Jayant Nath

Short and long-term outcomes of percutaneous left atrial appendage suture ligation: Results from a US multicenter evaluation

BACKGROUND Published studies of epicardial ligation of left atrial appendage (LAA) have reported discordant results. OBJECTIVE The purpose of this study was to delineate the safety and efficacy of LAA closure with the LARIAT device. METHODS This is a multicenter registry of 712 consecutive patients undergoing LAA ligation with LARIAT at 18 US hospitals. The primary end point was successful suture deployment, no leak by intraprocedural transesophageal echocardiography (TEE), and no major complication (death, stroke, cardiac perforation, and bleeding requiring transfusion) at discharge. A leak of 2-5 mm on follow-up TEE was the secondary end point. RESULTS LARIAT was successfully deployed in 682 patients (95.5%). A complete closure was achieved in 669 patients (98%), while 13 patients (1.8%) had a trace leak (<2 mm). There was 1 death related to the procedure. Ten patients (1.44%) had cardiac perforation necessitating open heart surgery, while another 14 (2.01%) did not need surgery. The risk of cardiac perforation decreased significantly after the introduction of a micropuncture (MP) needle for pericardial access. Delayed complications (pericarditis requiring >2 weeks of treatment with nonsteroidal anti-inflammatory drugs/colchicine and pericardial and pleural effusion after discharge) occurred in 34 (4.78%) patients, and the risk decreased significantly with the periprocedural use of colchicine. Follow-up TEE (n = 480) showed a leak of 2-5 mm in 6.5% and a thrombus in 2.5%. One patient had a leak of >5 mm. CONCLUSION LARIAT effectively closes the LAA and has acceptable procedural risks with the evolution of the use of the micropuncture needle for pericardial access and the use of colchicine for mitigating the postinflammatory response associated with LAA ligation and pericardial access.

IMPACT OF LEFT ATRIAL APPENDAGE EXCLUSION ON SYSTEMIC HOMEOSTASIS (THE LAA HOMEOSTASIS STUDY)

Left atrial appendage (LAA) a major source of ANP (atrial natriuretic peptide) which can influence the endocrine axis. The physiologic effects of LAA exclusion on systemic homeostasis have not been previously studied. 37 consecutive patients (7 women (19%)/30 men (81%); age 71±8; CHAD2 2.6±1.1;

Sequential Percutaneous LAA Ligation and Pulmonary Vein Isolation in Patients with Persistent AF: Initial Results of a Feasibility Study

Left atrial appendage (LAA) ligation results in LAA electrical isolation and a decrease in atrial fibrillation (AF) burden. This study assessed the feasibility of combined percutaneous LAA ligation and pulmonary vein isolation (PVI) in patients with persistent AF.

Measuring the Quality of Echocardiography Using the Predictive Value of the Left Ventricular Ejection Fraction

BACKGROUND One of the main challenges for imaging laboratories is demonstrating the quality of their studies. The aim of this study was to determine if echocardiographic training and experience are associated with the accuracy of left ventricular ejection fraction (LVEF) reporting using all-cause mortality as the gold standard. METHODS Survival was determined for consecutive patients undergoing echocardiography at one of four academic facilities. The relationship between LVEF and survival was determined for different groups of physician readers and sonographers on the basis of board certification and experience. Studies of physicians reading <200 studies were excluded. RESULTS Data from 63,108 patients and 40 physicians were included. There was moderate variation across physicians in the relationship between LVEF and 1-year mortality (area under the receiver operating characteristic curve interquartile range, 0.56-0.64). The relationship between LVEF and 1-year mortality was stronger for physicians board certified in echocardiography (area under the receiver operating characteristic curve, 0.60; 95% confidence interval, 0.59-0.61) compared with those not certified (area under the receiver operating characteristic curve, 0.56; 95% confidence interval, 0.55-0.57; P < .0001). Physician experience, years since training, and sonographer experience and certification were not clearly associated with the predictive value of LVEF. After adjustment for patient characteristics, the LVEF-mortality association of board-certified physicians remained stronger than the LVEF-mortality association of those not certified. CONCLUSIONS LVEF as determined by physicians board certified in echocardiography was associated with a stronger relationship with mortality than as determined by those not certified. The LVEF-mortality relationship may be useful as one measure of the quality of imaging.

Left atrial thrombus formation after successful left atrial appendage ligation: case series from a nationwide survey.

Percutaneous left atrial appendage (LAA) exclusion can be performed using endocardial occlusion devices or an endoepicardially placed suture delivery device (1-3). Thrombus formation on endocardial occlusion devices (Watchman, Boston Scientific, Marlborough, Massachusetts; or Amplatzer Cardiac Plug [ACP], St. Jude Medical, St. Paul, Minnesota) (1,2) has been attributed to platelet aggregation in the setting of a foreign body in the left atrium (LA). With the percutaneous endoepicardial ligation technique (Lariat, SentreHEART, Redwood City, California), there is no foreign body left behind, and the risk of thrombus formation should be insignificant. This study describes the clinical course of LA thrombi after the Lariat procedure in 19 patients. We conducted a nationwide survey of physicians performing procedures with the Lariat device in the United States to identify patients who developed LA thrombus after the procedure. Our study cohort comprised patients found to have LA thrombus post-procedure. Post-procedure surveillance imaging was not uniform across centers. Most patients underwent transesophageal echocardiogram (TEE)/computed tomography at 1 to 3 months post-procedure. Anticoagulation/antiplatelet therapy was initiated immediately after detection of LA thrombus. We collected demographic, clinical, and pre-procedural imaging characteristics of patients. Procedural variables and clinical course of patients after thrombus detection were recorded. Statistical analyses were performed using SPSS version 19.0 for Windows (SPSS, Inc., Chicago, Illinois). A total of 47 operators participated in the survey. Routine post-procedure imaging was performed by 44 (93.6%) operators. Three (6.4%) operators performed imaging only if clinically indicated. Routine post-procedure follow-up imaging was performed at 1 to 3 months and 3 to 6 months by 80% and 40% of the operators, respectively. Of the 964 patients who underwent the procedure, 19 (2%) had an LA thrombus. Table 1 lists some patient characteristics and includes follow-up data of the 19 patients. TABLE 1 Patient Characteristics and Follow-Up (n = 19) LA thrombus was detected within 90 days in 15 (79%) patients. TEEs performed in the first 6 months were negative for thrombi in 2 patients with clots discovered >200 days after the procedure. Eighteen patients received oral anticoagulants after detection of LA thrombus, whereas 1 patient received antiplatelet therapy. Thrombus remained unchanged at 90 days in the latter patient, requiring a switch to rivaroxaban. Serial TEEs were performed until thrombus resolution. Oral anticoagulation was discontinued in 16 patients after clot resolution, whereas 3 patients with unresolved thrombi remained on anticoagulation (30, 58, and 80 days, respectively). None of the patients had clinical evidence of stroke or peripheral embolism during follow-up. Our study highlights that the risk of LA thrombus formation with the device is low (2%). Most (79%) cases were detected within the first 90 days. Prompt initiation of anticoagulation can lead to thrombus resolution. This is the first investigation to describe the clinical course of LA thrombus post-procedure in a large cohort of patients receiving the Lariat device. In a clinical study involving 89 patients, no case of LA thrombus was detected on the 30-day post-procedure TEE. However, 1 patient had an LA thrombus away from the site of occlusion at 1-year follow-up (3). Our study is consistent in that, although uncommon, an LA thrombus can develop after the procedure. The pathophysiology of LA thrombus formation after the Lariat procedure remains unclear. Focal endocardial damage and inflammation around the LAA orifice secondary to tissue compression from the Lariat suture, causing edema and ischemic necrosis around the ligation site, can increase the propensity for LA thrombus formation. In our study, 17 of 19 (89%) patients developed a thrombus at the ligation site. Currently, there are no clear guidelines on LA thrombus surveillance after LAA ligation. We strongly support a follow-up TEE 30 to 90 days post-procedure. Given that the risk of thrombus formation is greatest during the first 3 months post-procedure, it may be appropriate for patients to receive antiplatelet or anticoagulant therapy during this period. The risk of LA thrombus in the absence of anticoagulation use post-procedure is low and is more frequently seen during the first 3 months after LAA ligation. Periodic imaging studies are essential for early detection of an LA thrombus. With prompt initiation of anticoagulation and close supervision, an LA thrombus can be managed safely.

Tricuspid Regurgitation: Pathophysiology and Management

Tricuspid regurgitation (TR) is one of the most commonly encountered valvular problems in clinical practice. Although diagnosed easily with echocardiography, it contributes to significant mortality and morbidity when severe. Once thought to be a benign functional valvular abnormality, TR has received more attention in recent years and different treatment options have emerged. However, there is no consensus regarding the superiority of one treatment approach over another. With the development of percutaneous atrioventricular valves, new horizons are open for exploration in the treatment of TR. Clinical indications of treatment are likely to change with increased use of left ventricular assist devices and increased survival of patients with poor right ventricular function. This review discusses the pathophysiology and management of TR along with newer treatment modalities currently under investigation.

LEFT ATRIAL APPENDAGE LIGATION AND ABLATION FOR PERSISTENT ATRIAL FIBRILLATION (LAALA-AF REGISTRY)

Left atrial appendage (LAA) isolation is known to be an important adjunctive therapy to improve outcomes of pulmonary vein isolation in patients with persistent AF. Percutaneous endo-epicardial LAA closure system (LARIAT) can result in both mechanical and electrical exclusion of the LAA and may

EFFECT OF ENDOEPICARDIAL PERCUTANEOUS LEFT ATRIAL APPENDAGE LIGATION (LARIAT) ON ARRHYTHMIA BURDEN IN PATIENTS WITH ATRIAL FIBRILLATION

Left atrial appendage is a very common non Pulmonary venous source of triggered activity. Electrical isolation of LAA seems to be effective in improving outcomes of RF ablation. It is not clear how ligation of the LAA impacts arrhythmia burden in patients with AF We prospectively followed AF

Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry

The anatomical, electrical, and clinical impact of incomplete Lariat left atrial appendage ligation remains unclear.

Five years of keeping a watch on the left atrial appendage—how has the WATCHMAN fared?

Left atrial appendage closure (LAAC) is a promising site-directed therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF) who are ineligible or contraindicated for long-term oral anticoagulation. A variety of LAAC modalities are available, including percutaneous endocardial occluder devices such as WATCHMANTM (Boston Scientific Corp., Marlborough, MA, USA), and an ever-increasing body of evidence is helping to define the optimal use of each technique. Similarly increased experience with LAAC has revealed challenges such as device-related thrombi and peri-device leaks for which the long-term significance and appropriate management are areas of active investigation. We review the evolution and long-term outcomes with the WATCHMANTM device with particular emphasis on the nuances of its use and its role in the broader landscape of appendageology.