Name: catheter ablation in combination with left atrial appendage closure for atrial fibrillation
Uploaded: 2013-02-26T11:57:00
Duration: 28 min 13 s
Description: Watch this Scientific Journal Video about Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation at JoVE.com

作者想感谢Ted的Van de Beek的波士顿科学公司在编制这份手稿对他的支持。

1。行前准备程序<ol><li>在执行过程之前，讨论的风险和利益的程序与病人，并获取签名的同意书。调整病人的维生素K拮抗剂剂量，以达到国际标准化比率为2.0〜3.0。继续抗心律失常药物治疗的程序的时间。 </li><li>无论是前一天或一​​天​​的程序，执行经食管超声心动图（TEE）来记录的情况下在LAA内血栓，评估在LAA的特性和类型，以确定适当的彪形大汉设备大小植入（见2012年朱庇特的更多信息，文章利用Mobius温克勒和他的同事）22。 </li><li>执行合并的导管射频消融和WATCHMAN左心耳闭合装置放置过程中的电生理实验室适当的诊断和成像设备的过程中。 </li><li>随着病人取仰卧位，administeŕ麻醉根据机构的协议。 </li></ol> 2。射频消融治疗<ol><li>确保电生理记录系统（巴德公司，马萨诸塞Lowell）正在使用的过滤器设置为100〜500 kHz和一个信号放大为5,000。 </li><li>一旦患者完全麻醉，管理20毫升1％利多卡因局部麻醉在腹股沟区。随即，清洁和准备腹股沟区插管。 </li><li>找到股静脉，插入静脉法国（8F）护套。介绍四极起搏导管插入冠状静脉窦。然后，将一个很长的导丝，取出护套。介绍一个标准的的静脉跨室间隔访问鞘。 </li><li>长的导丝取出，然后插入跨室间隔RF Brockenbrough针（贝里斯医疗器材公司，蒙特利尔，魁北克，加拿大），一个12.5F-outer-diameter/9.5F-inner-diameter可控的护套（通道，吟游诗人，洛厄尔，MA ），进行跨室间隔标点符号重。 </li><li>穿过房间隔后，猪尾巴导管在左心房的中心定位，并进行3D旋转血管造影。 </li><li>肺静脉消融导管（PVAC：美敦力/射频消融前沿，公司，卡尔斯巴德，加利福尼亚州）的是一个9F，过线，圆形，decapolar的映射和一个25毫米直径的阵列在远端冰山的消融导管。的的PVAC有10个电极在镍钛记忆合金框架，使肺静脉隔离的映射，消融和验证的。 0.032英寸的导丝插入到PVAC。 </li><li>下一步，将整个系统进入静脉鞘。由聚醋酸乙烯酯中收集到的信息被显示在监视器上，以产生与病人的心脏的三维图像显示的导管的位置。 </li><li>提供一个作为该过程的结果，以防止凝血丸10.000IE肝素。定位线的肺静脉的分支之一，然后提前进入肺静脉前庭的聚醋酸乙烯酯。 </li><li>使用fluoroscopiÇ指导，心电图和3D的电信号成像（ESI）重建评估的聚醋酸乙烯酯的位置进行调整，以获得最佳的接触与所有的电极。 </li><li>一旦达到一个令人满意的导管的位置，展开，通过选择适当的电极对提供的射频能量的射频（RF）消融。 </li><li>设置发电机调整功率来实现的目标温度为60℃，在所选择的对各电极。在大多数情况下，电极对将被激活，在第一个应用程序创建的重叠性病灶环。 </li><li>消融为60秒。检查显示器在消融过程中的条件。在15秒内，如果温度不高于50°C，终止应用程序，调整电极的位置，并重新开始。 </li><li>移动和旋转PVAC-导管环肺静脉病变。 </li><li>所有肺静脉重复此过程。 </li><li> CR后吃圆周所有肺静脉的病变，恢复窦性节律以直流电流的律（DCCV）。 </li><li>冠状静脉窦起搏演习结合各静脉内聚醋酸乙烯酯映射的局部电位（入口和出口块）的情况下检查，确认隔离。 </li><li>对于独立的电极对上残留的潜力，目标消融和相邻的一对，有利于达到目标温度。 </li></ol> 3。植入的彪形大汉设备<ol><li>一旦导管消融治疗的程序是完整的，守望的装置植入。 </li><li>推进0.035“硬导丝（ 如消融超级僵硬260厘米）成聚醋酸乙烯酯和位置的导丝在左上肺静脉。聚醋酸乙烯酯，同时保持导丝的位置。 </li><li>如果消融不进行植入前，肝素100 IU / kg体重管理得到活化凝血时间of 200-300秒。检查活化的凝血时间的水平，以确保，它仍然是200-250秒。根据需要继续监控，每30分钟。 </li><li>删除守望的包装在无菌条件下接入系统和扩张。仔细检查是否有损坏。 </li><li>填充60CC注射器用生理盐水冲洗的侧端口的彪形大汉访问的套。使用剩余的生理盐水冲洗扩张。将扩张的彪形大汉访问护套。 </li><li>推进彪形大汉接入鞘和扩张器在导丝进入左心房。作为守望的访问的护套接近中心的左心房，保持扩张和推进的初始位置，只在左心房的的彪形大汉访问鞘。 </li><li>取出扩张器和导线。在拧紧止血阀，允许回流血的可能性降到最低空气引入。用生理盐水冲洗彪形大汉访问护套。 </li><li>拧紧阀门的访问鞘。 </li><li>组（CON）公司LAA的尺寸，使用TEE测量的最大的LAA尺寸在4次，在0°，45°，90°和135°。 </li><li>用生理盐水冲洗猪尾巴导管在守望的访问护套线，并通过推进。然后，取出导丝连接的注射器造影剂的小辫子。 </li><li>在查看TEE，把守望的访问鞘逆时针调整鞘前推进的小辫子在所需的位置在远端部分的LAA。 </li><li>一旦猪尾巴导管已经达到了LAA，获得血管造影在右前斜（RAO）20〜30℃，尾鳍20-30℃。然后执行TEE用最少的0-135°扫描。套先进的LAA附近的墙或顶点时，同时促进更多的远侧任何解剖，这是最重要的。 </li><li>小心地推进访问最优越的叶猪尾导管鞘管，在血管造影，这是LAA叶situat2点左右在一个右前斜（RAO）20〜30℃，尾椎20〜30°，，，TEE它是最右边的叶LAA-135°。 </li><li>透视引导下，提前的彪形大汉访问鞘中的所需深度的基础上的标志带，对应到合适的大小LAA。 </li><li>一旦尽可能的小辫子是远端，注入造影剂。 </li><li>选择适当的彪形大汉器件尺寸的基础上最大LAA口尺寸和浆纱22。 </li><li>在无菌条件下，取出的的彪形大汉设备从包装，检查是否有损坏。要确认的设备连接到芯线，打开止血阀和缩回的移动设备大约1厘米。 </li><li>的移动设备的标记带的远侧尖端对齐。守望的设备不应突出。 </li><li>将一个大的含盐水60毫升注射器。系统冲洗几次，以除去任何空气。然后，淹没在输送导管的前端盐水拍打，以除去气泡。 </li><li>重新检查血管造影的访问鞘的位置。松开接入止回阀，从鞘中，慢慢取出的猪尾巴导管。允许套回流血。 </li><li>为了避免引入空气，通过注入生理盐水冲洗口淌从输送导管，然后，引进的彪形大汉设备系统。 </li><li>透视引导下，慢慢地推进输送导管进入接入鞘接入鞘线，直至最前端的标记带的标记带输送导管和稳定输送导管。 </li><li>收回的访问鞘和捕捉它的输送导管上。使用透视，再次确认在输送导管尖端的位置。不提前一次访问鞘输送系统已被抢购一空。 </li><li>如果需要重新定位，将输送系统，重新插入猪尾巴导管和推进的访问鞘为PROPER位置。 </li><li>一旦输送系统的位置，松开彪形大汉输送导管上的阀门。观察远端设备，以确保没有向前推进，或重新定位相对口。 </li><li>然后，向设备部署，持有部署旋钮静止和慢慢地缩回接入鞘/输送导管组件用一个缓慢超过3-5秒的期间的稳定的运动。 </li><li>撤回访问护套/输送导管组件，从设备到几厘米将它与LAA，留下的芯线连接。 </li><li>一旦设备已经部署，再次注入对比。然后，采用X光透视TEE，确认位置，锚，尺寸和密封（PASS）设备发布标准得到满足如下： </li><li> 的位置是 ：确认该设备被正确地定位，确保该装置的最大直径的平面跨越在LAA口和等于或恰好远侧孔口在LAA。 </li> &lt;李&gt; 主持人：确认设备是固定到位，，通过撤回的访问护套/交付导管组件1 - 2厘米面对的设备，然后轻轻地收回，并释放部署旋钮。 LAA和设备异口同声地移动。 </li><li> 大小：确认该设备是通过测量该装置的最大直径的平面在0°，45°，90°，135°，确保带螺纹的插入件是可见的标准4次使用TEE适当尺寸。该装置应该是80-92％的原始大小。 </li><li> 密封：采用彩色超声多普勒，确保所有的远端设备的叶是密封的。彩色流不应检测装置附近。如果有一个设备周围的是大于5毫米的间隙或喷射，该装置应被重新定位或完全夺回和替换。 </li><li>如果所有的发行条件得到满足，移动接入鞘/输送导管在脸上的设备和旋转部署逆时针转动旋钮3-5释放。 </li><li>发行完成后，造影剂进行血管造影记录，该装置仍处于地方。然后，使用TEE，请重新检查尺寸和密封。删除套管组件的左心房。 </li><li>如果该设备是在LAA或设备不符合标准的远端或近端，它可能是必要的部分或全部夺回设备（有关详细信息，请参阅莫比乌斯温克勒和他的同事们在2012年的朱庇特的文章）22。 </li></ol> 4。后程序<ol><li>一旦妥善安置的设备已被证实，取出护套。股静脉，然后被压缩了几个小时，至少6个小时的血压和心脏率监测病人应进行仔细的监测。 </li><li>请血肿和/或出血，定期根据机构的指导方针。每次的患者应给予抗生素预防Ë美国心脏协会的指导方针。注意：POST程序肝素不推荐使用。 </li><li>一旦病人是清醒的，进行神经系统检查。 </li><li>患者应保持至少45天的华法林和阿司匹林81毫克后的的植入程序（内部标准化比值= 2.0-3.0）。 </li><li>病人应住院过夜，翌日康复出院。经胸超声心动图（TTE）或胸部X射线可以进行确认的情况下，心包积液。 </li><li>在45天的评估守望的设备放置TEE。停止华法林是在医生的自由裁量权，如果完全封闭的LAA血栓的设备上被排除。如果流注意到设备周围的大于5毫米，应考虑使病人华法林，直到它已经降低到小于5毫米。 </li><li>停止华法林的患者应开始每天75毫克氯吡格雷经过6个月后植入物，并继续采取阿司匹林每天下去。 </li><li>植入后6个月内订定适当的性心内膜炎的预防。超过6个月的持续性心内膜炎的预防，是在医生的自由裁量权。 </li></ol>

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R. <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+closure.">Left atrial appendage closure.</a> Current Cardiology Reports. 12, 413-421 (2010).</li><li>Velthuis, S., 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+Closure+for+Stroke+Prevention+in+Patients+with+Atrial+Fibrillation+and+Hereditary+Hemorrhagic+Telangiectasia.">Left Atrial Appendage Closure for Stroke Prevention in Patients with Atrial Fibrillation and Hereditary Hemorrhagic Telangiectasia.</a> Case Reports in Cardiology. 3, (2012).</li><li>Swaans, M. J., Post, M. C., Rensing, B. J., Boersma, L. V. <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+closure+for+stroke+prevention+in+atrial+fibrillation.">Percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation.</a> Netherlands Heart Journal: Monthly Journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation. 20, 161-166 (2012).</li><li>Mobius-Winkler, S., 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=The+WATCHMAN+left+atrial+appendage+closure+device+for+atrial+fibrillation.">The WATCHMAN left atrial appendage closure device for atrial fibrillation.</a> J. Vis. Exp. (60), e3671 (2012).</li><li>Garcia-Fernandez, M. 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>

心内科圣安医院（荷兰Nieuwegein）监考费，培训/教育服务从Atritech /波士顿科学。 生产和免费使用这篇文章是由波士顿科学。

上面的文字描述作为房颤治疗和预防相关的血栓栓塞事件的联合导管消融和左心耳闭塞的程序。初步数据显示，这个过程可以安全地进行，患者在中风的高风险。执行合并过程中遇到的技术困难。虽然没有任一过程的改善，因为它们不互相影响，可以预期，合并的程序分别执行的程序，可以提供几个优点。合并过程中，可同时治疗房颤的症状和中风的风险减少，改善生活质量，为那些受AF。它也可能出现药物难治性患者的治疗方案，让他们接受植入的彪形大汉设备没有后续的华法林治疗。此外，反复的必要性，以及相关的风险，左心房减少干预和跨室间隔穿刺左心耳封闭成为理想的随访期间。 CA是一个既定的AF症状治疗，而最近的数据表明，它也是有效降低中风。在匹配的AF患者对回顾性分析，雷诺和他的同事们看到了一个显着减少卒中和短暂性脑缺血发作的患者接受消融相比，那些接受抗心律失常药物治疗16事件的相对危险性。数据还表明，通过手术结扎或设备放置有效地降低血栓事件截肢的LAA或闭塞。这些方法似乎不错：二尖瓣置换术的患者在一项研究中，接受手术结扎显著较少的招（3％和17％），19，23。一种微创，胸腔镜结扎使用循环网罗程序已成功执行14 15患者中风发生2例（4％）以上的下列42个月19,24。 的几个经皮导管LAA闭塞装置已被开发，包括应用Amplatzer心脏插头（AGA医疗），经导管修补程序（自定义医疗器械），经皮LAA的经导管的闭塞（PLAATO）系统，和左心耳封堵器的彪形大汉。目前，有关安全性和有效性的临床研究才公布PLAATO（这是不再可用）的彪形大汉。 PLAATO证明安全性和有效性，并提供证明LAA封闭使用镍钛记忆合金为基础的过滤器设备的概念。该器件是自膨式镍钛合金笼覆盖聚四氟乙烯是阻止血液从进入LAA 25。 64例的一个CHADS 2&gt; 2的非随机研究表明超过98％的患者完全闭塞。 5年后，卒中/短暂性脑缺血阿塔克施钾量减少至3.8％，较预期的6.6％，人口26。 从保护AF 18日 ，与华法林治疗的疗效比较的彪形大汉设备的研究获得的数据进一步支持基于设备的方法LAA闭塞。这项随机研究显示，植入彪形大汉被认为是导致中风和各种原因的死亡率在OAC符合条件的患者在非劣效性，提高的可能性，该过程最终可以被用来作为一种替代华法林治疗慢性患者谁是药物折射18。在荷兰心脏杂志上发表的研究，在2012年21，我们成功植入10例，9例并发CA的设备。需要注意的是，虽然剩余流量在45天随访有3例，Viles - 冈萨雷斯和他的同事证明，这个设备周围的剩余流量是不相关的一个增加的血栓栓塞事件风险27。 虽然现有的数据支持CA和使用的的彪形大汉设备作为有效的治疗AF的LAA闭塞，这两个过程都伴有并发症。一个世界性的加利福尼亚州进行的一项调查显示，在2010年的并发症发生在4.5％的患者14。最显着的并发症包括：死亡，脑血管血栓栓塞事件，extrapericardial肺静脉穿孔，心包填塞，狭窄，新发（医源性）14，15，28和非典型扑。从彪形大汉设备安置程序，可能会导致手术并发症包括严重的心包积液，设备栓塞术，手术相关的行程18。并发症的发生率在这两种情况下，已被发现依赖于操作者的经验15，29。 对于合并的过程中，安全方面的数据是有限的，我们的2012年的研究，在其中的COM褶皱被限制在一台设备等症。一半的患者并没有在3个月的随访记录房颤复发的。另一半的患者需要至少一个直流电复律。 1例患者重复消融，它是成功的21。虽然本研究是一小口，并且不提供直接的比较，与其他的治疗方法，在每一个独立的程序29中的安全性的研究，30表明，治疗抵消了安全风险增加的潜在好处。额外的安全性要考虑的问题是程序的时间，全身麻醉的要求，并增加胃肠道出血的风险与TEE监测，必须伴随着彪形​​大汉放置的时间越长。 虽然本文描述的方法描述了一种组合的程序彪形大汉放置和PV CA，重要的是要注意，彪形大汉放置不排除一方向分析y的LAA的电气隔离。迪BIASE和他的同事们最近的一项研究表明，在选定的组房颤复发的患者中，27％表明灶LAA后所产生的初始消融，这是最佳的处理通过完整的圆周LAA隔离31。这组病人特别是受益于LAA关闭，因为电气隔离的LAA可能导致LAA淤滞，甚至在窦性节律，使之更血栓形成。被认为是房颤消融和左心耳封闭的患者，可先进行电生理与药理挑战进行检测和消融可能LAA之前触发植入的彪形大汉设备31。 由于本研究是随机的，被限制在45天的随访10个高风险的病人，许多问题仍有待解决：合并CA /彪形大汉植入过程中更有效地行程公关evention和救灾的AF症状，仅比任何一种方法？利益的程序如何比较，如果程序的顺序是相反的，与闭塞第一LAA？如何安全的程序相比，无论是设备植入或CA吗？这是在低风险的患者有效？是需要的未来合并过程受消融？的程序进行在不服用华法林的患者中同样获得成功吗？未来的研究将包括一项随机对照研究，以研究是否将这些技术可以提高患者的预后和生活质量，在这些患者中。 请注意，执行此操作时，重要的是要仔细评估LAA解剖时，器件的尺寸和选择的设备放置在发布前进行全面检查。这也是非常重要的，以确保设备的降落区域的深度为等于或大于的最大宽度的第ËLAA口。这些步骤是为病人的安全性和有效性的程序的关键。

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

心房纤维性颤动（AF）是最常见的持续性心律失常，影响到数百万世界各地的个人1-3。快速，不规则，无序的心房电活动会引起心悸，乏力，呼吸困难，胸痛，头晕或不晕厥4，5。 AF的患者有5倍的风险较高，行程6。 常用的口服抗凝药物（OAC）与华法林的房颤患者中风的预防和已被证明是中风的风险降低了64％7。华法林治疗有几大缺点，但是，包括出血，不宽容，与其他药物和食品的相互作用，不符合规定和狭窄的治疗范围8-11。这些问题，连同升值的风险 - 效益比差，不注意的指引，或没有OAC监控门诊诊所也许可以解释为什么只有30-60％的患者与AF处方这种药物8。 与华法林的疗效有限和/或严重的副作用，与其他药物用于AF 12,13，结合相关的问题，强调需要有效的非药物治疗方法。一种方法是导管消融（CA），一个射频电流应用到心脏地区的一个过程，在这过程中创建小的消融灶，电隔离潜在的AF触发4。 CA是一个行之有效的治疗AF症状，14，15，也可以减少中风的危险。最近的数据显示，显着降低卒中和短暂性脑缺血发作的患者接受消融相比，那些接受抗心律失常药物治疗16事件的相对危险性。 由于左心耳（LAA），在超过90％的患者中是血栓源患者与非瓣膜性房颤17，另一种方法是用身体挡住退出LAA血栓预防中风。封闭LAA的方法之一，是通过经皮放置的WATCHMAN左心耳封堵器。守望的设备，类似于一个小型降落伞。它由覆盖镍钛合金帧，由织物聚对苯二甲酸乙二醇酯，以防止栓子，但没有血液，在愈合过程中排出。周围的周边的固定锚固定在LAA的（ 图1）的移动设备。至目前为止，守望的是唯一的植入经皮设备上的随机临床试验已经报告。在这项研究中，植入的彪形大汉被认为是至少一样有效华法林在预防中风（原因）和死亡（所有原因）18。此设备获得了欧洲通用 （CE）标记的使用华法林在欧盟符合条件的患者和那些有一个反面的抗凝治疗19 traindication到。 由于行之有效CA，以减轻房颤的症状和有前途的数据，两个程序结合的，希望进一步降低中风的发病率在高风险的患者缓解症状的同时减少血栓栓塞事件与CA和WATCHMAN植入。合并后的过程可能会最终使患者接受植入的彪形大汉设备没有后续的华法林治疗，因为CA过程本身降低血栓栓塞事件。这将带来以前无法治疗的患者，不适合华法林治疗，因为经常出血或其他华法林相关问题的途径。 合并过程双翼飞机透视TEE指导下进行全身麻醉。通过植入的彪形大汉LAA closu的导管射频消融后重新装置。数据库中的10例患者的非随机试验表明，此过程中，可以安全地执行与CHADS2评分大于1 21患者。进一步研究，以研究在减少症状从AF和相关的中风的合并过程的有效性，因此必要的。

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

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