Abstract
Background
Epicardial left atrial appendage (LAA) ligation may be an alternative to oral anticoagulation management and to endocardial LAA closure devices. We report long-term results after LAA ligation with the second-generation LARIAT device.
Methods
Retrospective study was performed on patients who underwent LAA ligation at our center. Follow-up included patient visits and transesophageal echocardiography (TEE) to assess LAA-to-LA leakages.
Results
76 patients with an indication for LAA closure underwent cardiac CT-based screening with 16 patients (21%) excluded from LAA ligation due to anatomical reasons. Finally, 48 patients (70 ± 9 years, 23 women) underwent LAA ligation with successful LAA closure in 44 patients (92%). Major periprocedural complications occurred in three patients (6%; one major femoral bleeding, one pneumothorax with surgical drainage, one right ventricular perforation with concomitant stroke). Additionally, minor complications occurred in 27% of the patients with mild pericarditis in eight of these patients being the most common adverse event. Clinical follow-up (median of 443 days, interquartile range 158; 773) was obtained from 38 patients. One thromboembolic event (transient ischemic attack) occurred. Complete LAA closure was demonstrated in 23/35 patients (66%) with TEE follow-up. Major leakages > 5 mm without documentation of intracardiac thrombi were documented in four patients (11%).
Conclusions
Epicardial LAA ligation with the second-generation LARIAT device was associated with a high acute success rate comparable to endocardial LAA closure devices. LAA ligation was accompanied by a relevant incidence of periprocedural complications with mild pericarditis being the most common adverse event. Follow-up demonstrated a moderate incidence of leakages after LAA exclusion, no intracardiac thrombus formation and only a single thromboembolic event. The effectiveness in preventing thromboembolic events needs further investigation in larger patient cohorts.
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Change history
02 July 2018
Unfortunately, an error occurred in the conclusion section of this article. The corrected conclusion text is given below.
References
Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P, PROTECT AF Investigators (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 374:534–542. https://doi.org/10.1016/S0140-6736(09)61343-X
Bartus K, Han FT, Bednarek J, Myc J, Kapelak B, Sadowski J, Lelakowski J, Bartus S, Yakubov SJ, Lee RJ (2013) Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol 62:108–118. https://doi.org/10.1016/j.jacc.2012.06.046
Bartus K, Gafoor S, Tschopp D, Foran JP, Tilz R, Wong T, Lakkireddy D, Sievert H, Lee RJ (2016) Left atrial appendage ligation with the next generation LARIAT(+) suture delivery device: early clinical experience. Int J Cardiol 215:244–247. https://doi.org/10.1016/j.ijcard.2016.04.005
Sievert H, Rasekh A, Bartus K, Morelli RL, Fang O, Kuropka J, Le D, Gafoor S, Luisa Heuer L, Safavi-Naeini P, Hue TF, Marcus GM, Badhwar N, Massumi A, Lee RJ (2015) Left atrial appendage ligation in nonvalvular atrial fibrillation patients at high risk for embolic events with ineligibility for oral anticoagulation: initial report of clinical outcomes. JACC Clin Electrophysiol 1:465–474. https://doi.org/10.1016/j.jacep.2015.08.005
Price MJ, Gibson DN, Yakubov SJ, Schultz JC, Di Biase L, Natale A, Burkhardt JD, Pershad A, Byrne TJ, Gidney B, Aragon JR, Goldstein J, Moulton K, Patel T, Knight B, Lin AC, Valderrábano M (2014) Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the US transcatheter LAA ligation consortium. J Am Coll Cardiol 64:565–572. https://doi.org/10.1016/j.jacc.2014.03.057
Miller MA, Gangireddy SR, Doshi SK, Aryana A, Koruth JS, Sennhauser S, d’Avila A, Dukkipati SR, Neuzil P, Reddy VY (2014) Multicenter study on acute and long-term safety and efficacy of percutaneous left atrial appendage closure using an epicardial suture snaring device. Heart Rhythm 11:1853–1859. https://doi.org/10.1016/j.hrthm.2014.07.032
Gunda S, Reddy M, Pillarisetti J, Atoui M, Badhwar N, Swarup V, DiBiase L, Mohanty S, Mohanty P, Nagaraj H, Ellis C, Rasekh A, Cheng J, Bartus K, Lee R, Natale A, Lakkireddy D (2015) Differences in complication rates between large bore needle and a long micropuncture needle during epicardial access: time to change clinical practice? Circ Arrhythm Electrophysiol 8:890–895. https://doi.org/10.1161/CIRCEP.115.002921
Tzikas A, Holmes DR Jr, Gafoor S, Ruiz CE, Blomström-Lundqvist C, Diener HC, Cappato R, Kar S, Lee RJ, Byrne RA, Ibrahim R, Lakkireddy D, Soliman OI, Nabauer M, Schneider S, Brachmann J, Saver JL, Tiemann K, Sievert H, Camm AJ, Lewalter T (2017) Percutaneous left atrial appendage occlusion: the Munich consensus document on definitions, endpoints, and data collection requirements for clinical studies. Europace 19:4–15. https://doi.org/10.1093/europace/euw141
Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ (2001) Validation of clinical classification schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 285:2864–2870
Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ (2010) Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the Euro Heart Survey on atrial fibrillation. Chest 137:263–272. https://doi.org/10.1378/chest.09-1584
Lakkireddy D, Afzal MR, Lee RJ, Nagaraj H, Tschopp D, Gidney B, Ellis C, Altman E, Lee B, Kar S, Bhadwar N, Sanchez M, Gadiyaram V, Evonich R, Rasekh A, Cheng J, Cuoco F, Chandhok S, Gunda S, Reddy M, Atkins D, Bommana S, Cuculich P, Gibson D, Nath J, Ferrell R, Matthew E, Wilber D (2016) Short and long-term outcomes of percutaneous left atrial appendage suture ligation: results from a US multicenter evaluation. Heart Rhythm 13:1030–1036. https://doi.org/10.1016/j.hrthm.2016.01.022
Jazayeri MA, Vuddanda V, Turagam MK, Parikh V, Lavu M, Atkins D, Earnest M, Di Biase L, Natale A, Wilber D, Reddy YM, Lakkireddy DR (2017) Safety profiles of percutaneous left atrial appendage closure devices: an analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016. J Cardiovasc Electrophysiol. https://doi.org/10.1111/jce.13362. (Epub ahead of print)
Massumi A, Chelu MG, Nazeri A, May SA, Afshar-Kharaghan H, Saeed M, Razavi M, Rasekh A (2013) Initial experience with a novel percutaneous left atrial appendage exclusion device in patients with atrial fibrillation, increased stroke risk, and contraindications to anticoagulation. Am J Cardiol 111:869–873. https://doi.org/10.1016/j.amjcard.2012.11.061
Gianni C, Di Biase L, Trivedi C, Mohanty S, Gökoğlan Y, Güneş MF, Bai R, Al-Ahmad A, Burkhardt JD, Horton RP, Krumerman AK, Palma EC, Valderrábano M, Gibson D, Price MJ, Natale A (2016) Clinical implications of leaks following left atrial appendage ligation with the LARIAT device. JACC Cardiovasc Interv 9:1051–1057. https://doi.org/10.1016/j.jcin.2016.01.038
Sarkozy A, Tokuda M, Tedrow UB, Sieria J, Michaud GF, Couper GS, John R, Stevenson WG (2013) Epicardial ablation of ventricular tachycardia in ischemic heart disease. Circ Arrhythm Electrophysiol 6:1115–1122. https://doi.org/10.1161/CIRCEP.113.000467
Sacher F, Roberts-Thomson K, Maury P, Tedrow U, Nault I, Steven D, Hocini M, Koplan B, Leroux L, Derval N, Seiler J, Wright MJ, Epstein L, Haissaguerre M, Jais P, Stevenson WG (2010) Epicardial ventricular tachycardia ablation: a multicenter safety study. J Am Coll Cardiol 55:2366–2372. https://doi.org/10.1016/j.jacc.2009.10.084
Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY (2014) Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 64:1–12. https://doi.org/10.1016/j.jacc.2014.04.029
Pillarisetti J, Reddy YM, Gunda S, Swarup V, Lee R, Rasekh A, Horton R, Massumi A, Cheng J, Bartus K, Badhwar N, Han F, Atkins D, Bommana S, Earnest M, Nath J, Ferrell R, Bormann S, Dawn B, Di Biase L, Mansour M, Natale A, Lakkireddy D (2015) Endocardial (Watchman) vs. epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm 12:1501–1507. https://doi.org/10.1016/j.hrthm.2015.03.020
Santoro F, Di Biase L, Santangeli P, Bai R, Danik S, Barrett C, Horton R, Burkhardt JD, Natale A (2014) Catheter-based epicardial closure of the left atrial appendage. Interv Cardiol Clin 3:219–227. https://doi.org/10.1016/j.iccl.2014.01.003
Rillig A, Tilz RR, Lin T, Fink T, Heeger CH, Arya A, Metzner A, Mathew S, Wissner E, Makimoto H, Wohlmuth P, Kuck KH, Ouyang F (2016) 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 9:e003461. https://doi.org/10.1161/CIRCEP.115.003461
Lakkireddy D, Mahankali AS, Kanmanthareddy A, Lee R, Badhwar N, Bartus K, Atkins D, Bommana S, Cheng J, Rasekh A, Di Biase L, Natale A, Nath J, Ferrell R, Earnest M, Reddy YM (2015) Left atrial appendage ligation and ablation for persistent atrial fibrillation: the LAALA-AF registry. JACC Clin Electrophysiol 1:1–8. https://doi.org/10.1016/j.jacep.2015.04.006
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T. F. and C.-H. H. received travel grants from SentreHeart. S.M. received speaker’s honoraria and travel grants from Medtronic. K.-H.K. received research grants and personal fees from St. Jude Medical, Medtronic, and Biosense Webster. A.M. received speaker’s honoraria and travel grants from Medtronic. The other authors report no conflicts of interest.
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Fink, T., Schlüter, M., Tilz, R.R. et al. Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience. Clin Res Cardiol 107, 1139–1147 (2018). https://doi.org/10.1007/s00392-018-1288-1
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DOI: https://doi.org/10.1007/s00392-018-1288-1