A CASE OF THE LEFT ATRIUM APPENDAGE OCCLUSION, SUGGESTIONS ON THE CLINICAL FIELD DEVELOPMENT

Aim. To evaluate the possibility of hybrid procedure that includes single-moment cryoballoon isolation of pulmonary veins (PV) ostia and implantation of occluder into the left atrium appendage (LAA) in patients of high thromboembolic and hemorrhagic risk and prominent symptoms in atrial fibrillation (AF) paroxysms.

Material and methods. From 2012 to 2016 y., 72 procedures performed, of LAA occluder implantation for patients with high thromboembolic and hemorrhagic risk (mean age 68±7,4 y. o., 48 females, 24 males, mean rate by CHA2DS2VASc 4,82±1,48 points), of those 3 underwent single-moment cryoballoon isolation of the PV ostia without electrical isolation of LAA. The parameters of the intervention were assessed, and prevalence of intra-operation complications in AF patients that included single-moment catheter cryoballoon isolation of PV ostia and implantation of LAA occluding device, in comparison with isolated LAA occluder implantation.

Results. Occluding device implantation was successful in 100% cases. Periprocedural efficacy of PV ostia isolation was 100%. In both groups, intraoperational complications were absent. Mean heparin time and dosage of contrast in the hybrid intervention group were higher: 94,3±6,8 min vs 59,7±19,95 min (p<0,05), 196,8±20,82 mL vs 124,6±30,24 mL (p<0,05), respectively.

Conclusion. Performing of the hybrid intervention that includes single-moment catheter isolation of PV ostia and implantation of the occluding device into LAA increases mean procedure duration and contrast load in comparison to isolated LAA occluder implantation, with no operational risk increase.

1. Stewart S, Hart CL, Hole DJ, et al. Population prevalence, incidence, and predictors of atrial fibrillation in the Renfrew/Paisley study. Heart. 2001; 86(5): 516–521.

2. Lloyd-Jones D, Adams R, Carnethon M, et al. American Heart Association Statistics Committee and Stroke Statistics Subcommittee, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics — 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009; 119(3): e21– e181.

3. Hart RG, Pearce LA, Aguilar MI. Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation. Ann Intern Med. 2007; 146(12): 857–867.

4. Ruff CT, Giugliano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomized trials. Lancet. 2014; 383(9921): 955–962.

5. Blackshear J, Odell J. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996; 61(2): 755-9.

6. Alli O, Doshi S, Kar S, et al. Quality of life assessment in the randomized PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) trial of patients at risk for stroke with nonvalvular atrial fibrillation. J Am Coll Cardiol. 2013; 61(17): 1790–1798.

7. Holmes DR, Doshi SK, Kar S, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol. 2015; 65(24): 2614–2623.

8. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. EuroIntervention 2014;10-online publish-ahead-of-print August 2014.

9. Post-Approval U.S. Experience With Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol. 2017 Jan 24;69(3):253-261.

10. Di Biase L, Burkhardt JD, Mohanty P et al. Left atrial appendage: an underrecognized trigger site of atrial fibrillation. Circulation. 2010 Jul 13;122(2):109-18.

11. Benussi S, Mazzone P, Maccabelli G, et al. Thoracoscopic appendage exclusion with an atriclip device as a solo treatment for focal atrial tachycardia. Circulation 2011;123:1575-8.

12. Afzal MR, Kanmanthareddy A, Earnest M, et al. Impact of left atrial appendage exclusion using an epicardial ligation system (LARIAT) on atrial fibrillation burden in patients with cardiac implantable electronic devices. Heart Rhythm 2015;12:52-9.

13. Kim D, Shim CY, Hong GR, et al. Clinical Implications and Determinants of Left Atrial Mechanical Dysfunction in Patients With Stroke. Stroke 2016;47:1444-51.

14. Yorgun H, Canpolat U, Kocyigit D, Çöteli C, Evranos B, Aytemir K. Left atrial appendage isolation in addition to pulmonary vein isolation in persistent atrial fibrillation: one-year clinical outcome after cryoballoon-based ablation. Europace. 2017 Mar 9.

15. Rillig A, Tilz RR, Lin T, Fink T, Heeger CH, Arya A et al. Unexpectedly high incidence of stroke and left atrial appendage thrombus formation after electrical isolation of the left atrial appendage for the treatment of atrial tachyarrhythmias. Circ Arrhythm Electrophysiol 2016; 9:e003461.