Role of left atrial appendage occlusion in patients with HeartMate 3

Open in a separate window OBJECTIVESLeft atrial appendage occlusion (LAAO) at the time of implantation may reduce thromboembolic events (TEs) during continuous-flow left ventricular assist device support. The HeartMate 3 (HM3) reduces TEs overall, but the efficacy of LAAO in HM3 is unknown.METHODSAdults receiving first HM3 implantation from November 2014 through December 2019 at a single, large medical centre were retrospectively reviewed. TEs included device thrombosis and ischaemic stroke. Patients were classified by whether they received LAAO or not. Incidence of TEs was compared between groups using cumulative incidence curves with competing risks (death and heart transplant) and risk factors for TEs were assessed with Fine and Gray competing risk regression.RESULTSA total of 182 patients received HM3, of whom 99 (54%) received LAAO versus 83 (46%) who did not. There were 14 TEs, including 13 strokes (7%) and 1 pump thrombosis (0.5%). No significant difference in the incidence of TEs in each group was found (Gray’s test: P = 0.35). LAAO was not associated with TEs in multivariable Fine–Gray analysis (P = 0.10) and no significant risk factors for TEs were found. There were zero disabling strokes in those who received LAAO compared to 6 (7%) in those who did not receive LAAO (P = 0.008).CONCLUSIONSA low number of TEs was observed in HM3 recipients. LAAO did not further reduce the overall rate of TEs in this patient population, though its use may be beneficial in preventing disabling ischaemic strokes after HM3 implantation.     

Uncommon complication from left atrial appendage occluder (LAAO)

To decrease the risk of stroke due to atrial fibrillation, cardiologists will insert a device known as a left atrial appendage occluder to the left atrial appendage. This will decrease the stagnant flow of blood in that particular region. Known complications of this procedure include perforation, migration and dislodgement.We report a case with uncommon late complication of this device causing erosion of the left ventricle, in which open heart operation was carried out to repair the defect.     

高龄冠心病合并心房颤动患者行非体外循环冠状动脉旁路移植术中左心耳处理的回顾性队列研究

目的 本文旨在探讨左室射血分数(LVEF)降低的高龄冠心病合并心房颤动(房颤)患者在非体外循环冠状动脉旁路移植术(OPCABG)中同期处理左心耳的手术技巧及效果评价.方法 纳入2013～ 2018年,84例OPCABGLVEF降低(＜50％)的高龄(年龄≥70岁)冠心病合并房颤患者在我科行非体外循环冠脉搭桥术.男54例...     

实时三维经食管超声心动图定量评价心房颤动患者左心耳形态及功能

目的探讨实时三维经食管超声心动图(RT-3D-TEE)定量评估心房颤动(AF)患者左心耳(LAA)形态和功能的可行性。方法选取56例拟接受射频消融术的阵发性AF患者(阵发组)、26例持续性AF患者(持续组)及同期11名健康人(对照组),采用RT-3D-TEE测量3组LAA各参数。结果与对照组比较,阵发组LAA舒张末期容积(LAA-EDV)、收缩末期容积(LAA-ESV)、开口最大面积(A_(max))及最小面积(A_(min))均增大,射血分数(LAA-EF)、最大排空速度(Vep)、面积变化率(A%)及直径变化率(D%)均减小(P均0.05);持续组LAA-EDV、LAA-ESV、A_(max)、A_(min)增大,LAA-EF、Vep、A%、D%减小(P均0.05);阵发组与持续组间各参数差异均无统计学意义(P均0.05)。LAA-EF与ESV (r=-0.73,P0.01)、EDV(r=-0.64,P0.01)、A_(max)(r=-0.36,P0.01)及年龄(r=-0.27,P=0.02)呈负相关,与A%、D%、Vep呈正相关(r=0.86、0.74、0.55,P均0.01),与D_(max)无明显相关(P0.05)。结论 RT-3D-TEE能定量分析AF患者LAA形态及功能变化,对于评估AF患者病情具有一定临床意义。     

左心耳封堵术后影响封堵器不完全内皮化的危险因素

目的 分析心房颤动（AF）患者左心耳封堵（LAAO）术后封堵器不完全内皮化的影响因素。方法 回顾性分析53例接受LAAO（封堵装置均为Watchman）治疗的AF患者。于术后3个月以双源CT评估封堵器是否完全内皮化;采用单因素及多因素logistic回归分析观察封堵器不完全内皮化的影响因素。结果 术后随访77~134天,中位随访时间100天。术后3个月,双源CT诊断不完全内皮化32例（不完全组）、完全内皮化21例（完全组）;组间左心室射血分数（LVEF）和二尖瓣反流（MR）差异有统计学意义（P均<0.05）,性别、年龄、AF类型等指标差异均无统计学意义（P均>0.05）。以LVEF和MR为自变量、完全内皮化与否为因变量行logistic回归分析,结果显示LVEF和MR均为封堵器不完全内皮化的独立影响因素（P均<0.05）。结论 二尖瓣轻度及以上反流及低射血分数可在一定程度上影响LAAO治疗AF术后封堵器内皮化,导致封堵器延迟内皮化或内皮化不完全。     

The high incidence of left atrial appendage thrombosis in patients on maintenance haemodialysis

Background. The incidence of intracardiac thrombosis in haemodialysispatients has not been studied. Here we determined the incidencein end-stage renal disease patients on maintenance haemodialysis. Methods. Transoesophageal echocardiography was performed in215 patients (125 males, 90 females; mean age 60 ± 9years). Any potential candidate with current or past chronicor intermittent atrial fibrillation or with cardiovascular diseaseswas excluded from the study. Results. Thrombi were found in the left atrial appendages in71 out of 215 subjects (33%). Based on multiple logistic regressionanalyses, the probability of finding a thrombus was found tobe increased in patients on chronic antiplatelet therapy (oddsratio 4.268) and in those with diabetes mellitus and a low haematocrit(0.3; odds ratio 7.173). Other clinical parameters, includinggender, age, duration of haemodialysis, blood pressure, leftventricular dimension, smoking habit or type of anticoagulationduring dialysis, were not associated with the incidence of leftatrial appendage thrombosis. Conclusions. Maintenance haemodialysis patients have a highincidence of left atrial appendage thrombosis. Either chronicuse of antiplatelet drugs or the background conditions requiringantiplatelet therapy, and the concomitant presence of diabetesmellitus and a low haematocrit may be involved in left atrialappendage thrombosis.     

Concurrent prophylactic left atrial appendage exclusion: results from a randomized controlled trial pilot study

Objective: The left atrial appendage is a significant source of cardioembolic thrombi. Open mitral valve surgery presents an opportune time to exclude this appendage from cardiovascular circulation. However, sparse randomized trial support exists for this concomitant procedure. We therefore designed a randomized controlled trial to assess the short- and long-term outcomes of concomitant left atrial appendage exclusion. This report details early outcomes of the pilot trial. Methods: Forty-three patients were randomized to either undergo concomitant suture exclusion of their left atrial appendage under direct vision or not during their open mitral valve surgery. Clinical and biochemical postoperative outcomes, including hemodynamic and hemostatic parameters, were analyzed. Results: There were no deaths in either group. The incidence of cerebrovascular events, myocardial infarction, respiratory failure, and acute renal injury were similar between groups; a composite outcome of 10 major postoperative complications occurred in 32% of the left atrial appendage exclusion group versus 38% of the control group (p = 0.75). Intensive care (median stay 2 days vs 1 day in the control group, p = 0.55) and hospital lengths of stay (median stay 9 days in both groups, p = 0.98) were also similar between groups. Specifically, no additional hemodynamic alterations (need for intra-aortic balloon pump in 1 vs 2 patients in the control group, p = 0.61) or hemostatic complications (no re-operations for bleeding in either group, need for blood product transfusion in 2 vs 1 patient in the control group, p = 1.0) were noted in the left atrial appendage exclusion group. Conclusions: This pilot trial demonstrates the safety of and feasibility of a larger trial powered to detect clinically relevant short- and long-term outcomes of concomitant left atrial appendage exclusion with open mitral valve surgery.     

Left atrial appendage perforation with Watchman device implantation: Strategies for surgical repair

Percutaneous occlusion of the left atrial appendage is increasingly being used as an alternative for stroke prevention in patients with non‐valvular atrial fibrillation at high risk of complications from long term anticoagulation. We describe a case of left atrial appendage perforation during Watchman device implantation requiring emergency repair of the left atrium using sternotomy and cardiopulmonary bypass. Technical considerations for surgical decision making are discussed; in hemodynamically unstable patients as well as those at high risk for embolization.     

Indexed left atrial size predicts all-cause and cardiovascular mortality in patients undergoing aortic valve surgery

Objectives

The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery.

Standalone epicardial left atrial appendage exclusion for thromboembolism prevention in atrial fibrillation

Open in a separate window OBJECTIVESMost strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients.METHODSThis was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated.RESULTSProcedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA₂DS₂-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0–2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up.CONCLUSIONSStudy proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.     

心房颤动患者行左心耳封堵术的围术期护理

目的探讨心房颤动患者行左心耳封堵术的围术期护理要点。方法对20例行左心耳封堵术的心房颤动患者术前给予心理支持和充分准备;术中加强全麻护理及与介入医生的配合;术后加强心律、术区和并发症的观察及护理;出院前做好健康指导。结果 20例患者手术均取得成功,术中术后均无严重并发症发生。结论做好房颤患者行左心耳封堵术的围术期护理,是保证患者配合治疗和手术成功的前提。     

Prevention of postoperative pneumothorax in patients undergoing cardiac surgery

BACKGROUND: Postoperative pneumothorax is a potentially fatal complication occurring in approximately 1.4% of patients after cardiac surgical procedures. Prevention of this complication could save lives, morbidity, and money in this large patient population. This study was undertaken to evaluate the effectiveness of a very simple technique to prevent this complication. METHODS: One thousand three hundred and ninety-seven consecutive adult patients undergoing cardiac surgical procedures performed by the author were evaluated. In each patient a 3-cm opening in the mediastinal pleura of any unopened hemithorax was performed to allow communication of the pleural space with the mediastinum. When a hemithorax had been opened for internal mammary harvesting, the usual pleural drain was inserted. A standard, straight mediastinal tube was then placed in routine fashion without any additional tube placement or unusual positioning. The essence of the approach was the establishment of communication of both pleural spaces with the mediastinum in such a way that any air exiting the lung would be able to evacuate through the mediastinal tube. RESULTS: One patient with obstructive lung disease developed a loculated basilar pneumothorax that was treated with chest tube placement. Two patients required maintenance of mediastinal tube drainage for persistent air leak for 7 and 9 days, respectively. No other patients required chest tube placement for pneumothorax. No patient experienced any complication that could be attributed to the small opening in the pleural space. CONCLUSIONS: The technique herein described is a safe and effective method for prevention of postoperative pneumothorax. It adds nothing to the cost of the surgical procedure. The author would recommend that this technique be adopted as a surgical routine.     

Congenital left atrial appendage aneurysm with unexpected course of left anterior descending coronary artery

The left atrial appendage (LAA) aneurysm is a rare condition that can produce local compressive effects and complications including supraventricular tachyarrhythmias, thromboembolic events and myocardial ischaemia. We present a rare case of a neonate with a congenital LAA aneurysm which resulted in local compressive effects on the left ventricle, severe mitral regurgitation and malposition of the left anterior descending (LAD) coronary artery. Intraoperatively, the LAD was found to be within the aneurysmal wall exterior to the left ventricular epicardium and was inadvertently injured during LAA aneurysm resection. Retrospective review of the preoperative computed tomography and echocardiography scans demonstrated the LAD lying within the wall of the LAA aneurysm, although this had not been well appreciated at that time. This highlights the importance of thorough multimodal preoperative imaging and intraoperative assessment for recognition of this rare association between the LAA aneurysm and LAD malposition, and prevention of inadvertent LAD injury during aneurysm resection.     

单次注射舒芬太尼在腹部手术与心脏手术患者的药代动力学比较

目的比较舒芬太尼在腹部手术与心脏手术患者的药代动力学特征。方法随机选择腹部手术(A组)与心脏手术(C组)患者各8例,全麻后分别静注舒芬太尼2μg/kg和5μg/kg。采用液相色谱-质谱联用法测定静注舒芬太尼后1、3、5、10、20、30、60、120、240和360 min血浆舒芬太尼浓度,并用3p97药理学程序计算药代动力学参数。结果舒芬太尼药代动力学三指数函数方程:A组为Cp(t)=2.86e-0.824t+0.75e-0.060t+0.14e-0.005t,C组为Cp(t)=18.81e-0.492t+4.35e-0.050t+0.28e-0.003t。A组药代动力学参数P、A、B、t1/2β和AUC分别是C组的6.6、5.8、2.0、1.8和4.6倍(P<0.05或P<0.01);而A组中心分布容积(Vc)和清除率(CL)大于或快于C组(P<0.05或P<0.01)。结论舒芬太尼在腹部手术和心脏手术患者药代动力学均可用三室模型描述,疾病性质、CPB与血液稀释可影响其药代动力学特征,临床用药应根据手术患者的具体情况调整用药剂量以做到用药个体化。     

The impact of spontaneous echocardiographic contrast in patients with left atrial enlargement undergoing cardiac valvular surgery

OBJECTIVE: The aim of this study was to evaluate the impact of either left atrial or aortic spontaneous echocardiographic contrast (SEC), as identified on intraoperative transesophageal echocardiography, on short-term morbidity and mortality in patients with left atrial enlargement undergoing cardiac valvular surgery. DESIGN: Retrospective and observational. SETTING: Single-center, university teaching hospital. PARTICIPANTS: The authors identified 197 patients (105 males and 92 females; mean age, 68 +/- 14 years) with left atrial enlargement who underwent surgical intervention for valvular heart disease from January 1, 2004 to January 1, 2005. MAIN RESULTS: Of the total population, 40 patients (20.3%) showed left atrial SEC, and 10 patients (5.1%) showed aortic SEC. On multivariate analysis, increasing left atrial size and the absence of mitral regurgitation were independent predictors for the presence of left atrial SEC. On multivariate analysis, the presence of atrial fibrillation and a dilated descending aorta were predictive of aortic SEC. Although the identification of left atrial SEC was an echocardiographic marker of an increased risk for thromboembolic events postoperatively, this finding did not hold true for the presence of aortic SEC. CONCLUSIONS: Intraoperative identification of left atrial dilatation or aortic dilatation is predictive of SEC in the left atrium or descending aorta, respectively. The identification of left atrial SEC is an echocardiographic marker of an increased risk for thromboembolic events in this high-risk population.