Los autores desean agradecer a Ted van de Beek de Boston Scientific por su apoyo durante la preparación de este manuscrito.

1. Pre-Procedimiento de preparación <ol><li> Antes de realizar el procedimiento, sobre los riesgos y beneficios del procedimiento con el paciente, y obtener un formulario de consentimiento firmado. Ajuste del paciente dosis de vitamina K antagonista para lograr un cociente normalizado internacional de 2,0 a 3,0. Continuar la terapia con fármacos antiarrítmicos hasta el momento del procedimiento. </li><li> O bien el día antes o el mismo día del procedimiento, realice un ecocardiograma transesofágico (ETE) para documentar la ausencia de trombos en la orejuela izquierda, evaluar las características y tipo de la LAA, y para determinar el tamaño WATCHMAN dispositivo adecuado para la implantación (véase el 2012 JoVE artículo de Mobius-Winkler y sus colegas para obtener más información) 22. </li><li> Realizar la ablación con catéter combinado y WATCHMAN Cierre LAA procedimiento de colocación de dispositivos en un laboratorio de electrofisiología con el equipo adecuado diagnóstico y de imagen para el procedimiento. </li><li> Con el paciente en posición supina, administer anestesia de acuerdo con protocolos institucionales. </li></ol> 2. Ablación con catéter <ol><li> Asegúrese de que el sistema de registro electrofisiológico (Bard Inc., Lowell, MA) está utilizando la configuración del filtro de 100 a 500 kHz y una amplificación de la señal de 5.000. </li><li> Una vez que el paciente es anestesiado completamente, administrar 20 ml de 1% de lidocaína como anestésico local en la región de la ingle. Inmediatamente, limpiar y preparar la región inguinal para la canalización. </li><li> Localice la vena femoral, e insertar una venoso 8 French (8F) vaina. Introducir un catéter cuadripolar en el seno coronario para fines de estimulación. A continuación, insertar un alambre de guía largo, y quitar la funda. Introducir un estándar de acceso venoso vaina transeptal. </li><li> Retire la guía larga, e insertar una aguja transeptal RF Brockenbrough (Baylis Medical Company Inc., Montreal, Quebec, Canadá) con una funda 12.5F-outer-diameter/9.5F-inner-diameter orientable (Canal, Bard, Lowell, MA ) y realizar una transeptal puntualidadre. </li><li> Después de cruzar el tabique interauricular, posicionar un catéter pigtail en el centro de la aurícula izquierda y realizar una angiografía rotacional 3D. </li><li> El catéter de la vena pulmonar ablación (PVAC: Medtronic / Ablation Frontiers, Inc., Carlsbad, CA) es un 9F, sobre-el-alambre, mapeo circular, decapolar y catéter de ablación con una matriz de 25-mm de diámetro en la punta distal. El PVAC tiene diez electrodos sobre un marco de nitinol que permiten la asignación, la ablación y la verificación de aislamiento de la vena pulmonar. Inserte un alambre de guía 0,032 pulgadas en la PVAC. </li><li> A continuación, insertar el sistema en su conjunto en la vaina venosa. La información reunida por el PVAc se visualiza en un monitor para generar una imagen 3D del corazón del paciente con la ubicación del catéter que se muestra. </li><li> Administrar un bolo de heparina para prevenir la coagulación 10.000IE como resultado del procedimiento. Coloque el cable en una de las ramas de la vena pulmonar y luego avanzar en el PVAc en el antro vena pulmonar. </li><li> Utilice fluoroscopic guía, electrocardiogramas y 3D eléctrico de la señal de imagen (ESI) de reconstrucción para evaluar la posición de la PVAC y ajustarlo para obtener el mejor contacto con todos los electrodos. </li><li> Una vez que una posición del catéter satisfactorio se consigue, comenzará frecuencia de radio (RF)-ablación al seleccionar los pares de electrodos apropiados para la entrega de energía de RF. </li><li> Ajuste el generador para ajustar la potencia para lograr un objetivo de temperatura de 60 ° C para cada electrodo en los pares seleccionados. En la mayoría de los casos, todos los pares de electrodos se activa durante las primeras aplicaciones para crear superposición de anillos de lesiones. </li><li> Ablación por 60 sec. Compruebe que el monitor de condiciones durante la ablación. Si la temperatura no se eleve por encima de 50 ° C dentro de 15 segundos, suspensión de la aplicación, ajustar la posición de los electrodos y empezar de nuevo. </li><li> Mover y rotar el PVAC-catéter para crear lesiones circunferenciales venas pulmonares. </li><li> Repita este procedimiento para todas las venas pulmonares. </li><li> Después de crcomer lesiones circunferenciales para todas las venas pulmonares, restaurar el ritmo sinusal mediante cardioversión de corriente directa (DCCV). </li><li> Confirmar aislamiento mediante la comprobación de la ausencia de potenciales locales (entrada y salida de bloque) con mapeo PVAC dentro de cada vena combinado con estimulación maniobras desde el seno coronario. </li><li> Para potenciales residuales en pares de electrodos aislados, la ablación único objetivo de que los pares y adyacente a facilitar alcanzar la temperatura objetivo. </li></ol> 3. La implantación del dispositivo WATCHMAN <ol><li> Una vez que el procedimiento de ablación por catéter es completa, el dispositivo se implanta WATCHMAN. </li><li> Avanzar un 0,035 &quot;alambre de guía rígido (por ejemplo, Amplatz Súper rígidas 260 cm) en el PVAc y la posición del alambre de guía en la vena pulmonar superior izquierda. Eliminar el PVAC mientras se mantiene la posición del alambre de guía. </li><li> Si la ablación no se realizó antes de la implantación, administrar heparina a 100 UI / kg de peso corporal para obtener un tiempo de coagulación activado of 200-300 sec. Comprobar el nivel de tiempo de coagulación activado para asegurar que es todavía 200-250 sec. Continuar el seguimiento de este min cada 30 según sea necesario. </li><li> Eliminar el Sistema de Acceso WATCHMAN y dilatador del envase en condiciones estériles. Cuidadosamente inspeccione los daños. </li><li> Llenar una jeringa de 60 cc con solución salina y limpie el puerto lateral de la vaina de acceso WATCHMAN. El uso de la solución salina que queda a ras del dilatador. Inserte el dilatador en la vaina de acceso vigilante. </li><li> Avanzar la vaina de acceso WATCHMAN y el dilatador sobre el alambre guía en la aurícula izquierda. A medida que la vaina de acceso WATCHMAN se acerca al centro de la aurícula izquierda, mantenga el dilatador y avanzar la vaina de acceso WATCHMAN a la posición inicial de la aurícula izquierda solamente. </li><li> Retire el dilatador y el alambre guía. Antes de apretar la válvula de hemostasia, permiten sangrar de nuevo para reducir al mínimo la posibilidad de introducción de aire. Enjuague vaina WATCHMAN acceso con solución salina. </li><li> Apretar la válvula de la vaina de acceso. </li><li> Para cOnfirmes las dimensiones de la LAA, utilice ETE para medir las dimensiones máximas LAA en 4 perspectivas a 0 °, 45 °, 90 ° y 135 °. </li><li> Enjuague el catéter pigtail con solución salina y adelantarlo a través del cable y acceso a través de la vaina vigilante. A continuación, quite el alambre guía y conectar una jeringa con medio de contraste para la coleta. </li><li> Mientras ve TEE, gire la vaina de acceso WATCHMAN antihorario para alinear la vaina más anterior y avanzar el cable flexible en la posición deseada en la porción distal de la LAA. </li><li> Una vez que el catéter pigtail ha llegado a la LAA, obtener una angiografía en oblicua anterior derecha (OAD) de 20-30 °, caudal 20-30 °. A continuación, realizar ETE con un mínimo de un barrido de 0-135 °. Esto es más importante cuando la vaina se hace avanzar cerca de la pared o el ápice de la LAA y durante el avance más distal en cualquier anatomía. </li><li> Cuidadosamente avanzar la vaina acceso a través del catéter pigtail en el lóbulo más superior: en la angiografía es el situat LAA lóbuloed en torno al 2 en punto de la una oblicua anterior derecha (OAD) de 20-30 °, caudal 20-30 º, en el TEE es el derecho más LAA lóbulo a 135 °. </li><li> Bajo guía fluoroscópica, avanzar la vaina de acceso WATCHMAN a la profundidad deseada en el LAA basado en la banda del marcador correspondiente al tamaño apropiado. </li><li> Una vez que la coleta es tan distante como sea posible, inyectar el material de contraste. </li><li> Seleccione el tamaño de WATCHMAN dispositivo apropiado basado en máxima LAA ostium dimensiones y tamaño 22. </li><li> En condiciones estériles, retire el dispositivo WATCHMAN del embalaje compruebe que no presenta daños. Para confirmar que el dispositivo está conectado al alambre de núcleo, abrir la válvula hemostática y retraer el dispositivo de aproximadamente 1 cm. </li><li> Alinear la punta distal del dispositivo con la banda del marcador. El dispositivo WATCHMAN no debe sobresalir. </li><li> Conecte una jeringa grande 60 cc que contiene solución salina. Enjuague el sistema varias veces para eliminar el aire. A continuación, sumergir la punta del catéter de entrega ensalina y tócalo para eliminar las burbujas. </li><li> Vuelva a verificar la posición de la vaina acceso por angiografía. Afloje la válvula de la vaina de acceso y retire lentamente el catéter pigtail de la vaina. Permitir que la funda a sangrar de nuevo. </li><li> Para evitar la introducción de aire, inyectar solución salina a través del puerto de purga de modo que gotea desde el catéter de suministro, a continuación, introducir el sistema del dispositivo WATCHMAN. </li><li> Bajo guía fluoroscópica, avanzar lentamente el catéter de entrega en la vaina de acceso hasta que la banda marcadora más distal sobre las líneas de acceso de la vaina con la banda del marcador en el catéter de administración y estabilizar el catéter de entrega. </li><li> Retirar la cubierta de acceso y encájelo en el catéter. Usando fluoroscopia, reconfirmar la posición de la punta del catéter de entrega. No haga avanzar la vaina de acceso una vez que el sistema de entrega se ha encajado en ella. </li><li> Si es necesario reposicionamiento, retire el sistema de entrega, vuelva a insertar el catéter pigtail y avanzar en la vaina de acceso a la proper posición. </li><li> Una vez que el sistema de suministro está posicionada, aflojar la válvula en el catéter de entrega WATCHMAN. Observar el extremo distal del dispositivo para asegurarse de que no avance hacia delante o reposicionamiento relativo a ostium se produce. </li><li> A continuación, para desplegar el dispositivo, mantenga el mando de despliegue estacionaria y lentamente retraer el acceso vaina / conjunto de catéter de entrega con un movimiento lento y estable durante un periodo de 3-5 segundos. </li><li> Retirar la vaina de acceso / entrega conjunto de catéter de unos pocos centímetros del dispositivo para alinearla con la LAA, dejando el hilo central conectado. </li><li> Una vez que el dispositivo ha sido desplegado, inyectar contraste de nuevo. Luego, con fluoroscopia y ecocardiografía transesofágica, confirmar la posición, Ancla, tamaño y Seal (PASS) Criterios de dispositivos de liberación se han cumplido las siguientes: </li><li> Posición: Confirmar el dispositivo está correctamente posicionado por asegurar que el plano del diámetro máximo del dispositivo abarca el ostium de la LAA y es en o justo distal al orificio de la LAA. </li> &lt;li Anchor&gt;: Confirmar el dispositivo se ancla en su lugar, mediante la retirada de la vaina de acceso / entrega conjunto de catéter de 1 a 2 cm de la cara del dispositivo de retracción después suavemente y liberar el botón de despliegue. El LAA y el dispositivo debe moverse al unísono. </li><li> Tamaño: Confirmar que el dispositivo es de tamaño apropiado midiendo el plano del diámetro máximo del dispositivo mediante ETE en el estándar de 4 puntos de vista 0 °, 45 °, 90 °, y 135 °, asegurando el inserto roscado es visible. El dispositivo debería ser 80-92% del tamaño original. </li><li> Seal: utilizando Doppler color, asegurarse de que todos los lóbulos distales al dispositivo están sellados. Flujo de color no debería ser detectado cerca del dispositivo. Si hay un hueco o chorro alrededor del dispositivo que es mayor que 5 mm, el dispositivo debe ser reposicionado o recapturados completamente y reemplazado. </li><li> Si todos los criterios de liberación se cumplen, mover el acceso vaina / entrega catéter hasta la cara del dispositivo y girarel mando de despliegue 3-5 vueltas en sentido antihorario para liberar. </li><li> Después de la liberación, lleve a cabo una angiografía con medio de contraste para documentar que el dispositivo se encuentra todavía en su lugar. Luego, utilizando TEE, vuelva a comprobar el tamaño y el sello. Eliminar el ensamblaje de vaina de la aurícula izquierda. </li><li> Si el dispositivo es demasiado distal o proximal en el LAA o los criterios de dispositivos no se cumplen, puede que sea necesario para recuperar parcial o totalmente el dispositivo (para más detalles consulte el artículo Jove 2012 por Möbius-Winkler y sus colegas) 22. </li></ol> 4. Después de la cirugía <ol><li> Una vez que la colocación correcta del dispositivo ha sido confirmado, retire la vaina. La vena femoral entonces se debe comprimir por un par de horas y el paciente deben ser monitorizados cuidadosamente durante al menos 6 horas con la presión arterial y la frecuencia cardíaca. </li><li> Compruebe si hay hematoma y / o sangrado a intervalos regulares de acuerdo con las directrices institucionales. El paciente debe administrarse profilaxis antibiótica por thdirectrices e American Heart Association. NOTA: heparina Mensaje procedimiento no se recomienda. </li><li> Una vez que el paciente está despierto, lleve a cabo un examen neurológico. </li><li> El paciente debe permanecer en la warfarina y la aspirina de 81 mg durante un mínimo de 45 días después del procedimiento de implante (relación interna normalizada = 2.0-3.0). </li><li> El paciente debe ser hospitalizado y dado de alta al día siguiente. Un ecocardiograma transtorácico (ETT) o una radiografía de tórax puede realizarse para confirmar la ausencia de derrame pericárdico. </li><li> A los 45 días, evaluará la colocación del dispositivo WATCHMAN con ETE. La cesación de la warfarina es a discreción del médico, si la LAA está completamente cerrada y trombo en el dispositivo fue descartada. Si el flujo se observó alrededor del dispositivo mayor que 5 mm, se debe considerar para mantener al paciente en la warfarina hasta que se ha disminuido a menos de 5 mm. </li><li> Los pacientes que dejan warfarina debe iniciarse clopidogrel 75 mg al día hasta los 6 meses después del implante y continúe tomando unaSpirin diaria indefinidamente. </li><li> Prescribir la profilaxis de la endocarditis adecuado durante 6 meses después de la implantación. Continuando profilaxis de la endocarditis más allá de 6 meses se deja a criterio del médico. </li></ol>

<ol>
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A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+left+atrial+appendage+obliteration+in+stroke+reduction+in+patients+with+mitral+valve+prosthesis:+a+transesophageal+echocardiographic+study.">Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study.</a> Journal of the American College of Cardiology. 42, 1253-1258 (2003).</li><li>Blackshear, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracoscopic+extracardiac+obliteration+of+the+left+atrial+appendage+for+stroke+risk+reduction+in+atrial+fibrillation.">Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation.</a> Journal of the American College of Cardiology. 42, 1249-1252 (2003).</li><li>Block, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Watching+the+watchman.">Watching the watchman.</a> Journal of the American College of Cardiology. 49, 1496-1497 (2007).</li><li>Block, P. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=+Percutaneous+left+atrial+appendage+occlusion+for+patients+in+atrial+fibrillation+suboptimal+for+warfarin+therapy:+5-year+results+of+the+PLAATO+(Percutaneous+Left+Atrial+Appendage+Transcatheter+Occlusion)+Study."> Percutaneous left atrial appendage occlusion for patients in atrial fibrillation suboptimal for warfarin therapy: 5-year results of the PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) Study.</a> JACC. Cardiovascular. 2, 594-600 (2009).</li><li>Viles-Gonzalez, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incomplete+occlusion+of+the+left+atrial+appendage+with+the+percutaneous+left+atrial+appendage+transcatheter+occlusion+device+is+not+associated+with+increased+risk+of+stroke.">Incomplete occlusion of the left atrial appendage with the percutaneous left atrial appendage transcatheter occlusion device is not associated with increased risk of stroke.</a> Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing. 33, 69-75 (2012).</li><li>Cappato, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Worldwide+survey+on+the+methods,+efficacy,+and+safety+of+catheter+ablation+for+human+atrial+fibrillation.">Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.</a> Circulation. 111, 1100-1105 (2005).</li><li>Reddy, V. Y., Holmes, D., Doshi, S. K., Neuzil, P., Kar, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+percutaneous+left+atrial+appendage+closure:+results+from+the+Watchman+Left+Atrial+Appendage+System+for+Embolic+Protection+in+Patients+with+AF+(PROTECT+AF)+clinical+trial+and+the+Continued+Access+Registry.">Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry.</a> Circulation. 123, 417-424 (2011).</li><li>Oral, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pulmonary+vein+isolation+for+paroxysmal+and+persistent+atrial+fibrillation.">Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation.</a> Circulation. 105, 1077-1081 (2002).</li><li>Biase, L. D. i., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+atrial+appendage:+an+underrecognized+trigger+site+of+atrial+fibrillation.">Left atrial appendage: an underrecognized trigger site of atrial fibrillation.</a> Circulation. 122, 109-118 (2010).</li></ol>

El Servicio de Cardiología del St. Antonius Hospital (Nieuwegein, Holanda) recibe honorarios proctoring para el entrenamiento / servicios educativos de Atritech / Boston Scientific. La producción y el libre acceso a este artículo es patrocinado por Boston Scientific.

El texto anterior describe un procedimiento de ablación con catéter combinado y oclusión orejuela auricular izquierda como tratamiento para la FA y la prevención de eventos tromboembólicos asociados. Los datos preliminares indican que este procedimiento puede ser realizado de forma segura en pacientes con alto riesgo de accidente cerebrovascular. No hay dificultades técnicas que se han encontrado en la ejecución de la intervención combinada. Si bien ninguna mejora a cualquiera de los procedimientos se puede esperar ya que no se influyen entre sí, el procedimiento combinado puede ofrecer varias ventajas sobre la realización de los procedimientos por separado. El procedimiento combinado permite el tratamiento simultáneo de síntomas de FA y la reducción del riesgo de accidente cerebrovascular, la mejora de la calidad de vida de las personas afectadas por la FA. También puede presentar drogas refractaria a los pacientes una opción de tratamiento por lo que les permite someterse a la implantación del dispositivo WATCHMAN sin tratamiento con warfarina posterior. Además, la necesidad de, y el riesgo asociado de, la repetición de una aurícula izquierdaintervención y la punción transeptal se reduce cierre LAA debe hacerse deseable durante el seguimiento. Mientras CA es un tratamiento establecido para los síntomas de AF, datos recientes sugieren que también es eficaz en la reducción de accidente cerebrovascular. En un análisis retrospectivo de los pares emparejados de pacientes de AF, Reynolds y sus colegas vieron una disminución significativa en el riesgo relativo de accidente cerebrovascular y ataque eventos transitorios isquémicos en pacientes sometidos a ablación en comparación con aquellos sometidos a tratamiento con fármacos antiarrítmicos 16. Los datos también indican que la amputación de la LAA o oclusión a través de la ligadura quirúrgica o dispositivo de colocación reduce eficazmente los eventos embólicos. Estos métodos parecen prometedores: en un estudio de pacientes sometidos a reemplazo valvular mitral aquellos que se sometieron a la ligadura quirúrgica tuvieron significativamente menos golpes (3 frente a 17%) 19, 23. A menos invasiva, la ligadura toracoscópica utilizando un procedimiento de trampa bucle se ha realizado con éxito en 14 de 15pacientes con enfermedad cerebrovascular en 2 pacientes (4%) en los siguientes 42 meses 19,24. Varias de catéteres percutáneos LAA dispositivos de oclusión se han desarrollado como el Amplatzer Cardiac Plug (AGA médica), el parche percutáneo (Custom Medical Devices), la oclusión percutánea transcatéter LAA (PLAATO) del sistema, y ​​el dispositivo WATCHMAN LAA oclusión. En la actualidad, los estudios clínicos sobre la seguridad y eficacia se publican sólo para PLAATO (que ya no está disponible) y el vigilante. El PLAATO demostró la seguridad y la eficacia y ofrece una prueba de concepto para el cierre de LAA utilizando un filtro basado en nitinol dispositivo. El dispositivo era una jaula autoexpandible de nitinol cubiertos de politetrafluoroetileno que impedía que la sangre entre en el LAA 25. Un estudio no aleatorizado de 64 pacientes con CHADS 2&gt; 2 mostró oclusión completa en más del 98% de los pacientes. Después de 5 años, el accidente cerebrovascular isquémico attac / transitoriostasa de k se redujo a 3,8% en comparación con el 6,6% esperado en una población 26. Los datos obtenidos del estudio PROTECT AF 18, que compara la eficacia del dispositivo WATCHMAN al tratamiento con warfarina más compatible con un enfoque basado en dispositivo de oclusión LAA. Este estudio aleatorio mostró que WATCHMAN implantación se encontró a no ser inferior en términos de todas las causas de apoplejía y todas las causas de mortalidad en los pacientes elegibles OAC, aumentando la posibilidad de que el procedimiento podría ser utilizado como una alternativa al tratamiento crónico con warfarina en pacientes que no utilizan sustancias refractiva 18. En el estudio publicado en Países Bajos Heart Journal en 2012 21, hemos podido implantar el dispositivo en 10 pacientes, de los cuales 9 fueron sometidos CA concurrente. Tenga en cuenta que aunque el flujo residual se observó en 3 de los casos a los 45 días de seguimiento, Viles-González y sus colegas han demostrado que este flujo residual alrededor del dispositivo no está asociado con unaumento del riesgo de eventos tromboembólicos 27. Si bien los datos disponibles apoyan tanto CA y la oclusión LAA utilizando el dispositivo WATCHMAN como tratamientos eficaces para la AF, ambos procedimientos están asociados con complicaciones. Una encuesta mundial de CA en el año 2010 demostró que las complicaciones ocurren en el 4,5% de los pacientes 14. Las complicaciones más importantes son: la muerte, eventos tromboembólicos cerebrales, perforación extrapericardial vena pulmonar, taponamiento, estenosis, y el aleteo atípico de nueva aparición (iatrogénico) 14, 15, 28. Complicaciones de procedimientos terapéuticos que pueden derivarse de procedimiento de colocación WATCHMAN dispositivo incluyen derrame pericárdico grave, la embolización del dispositivo, relacionada con el procedimiento carrera 18. En ambos casos, la incidencia de complicaciones ha encontrado que dependen de la experiencia del operador 15, 29. Para el procedimiento combinado, datos relacionados con la seguridad se limita a nuestro estudio de 2012, en la que comcaciones se limitaron a una embolia dispositivo. La mitad de los pacientes no han documentado la recurrencia de la FA a los 3 meses de seguimiento. La otra mitad de los pacientes requirieron al menos una cardioversión con corriente directa. Uno de los pacientes sometidos a ablación de repetición y fue un éxito 21. Aunque este estudio fue de una población pequeña y no proporcionar una comparación directa con otros métodos de tratamiento, los estudios de seguridad en cada uno de los procedimientos independientes 29, 30 sugieren que los beneficios potenciales de las compensaciones de tratamiento el aumento del riesgo de seguridad. Otras cuestiones de seguridad a tener en cuenta son los mayores tiempos de procedimiento, requisito para la anestesia general, y el riesgo aumentado de hemorragia GI-tracto con ETE seguimiento, que deberá acompañar a la colocación vigilante. Mientras que el procedimiento descrito en la presente memoria se describe un procedimiento combinado de colocación WATCHMAN y CA PV, es importante tener en cuenta que la colocación WATCHMAN no se opone a una estrategy de aislamiento eléctrico de la LAA. Un estudio reciente de Di Biase y colegas demostraron que en un grupo de pacientes seleccionados con recurrente AF, 27% ​​mostró focos derivados de la LAA después de una ablación inicial, la cual fue tratada de manera óptima a través de un completo aislamiento circunferencial LAA 31. Este grupo de pacientes podría beneficiarse especialmente de cierre LAA porque el aislamiento eléctrico de la LAA podría conducir a LAA estasis incluso durante el ritmo sinusal, por lo que es más trombogénico. En pacientes en los que la ablación de FA y el cierre LAA se considera, primero se podría realizar un estudio electrofisiológico con desafíos farmacológicos para detectar y extirpar LAA posibles desencadenantes antes de la implantación del dispositivo WATCHMAN 31. Teniendo en cuenta el presente estudio no es aleatorizado, y se limita a un 45-días de seguimiento de 10 pacientes de alto riesgo, muchas preguntas quedan por resolver: ¿Es la combinación de CA / VIGILANTE procedimiento de implantación más eficaz en tiempos prevención y alivio de los síntomas de FA que cualquier método solo? ¿Cómo las ventajas del procedimiento de comparar si el orden de los procedimientos se invierte, con LAA oclusión primero? ¿Cómo afecta la seguridad del procedimiento en comparación con el implante del dispositivo o bien CA en paz? ¿Es esto efectivo en pacientes de menor riesgo? Es la necesidad de ablaciones futuros afectados por el procedimiento combinado? ¿El procedimiento se realiza con el mismo éxito en pacientes que no toman warfarina? Los estudios futuros incluirán un estudio de control aleatorio para examinar si la combinación de estas técnicas mejora los resultados del paciente y la calidad de vida de estos pacientes. Tenga en cuenta que al realizar este procedimiento, es importante evaluar cuidadosamente la anatomía LAA la hora de seleccionar el tamaño del dispositivo y comprobar a fondo la colocación del dispositivo antes de soltarlo. También es muy importante asegurarse de que la profundidad de la zona de aterrizaje para el dispositivo es igual o mayor que la anchura máxima de the LAA ostium. Estos pasos son críticos para la seguridad del paciente y la eficacia del procedimiento.

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

La ablación con catéter se combina con la colocación del dispositivo auricular izquierdo WATCHMAN Cierre Appendage para prevenir el accidente cerebrovascular isquémico en un paciente con no-valvular fibrilación auricular.

Ablación con catéter en combinación con cierre de la orejuela izquierda por fibrilación auricular

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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33.1K vistas.  St. Antonius Hospital, The Netherlands. La ablación con catéter se combina con la colocación del dispositivo auricular izquierdo WATCHMAN Cierre Appendage para prevenir el accidente cerebrovascular isquémico en un paciente con no-valvular fibrilación auricular.

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.

El del reloj a la izquierda del dispositivo auricular Cierre Apéndices de la fibrilación auricular

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

Investigación

Medicina

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.

Robótica ablación de la fibrilación auricular

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.

Reducción de defectos del septo interauricular iatrogénica con una anterior e inferior del sitio de punción transeptal cuando Funcionamiento del Cryoballoon ablación con catéter

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.

Estenosis Atrial izquierda inducido arterialización venosa pulmonar y el grupo 2 la hipertensión pulmonar en rata

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.

Enfriar o calentar el esófago para reducir la lesión esofágica durante la ablación auricular izquierda en el tratamiento de la fibrilación auricular

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;

Evaluación ecocardiográfica de las comunicaciones auriculares antes del cierre transcatéter

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.

Pericarditis estéril en minicerdos de Aachener como modelo para la miopatía auricular y la fibrilación auricular

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.

Estimulación del estallido auricular transesofágico para la inducción de la fibrilación auricular en ratas

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.

Estimación de la función auricular bilateral mediante el seguimiento de la característica de resonancia magnética cardiovascular en pacientes con fibrilación auricular paroxística

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.

Reducción del tiempo y variabilidad del procedimiento con enfriamiento esofágico activo durante la ablación por radiofrecuencia para la fibrilación auricular

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