Bharath Yarlagadda

Mechanical function of the left atrium is improved with epicardial ligation of the left atrial appendage: Insights from the LAFIT-LARIAT Registry

BACKGROUNDnLeft atrial (LA) strain (ε) and ε rate (SR) analysis by 2-dimensional speckle tracking echocardiography is a novel method for functional assessment of the LA.nnnOBJECTIVEnThe purpose of this study was to determine the impact of left atrial appendage (LAA) exclusion by Lariat epicardial ligation on mechanical function of the LA by performing ε and SR analysis before and after the procedure.nnnMETHODSnA total of 66 patients who underwent successful LAA exclusion were included in the study. Of these 66 patients, 32 had adequate paired data for ε and SR analysis. SR during ventricular systole (LA-SRs) represents LA reservoir function, and SR during early ventricular diastole (LA-SRe) represents LA conduit function. ε and SR were determined from apical 4- and 2-chamber views using the electrocardiographic QRS as a reference point. LA volume index as surrogate for LA remodeling was measured from apical views.nnnRESULTSnMean patient age was 70 ± 9.2 years. LAA ligation resulted in improved reservoir function (LA-SRs: pre 0.72, confidence interval [CI] 0.63-0.83 vs post 0.81, CI 0.73-0.98; P = .043) and conduit function (LA-SRe: pre 0.74, CI 0.67-0.99 vs post 0.89, CI 0.82-1.07; P = .025). LA volume index improved significantly with the Lariat (pre 35.4, CI 29.4-37.2 vs post 29.2, CI 28.2-35.9; P <.023).nnnCONCLUSIONnLAA exclusion seems to improve mechanical function of the LA and results in reverse LA remodeling.

Leaks after left atrial appendage ligation with Lariat device: Incidence, pathophysiology, clinical implications and methods of closure- A case based discussion.

Catheter based left atrial appendage (LAA) closure techniques are emerging as a promising alternative for stroke prevention in patients who cannot tolerate oral anticoagulation. Lariat procedure involves percutaneous catheter based epicardial ligation of the LAA with a suture via an endo-epicardial hybrid approach. It offers the advantage of not leaving behind a focus for thrombus formation or embolization. Similar to surgical ligation of the left atrial appendage, Lariat ligation is limited by leaks in a small percentage of patients. The incidence of leaks is variable and can be seen in the immediate post procedure period or during follow up. The electrical and mechanical implications of leaks are still under debate. In this review, we discuss the incidence, pathophysiology, clinical implications and methods of closure of leaks after Lariat. In the end, we present a case of a Lariat leak closed with an Amplatzer septal occluder.

Congenital Absence of Left Atrial Appendage

Isolated absence of left atrial appendage is a very rare entity and is usually encountered as an incidental finding during routine imaging for other purposes. Lately, with increasing fund of knowledge about its potential role in cardio embolic phenomena, we have seen an increased trend in the use different techniques to exclude left atrial appendage from main left atrial chamber, in an effort to alleviate the stroke risk and therefore the need for long term anticoagulation. Clinical implications of absent left atrial appendage in such patients remains a mystery.

Indication, Patient Selection, and Referral Pathways for Left Atrial Appendage Closure

Left atrial appendage closure (LAAC) has emerged as a viable option for stroke prevention, especially in those intolerant of or not suitable for long-term oral anticoagulation therapy. This article describes the clinical characteristics, indications, and a proposed referral system for potential LAAC patients. Patient selection remains a challenge because of the paradox between the available randomized data on this intervention and the actual patient population who may gain maximum benefit. Further investigations comparing different LAAC devices with each other and with novel oral anticoagulants are needed. Also, the optimal antithrombotic regimen post-procedure has yet to be determined.

An interesting case of reverse electrical remodeling of the left atrium after radiofrequency ablation

Introduction Atrial remodeling caused by a variety of comorbidities culminates in the onset and perpetuation of atrial fibrillation (AF). AF by itself may result in atrial remodeling and contributes to the progressive nature of the arrhythmia. Radiofrequency ablation (RFA) is a well-established strategy for rhythm control in patients with symptomatic and drug-refractory AF. Successful RFA is associated with significant reverse remodeling of the left atrium (LA). Reverse electrical remodeling starts within hours to days and structural remodeling ensues over a period of months. There is a large body of literature suggesting a decrease in LA size and concurrent preservation of LA function after ablation during long-term follow-up. We present a case of reverse electrical remodeling of the LA as seen on 3-D mapping after AF ablation.

Temporal Relationships between Esophageal Injury Type and Progression in Patients Undergoing Atrial Fibrillation Catheter Ablation

BACKGROUNDnCurrently, little is known about the onset, natural progression, and management of esophageal injuries after atrial fibrillation (AF) ablation.nnnOBJECTIVESnWe sought to provide a systematic review on esophageal injury after AF ablation and identify temporal relationships between various types of esophageal lesions, their progression, and clinical outcomes.nnnMETHODSnA comprehensive search of PubMed and Web of Science was conducted until September 21, 2017. All AF ablation patients who underwent upper gastrointestinal endoscopy within 1 week of the procedure were included. Patients with esophageal lesions were classified into 3 types by using our novel Kansas City classification: type 1: erythema; type 2a: superficial ulcers; type 2b: deep ulcers; type 3a: perforation without communication with the atria; and type 3b: perforation with atrioesophageal fistula.nnnRESULTSnThirty studies met our inclusion criteria. Of the 4473 patients, 3921 underwent upper gastrointestinal evaluation. The overall incidence of esophageal injuries was 15% (570). There were 206 type 1 lesions (36%), 222 type 2a lesions (39%), and 142 type 2b lesions (25%). Six of 142 type 2b lesions (4.2%) progressed further to type 3, of which, 5 were type 3a and 1 was type 3b. All type 1 and type 2a and most type 2b lesions resolved with conservative management. One type 3a and 1 type 3b lesions were fatal.nnnCONCLUSIONnBased on our classification, all type 1 and most type 2 lesions resolved with conservative management. A small percentage (4.2% [6 of 142]) of type 2b lesions progressed to perforation and/or fistula formation, and these patients need to be followed closely.