Cleveland Clinic Policy

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1 Atrial Fibrillation: It is all about the Left Atrial Appendage LAA Occluder Device 3 Amigos Risk Stratification, Ablation, and LAA closure Allan L Klein M.D. Director of Pericardial Center Professor of Medicine Heart and Vascular Institute Cleveland Clinic President, ASE *No Conflicts to Declare Echocardiography in Atrial Fibrillation Cleveland Clinic Policy Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives DCC or Not? Tracing Atrial Fibrillation for 100 Years Einthoven 1906 Pulsus Inaequalis et Irregularis Fye WB. N Engl J Med 2006:355;

2 PV Antrum Isolation: Catheter Ablation Echocardiography in Atrial Fibrillation Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives Cardiovascular Imaging M-mode Echo - LAE is a significant predictor of stroke. Benjamin EJ et al. Circulation 1995;92: The size of LA size from M- mode is one the strongest independent predictors of later thromboembolism in patients with AF. Lang et al. J Am Soc Echocardiogr 2015 The stroke prevention in AF investigators. Annals of Internal Medicine 1992;116:6-12. Wazni et al. JACC 2006;48: Advances in Echo and CV Imaging in Atrial Fibrillation Transthoracic Echo LA dimensions and volumes RA dimensions and volumes LVEF LV diastolic function Valvular function 2

3 LAVI Intracardiac Echo Increased LA volume is associated with atrial fibrillation, stroke, and adverse cardiovascular outcomes Tsang TS, et al. Am J Cardiol 2002;90: Tsang TS, et al. J Am Coll Cardiol 2003;42: LA/LAA structure and function LA/LAA thrombus Inter-atrial septum Pulmonary vein anatomy / flows Lang et al. J Am Soc Echocardiogr 2015 Kizer JR, et al. Am Heart J 2006;151:412-8 Guide therapy Transesophageal Echo LA Phasic Function LA/LAA structure, function, SEC, and thrombus RA/RAA structure, function and thrombus Pulmonary vein anatomy / flows Inter-atrial septum (PFO) Ascending aorta and arch atheroma Guide therapy LA reservoir function Total LA stroke volume LA conduit function Passive LA stroke volume LA contractile function Active LA stroke volume LAmax LAmin LAmax LApreA LApreA - LAmin Left Atrial Appendage 3-D LA Strain Analysis Nucifora et al. Circ Cardiovasc Imaging 2011;4: Lang et al. J Am Soc Echocardiogr 2012;25:3-46 Yamamoto et al. Circ Cardiovasc Imaging 2014; 7: Saraiva RM, Klein AL et al. J Am Soc Echocardiogr 2010; 23:

4 CHADS2= 0 ROC Curves for Predicting Sinus Rhythm AUC: LAGLS total: 0.75±0.03 Total LAEF: 0.66±0.04 Max LAVi: 0.61±0.04 CHADS2= 1 CHADS2= 2 sensitivity 1-specificity LAGLS vs LAVi: p<0.001 LAGLS vs LAEF: p<0.001 LAGLS total Youden Index: CI: Sensitivity 78.2% Specificity 67.8% Echocardiography in Atrial Fibrillation J J Am Soc Echocardiogr 2014 Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives LA Global Longitudinal Strain (A) Recurrence (-) (B) Recurrence (+) Transesophageal Echo Modern Paradigm to Risk Stratification of Afib 26% 20%

5 Quote in the EP Lab It is 10 am in the EP Lab.How well do you know your appendage? AK Left Atrial Appendage TEE Evaluation From Smoke (SEC) to Thrombus No smoke Mild smoke Severe smoke Sludge Thrombus Know Your Appendage LAA Views by TEE Chicken Wing Windsock Cactus Cauliflower Di Biase et al J Am Coll Cardiol 2012; 60: ) TEE is highly accurate for detection of atrial thrombus Spectrum of LAA Thrombogenic Milieu Probe Clots/Pts Surgical Data Mügge (AJCI 1990) Mono 12/12 all confirmed Olson (JASE 1992) Mono 5/20 all confirmed Aschenberg (JACC 1986) Mono 6/21 all confirmed Hwang (AJC 1993) Mono 28/213 all confirmed, 2 missed Manning (Annals 1995) Mo/Bi/Mu 14/231 12/14 confirmed none missed Fatkin (AJC 1996) Biplane 9/60 5/9 confirmed none missed SEC Sludge Thrombus 5

6 Appropriateness Criteria Thrombus/sludge 10 year survey( n=2705) Grewal et al. J Am Coll Cardiol Imag 2012 Indications for TEE/DCC 50-Year-Old Man with 4 Days of Afib Hx of TIA and hypertension Presents with shortness of breath Works as TV anchor and wants to be back on the news soon BP 110/70, irregular pulse 100 BPM Trends In TEE Guided Cardioversion TEE Guided Strategy with LMWH J Am Soc Echocardiograph 2012;25:

7 TEE Guided Strategy LAA Flow TEE Guided Strategy with New Oral Anticoagulant DCC or No DCC? DCC or No DCC? No thrombus Successful cardioversion to NSR LMWH to warfarin overlap Back to the news anchor desk Thrombus present Warfarin x 4 weeks Repeat TEE, residual thrombus Patient died 2 months later 70-Year-Old Woman with 2 Weeks of Afib LAA Thrombus Hx of hypertension, diabetes and CHF EF 20% O/E BP 100/60, pulse 90 BPM Evidence of CHF

8 65-Year-Old Man with 8 Days of Afib TEE Guided Cardioversion Hx of hypertension Mild shortness of breath O/E BP 140 /80 pulse 95 BPM No evidence of CHF TEE Guided Cardioversion DCC or No DCC? LAA artifact Successful cardioversion to NSR Use of contrast to outline LAA DCC or No DCC? 75-Year-Old Woman with 2 months of Afib Hx of ischemic CM and HTN EF 25% Evidence of CHF 8

9 TEE guided approach Sludge Dynamic Viscid, gelatinous More dense and layered than smoke No discreet or organized mass Present throughout the cardiac cycle DCC or No DCC? J Am Soc Echocardiogr 2014 DCC or No DCC? Sludge Survival and Thromboembolism Sludge Rate control Long term warfarin 9

10 LAA with Contrast Echocardiography in Atrial Fibrillation Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives Echocardiography 2013; Mechanisms of Thromboembolism LAA Thrombus Expulsion Parekh et al. Circulation 2006 Mechanisms of Thromboembolism Atrial Stunning Atrial Fibrillation Pre Cardioversion Grimm et al. J Am Coll Cardiol 1993;22: Sinus Rhythm Post Cardioversion Atrial Fibrillation > 2 days duration to undergo DCC TEE-Guided Strategy Random Assignment (1:1) Conventional Strategy Therapeutic anticoagulation with heparin or warfarin TEE Thrombus detected No DCC No Thrombus detected DCC 3 weeks 3 weeks warfarin warfarin No Thrombus DCC 4 weeks warfarin ACUTE Multicenter Study Design Repeat TEE Thrombus No DCC 4 weeks warfarin 4 weeks warfarin DCC 4 weeks warfarin Follow-up at 8 weeks after assignment

11 Primary Endpoints Embolic Events TEE Conventional n = 619 n = 603 p value ACUTE II Pilot Study Length of Stay until Discharge Hospital Days Enrollment 8 8 CVA 4 (0.65%) 2 (0.33%) TIA 1 (0.16%) 1 (0.17%) Peripheral Embolism Composite: CVA, TIA, & Peripheral Embolism 5 (0.81%) 3 (0.50%) P=0.003 P< Enoxaparin UFH Enoxaparin UFH Chest Guidelines Patients with Afib > 48 hours or of unknown duration undergoing pharmacologic or electrical DCC, we recommend therapeutic AC ( adjusted dose VKA therapy, target INR range 2-3, LMWH or dabigatran) for at least 3 weeks before CV or a TEE guided approach with abbreviated anticoagulation before cardioversion rather than no anticoagulation Klein et al. Eur Heart J 2006;27: Grade 1 B ACUTE II Study Endpoints Echocardiography in Atrial Fibrillation LMWH UFH P value (n=76) (n=79) Embolic Events 0 0 NS Major Bleeding 0 0 NS Minor Bleeding, n (%) 3 (4%) 3 (4%) NS Mortality 0 0 NS Sinus Rhythm 55/72 (76%) 44/77 (57%) at 5 weeks, n (%) Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives

12 Conclusions The prevalence of LA/LAA sludge/thrombus in patients with AF undergoing a pre-pvi screening TEE is very low (<2%) and increases significantly with higher CHADS 2 scores. This suggests that a screening TEE before PVI should be preformed in patients with a CHADS 2 score of 1, and in patients with a CHADS 2 score of 0 when the AF is persistent and therapeutic anticoagulation has not been maintained for 4 weeks before the procedure. (J Am Coll Cardiol 2009;54: ) CONCLUSIONS In the ROTEA study, TEE was feasible in assessing PVs before and after ablation, providing both anatomic and functional information that complemented CT. PV ostial dimensions after ablation can be monitored using either modality, although TEE underestimates PV dimensions, especially for the inferior veins To et al. J Am Soc Echocardiogr 2011:24: Looking Before Cooking Right Middle Veins J Am Coll Cardiol 2009 Ablation Guidelines Pulmonary Vein Assessment Prior to undergoing an AF ablation procedure, a TEE should be performed in all patients with AF more than 48 hours in duration or of an unknown duration if adequate systemic anticoagulation has not been maintained for at least 3 weeks prior to the ablation Calkins et al. Heart Rhythm 2012;9: e21 64 slice Multi-detector CT TEE 12

13 Transesophageal Echo Left Pulmonary Veins High Grade Stenosis LAA Closure Device FDA Approval LLPV LUPV Holmes et al. Lancet 2009:374; Holmes et al. J Am Coll Cardiol 2014;64:1-12 Reddy et al. JAMA 2014:312: Echocardiography in Atrial Fibrillation Introduction Role of echo in afib Cardioversion ACUTE studies PV isolation Future perspectives LAA Closure Device Atrial Clip Conclusion: There is a high occurrence of unsuccessful surgical LAA closure. Of the various techniques, excision appears to be the most successful. Kanderian et al. J Am Coll Cardiol 2008; Courtesy of Marc Gillinov 13

14 De-Novo Thrombus Formation and Latent Ligation Failure Following LAA Exclusion Role of antiplatelet or AC post LAA closure and routine TEE follow-up? Gray and Rubenson JACC Imaging 2013;11: Post Stapler of LAA Thrombus Implications? Stroke Prevention 3D TEE Cardioversion Is TEE Still Needed? Definitely LAA Closure Device 2 Years Later Leak Around the Device Atrial Fibrillation It is All About the LAA Risk stratification Cardioversion Ablation NOAC s LAA occlusion 14

15 Thank you Left Atrial Appendage Center 15