Filling the gap: interventional occlusion of incompletely ligated left atrial appendages

Transcription

1 Europace (2015) 17, doi: /europace/euu164 CLINICAL RESEARCH Ablation for atrial fibrillation Filling the gap: interventional occlusion of incompletely ligated left atrial appendages Stefano Bordignon, Alexander Fürnkranz, Laura Perrotta, Daniela Dugo, Athanasios Kostantinou, Britta Schullte-Hahn, Bernd Nowak, KR Julian Chun and Boris Schmidt* Med. Klinik III, Cardioangiologisches Centrum Bethanien, Markus Krankenhaus, Wilhelm-Epstein-Str. 4, Frankfurt am Main, Germany Received 22 March 2014; accepted after revision 26 May 2014; online publish-ahead-of-print 6 August 2014 Aims Patients undergoing heart surgery and with history of atrial fibrillation are often treated with intraoperative left atrial appendage (LAA) ligation. Incomplete LAA ligation is often described and can be associated with thrombo-embolic complications. To describe a case series of percutaneous LAA occlusion in patients previously treated with surgical LAA ligation.... Methods Over 179 patients treated with implantation of an LAA occluder system at our centre, 3 (1.6%) were previously treated and results with a surgical LAA suture exclusion (2 males, age years). Patients 1 and 3 presented a hammerhead LAA morphology with an open neck and were successfully treated with an AGA Cardiac Plug (ACP St Jude Medical) Device. Patient 2 had a conic monolobar LAA with a small neck, and the occlusion could be performed using a Watchman (Boston Scientific) device. After discharge on dual antiplatelet therapy, all the patients could be switched to single aspirin (ASA) therapy after a 6-week transoesophageal echocardiography control.... Conclusion Left atrial appendage occlusion in patient with incomplete surgical ligation using percutaneous LAA occluder devices appears to be feasible, and studies including a larger number of patients are needed Keywords Percutaneous LAA occlusion Surgically ligation Stroke prevention Atrial fibrillation Introduction In patients with a history of atrial fibrillation (AF) undergoing open heart surgery, left atrial appendage (LAA) ligation or exclusion may be considered. 1,2 Since many years, this technique has been performed by surgeons in patients undergoing mitral valve surgery, 3 and coronary artery bypass interventions. 4 While no evidence from randomized studies exists on stroke risk reduction by surgical LAA ligation, several follow-up studies demonstrated incomplete exclusion of the LAA after surgery in up to 60% of patients by transoesophageal echocardiography (TEE). 5 7 Thereby, LAA suture exclusion was the most unsuccessful technique compared with LAA excision or with stapler exclusion. Moreover, in 41% of all patients with incomplete LAA exclusion a LAA thrombus was found, suggesting that incomplete LAA exclusion may increase thrombogenicity. Oppositely, interventional LAA occlusion results in favourable clinical outcomes compared with medical therapy Therefore, it remains uncertain, whether patients with incompletely ligated LAAs should undergo an interventional LAA occlusion procedure. We therefore sought to determine the feasibility of interventional LAA closure with different devices. Methods All procedures were performed in conscious sedation using boluses of midazolam, fentanyl, followed by a 1% propofol infusion. First, a careful analysis of the individual LAA anatomy was performed and the absence of intracardiac thrombus was documented using TEE. Left atrial appendage anatomy was evaluated in several planes (08, 458, 908, 1358) to determine the LAA ostial geometry, the LAA neck size and length, and to define the number and size of LAA lobes. Left atrial appendage depth was measured comparing the largest longitudinal axis to the largest transversal axis. After single transseptal puncture in a modified Brockenbrough technique, a 8F transseptal sheath (SL-1, St Jude Medical) was advanced to the left atrium (LA). Immediately after transseptal puncture, a heparin * Corresponding author. Tel: ; fax: address: b.schmidt@ccb.de Published on behalf of the European Society of Cardiology. All rights reserved. & The Author For permissions please journals.permissions@oup.com.

2 Percutaneous occlusion of surgically ligated LAA 65 What s new? No clear data about management of incompletely ligated left atrial appendage (LAA) are available. A recent case series shows that incompletely ligated LAA can be managed with a percutaneous occlusion using a device designed for patent foramen ovale occlusion. We first report occlusion of incompletely surgically ligated LAA using percutaneous LAA occluder devices, describing anatomical characteristics that help in the choice of the device. bolus of 100 IU/kg body weight was administered to maintain the activated clotting time.250 s. Using a pigtail catheter, complementary LAA angiographies were carried out in two different angulations [right anterior oblique (RAO) 308,208 caudal and RAO 308/158 cranial]. After proper device selection, the transseptal sheath was exchanged for the delivery sheath using a guidewire in the left superior pulmonary vein. Procedural details on the implant process are given in the Results section. Results Over 179 patients treated with implantation of an LAA occluder system at our centre, 3 (1.6%) were previously treated with a surgical LAA suture exclusion. The following three procedural (anatomical) characteristics were found. Patient characteristics Patient #1, a 72-year-old male with persistent AF, underwent aortic valve replacement and mitral valve reconstruction in 2011 accompanied by LAA ligation and intraoperative cryoablation. During two additional catheter ablations, LA substrate modification was performed resulting in electrical LAA isolation. Patient #2, a 73-year-old male with paroxysmal AF, had a triple coronary artery bypass surgery with LAA ligation in Due to labile international normalized ratio (INR) values and a high bleeding risk, LAA occluder implantation was proposed. Patient #3, a 76-year-old female with paroxysmal AF, underwent mitral valve reconstruction for severe mitral regurgitation in conjunction with LAA ligation in After multiple ablation procedures resulting in electrical LAA isolation, LAA occlusion was performed due to a high bleeding risk. Ligated left atrial appendage with major transversal axis open neck with hammerhead left atrial appendage In Patients #1 and #3, TEE and LAA angiography revealed a hammerhead morphology determined by a narrow and very short neck and a major transversal axis with a short posterior and long anterior pseudo-lobe (Figures 1A and 3A/B). This distorted anatomy resulted in an absent landing zone as well as missing longitudinal depth required for the regular AGA Cardiac Plug (ACP) or Watchman implantations. We therefore decided to use the LAA isthmus at Figure 1 Left atrial appendage occlusion in Patient 1. See the text for description.

3 66 S. Bordignon et al. Figure 2 Left atrial appendage occlusion in Patient 3. See the text for description. the neck as anchoring zone for the waist between the lobe and the disc of an ACP device. In both cases, the LAA orifice was cannulated with the ball-shaped, partially opened lobe of the ACP device (24 and 20 mm in #1 and #3, respectively; Figures 1B and 3C). Then, the device was actively pushed beyond the LAA neck to allow for a complete ACP lobe release in both LAA pseudo-lobes (Figure 1C). Lobe stability was assessed by a light pull manoeuvre at the sheath. Subsequently, the ACP disc was released by unsheathing (Figures 1D and 3D) and coverage of the LAA ostium was assessed, both, by TEE and contrast injection (Figures 1E and 3E). Both procedures were performed uneventful. Ligated left atrial appendage with a major longitudinal axis conic monolobar mini neck In Patient #2, TEE indicated a very narrow LAA orifice of 5 mm opening into a single lobe, conic-shaped LAA (Figure 2A). This hindered LAA cannulation with a ball-shaped ACP device. For LAA angiography, the LAA was intubated with the transseptal sheath guided via a steerable diagnostic electrophysiology catheter (Biosense Webster, D-Type, 6F; Figure 2B). Due to its conic shape, we opted for a 21 mm Watchman LAA occlusion device. The transseptal sheath was exchanged for the delivery system via a wire (Amplatz Extra Stiff Wire Guide Cook Inc.) placed in the LAA (Figure 2C and D). Due to the short longitudinal LAA axis, the delivery sheath was positioned only few millimetres behind the LAA orifice, but the appropriate delivery marker could not be placed at the presumed landing zone. Therefore, the device release had to be performed by a combined active device pushing and de-sheathing, so called wave-ride manoeuvre assuring a static position of the device distal to the LAA orifice (Figure 2E and F). Complete occlusion was confirmed by TEE. Post-procedural follow-up After exclusion of pericardial effusion, all patients were discharged on dual antiplatelet therapy [aspirin (ASA) 100 mg and clopidogrel 75 mg per day]. After 6 weeks, a TEE confirmed persistent LAA occlusion without thrombus formation on the occluder in all patients. Consequently, clopidogrel therapy was stopped. During a follow-up of 7, 8, and 16 months, respectively, no thrombo-embolic or haemorrhagic complications occurred on ASA monotherapy. Discussion The present case series illustrates the pitfalls of interventional LAA occlusion in patients who had previously undergone incomplete surgical LAA ligation. It highlights the procedural manoeuvres as well as the importance of perfect imaging of the individual LAA anatomy to employ the appropriate implant strategy. Pitfalls of surgical left atrial appendage ligation In AF patients undergoing heart surgery, concomitant LAA ligation may be considered according to current AF guidelines (Level of

4 Percutaneous occlusion of surgically ligated LAA 67 Figure 3 Left atrial appendage occlusion in Patient 2. See the text for description. evidence C), 1 although randomized trials proving its efficacy in stroke prevention are missing. Among the different surgical techniques, LAA excision may provide the most reliable results, but stapling and ligation are the most commonly performed interventions. While in the LAAOS trial suture and stapler exclusion were proven to be safe, postprocedural TEEs revealed complete LAA occlusion in only 45 72% of patients with suture or stapler ligation, respectively. 4 In several studies, as a result of the persistent LA to LAA communication, thrombus formation was detected in 40% of patients. 7,12,13 The risk of embolization due to incomplete surgically ligated LAA is not well assessed. These patients could be treated with standard oral anticoagulation. The exact INR range in this setting is unknown, because incomplete ligation may predispose to thrombus formation in pockets of stagnant blood flow. This highlights the clinical relevance of interventional LAA closure in patients with incomplete LAA ligation as an alternative to continuing oral anticoagulation. Electrical left atrial appendage isolation as an indication to percutaneous left atrial appendage occlusion In two of the presented patients, the LAA was electrically isolated during repeated AF ablation procedures. These patients have a higher thrombo-embolic risk, due to impaired LAA transport function represented by decreased emptying velocities. 14 Percutaneous LAA occlusion seems to be a reasonable alternative to lifelong oral anticoagulants (OAC). Implantation success In recent reports, implant success rates vary between 90 and 95% using the Watchman device. 9,10 The success rate is determined by operator experience, but also by the suitability of the individual LAA anatomy to the available devices, as recently demonstrated in a case series using an Amplatzer septal occluder device. 15 In the present series, anatomical characteristics were described, favoring occluder selection and demonstrating that LAA occluder devices can be used in previously ligated LAA. Pre-procedural imaging using TEE is an indispensable pre-requisite for a successful implantation. Moreover, procedural tricks may have to be employed to successfully implant the LAA occluder. Due to the distorted anatomy, the delivery sheath could only be advanced to the presumed landing zone. Device release was accomplished by a push pull manoeuvre to ascertain a proper placement. However, actively pushing the device out of the sheath is not recommended to avoid cardiac perforation. Limitations We report our results about occlusion of LAA incompletely ligated in a small case series among a bigger collective of percutaneous LAA occlusion. The small number of patients reflects the relatively low incidence of this clinical condition. More data are needed to

5 68 S. Bordignon et al. define safety and efficacy of percutaneous occlusion of incompletely ligated LAA. Conclusion Given the high acute procedural success rate and the favourable mid-term outcome of the presented patients, interventional LAA closure in patients with incompletely ligated LAAs may offer a sound alternative to OAC continuation. Conflict of interest: B.S. is an advisory-board member for Boston Scientific and St Jude Medical. All other authors have no disclosure regarding this topic. Funding S.B. and L.P. were supported by an EHRA-Fellowship education grant. References 1. Camm AJ, Lip GYH, De Caterina R, Savelieva I, Atar D, Hohnloser SH et al focused update of the ESC Guidelines for the management of atrial fibrillation: an update of the 2010 ESC Guidelines for the management of atrial fibrillation. Developed with the special contribution of the EuropeanHeart Rhythm Association. Europace 2012;14: Lewalter T, Kanagaratnam P, Schmidt B, Rosenqvist M, Nielsen-Kudsk JE, Ibrahim R et al. Ischaemic stroke prevention in patients with atrial fibrillation and high bleeding risk: opportunities and challenges for percutaneous left atrial appendage occlusion. Europace 2014;16: Madden JL. Resection of the left auricular appendix; a prophylaxis for recurrent arterial emboli. J Am Med Assoc 1949;140: Healey JS, Crystal E, Lamy A, Teoh K, Semelhago L, Hohnloser SH et al. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J 2005;150: Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol 2000;36: Garcia-Fernandez MA, Perez-David E, Quiles J, Peralta J, Garcıa-Rojas I, Bermejo J et al. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. J Am Coll Cardiol 2003;42: Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol 2008;52: Sievert H. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation 2002;105: Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry (CAP). Circulation 2011;123: Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial (Protect AF). Lancet 2009;374: Elsevier Ltd. 11. Chun KJ, Bordignon S, Urban V, Perrotta L, Dugo D, Fürnkranz A et al. Left atrial appendage closure followed by 6 weeks of antithrombotic therapy: a prospective single-center experience. Heart Rhythm 2013;10: Donnino R, Tunick PA, Kronzon I. Left atrial appendage thrombus outside of a successful ligation. Eur J Echocardiogr 2008;9: Rosenzweig BP, Katz E, Kort S, Schloss M, Kronzon I. Thromboembolus from a ligated left atrial appendage. J Am Soc Echocardiogr 2001;14: Tilz RR, Schmidt B, Menon SD, Chun KR, Fuernkranz A, Metzner A et al. Abstract 2253: left atrial appendage function and clinical outcome after electrical isolation of left atrial appendage in patients undergoing atrial fibrillation ablation (Abstract). Circulation 2008;118:S_694 S_ Aryana A, Cavaco D, Arthur A, O Neill PG, Adragão P, D Avila A. Percutaneous endocardial occlusion of incompletely surgically ligated left atrial appendage. J Cardiovasc Electrophysiol 2013;24: