Atrial fibrillation is the most common type of persistent arrhythmia. In addition to causing palpitations and discomfort, the onset of atrial fibrillation increases the risk of thromboembolism [
Written informed consent was obtained from each patient. Procedures were performed in accordance with ethical standards. From March 2018 to November 2018, percutaneous LAAO was performed with the guidance of TEE in a total of 14 patients. All patients underwent LAA closure under general anesthesia.
The CHA2DS2-VASC scores of the patients included in this group were greater than or equal to 2. Furthermore, these patients were not suitable for long-term oral anticoagulation, and stroke or embolism events could still occur on the basis of the INR standard after taking warfarin.
Exclusion criteria were inner diameter of LA > 65 mm, spontaneous development of intracardiac thrombus, severe mitral valve lesions and pericardial effusion > 3 mm, life expectancy <1 year, low risk of stroke or low risk of bleeding, taking warfarin for other reasons, and complex atherosclerotic plaques in the ascending aorta/aortic arch. Patients undergoing elective cardiac surgery whose patent foramen ovale (PFO) was not closed with an atrial septal aneurysm and right-left shunt and who were in cardiac dysfunction were also excluded.
We choose the LAmbre™ occluder device (Lifetech) for occlusions by the femoral vein pathway because it can be applied to a variety of left appendage structures and has a unique hook anchoring design that creates a more stable block.
The procedure for percutaneous occlusion of the left appendage through the femoral vein pathway was as follows (Figure
Operation procedure of percutaneous occlusion of the left atrial appendage through the femoral vein pathway. (a) The tent structure. (b). Successful atrial septum puncture. (c) Push-and-pull test. (d) Closure with successful release.
The end points of this study refer to the standardized end points/criteria included in the Munich consensus paper on LAAO by Tzikas et al. [
SPSS 22.0 software was used for the statistical analysis. Estimated frequencies of event occurrences are expressed as percentages or rates. Continuous variables are summarized as the mean and SD.
The average age of patients in this group, including 9 males and 5 females, was 67.1 ± 9.5 years, and all of them had atrial fibrillation. Nine patients had hypertension before the operation, 4 patients had a history of cerebral infarction, one of the patients had diabetes, and none of the patients had valve disease. The average CHA2DS2VASc score was 3.5 ± 2.1, and the average HASBLED score was 3.6 ± 0.9 (Table
Baseline patient characteristics.
| |
---|---|
Age (y) | 67.1 ± 9.5 |
Sex (male/female) | 9 (64.3%)/5 (35.7%) |
Congestive heart failure/LV dysfunction | 5 (35.7%) |
Hypertension | 9 (64.3%) |
Diabetes mellitus | 1 (7.1%) |
Stroke/TIA/TE | 4 (28.6%) |
Vascular disease | 5 (35.7%) |
CHA2DS2VASc score, |
|
0 to 1 | 0 |
2 | 7 |
3 | 2 |
4 | 1 |
5 | 0 |
6 | 1 |
7 | 1 |
8 | 1 |
Mean CHA2DS2VASc score | 3.5 ± 2.1 |
Mean HASBLED score | 3.6 ± 0.9 |
LV, left ventricular; TIA, transient cerebral ischemic attacks; TE, thromboembolism.
TEE-guided LAAO was successfully completed for all patients in the group. The mean LAA width was 23.9 ± 1.9 mm (Table
Procedure findings.
| |
---|---|
TEE assessment | |
LAA ostium width (mm) | 23.9 ± 1.9 |
LAA work length (mm) | 22.8 ± 7.2 |
Diameter of seal plate of the devices (mm) | 27.7 ± 3.3 |
Number of devices, |
1 |
LAA, left atrial appendage; TEE, transesophageal echocardiography.
No complications that seriously affected a patient’s life occurred during the perioperative period. During the operation, there was one patient who developed a reaction to the anesthesia (nausea and vomiting after surgery) (Table
Perioperative complications.
| |
---|---|
Major complications | 0 (0%) |
Cardiac tamponade | 0 |
Stroke | 0 |
Myocardial infarction | 0 |
Device dislocation | 0 |
Malignant arrhythmia | 0 |
Death | 0 |
Minor complications | 2 (14.3%) |
Pericardial effusion | 0 |
Residual shunt | 0 |
Thrombus | 0 |
Access-related complications/hematoma | 1 |
Anesthesia reaction | 1 |
Pericarditis | 0 |
Renal and hepatic injuries | 0 |
Device-related complications | 0 |
All complications | 2 (14.3%) |
Patients with atrial fibrillation (AF), which is the most common arrhythmia, have an increased risk for stroke [
The mortality and disability rates of atrial fibrillation are high, which seriously threaten the life and quality of life of patients. Warfarin anticoagulation is the first choice of therapy, but due to the existence of anticoagulant contraindications and other factors, some patients refuse drug treatment or are not allowed for drug treatment. According to the statistics, more than 90% of thrombi of patients with nonvalvular atrial fibrillation originate in the left atrial appendage. In recent years, many clinical studies in home and abroad have shown that LAAO can reduce the risk of stroke in patients with atrial fibrillation. A multicenter clinical study of 110 patients showed that treatment with LAAO can reduce the risk of stroke, major bleeding, and death compared with other therapeutic strategies [
The European Society of Cardiology Guidelines for managing atrial fibrillation stated in 2016 that LAA occlusion may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment (e.g., those with a previous life-threatening bleed without a reversible cause). Class IIb, level B surgical occlusion or exclusion of the LAA may be considered for stroke prevention in patients undergoing thoracoscopic AF surgery. Class IIb, level B surgical LAA occlusion or exclusion concomitant to cardiac surgery has been performed for many decades and with various techniques. Multiple observational studies have indicated the feasibility and safety of surgical LAA occlusion/exclusion, but only limited controlled trial data are available [
Currently, the most commonly used technique in clinical practice is LAAO via percutaneous transcutaneous catheter under the guidance of angiography and TEE. Such an operation process is complex, the operating time is long, and the incidence of complications is relatively high; rates for major complications, including significant pericardial effusion, tamponade, and periprocedural stroke, are reported to be between 3.7% and 7.7% [
The regular 2D transesophageal echocardiogram can show each side of the LAA, enabling observation of the presence of a thrombus and measurement of its largest and least diameters and the depth of the LAA. However, there is no imaging advantage for an LAA with a complex structure or different opening forms.
Three-dimensional TEE can be used to quickly obtain a perpendicular LAA section, and the multisection surface can display the diameter of the LAA opening in real time, reduce the steps required during surgery, and shorten the measurement time. It can directly image the complex anatomical structure of the LAA and display its shape, internal structure, and thrombus [
After the successful release of the plugging device, TEE can evaluate its position and residual shunt at multiple angles and on multiple planes. More importantly, TEE can dynamically display the changes in the above observation indexes during the pushing and pulling experiment in real time.
To summarize, the successful completion of percutaneous transcatheter LAAO, purely TEE-guided atrial septal puncture, and the release of the occluder is the key to the success of this procedure. Since many patients in atrial fibrillation have a right atrium enlargement, and the inferior vena cava and atrial septum are not completely in the same plane, and the normal atrial septum puncture catheter may not succeed in moving the atrial septum to the left atrial surface after it is ultrasonically guided to the atrial septum position, so that the puncture may cause the heart to rupture. We used a modified atrial septal puncture catheter, which has a larger angle and a longer length from the angle to the tip of the catheter. Under the protection of a guidewire and the guidance of TEE, it is easy to create a “tent” structure at the atrial septum. We still choose to puncture the lower part of the atrial septum, so that the guidewire and catheter can enter the LAA more easily. 2D and 3D TEE can monitor the puncture process in real time to ensure the safety of the procedure. Secondly, before releasing the occluder, the conveying sheath should be placed in the upper left pulmonary vein, and it is afterwards guided by a pigtail catheter to the left atrial appendage; this prevents penetration of bleeding from the left atrial appendage. In one patient, the postoperative X-ray suggested a high density shadow in the upper left lungs, considered to be upper left pulmonary vein branch bleeding, but if it were LAA bleeding, it could lead to serious cardiac tamponade.
Berti et al. reported intracardiac echocardiography- (ICE-) guided LAAO [
There were several limitations in our present study. This single-center study was small and nonrandomized. There was no control group. Further study will analyze LAAO guided by pure TEE and fluoroscopy and compare the two methods.
LAAO is feasible and safe under the guidance of TEE.
TEE-guided LAAO is safe and reliable, and the role of TEE is most likely to be further explored.
The data used to support the findings of this study are included within the tables of the article.
The authors declare that they have no conflicts of interest.
The authors thank Professor Feng Li for his great help in contributing to improving LAAO. This project was supported by the Science and Technology Commission of Shanghai Municipality (CN), China (Grant no. 17411966600).