Mathieu Lempereur

Percutaneous Left Atrial Appendage Closure: Procedural Techniques and Outcomes

Percutaneous left atrial appendage closure technology for stroke prevention in patients with atrial fibrillation has significantly advanced in the past 2 decades. Several devices are under clinical investigation, and a few have already received Conformité Européene (CE)-mark approval and are available in many countries. The WATCHMAN device (Boston Scientific, Natick, Massachusetts) has thexa0most supportive data and is under evaluation by the U.S. Food and Drug Administration for warfarin-eligible patients. The Amplatzer Cardiac Plug (St. Jude Medical, Plymouth, Minnesota) has a large real-world experience over the past 5 years, and a randomized trial comparing Amplatzer Cardiac Plug with the WATCHMAN device is anticipated in the near future. The Lariat procedure (SentreHEART Inc., Redwood City, California) has also gained interest lately, but early studies were concerning for high rates of serious pericardial effusion and major bleeding. The current real-world experience predominantly involves patients who are not long-term anticoagulation candidates or who are perceived to have high bleeding risks. This pattern of practice is expected to change when the U.S. Food and Drug Administration approves the WATCHMAN device for warfarin-eligible patients. This paper reviews in depth the procedural techniques, safety, and outcomes of the current leading devices.

Cardiac CT angiography for device surveillance after endovascular left atrial appendage closure

AIMSnLeft atrial appendage (LAA) device imaging after endovascular closure is important to assess for device thrombus, residual leak, positioning, surrounding structures, and pericardial effusion. Cardiac CT angiography (CCTA) is well suited to assess these non-invasively.nnnMETHODS AND RESULTSnWe report our consecutive series of non-valvular atrial fibrillation patients who underwent CCTA post-LAA closure with Amplatzer Cardiac Plug (ACP), Amulet (second generation ACP), or WATCHMAN devices. Patients underwent CCTA typically 1-6 months post-implantation. Prospective cardiac-gated CCTA was performed with Toshiba 320-detector or Siemens 2nd generation 128-slice dual-source scanners, and images interpreted with VitreaWorkstation™. GFR <30 mL/min/1.73 m(2) was an exclusion. We assessed for device thrombus, residual LAA leak, device embolization, position, pericardial effusion, optimal implantation, and device lobe dimensions. Forty-five patients underwent CCTA at median 97 days post-LAA closure (18 ACP, 9 Amulet, 18 WATCHMAN). Average age was 75.5 ± 8.9 years, mean CHADS2 score 3.1 ± 1.3, and CHADS-VASc score 4.9 ± 1.6. All had contraindications to oral anticoagulation. Post-procedure, 41 (91.1%) were discharged on DAPT. There was one device embolization (ACP, successfully retrieved percutaneously) and one thrombus (WATCHMAN, resolved with 3 months of warfarin). There were two pericardial effusions, both pre-existing and not requiring intervention. Residual leak (patency) was seen in 28/44 (63.6%), and the mechanisms of leak were readily identified by CCTA (off-axis device, gaps at orifice, or fabric leak). Mean follow-up was 1.2 ± 1.1year, with no death, stroke, or systemic embolism.nnnCONCLUSIONnCCTA appears to be a feasible alternative to transoesophageal echocardiography for post-LAA device surveillance to evaluate for device thrombus, residual leak, embolization, position, and pericardial effusion.

Changes in Left Atrial Appendage Dimensions Following Volume Loading During Percutaneous Left Atrial Appendage Closure

OBJECTIVESnThis study sought to determine whether volume loading alters the left atrial appendage (LAA) dimensions in patients undergoing percutaneous LAA closure.nnnBACKGROUNDnPercutaneous LAA closure is increasingly performed in patients with atrial fibrillation and contraindications to anticoagulation, to lower their stroke and systemic embolism risk. The safety and efficacy of LAA closure relies on accurate device sizing, which necessitates accurate measurement of LAA dimensions. LAA size may change with volume status, and because patients are fasting for these procedures, intraprocedural measurements may not be representative of true LAA size.nnnMETHODSnThirty-one consecutive patients undergoing percutaneous LAA closure who received volume loading during the procedure were included in this study. After an overnight fast and induction of general anesthesia, patients had their LAA dimensions (orifice and depth) measured by transesophageal echocardiography before and after 500 to 1,000 ml of intravenous normal saline, aiming for a left atrial pressure >12 mm Hg.nnnRESULTSnSuccessful implantation of LAA closure device was achieved in all patients. The average orifice size of the LAA at baseline was 20.5 mm at 90°, and 22.5 mm at 135°. Following volume loading, the average orifice size of the LAA increased to 22.5 mm at 90°, and 23.5 mm at 135°. The average increase in orifice was 1.9 mm (p < 0.0001). The depth of the LAA also increased by an average of 2.5 mm after volume loading (p < 0.0001).nnnCONCLUSIONSnIntraprocedural volume loading with saline increased the LAA orifice and depth dimensions during LAA closure. Operators should consider optimizing the left atrial pressure with volume loading before final device sizing.

Device-associated thrombus formation after left atrial appendage occlusion: A systematic review of events reported with the Watchman, the Amplatzer Cardiac Plug and the Amulet

This study aimed to provide a systematic review of device‐associated thrombosis (DAT) after left atrial appendage occlusion (LAAO) with the Watchman, Amplatzer Cardiac Plug, and Amulet devices.

Stent mal-apposition with resorption of intramural hematoma with spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). Conservative management is typically recommended but revascularization may be necessary if ongoing ischemia or adverse anatomical characteristics are present. Percutaneous coronary intervention (PCI) of SCAD can be fraught with challenges, and intracoronary imaging with optical coherence tomography (OCT) may provide insights on optimizing the acute results and identify long-term stent-related adverse events. We report three cases of SCAD treated with drug-eluting stents (DES) with OCT follow-up showing stent mal-apposition at different stages of follow-up. The clinical significance of these OCT findings and management options are discussed.

Impact of gender difference in hospital outcomes following percutaneous coronary intervention. Results of the Belgian Working Group on Interventional Cardiology (BWGIC) registry

AIMSnTo determine whether there are gender-based differences in in-hospital outcomes among patients undergoing percutaneous coronary intervention (PCI).nnnMETHODS AND RESULTSnWe studied a large cohort using clinical data from a registry of 130,985 PCI procedures in Belgium, from January 2006 to February 2011. Compared to males, females were significantly older (70.3 vs. 64.8 years), and were more frequently diabetic or hypertensive. Men smoked more and more frequently had previous myocardial infarction (MI), previous PCI or previous coronary artery bypass graft (CABG) surgery. Coronary artery disease (CAD) was less severe in women, and PCI to the left anterior descending artery was more common in female patients. Unadjusted in-hospital mortality rates were higher in females versus males (2.5% for women and 1.6% for men, p<0.0001). After multivariable analysis, female gender remained an independent predictor of mortality (odds ratio 1.35, 95% CI: 1.22-1.49, p<0.0001).nnnCONCLUSIONSnGender-based differences in hospital mortality rates after PCI were observed in this large registry. Female sex remained an independent predictor of mortality after multivariable adjustment.

Spontaneous Coronary Artery Dissection Associated With β-HCG Injections and Fibromuscular Dysplasia

Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome predominantly affecting younger women. SCAD is often associated with predisposing arterial abnormalities and precipitating emotional, physical, and hormonal stressors. We previously showed that fibromuscular dysplasia is strongly associated with SCAD and may be a causative factor. Hormonal changes related to pregnancy and sex hormones have also been shown to be an important cause of SCAD. We describe the first case report, to our knowledge, of SCAD associated with β-human growth hormone injections in a patient with concomitant FMD.

Optical coherence tomography (OCT) evaluation of intermediate coronary lesions in patients with NSTEMI

INTRODUCTIONnCoronary angiography is commonly performed following non-ST segment elevation myocardial infarction (NSTEMI) to assess the need for revascularization. Some of these patients have myocardial infarction (MI) with no obstructive coronary atherosclerosis (MINOCA). Patients without severe obstructive lesions are usually treated conservatively. However, coronary angiography has known limitations in the assessment of lesion severity. We report our experience of using coronary Optical Coherence Tomography (OCT) in a series of patients without severe obstructive coronary lesions.nnnMETHODSn165 patients underwent coronary OCT at Vancouver General Hospital. NSTEMI was the clinical presentation in 70 patients and 26 had angiographically intermediate lesions with 40%-69% diameter stenosis. Prior to OCT image acquisition, intracoronary nitroglycerin 100-200μg was administered. Blood in the vessel was displaced using contrast media by manual injections.nnnRESULTSnOCT of the angiographically intermediate lesions showed larger minimal luminal area (MLA) than the angiographically severe lesions (MLA 3.3mm(2)±1.8mm(2) vs. 1.6mm(2)±0.6mm(2), p<0.001) and less severe % lumen area stenosis (54.2%±11.4% vs. 70.9%±6.8%, p=0.001). Plaque rupture or intracoronary thrombus was detected in 8/26 (31%) patients. PCI with stent deployment was performed in 16 patients (62%).nnnCONCLUSIONnIn stabilized patients with NSTEMI and angiographically intermediate disease, OCT examination confirmed the lack of severe anatomical stenosis in most patients. However, OCT also identified coronary lesions with unstable features. Further research is needed to help guide management of this subgroup of patients.

Trapped Rotablation Wire Causing Longitudinal Stent Deformation

Longitudinal stent deformation is a recently described complication of percutaneous coronary intervention. It can lead to serious adverse outcomes. The precipitating mechanisms and treatment strategies have been described. We report a case of longitudinal stent deformation that occurred with the removal of a trapped rotablation guide wire.

Transcatheter left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation: results from the Belgian registry.

AIMSnThis study aimed to assess the safety and efficacy at midterm follow-up of left atrial appendage occlusion (LAAO) using different devices, in real life in Belgium.nnnMETHODS AND RESULTSnBetween June 2009 and November 2016, 457 consecutive patients (63% male, 75±12 yrs, CHA2DS2-VASc 4±0.6, HAS-BLED 3.5±0.7) undergoing LAAO were included. Technical success was 97.1%. There were 19 periprocedural major adverse events (4.1%) including three deaths (0.6%), nine tamponades (1.9%), four major bleedings (0.8%) and two device embolisations (0.4%). Among patients successfully implanted having a complete follow-up (672 patient-years, median follow-up 370 days), the actual annual stroke rate was 1.2%, lower than the expected stroke risk of 4% (70% reduction). The observed bleeding rate was 2%, while the calculated risk was 3.7% (46% reduction). Kaplan-Meier analysis showed a similar overall survival (93±2% and 87±3% versus 91±3% and 87±4%; p=0.35) and event-free survival (92±2% and 84±3% versus 88±3% and 80±5%; p=0.17) at one and two years, for the ACP/Amulet versus the WATCHMAN groups of patients, respectively.nnnCONCLUSIONSnThe data from the Belgian left atrial appendage occlusion registry suggest that the procedure is effective and relatively safe in a real-world setting, using either the WATCHMAN or the ACP/Amulet device.