فإن الكتاب أود أن أشكر تيد فان دي بيك العلمي بوسطن لدعمه أثناء إعداد هذه المخطوطة.

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وزارة القلب والأوعية الدموية القديس انطونيوس مستشفى (NIEUWEGEIN، هولندا) يتلقى رسوم proctoring للتدريب / الخدمات التعليمية من Atritech / بوسطن العلمية. ويرعى الإنتاج وحرية الوصول إلى هذه المقالة عن طريق العلم بوسطن.

النص السابق يصف إجراء لاجتثاث القثطرة واليسار مجتمعة انسداد أطرافهم الأذيني AF لعلاج والوقاية من الانصمام الخثاري الأحداث المرتبطة بها. البيانات الأولية تشير إلى أن هذا الإجراء يمكن أن يؤديها بأمان في المرضى المعرضين لمخاطر عالية للسكتة الدماغية. وقد واجهت أي صعوبات فنية في تنفيذ الإجراء المشترك. بينما يمكن توقع أي تحسن على أي إجراء لأنها لا تؤثر على بعضها البعض، قد تقدم مجتمعة الإجراء العديد من المزايا تنفيذ الإجراءات بشكل منفصل. الإجراء مجتمعة في وقت واحد يمكن علاج أعراض AF والحد من خطر السكتة الدماغية، وتحسين نوعية الحياة للمتضررين من AF. قد تقدم أيضا المخدرات الحرارية مريض خيار العلاج عن طريق السماح لهم للخضوع لزرع الجهاز الحارس دون علاج الوارفارين اللاحقة. وعلاوة على ذلك، فإن الحاجة إلى والمخاطر المرتبطة بها من والمتكررة ترك الأذينييتم تقليل التدخل وثقب عبر الحاجز يجب إغلاق LAA تصبح مرغوب فيه خلال فترة المتابعة. في حين CA هو العلاج المقررة للأعراض AF، والبيانات الأخيرة تشير إلى أنه هو أيضا فعالة في الحد من السكتة الدماغية. في تحليل بأثر رجعي من مطابقة أزواج المريض AF، ورأى رينولدز وزملاؤه انخفاض ملحوظ في مخاطر الإصابة بالسكتة الدماغية النسبية وعابرة هجوم الدماغية الأحداث بين المرضى الذين خضعوا الاجتثاث مقارنة مع تلك التي تمر العلاج بالعقاقير ارتفاع معدل ضربات القلب 16. تشير البيانات أيضا أن بتر LAA أو انسداد طريق ربط الجراحية أو جهاز إيداع الأحداث بشكل فعال يقلل من صمي. هذه الطرق تبدو واعدة: في دراسة أجريت على المرضى الذين يخضعون لاستبدال الصمام التاجي تلك التي خضع ربط الجراحي كان السكتات الدماغية أقل بكثير (3 مقابل 17٪) 19، 23. وقد أجريت أقل الغازية، ربط thoracoscopic باستخدام إجراء كمين حلقة بنجاح في 14 من 15المرضى الذين يعانون من السكتة الدماغية التي تحدث في 2 المرضى (4٪) خلال الأشهر ال 42 التالية 19،24. وقد تم تطوير العديد من الأجهزة عن طريق الجلد القسطرة LAA بما في ذلك انسداد التوصيل القلبي Amplatzer (AGA الطبية)، والبقعة عبر القسطرة (مخصص الأجهزة الطبية)، وعبر القسطرة عن طريق الجلد انسداد LAA (PLAATO) النظام، وانسداد الجهاز حارس LAA. في الوقت الحاضر، وتنشر الدراسات السريرية بشأن مأمونية ونجاعة فقط لPLAATO (الذي لم يعد متاحا) والحارس و. أظهرت PLAATO سلامة وفعالية، ويقدم دليلا على مفهوم للإغلاق LAA باستخدام عامل تصفية يستند إلى الننتول الجهاز. وكان الجهاز قفص الننتول الذاتي توسيع تغطيتها في بولي تترافلوروإيثيلين التي حالت دون الدم من الدخول إلى LAA 25. أظهرت دراسة غير عشوائية من 64 المرضى الذين يعانون من CHADS 2 من&gt; 2 انسداد كامل في أكثر من 98٪ من المرضى. بعد 5 سنوات، والسكتة الدماغية اتاك / عابر الدماغيةتم تخفيض معدل ك إلى 3.8٪ بالمقارنة مع 6.6٪ المتوقعة في عدد السكان 26. البيانات التي تم الحصول عليها من الدراسة AF PROTECT 18، التي قارنت فعالية الجهاز حارس للعلاج مع الوارفارين زيادة دعم نهج الجهاز الذي يستند إلى انسداد LAA. وأظهرت هذه الدراسة العشوائية التي تم العثور حارس زرع أن يكون غير أدنى من حيث جميع الأسباب السكتة الدماغية ومعدل الوفيات في المرضى المؤهلين OAC، أثار احتمال أن تكون في نهاية المطاف يمكن أن تستخدم الإجراء كبديل للعلاج الوارفارين المزمنة لدى المرضى الذين لا يستخدمون العقاقير المنشطة الانكسار 18. في دراسة نشرت في مجلة القلب في هولندا 2012 21، ونحن زرع بنجاح الجهاز في 10 مرضى، 9 منهم خضع CA المتزامنة. ملاحظة أنه على الرغم من تدفق ينظر المتبقية في 3 حالات في 45 يوما متابعة، Viles-جونزاليس وزملاؤه أظهرت أن لا يرتبط هذا التدفق المتبقية حول الجهاز معزيادة خطر الانسداد التجلطي الأحداث 27. في حين أن البيانات المتاحة دعم كل CA وانسداد LAA استخدام الجهاز حارس وعلاجات فعالة لAF، وترتبط كل الإجراءات مع مضاعفات. وأظهر مسح في جميع أنحاء العالم في عام 2010 من CA مضاعفات التي تحدث في 4.5٪ من المرضى 14. وأهم مضاعفات تشمل ما يلي: الموت، والأحداث الانصمام الخثاري الدماغي، خارج التأمور ثقب الوريد الرئوي، دكاك، تضيق، وترفرف شاذة من بداية جديدة (علاجي المنشأ) 14، 15، 28. التعقيدات الإجرائية التي قد تنجم عن الجهاز حارس الإجراء موضع انصباب التامور تشمل خطيرة، الانصمام الجهاز، والإجراءات ذات الصلة 18 السكتة الدماغية. في كلتا الحالتين، فقد وجد من حدوث مضاعفات الاعتماد على خبرة المشغل 15، 29. لإجراء العملية المشتركة، وتقتصر البيانات المتعلقة بالسلامة لدراسة 2012 لدينا، والتي COMواقتصرت plications إلى انسداد جهاز واحد. لم نصف المرضى وقد وثقت تكرار AF في الشهر 3-المتابعة. مطلوب النصف الآخر من المرضى واحد على الأقل تقويم نظم القلب التيار المباشر. خضع مريض واحد وتكرار التذرية كانت ناجحة 21. على الرغم من هذه الدراسة هو عدد صغير من السكان ولا يقدم مقارنة مباشرة مع غيرها من أساليب العلاج، ودراسات السلامة في كل من الإجراءات المستقلة 29 و 30 تشير إلى أن الفوائد المحتملة من العلاج إزاحة الزيادة في مخاطر السلامة. قضايا السلامة إضافية للنظر هي أوقات أطول الإجرائية، شرط التخدير العام، وزيادة خطر النزيف المسالك GI-TEE مع الرصد والتي يجب أن تصاحب وضع الحارس. في حين أن الإجراء المذكور هنا يصف إجراء مجتمعة موضع الحارس وCA PV، من المهم أن نلاحظ أن وضع الحارس لا تمنع الاستراتيجيهذ من العزلة الكهربائية للLAA. دراسة حديثة أجرتها بيازي دي وزملاؤه أظهرت أن المريض في مجموعة مختارة مع AF المتكررة، وأظهرت 27٪ بؤر الناشئة عن LAA بعد الاجتثاث الأولي، الذي كان يعالج على النحو الأمثل عن طريق العزلة كاملة LAA كفافي 31. قد تستفيد هذه الفئة من المرضى خاصة من إغلاق LAA بسبب العزلة الكهربائية للLAA يمكن أن يؤدي إلى ركود LAA حتى خلال إيقاع الجيوب الأنفية، مما يجعله أكثر تخثرا. في المرضى الذين يعتبر AF الاجتثاث وإغلاق LAA، يمكن للمرء أولا إجراء دراسة الكهربية مع التحديات الدوائية لكشف ويجتذ LAA ممكن يطلق قبل زرع الجهاز الحارس 31. بالنظر إلى الدراسة ليست عشوائية، ويقتصر على يوم 45 متابعة مع المرضى عالية المخاطر 10، العديد من الأسئلة التي لا يزال يتعين التصدي لها: هل في التقرير الجامع للإجراء زرع CA / حارس أكثر فعالية في مجال العلاقات العامة السكتة الدماغيةوevention تخفيف من أعراض AF من أي من الطريقتين وحدها؟ كيف فوائد إجراء مقارنة إذا تم عكس ترتيب الإجراءات، مع انسداد LAA الأول؟ كيف سلامة الإجراء مقارنة زرع الجهاز أو CA وحده؟ هذا هو فعالة في المرضى الأقل خطرا؟ هو الحاجة إلى ablations المستقبل المتضررين من الإجراء المشترك؟ لا يمكن أن يؤديها الإجراء بنفس القدر من النجاح في المرضى الذين لا يأخذون الوارفارين؟ والدراسات المستقبلية تتضمن دراسة مراقبة عشوائية لدراسة ما إذا كان الجمع بين هذه التقنيات على تحسين نتائج المريض ونوعية الحياة لدى هؤلاء المرضى. لاحظ أنه عند تنفيذ هذا الإجراء من المهم أن تجري تقييما دقيقا لتشريح LAA عند اختيار حجم الجهاز وفحص دقيق لموضع الجهاز قبل إطلاقه. من المهم أيضا للغاية للتأكد من أن عمق منطقة الهبوط للجهاز تساوي أو أكبر من أقصى عرض لها اله LAA الفوهة. هذه الخطوات هي الحاسمة لسلامة المرضى وفعالية هذا الإجراء.

catheter ablation in combination with left atrial appendage closure for atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

In a preliminary study of WATCHMAN implantation in 10 patients that had a high risk of stroke and bleeding, 9 of the patients received the device after a catheter ablation. The data from this study is published in the Netherlands Heart Journal, and is presented here with permission 21. All patients included in the study were fully informed about the procedure and signed a consent form. The study was approved by the hospital's ethics committee and all procedures were performed in accordance with the hospital's ethics standards and the Helsinki Declaration of 1975 (revised in 2008).
The characteristics of these patients are summarized in Table 1. All patients had documented AF with a high stroke risk (CHADS2 &gt;1) and all but one of the patients had history of stroke. LAA closure was indicated as an alternative to OAC for the following reasons: stroke during OAC therapy (3/10), severe bleeding during OAC therapy (2/10) and patient preference (5/10). Prior to the procedure all patients were taking a vitamin K antagonist. The median CHADS2 score for this group was 3, with a median CHA2DS2-VASc score of 3.5 and a median HAS-BLED score of 1.5. Prior to the procedure, all patients underwent TEE to exclude LAA thrombus and to rule out structural cardiac abnormalities. Among patients, the average maximum LAA diameter was 20.2&plusmn;2.2 mm with an average depth of 27.9&plusmn;5.4 mm. 40% of the patients had a multi-lobular atrial appendage.
Table 2 outlines procedural characteristics. The WATCHMAN LAA closure device was successfully placed in all 10 patients. Based on patient anatomy determined during preliminary TEE, three different device sizes were used. The median total procedure time was 104 min (range 75-167 min), including a median 56 min (range 38-137 min) for LAA occlusion. During the procedure, an asymptomatic catheter thrombus occurred in one patient. The thrombus was aspirated and the patient received an extra bolus of heparin. Prolonged femoral vein bleeding in this patient necessitated a blood transfusion and extended hospitalization. All other patients were discharged from the hospital on the day following the procedure (Table 2). OAC was continued at least until TEE was performed at 45 days, at which point the device position and closure rate was assessed.
The findings at the 45-day patient follow-up are summarized Table 3. Successful device implantation was defined as long-term sealing of the LAA as measured by TEE 45 days after the procedure without major adverse events. Residual flow (&lt; 5 mm) around the device was allowed after the procedure (according to the PROTECT-AF study). Importantly, no thromboembolic cerebral events occurred. Minimal residual flow was observed in 3 patients. TEE revealed asymptomatic embolization of the device in one patient, and the device was percutaneously retrieved via the femoral vein. Thrombus was not seen on the device in any cases. One patient required a redo-ablation procedure 3 months after the initial procedure, in which pulmonary vein isolation was successful. The implanted LAA device was not affected by and did not interfere with the procedure. Three of the 10 patients were able to discontinue warfarin treatment at 45 days. In the PROTECT-AF18 and Continues Access Registry29 device embolization occurred in 3 patients out of the 1,002 patients implanted.
Figure 2 shows a TEE screen capture of the LAA in one example patient in which no residual flow is observed 45 days post-procedure. In contrast, flow around the device, as evidenced by color Doppler, is seen for another patient (Figure 3).
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Baseline Characteristics</td>
		</tr>
		<tr>
			<td>Number, n</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>61.6 +/9.6</td>
		</tr>
		<tr>
			<td>Sex (%female)</td>
			<td>5 (50)</td>
		</tr>
		<tr>
			<td>Median CHADS2</td>
			<td>3 (2-4)</td>
		</tr>
		<tr>
			<td>2</td>
			<td>4 (40)</td>
		</tr>
		<tr>
			<td>3</td>
			<td>4 (40)</td>
		</tr>
		<tr>
			<td>4</td>
			<td>2 (20)</td>
		</tr>
		<tr>
			<td>CHA2DS2-VASc</td>
			<td>3.5 (2-6)</td>
		</tr>
		<tr>
			<td>HAS-BLED</td>
			<td>1.5 (1-4)</td>
		</tr>
		<tr>
			<td>Vitamin K antagonist, n(%)</td>
			<td>10 (100)</td>
		</tr>
		<tr>
			<td colspan="2">Indication, n(%)</td>
		</tr>
		<tr>
			<td>Bleeding with OAC</td>
			<td>2 (20)</td>
		</tr>
		<tr>
			<td>Stroke using OAC</td>
			<td>3 (30)</td>
		</tr>
		<tr>
			<td>Patient Preference</td>
			<td>5 (50)</td>
		</tr>
		<tr>
			<td colspan="2">LAA, mm</td>
		</tr>
		<tr>
			<td>LAA width</td>
			<td>20.2+/2.2</td>
		</tr>
		<tr>
			<td>LAA length</td>
			<td>27.9+/-5.4</td>
		</tr>
		<tr>
			<td>Multilobular</td>
			<td>4 (40)</td>
		</tr>
	</tbody>
</table>
Table 1. Baseline characteristics of patients enrolled in the study. Data reprinted with permission from the Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, OAC=oral anticoagulation, LAA=left atrial appendage.
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Procedural characteristics</td>
		</tr>
		<tr>
			<td>PVAC, n(%)</td>
			<td>9 (90)</td>
		</tr>
		<tr>
			<td>Size device (mm)</td>
			<td>24 (21-27)</td>
		</tr>
		<tr>
			<td>21</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>24</td>
			<td>8 (80)</td>
		</tr>
		<tr>
			<td>27</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>LAA Occlusion Time (min)</td>
			<td>56 (38-137)</td>
		</tr>
		<tr>
			<td>Total procedural time (min)</td>
			<td>104 (75-167)</td>
		</tr>
		<tr>
			<td>Devices, n</td>
			<td>2 (1-3)</td>
		</tr>
		<tr>
			<td colspan="2">Complications, n(%)</td>
		</tr>
		<tr>
			<td>Catheter thrombus</td>
			<td>1 (10)*</td>
		</tr>
		<tr>
			<td>Inguinal bleeding</td>
			<td>1 (10)*</td>
		</tr>
		<tr>
			<td>Pericardial effusion</td>
			<td>0 (0)*</td>
		</tr>
		<tr>
			<td colspan="2">TEE</td>
		</tr>
		<tr>
			<td>Successful implantation</td>
			<td>10 (100)</td>
		</tr>
		<tr>
			<td>Residual Flow</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>Hospitalization, days</td>
			<td>2 (2-7)</td>
		</tr>
	</tbody>
</table>
Table 2. Procedural characteristics. Data reprinted with permission from the Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, PVAC=pulmonary vein ablation catheter, TEE=Transesophageal echocardiography. *Both in the same patient.
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Follow-up characteristics at 45 days</td>
		</tr>
		<tr>
			<td>Number, n (%)</td>
			<td>10</td>
		</tr>
		<tr>
			<td>TEE, n (%)</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Residual flow</td>
			<td>3 (33)</td>
		</tr>
		<tr>
			<td>Device embolization</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>Thrombus on device</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Vitamin K antagonist, n(%)</td>
			<td>6 (67)</td>
		</tr>
		<tr>
			<td colspan="2">Complications during follow-up, n(%)</td>
		</tr>
		<tr>
			<td>Death</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Stroke or TIA</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Bleeding</td>
			<td>1 (10)</td>
		</tr>
	</tbody>
</table>
Table 3. 45-day follow-up. Data reprinted with permission from Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, TEE=Transesophageal echocardiography, TIA=transient ischemic attack.
<img alt="Figure 1" src="/files/ftp_upload/3818/3818fig1.jpg" /> 
 Figure 1. The WATCHMAN Device. The WATCHMAN device is a nitinol cage covered with a Polyethyl terephthalate membrane. Fixation barbs around the perimeter secure the device in the LAA.
<img alt="Figure 2" src="/files/ftp_upload/3818/3818fig2.jpg" /> 
 Figure 2. A complete LAA isolation or occlusion. TEE with color Doppler demonstrating proper positioning and occlusion at 45 days post-procedure from different TEE-angulations in a single patient. As the TEE probe looks at the device between 0-180 &deg;, there is no flow in the appendage and that the device is appropriately placed in all views.
<img alt="Figure 3" src="/files/ftp_upload/3818/3818fig3.jpg" /> 
 Figure 3. An incomplete LAA occlusion. TEE with color Doppler 45 days post-procedure demonstrating flow (leak) around the device. As the TEE probe looks at the device between 0-180 &deg;, a small gap (&lt;5 mm) with color flow is seen around the device. These findings still can be qualified as successful sealing. Therefore OAC can be stopped. All images are from the same patient.

Watch this Scientific Journal Video about Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation at JoVE.com

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

يتم الجمع بين اجتثاث القثطرة مع وضع الحارس بقي الأذيني جهاز اختتام ذيلا لمنع السكتة الدماغية في المريض مع المنظمات غير صمامي الرجفان الأذيني.

اجتثاث القثطرة في تركيبة مع الزمن لاختتام أطرافهم الأذيني الرجفان الأذيني

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

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JoVE Journal

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33.1K Views.  St. Antonius Hospital, The Netherlands. يتم الجمع بين اجتثاث القثطرة مع وضع الحارس بقي الأذيني جهاز اختتام ذيلا لمنع السكتة الدماغية في المريض مع المنظمات غير صمامي الرجفان الأذيني.

Video: Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily elderly people, its prevalence increases parallel with age. As such, it is expected that 15.9 million Americans will be affected by the year 2050 2. Ischemic stroke occurs in 5% of non-anticoagulated AF patients each year. Current treatments for AF include rate control, rhythm control and prevention of stroke 3.
The American College of Cardiology, American Heart Association, and European Society of Cardiology currently recommended rate control as the first course of therapy for AF 3. Rate control is achieved by administration of pharmacological agents, such as &beta;-blockers, that lower the heart rate until it reaches a less symptomatic state 3. Rhythm control aims to return the heart to its normal sinus rhythm and is typically achieved through administration of antiarrhythmic drugs such as amiodarone, electrical cardioversion or ablation therapy. Rhythm control methods, however, have not been demonstrated to be superior to rate-control methods 4-6. In fact, certain antiarrhythmic drugs have been shown to be associated with higher hospitalization rates, serious adverse effects 3, or even increases in mortality in patients with structural heart defects 7. Thus, treatment with antiarrhythmics is more often used when rate-control drugs are ineffective or contraindicated. Rate-control and antiarrhythmic agents relieve the symptoms of AF, including palpitations, shortness of breath, and fatigue 8, but don't reliably prevent thromboembolic events 6.
Treatment with the anticoagulant drug warfarin significantly reduces the rate of stroke or embolism 9,10. However, because of problems associated with its use, fewer than 50% of patients are treated with it. The therapeutic dose is affected by drug, dietary, and metabolic interactions, and thus requires detailed monitoring. In addition, warfarin has the potential to cause severe, sometimes lethal, bleeding 2. As an alternative, aspirin is commonly prescribed. While aspirin is typically well tolerated, it is far less effective at preventing stroke 10. Other alternatives to warfarin, such as dabigatran 11 or rivaroxaban 12 demonstrate non-inferiority to warfarin with respect to thromboembolic events (in fact, dabigatran given as a high dose of 150 mg twice a day has shown superiority). While these drugs have the advantage of eliminating dietary concerns and eliminating the need for regular blood monitoring, major bleeding and associated complications, while somewhat less so than with warfarin, remain an issue 13-15.
Since 90% of AF-associated strokes result from emboli that arise from the left atrial appendage (LAA) 2, one alternative approach to warfarin therapy has been to exclude the LAA using an implanted device to trap blood clots before they exit. Here, we demonstrate a procedure for implanting the WATCHMAN Left Atrial Appendage Closure Device. A transseptal cannula is inserted through the femoral vein, and under fluoroscopic guidance, inter-atrial septum is crossed. Once access to the left atrium has been achieved, a guidewire is placed in the upper pulmonary vein and the WATCHMAN Access Sheath and dilator are advanced over the wire into the left atrium. The guidewire is removed, and the access sheath is carefully advanced into the distal portion of the LAA over a pigtail catheter. The WATCHMAN Delivery System is prepped, inserted into the access sheath, and slowly advanced. The WATCHMAN device is then deployed into the LAA. The device release criteria are confirmed via fluoroscopy and transesophageal echocardiography (TEE) and the device is released.

The accompanying video describes a procedure for percutaneous placement of the WATCHMAN Left Atrial Appendage (LAA) Device. The WATCHMAN is a nitinol device designed to be permanently implanted at, or slightly distal to, the opening of the left atrial appendage (LAA) to trap blood clots before they exit the LAA, preventing thromboembolic stroke.

بقي الحارس الأذيني سيلة إغلاق لاحقة لالرجفان الأذيني

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

الروبوتية تذرية من الرجفان الأذيني

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

الحد من العيوب علاجي المنشأ الحاجزي الأذيني مع الأمامي والسفلي الموقع عبر الحاجز الثقب عند تشغيل Cryoballoon تذرية قسطرة

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Left Atrial Stenosis Induced Pulmonary Venous Arterialization and Group 2 Pulmonary Hypertension in Rat

The mechanism of mitral stenosis-induced pulmonary venous arterialization and group 2 pulmonary hypertension (PH) is unclear. There is no rodent model of group 2 PH, due to mitral stenosis (MS), to facilitate the investigation of disease mechanisms and potential therapeutic strategies. We present a novel rat model of pulmonary venous congestion-induced pulmonary venous arterialization and group 2 PH caused by left atrial stenosis (LAS). LAS is achieved by constricting the left atrium using a half-closed titanium clip. After the LAS surgery, a rat model with a transmitral inflow velocity greater than or equal to 2.0 m/s on echocardiography gradually develops pulmonary venous arterialization and group 2 PH over an 8- to 10-week period. In this protocol, we provide the step-by-step procedure of how to perform the LAS surgery. The presented LAS rat model mimics MS in humans and is useful for studying the underlying molecular mechanism of pulmonary venous arterialization and for the preclinical evaluation of therapies for group 2 PH.

Left atrial stenosis (LAS) is a novel surgical technique used for studying group 2 pulmonary hypertension (PH) and mechanisms underlying pulmonary venous arterialization. Here, we present a protocol to constrict the left atrium using a titanium clip to cause pulmonary venous arterialization and moderate PH in a rat.

تضيق أذينية الأيسر الناجم عن أرتيرياليزيشن الوريدي الرئوي وارتفاع ضغط الدم الرئوي المجموعة 2 في الفئران

The mechanism of mitral stenosis-induced pulmonary venous arterialization and group 2 pulmonary hypertension (PH) is unclear. There is no rodent model of ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

تبريد أو تسخين المريء للحد من إصابة المريء أثناء الاستئصال الأذيني الأيسر في علاج الرجفان الأذيني

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

التقييم صدى القلب للاتصالات الأذينية قبل إغلاق عبر القسطر

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

Sterile Pericarditis in Aachener Minipigs As a Model for Atrial Myopathy and Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia caused by structural remodeling of the atria, also called atrial myopathy. Current therapies only target the electrical abnormalities and not the underlying atrial myopathy. For the development of novel therapies, a reproducible large animal model of atrial myopathy is necessary. This paper presents a model of sterile pericarditis-induced atrial myopathy in Aachener minipigs. Sterile pericarditis was induced by spraying sterile talcum and leaving a layer of sterile gauze over the atrial epicardial surface. This led to inflammation and fibrosis, two crucial components of the pathophysiology of atrial myopathy, making the atria susceptible to the induction of AF. Two pacemaker electrodes were positioned epicardially on each atrium and connected to two pacemakers from different manufacturers. This strategy allowed for repeated non-invasive atrial programmed stimulation to determine the inducibility of AF at specified time points after surgery. Different protocols to test AF inducibility were used. The advantages of this model are its clinical relevance, with AF inducibility and the rapid induction of inflammation and fibrosis-both present in atrial myopathy-and its reproducibility. The model will be useful in the development of novel therapies targeting atrial myopathy and AF.

We describe a sterile pericarditis model in minipigs to study atrial myopathy and atrial fibrillation (AF). We present surgical and anesthetic techniques, strategies for vascular access, and a protocol to study the inducibility of AF.

التهاب التامور المعقم في Aachener Minipigs كنموذج لاعتلال العضلات الأذيني والرجفان الأذيني

Atrial fibrillation (AF) is the most common arrhythmia caused by structural remodeling of the atria, also called atrial myopathy. Current therapies only ...

Transesophageal Atrial Burst Pacing for Atrial Fibrillation Induction in Rats

Animal studies have brought important insights into our understanding regarding atrial fibrillation (AF) pathophysiology and therapeutic management. Reentry, one of the main mechanisms involved in AF pathogenesis, requires a certain mass of myocardial tissue in order to occur. Due to the small size of the atria, rodents have long been considered 'resistant' to AF. Although spontaneous AF has been shown to occur in rats, long-term follow-up (up to 50 weeks) is required for the arrhythmia to occur in those models. The present work describes an experimental protocol of transesophageal atrial burst pacing for rapid and efficient induction of AF in rats. The protocol can be successfully used in rats with healthy or remodeled hearts, in the presence of a wide variety of risk factors, allowing the study of AF pathophysiology, identification of novel therapeutic targets, and evaluation of novel prophylactic and/or therapeutic strategies.

The present work describes an experimental protocol of transesophageal atrial burst pacing for efficient induction of atrial fibrillation (AF) in rats. The protocol can be used in rats with healthy or remodeled hearts, allowing the study of AF pathophysiology, identification of novel therapeutic targets, and evaluation of new therapeutic strategies.

سرعة انفجار الأذين عبر المريء لتحريض الرجفان الأذيني في الفئران

Animal studies have brought important insights into our understanding regarding atrial fibrillation (AF) pathophysiology and therapeutic management. ...

Estimating Bilateral Atrial Function by Cardiovascular Magnetic Resonance Feature Tracking in Patients with Paroxysmal Atrial Fibrillation

Atrial fibrillation (AF) is the most common form of arrhythmia. Atrial remodeling is considered the most critical mechanism for the presence and development of atrial fibrillation. Also, atrial remodeling can lead to the enlargement and dysfunction of the left atrium (LA), resulting in thrombosis and heart failure. Functional changes in left atrial strain and strain rate occur before structural alterations and are closely associated with structural remodeling and left atrial fibrosis. These parameters are sensitive biomarkers for atrial function. Cardiac magnetic resonance feature tracking (CMR-FT) is a novel, non-invasive, post-processing technique that can evaluate left atrial strain and strain rate. The CMR-FT was utilized in this investigation to assess the bilateral atrium strain rate in individuals with paroxysmal AF. Modifications in each segmental strain were evaluated using segmental analysis. The CMR-FT is recommended for non-invasive evaluations in the clinical assessment of atrial strain among existing strain imaging techniques. Further, it is a flexible parameter measurement with good reproducibility, high soft-tissue resolution, and post-processing based on standard cine balanced steady-state free precision (bSSFP) long-axis images without requiring a new sequence acquisition.

The atrial function is associated with the strain and strain rate. The cardiac magnetic resonance feature tracking (CMR-FT) technique was used in this study to quantify left and right atrial global and segmental longitudinal strain and strain rate in individuals with paroxysmal atrial fibrillation.

تقدير وظيفة الأذين الثنائية عن طريق تتبع ميزة الرنين المغناطيسي للقلب والأوعية الدموية في المرضى الذين يعانون من الرجفان الأذيني الانتيابي

Atrial fibrillation (AF) is the most common form of arrhythmia. Atrial remodeling is considered the most critical mechanism for the presence and ...

Reduced Procedure Time and Variability with Active Esophageal Cooling During Radiofrequency Ablation for Atrial Fibrillation

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the esophagus from inadvertent thermal injury. Active esophageal cooling is increasingly being used over traditional luminal esophageal temperature (LET) monitoring, and each approach may influence procedure times and the variability around those times. The objective of this study is to measure the effects on procedure time and variability in procedure time of two different esophageal protection strategies utilizing advanced informatics techniques to facilitate data extraction. Trained clinical informaticists first performed a contextual inquiry in the catheterization laboratory to determine laboratory workflows and observe the documentation of procedural data within the electronic health record (EHR). These EHR data structures were then identified in the electronic health record reporting database, facilitating data extraction from the EHR. A manual chart review using a REDCap database created for the study was then performed to identify additional data elements, including the type of esophageal protection used. Procedure duration was then compared using summary statistics and standard measures of dispersion.&#160;A total of 164 patients underwent radiofrequency PVI over the study timeframe; 63 patients (38%) were treated with LET monitoring, and 101 patients (62%) were treated with active esophageal cooling. The mean procedure time was 176 min (SD of 52 min) in the LET monitoring group compared to 156 min (SD of 40 min) in the esophageal cooling group (P = 0.012). Thus, active esophageal cooling during PVI is associated with reduced procedure time and reduced variation in procedure time when compared to traditional LET monitoring.

This study utilized advanced informatics techniques to compare procedure duration in patients undergoing radiofrequency atrial ablation treated with active esophageal cooling to those treated with traditional luminal esophageal temperature monitoring. Contextual inquiry, workflow analysis, and data mapping were utilized. The findings demonstrated reduced procedure time and variability with active cooling.

تقليل وقت الإجراء وتنوعه مع تبريد المريء النشط أثناء الاستئصال بالترددات الراديوية للرجفان الأذيني

Various methods are utilized during radiofrequency (RF) pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF) to protect the ...