of thromboembolic events and severe bleeding and mortality rates were documented. The reduction in the risk of thromboembolism and bleeding after LAAO was quantified. Results: The mean follow-up duration was 74.18 months. The average CHADS2 score was 1.9 ±1.0, CHA2DS2-VAS score was 2.8 ±1.5, and HAS-BLED score was 2.7 ±1.0. The mean annual thromboembolic event rate was 0.7%, resulting in a 75% reduction in estimated thromboembolic risk. The annual occurrence of major bleeding complications was 0.8%, leading to a 67.9% reduction in estimated bleeding risk. The overall annual mortality rate was 1.2%. Conclusions: Epicardial LAAO employing the LARIAT device yields commendable long-term outcomes by reducing stroke and bleeding risk. [ABSTRACT FROM AUTHOR]

Background: Through a case of atrial fibrillation (AF) combined with coronary artery fistula, a one-stop interventional operation treatment of "AF radiofrequency ablation + left atrial appendage closure (LAAC) + coronary artery fistula (CAF) embolization" was performed. We have checked the relevant literature, and there is no similar report, which may help clinicians deal with similar situations. Case presentation: The patient had a 6-year history of paroxysmal AF, and had experienced negative effects of the drug treatment. She had suffered many years of repeated hemoptysis due to bronchiectasis, and could not tolerate anticoagulation therapy. After in-depth clinical discussion, a one-stop interventional operation including AF radiofrequency ablation, LAAC, and CAF embolization, was formulated according to the patient's situation. The patient recovered and was discharged smoothly. Conclusions: In patients with AF combined with coronary artery-bronchial artery fistula, a one-stop interventional operation treatment of "AF radiofrequency ablation + LAAC+ CAF embolization" was performed. It can effectively improve the anticoagulation-worsened haemoptysis in patients with AF. [ABSTRACT FROM AUTHOR]

Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) combined with left atrial appendage occlusion (LAAO) is a feasible approach for atrial fibrillation (AF) patients. Its role in octogenarians with AF is unclear. Hypothesis: In AF patients over 80 years, CA combined with LAAO is a feasible way in restoring sinus rhythm and preventing stroke. Methods: This is a single‐center retrospective study. Patients who underwent CA and LAAO in a single procedure between March 2018 and December 2020 were included. Efficacy endpoints included procedural success rate, AF recurrence rate, and thromboembolic events. Safety endpoints included pericardial effusion/cardiac tamponade, device‐related thrombus (DRT), all‐cause death, and major bleeding. Results: Five hundred and five patients (mean age 69.5 ± 7.7 years; 230 [45.5%] female) were included, with 46 (9.1%) patients aged ≥80 years old (octogenarian group). Prevalence of paroxysmal AF (25 [54.3%] vs. 207 [45.1%], p < 0.001) and CHA2DS2VASc score (4.1 ± 1.3 vs. 3.1 ± 1.4, p < 0.0001) were higher in octogenarian patients. There were six cases (1.2%) of pericardial effusion (all in nonoctogenarian patients). At 3 months postprocedure, 437 patients underwent TEE/CT. Thirty‐two (80%) octogenarian patients and 308 (77.6%) nonoctogenarian patients had no peri‐device leak. After a mean follow‐up of 26.9 ± 9.1 months, AF was documented in 10 (21.7%) patients in octogenarian group and in 103 (22.4%) patients in nonoctogenarian group (p = 0.99). The annual thromboembolic risk was 2.1% and 0.8% in the octogenarian group and nonoctogenarian group, respectively. Death occurred in 16 nonoctogenarian patients. One major bleeding was recorded in the octogenarian group. Conclusions: The combination of CA and LAAO in a single procedure is a feasible treatment option in octogenarians with comparable efficacy and safety profile. [ABSTRACT FROM AUTHOR]

Purpose of Review: Intracardiac echocardiography (ICE) has emerged as a powerful imaging tool to guide percutaneous left atrial appendage closure (LAAC). Herein, we review an imaging protocol for ICE-guided LAAC and discuss the evidence for its use. Recent Findings: Standardized imaging protocols have been proposed but have not been fully validated. ICE imaging yields similar procedural and clinical outcomes when compared to transesophageal echocardiography (TEE) to guide LAAC. Despite benefits of avoiding general anesthesia, TEE, and multiple physicians for LAAC procedures, ICE imaging remains under-utilized. Novel ICE catheters with 3D imaging capabilities may improve accuracy and efficiency of LAAC device implantation. Summary: ICE guidance is feasible, safe, and effective for LAAC. As the field evolves, further studies will be necessary to assess this technological advancement in imaging guidance. [ABSTRACT FROM AUTHOR]

Thrombotic complications of atrial fibrillation continue to pose a significant challenge in clinical practice today. Left atrial appendage occlusion (LAAO) has emerged as a promising alternative to oral anticoagulation for high-risk patients with atrial fibrillation. However, despite the potential benefits, there is still the possibility of life-threatening complications such as device dislocation. In this case study, we present a patient who experienced severe hemodynamic disturbances due to the embolization of LAAO device into the left ventricular outflow tract, resulting in a torn mitral valve and secondary massive mitral regurgitation, just 3 hours after the procedure. As a result, emergent surgical intervention was required to remove the device and repair the mitral valve. We also conducted a review of previous studies on the retrieval of dislodged left atrial appendage occluders through surgical procedures. It is crucial to maintain vigilance, foster interdisciplinary collaboration, and respond promptly to ensure the safety and efficacy of LAAO procedures.

BackgroundLeft atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation for mitigating ischemic stroke risk in selected patients with atrial fibrillation (AF), but safety data in patients with significant kidney disease are limited.ObjectiveTo determine the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with procedural complications and in-hospital outcomes after LAAO in AF patients.MethodsData were extracted from National Inpatient Sample for calendar years 2015-2018. Watchman implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO.ResultsA total of 36,065 Watchman recipients were included in the final analysis. CKD (9.8%, n = 3545) and ESRD (3%, n = 1155) were associated with a higher prevalence of major complications and mortality in crude analysis compared to no CKD. After multivariate adjustment for potential confounders, CKD was associated with length of stay (LOS) >1 day (adjusted odds ratio [aOR] 1.355; 95% confidence interval [CI] 1.234-1.488), median cost >$24,663 (aOR 1.267; 95% CI 1.176-1.365), and acute kidney injury (aOR 4.134; 95% CI 3.536-4.833), while ESRD was associated with in-patient mortality (aOR 7.156; 95% CI 3.294-15.544).ConclusionThe prevalence of CKD and ESRD was approximately 13% in AF patients undergoing Watchman LAAO implantations. CKD was independently associated with prolonged LOS, higher hospitalization costs, and acute kidney injury, while ESRD was independently associated with in-patient mortality.

Abstract Background Left atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness. Methods 303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes. Results Average age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up. Conclusion LAA amputation can be performed safely and completely leaving minimal to no LAA residual stump.

Key Clinical Message Acute thrombus formation on the delivery sheath is rare condition during percutaneous left atrial appendage occlusion. We presented two cases that transesophageal echocardiography (TEE) showed a floating thrombus attached to the tip of delivery sheath during the procedure. Cerebral embolic protection devices were used to prevent neurological events after thrombus was detected. The neurological function was not impaired post‐procedure.

Background: Percutaneous left atrial appendage occlusion (LAAO) has emerged as a stroke prevention strategy in patients with nonvalvular atrial fibrillation (NVAF), and these patients were required to receive antithrombotic therapy postprocedure. However, the optimal antithrombotic strategy after LAAO remains controversial. This study explored the safety and efficacy of different antithrombotic strategies after LAAO through a network comparison method. Methods: We systematically searched the MEDLINE, Embase, and Cochrane Library databases for studies that reported the interested efficacy and safety outcomes (stroke, device-related thrombus (DRT), and major bleeding) of different antithrombotic strategies [DAPT (dual antiplatelet therapy), DOACs (direct oral anticoagulants), and VKA (vitamin k antagonist)] in patients who had experienced LAAO. Pairwise comparisons and network meta-analysis were performed for the interested outcomes. Risk ratios (RRs) with their confidence intervals (CIs) were calculated using a random-effects model. The rank of the different strategies was calculated using the surface under the cumulative ranking curve (SUCRA). Results: Finally, 10 observational studies involving 1,674 patients were included. There was no significant difference in stroke, DRT, and major bleeding among the different antithrombotic strategies (DAPT, DOACs, and VKA). Furthermore, DAPT ranked the worst in terms of stroke (SUCRA: 19.8%), DRT (SUCRA: 3.6%), and major bleeding (SUCRA: 6.6%). VKA appeared to be superior to DOACs in terms of stroke (SUCRA: 74.9% vs. 55.3%) and DRT (SUCRA: 82.3% vs. 64.1%) while being slightly inferior to DOACs in terms of major bleeding (SUCRA: 71.0% vs. 72.4%). Conclusion: No significant difference was found among patients receiving DAPT, DOACs, and VKA in terms of stroke, DRT, and major bleeding events after LAAO. The SUCRA indicated that DAPT was ranked the worst among all antithrombotic strategies due to the higher risk of stroke, DRT, and major bleeding events, while VKAs were ranked the preferred antithrombotic strategy. However, DOACs are worthy of consideration due to their advantage of convenience. [ABSTRACT FROM AUTHOR]

Device-related thrombus (DRT) remains one of the main concerns after left atrial appendage occlusion (LAAO). Several risk factors have been proposed, but most cannot be modulated. A modifiable factor such as device implantation depth is a potential target to adjust the risk for DRT. The aim of this study was to assess the impact of LAAO device implantation depth as a predisposing factor for DRT. The study included patients who underwent successful LAAO at 9 centers in Europe and Canada. Patients were classified into 2 groups: proximal device implantation (covered pulmonary ridge [PR] in the lobe and disc cohort or <5 mm from the PR in the single-lobe cohort) and distal device implantation (uncovered PR in the disc and lobe cohort and ≥5 mm in the single-lobe cohort). A total of 1,317 patients were included. Among these, proximal and distal device implantation was achieved in 732 (55%) and 585 (45%) patients, respectively. No differences in procedural outcomes were observed between the groups. At follow-up, patients with proximal implantation had a lower incidence of DRT (2.3%) than those with distal implantation (12.2%) (P < 0.001). Deeper device implantation and a larger uncovered left atrial appendage area were associated with a higher incidence of DRT (P < 0.001), regardless of device type. In multivariable analysis, distal implant (HR: 5.92; 95% CI: 3.39-10.36) and no or single antiplatelet therapy (HR: 1.62; 95% CI: 0.99-2.62) emerged as independent predictors of DRT. LAAO device implantation depth is an independent risk factor for DRT. Deeper device implantation and larger uncovered left atrial appendage areas were associated with a higher incidence of DRT. [Display omitted] [ABSTRACT FROM AUTHOR]

Atrial fibrillation is now a pandemic in our ageing community. Although James L. Cox devised a surgical procedure with near-universal curative success in 1987, catheter-based interventions have flourished. For persistent atrial fibrillation (AF), however, an isolated endocardial approach has limitations: procedural times are long, carry risk, and the outcomes are not durable. By combining left atrial endocardial and epicardial interventions with staged mapping, we optimise the benefits of both approaches. Our initial series of hybrid ablation for persistent atrial fibrillation reports excellent early outcomes, freedom from complications and excellent success at follow-up. [ABSTRACT FROM AUTHOR]

Left atrial appendage occlusion has proven to be an effective strategy in reducing the risk of stroke and systemic embolism in patients with atrial fibrillation. Worldwide, most left atrial appendage occlusions are performed using transesophageal echocardiography, which requires the use of monitored anesthesia care or general anesthesia, resulting in prolonged inroom and procedural times, delays in procedural scheduling (due to a low availability of anesthetic and echocardiography services) and the risks associated with anesthesia per se. Moreover, the additional personnel required to perform left atrial appendage occlusion guided by transesophageal echocardiography increases the number of people exposed to ionizing radiation, which is particularly high for the transesophageal echocardiography operator, who stands beside the fluoroscopy tube and frequently introduces his/her hands in the fluoroscopy field. Intracardiac echocardiography has gained acceptance to guide left atrial appendage occlusion in recent years, given its high availability in electrophysiology labs, as well as its potential to reduce in-room and procedural times, reduce the need for extensive recovery times, avoid the use of general anesthesia and facilitating same-day discharge, all of which could result in a reduction of total procedure-related costs. In this article, we discuss the evidence supporting the use of intracardiac echocardiography guidance during left atrial appendage occlusion. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO. [ABSTRACT FROM AUTHOR]

Aims Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized head-to-head trial comparing the Amulet and Watchman 2.5 LAAO devices with fundamentally different designs. The predictors and mechanistic factors impacting differences in PDLs within the Amulet IDE trial are assessed in the current analysis. Methods and results An independent core lab analysed all images for the presence or absence of severe PDL (>5 mm). The incidence, mechanistic factors, predictors using propensity score-matched controls, and evolution of severe PDLs through 18 months were assessed. Of the 1878 patients randomized in the trial, the Amulet occluder had significantly fewer severe PDLs than the Watchman device at 45 days (1.1 vs. 3.2%, P < 0.001) and 12 months (0.1 vs. 1.1%, P < 0.001). Off-axis deployment or missed lobes were leading mechanistic PDL factors in each device group. Larger left atrial appendage (LAA) dimensions including orifice diameter, landing zone diameter, and depth predicted severe PDL with the Watchman device, with no significant anatomical limitations noted with the Amulet occluder. Procedural and device implant predictors were found with the Amulet occluder attributed to the learning curve with the device. A majority of Watchman device severe PDLs did not resolve over time through 18 months. Conclusion The dual-occlusive Amplatzer Amulet LAA occluder provided improved LAA closure compared with the Watchman 2.5 device. Predictors and temporal observations of severe PDLs were identified in the Amulet IDE trial. Clinical trial registration https://clinicaltrials.gov Unique identifier NCT02879448. [ABSTRACT FROM AUTHOR]

The Amulet (Abbott) left atrial appendage occluder investigational device exemption trial is the largest randomized trial evaluating the safety and effectiveness of the Amulet left atrial appendage occluder compared with the Watchman 2.5 device (Boston Scientific) through 5 years. This analysis evaluated the device effect on 3-year outcomes in the Amulet investigational device exemption trial. The medication regimen and key clinical outcomes were reported through 3 years including: 1) the composite of ischemic stroke or systemic embolism (SE); 2) the composite of all strokes, SE, or cardiovascular (CV) death; 3) major bleeding; and 4) all-cause death and CV death. A total of 1,878 patients at 108 sites were randomized. A significantly higher percentage of patients were free of oral anticoagulation usage at 3 years with Amulet (96.2%) vs Watchman (92.5%) (P < 0.01). Clinical outcomes were comparable for the composite of ischemic stroke or SE (5.0% vs 4.6%; P = 0.69); the composite of all strokes, SE, or CV death (11.1% vs 12.7%; P = 0.31); major bleeding (16.1% vs 14.7%; P = 0.46); all-cause death (14.6% vs 17.9%; P = 0.08); and CV death (6.6% vs 8.5%; P = 0.14) for Amulet and Watchman, respectively. Through 3 years, device factors (device-related thrombus or peridevice leak ≥3 mm) preceded ischemic stroke events and CV deaths more frequently in Watchman compared with Amulet patients. The Amulet occluder demonstrated continued safety and effectiveness with over 96% free of oral anticoagulation usage through 3 years in a high-risk population compared to the Watchman device. (AMPLATZER Amulet LAA Occluder Trial [Amulet IDE]; NCT02879448) [Display omitted] [ABSTRACT FROM AUTHOR]

Left atrial appendage occlusion (LAAO) procedures are widely guided by standard transesophageal echocardiography (TEE) probes, requiring general anesthesia in most patients. The use of miniaturized TEE probes allows for LAAO guidance under local anesthesia and offers an attractive imaging alternative to standard TEE probes. The aim of this study was to assess the safety and efficacy of miniaturized TEE probes for procedural guidance of LAAO. Multicenter retrospective observational study of LAAO procedures performed under miniaturized TEE guidance and conscious sedation. The primary efficacy endpoint was technical success. The secondary efficacy endpoint was procedural success (technical success without major periprocedural complications). The safety outcome was a composite of major periprocedural complications. A total of 546 consecutive LAAO procedures were performed in 5 European centers. Technical success was achieved in 534 (98.0%) patients. Sixteen major periprocedural complications occurred in 15 (2.9%) patients, yielding a procedural success rate of 97.0%. Conversion to general anesthesia was required in 4 (0.7%) patients. Short-term imaging follow-up was available in 422 patients with an incidence of major (>5 mm) TEE-detected residual leaks of 0.7%, complete LAA occlusion of 82.2% on cardiac computed tomography, and device-related thrombus of 5%. As compared with procedural 2-dimensional imaging for device sizing, preprocedural assessment by 3-dimensional imaging resulted in improved technical success (100% vs 95.0%; P < 0.001). LAAO under conscious sedation and miniaturized TEE guidance is safe and feasible with a high rate of technical success and a low rate of periprocedural complications. [Display omitted] [ABSTRACT FROM AUTHOR]

Opinion Statement: Patients with cancer are at risk of developing cardiovascular disease (CVD) including atherosclerotic heart disease (AHD), valvular heart disease (VHD), and atrial fibrillation (AF). Advances in percutaneous catheter-based treatments, including percutaneous coronary intervention (PCI) for AHD, percutaneous valve replacement or repair for VHD, and ablation and left atrial appendage occlusion devices (LAAODs) for AF, have provided patients with CVD significant benefit in the recent decades. However, trials and registries investigating outcomes of these procedures often exclude patients with cancer. As a result, patients with cancer are less likely to undergo these therapies despite their benefits. Despite the inclusion of cancer patients in randomized clinical trial data, studies suggest that cancer patients derive similar benefits of percutaneous therapies for CVD compared with patients without cancer. Therefore, percutaneous interventions for CVD should not be withheld in patients with cancer, as they may still benefit from these procedures. [ABSTRACT FROM AUTHOR]

Background Contemporary procedural guidelines for percutaneous left atrial appendage occlusions (LAAO) with the WATCHMAN device often require the utilization of pre-screening imaging, general anaesthesia, intubation, a dedicated intra-procedural echocardiographer, and overnight observation. For these reasons, LAAO with the WATCHMAN is not economically feasible for many hospital systems. Thus, we sought to evaluate a newstrategy for implantation that may provide a more minimalistic and less cumbersome approach to LAAO. Case summary We describe five cases utilizing single-operator left atrial appendage occlusion utilizing conscious sedation, transoesophageal echocardiography, lack of outpatient pre-imaging, and same-day expedited discharge (SOLO-CLOSE)—a novel single-operator procedural strategy for LAAO that safely foregoes the aforementioned procedural requirements and allows for same-day early discharge. All five patients were observed according to our newly devised SOLO-CLOSE protocol and were safely discharged home the same day. Follow-up transoesophageal echocardiography (TEE) at 45 days and 1 year revealed well-seated and well-anchored devices with no leaks (<5 mm) or device-related thrombi. Discussion The SOLO-CLOSE series is the first ever documented WATCHMAN strategy that utilizes a single-operator, TEE-guided, nurse-driven conscious sedation protocol that defers pre-screening imaging and allows for same-day discharge. The versatility of this technique allows proceduralists to comfortably achieve successful LAAO despite a wide range of risk profiles. This single-operator technique has potential to become a widely accepted universal approach for non-pharmacological cardioembolic stroke prophylaxis due to its efficacy, safety, simplicity, and presumable cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background Left atrial appendage occlusion (LAAO) has emerged as an alternative to oral anticoagulation therapy for stroke prevention in atrial fibrillation, but data comparing LAAO with direct oral anticoagulant (DOAC) are sparse. Methods and Results This cohort study compared LAAO (with or without prior anticoagulation) with a switch of one DOAC to another DOAC by 1:2 propensity score matching. The primary outcome was a composite of all‐cause mortality, ischemic stroke, and major bleeding. A total of 2350 patients (874 in the LAAO group and 1476 in the DOAC switch group) were included. After a mean follow‐up of 1052±694 days, the primary outcome developed in 215 (24.6%) patients in the LAAO group and in 335 (22.7%) patients in the DOAC switch group (hazard ratio [HR], 0.94 [95% CI, 0.80–1.12]; P=0.516). The LAAO group had a lower all‐cause mortality (HR, 0.49 [95% CI, 0.39–0.60]; P

Background: The electrophysiological responses of the left atrial appendage (LAA) during pulsed‐field electrical isolation have not been established. Objective: This study aims to investigate the electrical responses of the LAA during pulsed‐field electrical isolation using a novel device and their relations to acute isolation success. Methods: Six canines were enrolled. The E‐SeaLA™ device, which is able to perform LAA occlusion and ablation simultaneously, was deployed into the LAA ostium. LAA potentials (LAAp) were mapped via a mapping catheter, and the LAAp recovery time (LAAp RT, the time between the last pulsed spike and the first recovered LAAp) was measured after pulsed‐train delivery. The initial pulse index (PI, corelated to pulsed‐field intensity) was adjusted during the ablation procedure until LAAEI was achieved. Acute LAA electrical isolation (LAAEI) success was defined as LAAp disappearance or exit and entrance conduction block, confirmed through a drug test and a 60‐minute waiting period. Result: All canines achieved successful LAA occlusion without peri‐device leaks. Acute LAA electrical isolation (LAAEI) was achieved in five out of six canines (5/6, 83.3%). Very late LAAp recurrence (LAAp RT > 600 s) was observed during PFA. Early recurrence (LAAp RT < 30 s) was observed in two canines (2/6, 33.3%) post‐PFA. Intermediate recurrence (LAAp RT ~ 120 s) was observed in three canines (3/6, 50%) post‐PFA. The two canines with intermediate recurrence achieved LAAEI with higher PI ablations. The one canine with early LAAp recurrence had a peri‐device leak and achieved LAAEI by the same PI after replacing with a larger size device and eliminating the peri‐device leak. Another canine with early recurrence (1/6, 16.7%) failed to achieve LAAEI due to epicardial connection with persistent left superior vena cava. No coronary spasm, stenosis or other complications were observed. Conclusion: These results suggest that with proper device‐tissue contact and pulse intensity, LAAEI can be achieved using this novel device without serious complications. The LAAp RT patterns observed in this study could inform and guide the adjustment of the ablation strategy. [ABSTRACT FROM AUTHOR]

The optimal approach for prevention of cardiovascular events and reduction of bleeding in patients with acute coronary syndrome (ACS) and atrial fibrillation (AF) is still controversial. The aim of our study is to asses our single-center experience with concomitant left atrial appendage occlusion (LAAO) and percutaneous coronary intervention (PCI). 50 patients with ACS without ST elevation and history of AF were randomized after successful PCI to LAAO or conventional medical therapy. The primary endpoints were safety and length of hospitalization. The follow-up period was 30 days. The mean procedural times were 113 ± 23 min PCI + LAAO implantation and 39 ± 19 min of PCI only (p < 0.001), while mean fluoroscopy times were 18 ± 8 min and 12 ± 8 min (p < 0.001), respectively. No procedure-related complications were observed. There was no difference observed for length of hospitalization between two groups. LAAO in patients with ACS and AF undergoing PCI appears safe. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common cardiac arrhythmia and if untreated, significantly increases both the risk of intracardiac thrombus formation and ischemic stroke. In patients with nonvalvular AF (NVAF), the left atrial appendage (LAA) has been estimated to be the source of thrombus development in 91% to 99% of cases. Consequently, oral anticoagulation (OAC) to provide stroke prevention has become the standard of care for most AF patients; however, OACs are associated with a risk of bleeding and their efficacy depends on optimal patient compliance. In terms of alternative approaches to preventing embolic events, surgical LAA excision was attempted as early as in the late 1940s in patients with valvular AF; LAA excision remains a recommendation in surgical guidelines for NVAF patients who need open-heart coronary bypass or valvular replacement/repair surgeries. However, due to its invasive nature surgical LAA intervention has limited clinical application in present cardiology practice. Percutaneous LAA occlusion (LAAO) is increasingly being performed as an alternative to OAC for stroke prevention; this is particularly the case in patients at increased bleeding risk. Substantial progress has been made in percutaneous LAAO therapy since its inception some twenty years ago. Herein we systematically review both the critical literature that led to the development of LAAO, and the increasing clinical evidence supporting the application of this treatment strategy in NVAF. To this end we focus on recently published critical evaluations of United States Food and Drug Administration (US FDA) and Conformité Européenne (Commercial Sale of Licensed Product in the EU) (CE-Mark) approved LAAO devices, summarize the current status of LAAO therapy, and discuss the future perspectives regarding the knowledge and technology gaps in this area by recognizing the potential contributions of many ongoing but likely transformative clinical trials. [ABSTRACT FROM AUTHOR]

Objective: Left atrial appendage (LAA) closure is associated with reduced rates of stroke in patients with atrial fibrillation (AF). We evaluated trends in LAA closure, the association of LAA closure with stroke/systemic embolism, and its safety profile in patients with AF who underwent cardiac surgery in California. We further tested for hospital-level variation in concomitant LAA closure. Methods: Adults who underwent coronary artery bypass grafting and/or valve surgery with preoperative AF were identified in the 2016 to 2019 Office of Statewide Health Planning and Development databases. Propensity score matching was performed to study risk-adjusted associations of LAA closure with ischemic stroke/systemic embolism. Hospital-level variation was studied using intraclass correlation coefficients. Results: Among 18,434 patients with AF who underwent coronary artery bypass grafting/valve surgery, 47.7% received LAA closure. Rates of LAA closure increased from 44.4% to 51.4% from 2016 to 2019 (P

[Display omitted] [ABSTRACT FROM AUTHOR]

Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45–90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management.

[Display omitted] [ABSTRACT FROM AUTHOR]

BackgroundWith an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms.ObjectivesThe purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF.MethodsForty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching.ResultsIn the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up.ConclusionsThe DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores.

Background The interrelationships between left atrial appendage (LAA) dimensions and device following implantation are unknown. We aimed to analyze the impact of Watchman device implantation on LAA dimensions following its percutaneous closure and potential predictors of remodeling. Methods and Results All consecutive LAA closure procedures performed at 2 centers between November 2017 and December 2020 were included in the WATCH‐DUAL (Watchman 2.5 Versus Watchman FLX in a Dual‐Center Left Atrial Appendage Closure Cohort) registry. This study included patients who had pre‐ and postintervention computed tomography scan analysis. The LAA and device dimensions were measured in a centralized core lab by 3‐dimensional computed tomography scan reconstruction methods, focusing on the device landing zone. This analysis included 104 patients (age, 76.0 [range, 72.0–83.0] years; 72% men; 53% Watchman FLX; 47% Watchman 2.5). The baseline characteristics were comparable between Watchman 2.5 and Watchman FLX groups, except for the higher use of oversizing in the latter group. The median delay for computed tomography control was 49 (range, 43–64) days. The landing zone area (median, 446 [range, 363–523] versus 290 [222–366] mm2; P

Left atrial appendage (LAA) was shown to harbor triggers and substrate for atrial arrhythmia, electrical isolation of the LAA can be a potential treatment. We describe the use of a novel device that combines electrical isolation of the LAA using pulsed field ablation and mechanical LAA occlusion in a single procedure. (Level of Difficulty: Advanced.)

Background: Left atrial appendage (LAA) is the origin of most heart thrombi which can lead to stroke or other cerebrovascular event in patients with non-valvular atrial fibrillation (AF). This study aimed to prove safety and low complication rate of surgical LAA amputation using cut and sew technique with control of its effectiveness. Methods: 303 patients who have undergone selective LAA amputation were enrolled in the study in a period from 10/17 to 08/20. The LAA amputation was performed concomitant to routine cardiac surgery on cardiopulmonary bypass with cardiac arrest with or without previous history of AF. The operative and clinical data were evaluated. Extent of LAA amputation was examined intraoperatively by transoesophageal echocardiography (TEE). Six months in follow up, the patients were controlled regarding clinical status and episodes of strokes. Results: Average age of study population was 69.9 ± 19.2 and 81.9% of patients were male. In only three patients was residual stump after LAA amputation larger than 1 cm with average stump size 0.28 ± 0.34 cm. 3 patients (1%) developed postoperative bleeding. Postoperatively 77 (25.4%) patients developed postoperative AF (POAF), of which 29 (9.6%) still had AF at discharge. On 6 months follow up only 5 patients had NYHA class III and 1 NYHA class IV. Seven patients reported with leg oedema and no patient experienced any cerebrovascular event in early postoperative follow up. Conclusion: LAA amputation can be performed safely and completely leaving minimal to no LAA residual stump. [ABSTRACT FROM AUTHOR]

The impact of preprocedure imaging on the safety and effectiveness of left atrial appendage occlusion (LAAO) remains unclear. This study sought to determine the rates of use of preprocedure computed tomography (CT)/cardiac magnetic resonance (CMR) and its association with safety and effectiveness of LAAO procedures. The National Cardiovascular Data Registry LAAO Registry was used to evaluate patients who underwent attempted LAAO with the WATCHMAN and WATCHMAN FLX devices between January 1, 2016, and June 30, 2021. Safety and effectiveness of LAAO procedures was compared by use vs nonuse of preprocedural CT/CMR. Outcomes of interest included implantation success (deployment and release of device), device success (device released with peridevice leak <5 mm), and procedure success (device released with peridevice leak <5 mm and no in-hospital major adverse events [MAE]). Multivariable logistic regression was used to assess the relationship between preprocedure imaging and outcomes. Preprocedure CT/CMR was used for 18.2% (n = 20,851) of the 114,384 procedures in this study. CT/CMR use was more common among government and university hospitals and hospitals in the Midwest and South; it was less common among patients with uncontrolled hypertension, with abnormal renal function, and without prior thromboembolism. Overall rates of implantation success, device success, and procedure success were 93.4%, 91.2%, and 89.4%, respectively. Preprocedure CT/CMR was independently associated with an increased likelihood of implantation success (OR: 1.08; 95% CI: 1.00-1.17), device success (OR: 1.10; 95% CI: 1.04-1.16), and procedural success (OR: 1.07; 95% CI: 1.02-1.13). MAE were uncommon (2.3%) and not associated with use of preprocedure CT/CMR (OR: 1.02; 95% CI: 0.92-1.12). Preprocedure CT/CMR was associated with an increased likelihood of successful LAAO implantation; however, the magnitude of benefit appears small and it was not associated with MAE. [Display omitted] [ABSTRACT FROM AUTHOR]

Atrial fibrillation is the most common arrhythmia worldwide, placing a large population at risk for potentially disabling ischemic strokes, yet an estimated 50% of eligible patients cannot tolerate or are contraindicated to receive oral anticoagulation. Within the last 15 years, transcatheter options for left atrial appendage closure (LAAC) have provided a valuable alternative to chronic oral anticoagulation for reducing risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation. With newer generation devices such as Watchman FLX and Amulet gaining approval from the US Food and Drug Administration in recent years, several large clinical trials have demonstrated the safety and efficacy of transcatheter LAAC in a population intolerant to systemic anticoagulation. In this contemporary review, we discuss the indications for transcatheter LAAC and the evidence evaluating the use of various device therapies currently available or in development. We also examine current unmet challenges in intraprocedural imaging and controversies in postimplantation antithrombotic regimens. Several ongoing seminal trials are hoping to clarify the role of transcatheter LAAC as a safe, first-line option for all patients with nonvalvular atrial fibrillation. [ABSTRACT FROM AUTHOR]

In the wake of rapid advancement in cardiovascular procedural technologies, physician-led preprocedural planning utilizing multi-modality imaging training is increasingly recognized as invaluable for procedural accuracy. Left atrial appendage occlusion (LAAO) is one such procedure in which complications such as device leak, cardiac injury, and device embolization can be decreased substantially with incorporation of physician driven imaging and digital tools. We discuss the benefits of cardiac CT and 3D printing in preprocedural planning for the Heart Team, as well as novel applications by physicians of intraprocedural 3D angiography and dynamic fusion imaging. Furthermore, incorporation of computational modeling and artificial intelligence (AI) may yield promise. For optimal patient-centric procedural success, we advocate for standardized preprocedural imaging planning by physicians within the Heart Team as an essential part of LAAO. [ABSTRACT FROM AUTHOR]

Background: Patients undergoing left atrial appendage (LAA) occlusion (LAAO) are multi-morbid, including mitral valve disease (MVD) which is associated with anatomic changes of the left atrium (LA). This study aims to identify how atrial myopathy in MVD influences outcomes in LAAO. Methods: Atrial myopathy in MVD was defined as LA diameter > 45 mm (♀) and > 48 mm (♂) and existing MVD or history of surgical/interventional treatment. Patients were compared with controls from the prospective, multicentre LAArge registry of LAAO. Results: A total of 528 patients (52 MVD, 476 no-MVD) were included. The MVD group was significantly more likely to be older (78.2 years vs 75.9 years, p = 0.036) and female (59.6% vs 37.8%, p = 0.002). Altered LA anatomy was observed in MVD with significantly larger LA diameter (53 mm vs. 48 mm, p < 0.001) and LAA Ostia [at 135° 23.0 mm (20.5, 26.0) vs 20.0 mm (18.0, 23.0), p = 0.002]. Implant success was high with 96.2% and 97.9%, respectively, without differences in severe complications (7.7% vs 4.6%, p = 0.31). One-year mortality (17.8% vs 11.5%, p = 0.19) and a combined outcome of death, stroke, and systemic embolism (20.3% vs 12.4%, p = 0.13) were not different. Independent predictors of the combined outcome were peripheral artery disease (HR 2.41, 95% CI 1.46–3.98, p < 0.001) and chronic kidney disease (HR 3.46, 95% CI 2.02–5.93, p < 0.001) but not MVD and atrial myopathy. Conclusion: Patients with MVD present with altered LA anatomy with increased LA and LAA diameter. However, procedural success and safety in LAAO are not compromised. One-year mortality is numerically higher in patients with MVD but driven by comorbidities. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the value of individualized planning of left atrial appendage occlusion (LAAO) using cardiac computed tomography angiography (CCTA) reconstruction techniques. Methods. A total of 96 patients treated for LAAO with the Watchman occluder were included in this study. All patients were randomized by random number table in a 2:1 ratio into the CCTA (+) and CCTA (−) groups according to whether CCTA was performed preoperatively. 3D cardiac reconstruction was performed preoperatively in the CCTA (+) group to plan the location of the atrial septal puncture site, left atrial appendage(LAA) landing zone, predict the size of the occluder and simulate occluder release. In the CCTA(−) group, only transesophageal echocardiography (TEE) and fluoroscopy were used to guide LAAO. Results. The number of occluders used in a single procedure (1.06 ±.24 vs 1.22 ±.42), the number of intraoperative angiography positions (1.23 ±.58 vs 2.28 ±.85) and the procedure time (45.88 ± 5.08 vs 62.44 ± 5.60) in the CCTA(+) group were lower than in the CCTA(−) group (P <.05), and the first-attempt blocking success rate was higher than that of the CCTA(−) group (85.9% vs 65.6%, P =.021). Furthermore, the Bland-Altman plots showed good agreement between the longest diameter of the CCTA-predicted landing zone and the longest diameter of the actual landing zone (95% LoA −7.49, 10.24). A strong positive correlation was observed between the predicted compression ratio and the actual compression ratio (r =.890, P <.001). In addition, a strong positive correlation was found between the CCTA-predicted longest diameter of the landing zone and the actual occluder size (r =.863, P <.001). Conclusion. Accurate planning for LAAO using preoperative CCTA can reduce intraoperative angiography positions and occluder changes, shorten the procedure time, increase the success rate of first-attempt blocking and reduce the difficulty of the procedure. [ABSTRACT FROM AUTHOR]

Introduction: Most patients undergoing a left atrial appendage occlusion (LAAO) procedure are admitted for overnight observation. A same‐day discharge strategy offers the opportunity to improve resource utilization without compromising patient safety. We compared the patient safety outcomes and post‐discharge complications between same‐day discharge versus hospital admission (HA) (>1 day) in patients undergoing LAAO procedure. Methods: A systematic search of MEDLINE and Embase was conducted. Outcomes of interest included peri‐procedural complications, re‐admissions, discharge complications including major bleeding and vascular complications, ischemic stroke, all‐cause mortality, and peri‐device leak >5 mm. Mantel–Haenszel risk ratios (RRs) with 95% CIs were calculated. Results: A total of seven observational studies met the inclusion criteria. There was no statistically significant difference between same‐day discharge versus HA regarding readmission (RR: 0.61; 95% confidence interval [CI]: [0.29–1.31]; p =.21), ischemic stroke after discharge (RR: 1.16; 95% CI: [0.49–2.73]), peri‐device leak >5 mm (RR: 1.27; 95% CI: [0.42–3.85], and all‐cause mortality (RR: 0.60; 95% CI: [0.36–1.02]). The same‐day discharge study group had significantly lower major bleeding or vascular complications (RR: 0.71; 95% CI: [0.54–0.94]). Conclusions: This meta‐analysis of seven observational studies showed no significant difference in patient safety outcomes and post‐discharge complications between same‐day discharge versus HA. These findings provide a solid basis to perform a randomized control trial to eliminate any potential confounders. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and its prevalence increases with age. AF causes palpitations, heart failure, and cardiogenic embolism. Of them, the most critical and fatal complication is a cardio-embolic event. Oral anticoagulation plays a central role in reducing stroke risk in AF patients. Recently, when oral anticoagulation is considered in patients with non-valvular AF who are eligible for direct oral coagulations, they are preferred to vitamin K antagonist based on accumulating evidence. Although many patients can tolerate oral anticoagulation, there is a subset of patients who cannot tolerate long-term oral anticoagulation. Such a subset has a higher bleeding risk as indicated by the HAS-BLED score under oral anticoagulation. This subset of patients requires effective and safe non-pharmacological alternative therapies for stroke prevention. One of the promising non-pharmacological therapies is left atrial appendage closure. Three randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using WATCHMAN family to oral anticoagulation (Boston Scientific, Marlborough, MA, USA). WATCHMAN FLX, which was innovated following WATCHMAN 2.5, was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved issues remain, including device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage. Left atrial appendage closure for patients with non-valvular AF may be an alternative therapy to avoid cardiac embolism for high bleeding risk patients with contraindications to long-term oral anticoagulation therapy. [Display omitted] • Atrial fibrillation (AF) causes cardiogenic embolism which is the critical complication. • Oral anticoagulation (OAC) plays a central role in reducing stroke risk in AF patients. • There is a subset of patients who cannot tolerate OAC due to high-bleeding risk. • One of the promising non-pharmacological therapies is left atrial appendage closure (LAAC). • LAAC may be an alternative therapy to avoid stroke for AF patients with high bleeding risk by OAC. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common arrhythmia and can be treated with catheter ablation (CA) combined with left atrial appendage occlusion (LAAO). The study is designed to compare the safety and efficacy of guiding the combined procedure by digital subtraction angiography (DSA) with or without transesophageal echocardiography (TEE). Methods: From February 2019 to December 2020, 138 patients with nonvalvular AF who underwent CA combined with LAAO procedure were consecutively included, and two cohorts were built according to intraprocedural guidance (DSA or DSA with TEE). Periprocedural and follow‐up outcomes were compared with investigate the feasibility and safety between the two cohorts. Results: 71 patients and 67 patients were included in the DSA cohort and TEE cohort, respectively. Age and gender were comparable, despite the TEE cohort having a higher proportion of persistent AF (37 [55.2%] vs. 26 [36.6%]) and hemorrhage history (9 [13.4%] vs. 0). The procedure time of the DSA cohort was significantly reduced (95.7 ± 27.6 vs. 108.9 ± 30.3 min, p =.018), with a nonsignificant longer fluoroscopic time (15.2 ± 5.4 vs. 14.4 ± 7.1 min, p =.074). And the overall incidence of peri‐procedural complications was similar between cohorts. After an average of 24 months of clinical follow‐up, only three patients in the TEE cohort had ≤3 mm residual flow (p =.62). Kaplan–Meier estimates showed nonsignificant differences between the cohorts for freedom from atrial arrhythmia (log‐rank p =.964) and major adverse cardiovascular events (log‐rank p =.502). Conclusions: Compared with DSA and TEE guidance, DSA‐guided combined procedure could shorten the procedural time, while achieving similar periprocedural and long‐term feasibility and safety. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is a well-established risk factor for intracardiac thrombosis. Left atrial appendage occlusion (LAAO) is emerging as a viable alternative to oral anticoagulation (OAC) for high-risk AF patients who are contraindicated to long-term OAC. Case summary A 74-year-old man with a history of permanent AF and subdural haemorrhage on warfarin therapy was referred to our facility for further management. Cardiac CT imaging revealed large bi-atrial thrombi for which apixaban therapy was initiated. Serial imaging over nine months showed gradual shrinkage and then resolution of the thrombi. In line with the patient's preference to avoid life-long OAC, he received LAAO using an Amplatzer™ Amulet™ device. Follow-up transoesophageal echocardiography showed a well-seated device with no leak and no thrombus. Discussion We discussed the key issues surrounding management of bi-atrial thrombi and the decision to perform LAAO in these circumstances, relying on shared decision making and multi-disciplinary team input. [ABSTRACT FROM AUTHOR]