Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus

Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.     

Recurrent syncope after left atrial appendage occlusion

We present the case of a 72‐year‐old woman with permanent atrial fibrillation and contraindication to long‐term oral anticoagulant therapy who underwent left atrial appendage (LAA) occlusion. A 24‐mm Amplatzer Cardiac Plug (St Jude Medical) device was deployed. The inferior part of the external disc of the device appeared to be over the posterior leaflet of the mitral valve but no significant mitral stenosis or mitral regurgitation was detected before deployment. After the procedure the patient suffered several syncopes when she tried to stand up. A transesophageal echocardiography (TEE) was performed and no significant differences on the device position were detected, it was not possible to perform the TEE in a stand‐up position due to the patient symptoms (hypotension, tachycardia, dizziness, and loss of consciousness). After discussion with the surgical team, surgical removal of the device and surgical exclusion of LAA was performed. The symptoms disappeared and the patient was discharged. In the best of our knowledge, this is the first time that recurrent syncope has been described as a complication of LAA occlusion. © 2014 Wiley Periodicals, Inc.     

Congenital Absence of the Left Atrial Appendage Visualized by 3D Echocardiography in Two Adult Patients

Congenital absence of left atrial appendage (LAA) is an extremely rare condition and its physiological consequences are unknown. We present two cases of incidental finding of a congenitally absent LAA in a 79‐year‐old male who presented for routine transesophageal echocardiogram (TEE) to rule out intracardiac thrombus prior to placement of biventricular implantable cardioverter‐defibrillator and a 54‐year old female who presented for TEE prior to radiofrequency ablation of atrial fibrillation. Characterization of patients with such an absence is important because congenitally absent LAA may be confused with flush thrombotic occlusion of the appendage. There are very few published reports of congenital absence of LAA. To our knowledge, our report is the first to demonstrate the congenital absence of LAA by 3D transesophageal echocardiography.     

Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials

OBJECTIVES: These studies were conducted to evaluate the feasibility of percutaneous left atrial appendage (LAA) occlusion using the PLAATO system (ev3 Inc., Plymouth, Minnesota). BACKGROUND: Patients with atrial fibrillation (AF) have a five-fold increased risk for stroke. Other studies have shown that more than 90% of atrial thrombi in patients with non-rheumatic AF originate in the LAA. Transvenous closure of the LAA is a new approach in preventing embolism in these patients. METHODS: Within two prospective, multi-center trials, LAA occlusion was attempted in 111 patients (age 71 +/- 9 years). All patients had a contraindication for anticoagulation therapy and at least one additional risk factor for stroke. The primary end point was incidence of major adverse events (MAEs), a composite of stroke, cardiac or neurological death, myocardial infarction, and requirement for procedure-related cardiovascular surgery within the first month. RESULTS: Implantation was successful in 108 of 111 patients (97.3%, 95% confidence interval [CI] 92.3% to 99.4%) who underwent 113 procedures. One patient (0.9%, 95% CI 0.02% to 4.9%) experienced two MAEs within the first 30 days: need for cardiovascular surgery and in-hospital neurological death. Three other patients underwent in-hospital pericardiocentesis due to a hemopericardium. Average follow-up was 9.8 months. Two patients experienced stroke. No migration or mobile thrombus was noted on transesophageal echocardiogram at one and six months after device implantation. CONCLUSIONS: Closing the LAA using the PLAATO system is feasible and can be performed at acceptable risk. It may become an alternative in patients with AF and a contraindication for lifelong anticoagulation treatment.     

Importance of Persistent Right-to-Left Shunt After Patent Foramen Ovale Closure in Cryptogenic Stroke Patients

Percutaneous closure of patent foramen ovale (PFO) is widely performed to prevent recurrent stroke or transient ischemic attack in patients with cryptogenic stroke. However, the influence of different degrees of right-to-left shunting (RLS) has rarely been reported.We retrospectively evaluated the cases of 268 patients with cryptogenic stroke who underwent PFO closure at our hospital from April 2012 through April 2015. In accordance with RLS severity, we divided the patients into 2 groups: persistent RLS during normal breathing and the Valsalva maneuver (n=112) and RLS only during the Valsalva maneuver (n=156). Baseline characteristics, morphologic features, and procedural and follow-up data were reviewed. The primary endpoint was stroke or transient ischemic attack.More patients in the persistent group had multiple or bilateral ischemic lesions, as well as a larger median PFO diameter (2.5 mm [range, 1.8–3.9 mm]) than did patients in the Valsalva maneuver group (1.3 mm [range, 0.9–1.9 mm]) (P <0.001). Atrial septal aneurysm was more frequent in the persistent group: 25 patients (22.3%) compared with 18 (11.5%) (P=0.018). Three patients in the persistent group had residual shunting. The annual risk of recurrent ischemic stroke was similar between groups: 0.298% (persistent) and 0.214% (Valsalva maneuver).Our findings suggest that patients with persistent RLS have more numerous severe ischemic lesions, larger PFOs, and a higher incidence of atrial septal aneurysm than do those without. Although our persistent group had a greater risk of residual shunting after PFO closure, recurrence of ischemic events did not differ significantly from that in the Valsalva maneuver group.     

Thrombus formation after left atrial appendage exclusion using an amplatzer cardiac plug device

The feasibility and safety of left atrial appendage closure with the Amplatzer cardiac plug (AGA Medical Corp., Minneapolis, MN) have been recently published; no thrombus formation on the device surface has been reported previously. We describe a case of a 66‐year‐old man with permanent atrial fibrillation, previous stroke, and contraindication for long‐term oral anticoagulant therapy. A 22‐mm ACP device was deployed successfully without complications. The patient was discharged on acetyl salicylic acid 100 mg and clopidogrel 75 mg daily. After 4 weeks, the patient was admitted for a lower gastrointestinal bleeding and clopidogrel was stopped. A 3‐month follow‐up echocardiogram confirmed the exclusion of the LAA but it demonstrated the presence of a thrombus on the atrial surface of the device. It was decided to keep the patient on acetyl salicylic acid 100 mg with the addition of enoxaparin 60 mg bid. Transesophageal echocardiogram demonstrated total resolution of the thrombus after 2 months. © 2011 Wiley Periodicals, Inc.     

Papillary Fibroelastoma in Differential Diagnosis of Left Atrial Appendage Masses

Papillary fibroelastomas are benign tumors that usually originate from cardiac valves but may have other endocardial origins. We report the cases of 2 patients in whom left atrial appendage masses were initially diagnosed as thrombus. They were treated for embolic stroke and their symptoms resolved; however, their left atrial appendage masses did not regress. After surgery, histologic analysis of the resected masses revealed papillary fibroelastoma in both cases. We discuss the diagnostic and therapeutic dilemmas encountered in patients with papillary fibroelastomas and cardiac masses other than thrombus.     

Intraprocedural and long-term incomplete occlusion of the left atrial appendage following placement of the WATCHMAN device: a single center experience

Incomplete LAA Occlusion by WATCHMAN Device . Introduction: Transcatheter left atrial appendage (LAA) closure with the WATCHMAN device has become one of the therapeutic options in atrial fibrillation (AF) patients who are at high risk for ischemic stroke. However, the incidence and evolution of incomplete occlusion of the LAA during and after placement of the WATCHMAN device has not been reported. Methods and Results: Fifty‐eight consecutive patients who had undergone WATCHMAN device implant were included in the study. Intraprocedural, 45‐day and 12‐month transesophageal echocardiogram images were reviewed and analyzed. Peridevice gap was noted in 16 (27.6%), 17 (29.3%), and 20 (34.5%) patients across the 3 time points. Intraprocedural gaps are more likely to be persistent until 12 months and become larger in size over time. New gap also occurs during follow‐up even if the LAA was completely sealed at implantation. One patient had an ischemic stroke 4.7 months after implant; another patient developed a left atrial thrombus over the device 21.6 months after implant. Both patients had intraprocedural gap and discontinued warfarin therapy after the 45‐day evaluation. Conclusion: Incomplete LAA occlusion with a gap between the WATCHMAN device surface and the LAA wall is relatively common. Intraprocedural gaps are more likely to become bigger over time and persist, while new gaps also occur during follow‐up. Further studies are warranted to verify whether the presence and persistence of a peridevice gap is associated with increased risk of thromboembolic event in AF patients implanted with a WATCHMAN device. (J Cardiovasc Electrophysiol, Vol. 23, pp. 455‐461, May 2012)     

Off-Pump Continuous-Flow Left Ventricular Assist Device Implantation

Continuous-flow left ventricular assist device implantation is the typical treatment for end-stage heart failure. Improvements in device engineering and technology, surgical experience and technique, and perioperative management have advanced the field, and short-term results approach those of heart transplantation. Further improvements may be achieved by minimizing adverse physiologic effects associated with cardiopulmonary bypass. Therefore, we have developed an off-pump implantation approach for continuous-flow left ventricular assist devices. We detail our surgical technique for off-pump implantation of the HeartWare device.     

Left atrial thrombus after complete left atrial appendage exclusion with LARIAT device

A 74‐year‐old woman with paroxysmal atrial fibrillation underwent left atrial appendage (LAA) exclusion with a LARIAT snare device. Transesophageal echocardiogram one month later demonstrated a left atrial thrombus at orifice of the completely occluded LAA that subsequently resolved with two months of anticoagulation. This case highlights that LAA ligation with LARIAT device continues to pose a risk for left atrial thrombosis in the immediate post‐operative period. It also emphasizes the need for further evidence regarding antiplatelet and anticoagulation therapy in these patients. © 2014 Wiley Periodicals, Inc.     

Progressive Increase in Peridevice Leakage After the Implantation of the Watchman Device on Long-term Serial Echocardiographic Follow-up

Percutaneous left atrial appendage (LAA) occlusion using the Watchman device (Atritech, Plymouth, MN) is suggested as an alternative modality to warfarin for stroke prevention in patients with nonvalvular atrial fibrillation (AF). However, peridevice leakage resulting from incomplete LAA occlusion remains 1 of the most frequent limitations. We report a case of progressive increase in peridevice leakage after Watchman device implantation on long-term transesophageal echocardiographic follow-up accompanied by stroke.     

经胸超声心动图多切面扫查法对左心耳及左心耳血栓的显示效果

目的探讨经胸超声心动图多切面扫查法对左心耳的显示及左心耳血栓检出的效果。方法入选32例心房颤动(房颤)患者,分别采用经胸二维超声心动图多切面扫查法及常规扫查法显示左心耳,并记录左心耳血栓的发生情况。常规扫查法采用调整的大动脉短轴切面进行观察,多切面扫查法在调整的大动脉短轴及其临近切面基础上同时进行调整的左心两腔切面及其邻近切面进行观察。以经食管超声心动图检查作为左心耳血栓检出的"金标准",比较多切面扫查法和常规扫查法对左耳血栓检出的敏感性、特异性。结果经胸超声心动图对左心耳的显示率:常规扫查法为50.0%,多切面扫查法为81.2%,两种方法左心耳的显示率有统计学差异(P0.05)。常规扫查法检出左心耳血栓的敏感性为27.3%、特异性90.5%;多切面扫查法检出左心耳血栓的敏感性为63.6%,特异性为95.2%。对于左心耳血栓的检出,多切面扫查法与经食管超声心动图一致性更好,优于常规扫查法。结论多切面扫查法能提高经胸超声心动图对左心耳的显示效果及左心耳血栓的检出,具有一定的临床实用价值。     

Interventioneller Vorhofohrverschluss zur Schlaganfallprophylaxe bei Vorhofflimmern

Ischemic stroke is a major risk factor for morbidity and mortality in western societies. Besides oral anticoagulation (OAC), interventional left atrial appendage (LAA) occlusion has been recently introduced for stroke prophylaxis in patients with atrial fibrillation. This procedure has proven its non-inferiority to OAC in terms of safety and efficacy in randomized trials. So far mainly patients with contraindications to OAC or with an elevated risk for both embolic and bleeding events have been treated with LAA occlusion devices. Various devices are currently in use in the clinical routine, mainly using a transseptal access to the LAA. It has been shown that in experienced centers the procedure can be performed with a minimum risk for serious complications. After successful LAA occlusion dual anti-platelet therapy or OAC is necessary until the device is fully endothelialized after approximately 3 months. In the clinical practice a dual platelet inhibition is often used; however, data from large registries imply that OAC can most likely be safely discontinued directly after implantation. Interventional LAA occlusion is therefore a viable option for stroke prevention in atrial fibrillation.     

Use of intracardiac echocardiography to guide implantation of a left atrial appendage occlusion device (PLAATO).

BACKGROUND: Over 90% of thrombi in atrial fibrillation (AF) originate from the left atrial appendage (LAA). Patients with contraindications to anticoagulation are potential candidates for LAA occlusion using the Percutaneous Left Atrial Appendage Transcatheter Occlusion system (PLAATO, ev3 Inc., Plymouth, MN). Transesophageal echocardiography (TEE) is typically used to guide implantation. OBJECTIVE: This study sought to examine the utility of intracardiac echocardiography (ICE) in providing adequate imaging guidance as an alternative to TEE during PLAATO implantation. METHODS: The study group consisted of 10 patients who underwent PLAATO implantation with simultaneous TEE and ICE imaging guidance. ICE was used to perform the following tasks typically fulfilled by TEE: (1) verification of the absence of LAA thrombus, (2) identification of the LAA ostial dimension for device sizing, (3) guidance of transseptal puncture, (4) verification of the delivery sheath position, and (5) confirmation of location and stability of device before its irrecoverable release. The ability of ICE to perform these tasks was assessed from three separate positions: the standard right atrial (RA) position, within the coronary sinus (CS), and the right ventricular outflow tract. RESULTS: ICE imaging of the LAA was optimal from within the CS, although imaging from the proximal pulmonary artery provided better visualization of the distal LAA in cross-section. The LAA dimensions, confirmation of the absence of LAA thrombus, proper positioning of the delivery sheath, verification of location and stability of the device obtained by ICE were consistent with findings from TEE. CONCLUSION: Using nonconventional imaging planes, ICE imaging was able to perform the intraprocedural functions provided by TEE during implantation of the PLAATO left atrial appendage occlusion device.     

Effect of elevated left ventricular diastolic filling pressure on the frequency of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation

We investigated the relation between left ventricular diastolic dysfunction and left atrial appendage (LAA) thrombus in patients with atrial fibrillation (AF). We performed transesophageal echocardiography to examine LAA thrombus or spontaneous echo contrast (SEC) and to measure LAA emptying flow velocity in consecutive 376 patients with AF. We estimated diastolic filling pressure as the ratio of early transmitral flow velocity (E) to mitral annular velocity (e') on transthoracic echocardiogram. E/e' ratio in 28 patients (7.4%) with LAA thrombi was higher than that in patients without thrombus (18.3 ± 9.3 vs 11.4 ± 5.9, p <0.0001). The fourth quartile of E/e' (>13.6) consisted of 19 patients with thrombi and had a higher prevalence of thrombi than the others (p <0.0001). Multivariate regression analysis selected E/e' ≥13 as an independent predictor of LAA thrombus with an odds ratio of 3.50 (1.22 to 10.61) in addition to LA dimension and ejection fraction. Increased quartile of E/e' was negatively associated with LAA flow velocity and positively with rate of SEC. In conclusion, increased diastolic filling pressure is associated with a higher rate of LAA thrombus in AF, partly through blood stasis or impaired LAA function.     

Percutaneous Closure versus Medical Therapy Alone for Cryptogenic Stroke Patients with a Patent Foramen Ovale: Meta-Analysis of Randomized Controlled Trials

Of cryptogenic stroke patients younger than 55 years of age, up to 61% have had a patent foramen ovale (PFO). Observational studies have revealed reductions in recurrent neurologic events through PFO closure versus medical therapy, and randomized controlled trials have shown nonsignificant trends toward benefit. We systematically searched for randomized controlled trials of percutaneous PFO closure with medical therapy versus medical therapy alone in patients with cryptogenic stroke and performed a meta-analysis of treatment outcomes. The primary endpoint was combined death, stroke, and transient ischemic attack.We included 3 trials. Of 2,303 total patients, 1,150 underwent PFO closure and 1,153 received medical therapy (median follow-up period, 2.6 yr). The pooled incidence of the primary endpoint was 1.2 events per 100 patient-years in the closure group (95% confidence interval [CI], 0.2–2.3) and 1.8 in the therapy group (95% CI, 0.7–2.9) (P=0.32); the number needed to treat was 167 (range, 100–500). The corresponding pooled hazard ratio was 0.67 (95% CI, 0.44–1.01; P=0.054) in favor of closure. Closure was associated with an increased risk of atrial fibrillation: relative risk=3.51 (95% CI, 1.44–8.55; P=0.006). When stratified by device, use of the Amplatzer™ PFO Occluder resulted in significant stroke-prevention benefit over medical therapy alone: hazard ratio=0.44 (95% CI, 0.21–0.95; P=0.037).When compared with medical therapy alone, PFO closure with medical therapy showed a trend toward a decreased hazard of combined events, although the absolute event reduction was small and the number needed to treat was high.     

Self-Expandable Device for Percutaneous Closing of Left Atrial Appendage With Organized Thrombus in a Patient With Permanent Atrial Fibrillation

While a left atrial appendage (LAA) occlusion device may reduce the risk of cardioembolic stroke in patients with nonvalvular atrial fibrillation, an antithromboembolic strategy for patients with an organized thrombus in the LAA is still unclear. The present case is the first report of percutaneous closing of an LAA and organized thrombus with a self-expandable LAA occlusion device without complication. This minimally invasive intervention is a potential treatment option in a patient with significant risk of recurrent thromboembolism.     

Anatomical analysis of the left atrial appendage using segmented, three-dimensional cardiac CT: a comparison of patients with paroxysmal and persistent forms of atrial fibrillation

Purpose

Successful implantation of percutaneous left atrial appendage (LAA) occlusion devices requires an accurate understanding of LAA anatomy and orifice dimensions. We sought to quantitatively compare LAA anatomy in patients with paroxysmal and persistent patterns of atrial fibrillation (AF).

Methods

Fifty-nine consecutive patients undergoing catheter ablation for AF underwent pre-procedural multislice cardiac computed tomography (CT) scans. Maximal LAA orifice dimensions and left atrial and LAA volumes were measured from three-dimensional segmented CT reconstructions. Thirty-six patients with paroxysmal and 23 with persistent AF were analysed.

Results

The mean maximal LAA orifice dimension was larger in persistent (27.2?±?4?mm) than paroxysmal AF (22.9?±?3?mm, p?r?=?0.76), maximal LAA orifice dimension (r?=?0.63) and left atrial volume.

Conclusions

Increased LAA orifice dimension is associated with left atrial enlargement in AF. This finding may impact LAA occlusion device sizing.     

A novel approach to treat residual peridevice leakage after left‐atrial appendage closure

Left atrial appendage (LAA) device closure has emerged as an alternative treatment to conventional anticoagaluation therapy for the prevention of thromboembolic events in patients with atrial fibrillation. In 8–10% of patients with interventional LAA obliteration, relevant residual flow into the LAA persists due to incomplete seal. We present two cases in whom for the first time two different devices were placed to complete occlusion after residual leak with a first device.© 2013 Wiley Periodicals, Inc.     

Left atrial appendage occlusion using a Watchman device in a transplanted heart with biatrial anastomosis

A percutaneous left atrial appendage (LAA) occlusion using a Watchman device was performed in a patient with prior biatrial anastomosis orthotopic heart transplant (OHT). Due to the anatomical changes following biatrial anastomosis, transesophageal echocardiography (TEE) imaging and transseptal puncture become technically challenging. We describe how the standard LAA views on TEE were obtained for device sizing, and how the transseptal puncture was modified to cross the scarred septum. This case demonstrates that LAA occlusion using a Watchman device in biatrial anastomosis OHT is safe and can successfully be done.