laa ligation and ablation - dr marcin kuniewicz
TRANSCRIPT
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LAA closure and AF ablation therapeutic option
Jacek BednarekOddział Elektrokardiologii
Krakowski Szpital Specjalistyczny im. Jana Pawła IIMarcin Kuniewicz
Krakowski Szpital Specjalistyczny im. Jana Pawła IIAnatomy Department UJ CM Kraków
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The aim of AF ablation and LAA closure
• To decrease the risk of embolic complication in AF patients
• Atrial fibrillation ablation : protection of arrhythmia occurence in the paroxysmal forms, termination of chronic arrhythmia. The effects still non-satisfactory.
• Left atrial appendage (LAA) closure: protection of systemic embolism in the course of atrial fibrillation, since 95% of left atrial thrombus formation are found in LAA.
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Hybrid left atrial appendage closure and
atrial fibrillation ablation
• Is it safe and efficient ?• Should one perform both procedures in the
same day?• Economic aspect
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The basic types of atrial fibrillation ablation
• High-temperature radiofrequency pulmonary veins isolation (electrophysiological and anatomical circumferential subtypes)
• Low-temperature baloon cryoablation – pulmonary veins isolation
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Circumferential pulmonary vein
isolation using RF energy and 3-D mapping system
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Baloon cryoablation – pulmonary veins isolation
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Types of left atrial appendage closure
• Intracardiac implantable device into the lumen of appendage. Watchman device, Amplatzer device, in Platoo device. The foreign body remain inside the heart. Performed in local anasthesia.
• Extracardiac loop appendage ligation. LARIAT system. There is no foreign body inside the heart. Performed under general anesthesia.
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LARIAT system LAA ligationLARIAT system LAA ligation
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FindrWIRZ LARIAT EndoCATH
LARIAT system LAA ligationLARIAT system LAA ligation
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Swaans MJ et al., 2012 „Ablation for AF in combination with LAAC: first results of feasibility study”
• 30 AF patients with CHADS2VASc>3 and HAS-BLED>2
• Firstly RF CPVI ablation, next WATCHMAN closure • Total procedures duration time: 25-115, mean 97
min• In 30% of patients still AF afterwards• The hybrid procedures are safe method
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Swaans MJ et al., 2011Cathether ablation in combination
with LAA closure for trial fibrillation
• 10 AF patients with CHADS2>1• Non-randomized clinical trial• Firstly CPVI ablation, next WATCHMAN closure• The hybrid procedures can be performed safely
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Arguments for hybrid procedures
• Rafael Hernandez-Estefania et al., 2012: In 13% of PLAATO cases (Ostermayer et al 2005) and in 14% of WATCHMAN cases (PROTECT AF study, 2011) up to 5 mm leakage around the device since the LAA ostium in not round, but oval in shape.
• The effectiveness of ablation around 60 – 80%• Effectiveness of each procedure below 100%• High safety regarding WATCHMAN system closure.
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Krzysztof Bartuś, Jacek Bednarek et al., observation of first LARIAT ligation cases,
Kraków 2009• 13 AF patients: LAA LARIAT closure and CPVI ablation in
the same day, general anesthesia• Significantly bigger hemorrhage to pericardial space
after the procedure in comparison to subsequent over 200 lone LARIAT ligation cases (probably due to high dose of heparine required for ablation)
• No verbal contact with patients during ablation• Limited time for more ligation procedures the same
day• Only one procedure can be reimbursed under our
circumstances – financial deficit for the hospital
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Conclusions
• Intracardiac LAA closure device implantation can be safely performed with AF ablation as a hybrid procedure, although the financial benefit is questionable
• Extracardiac LAA ligation seems to be not recommended as the part of hybrid procedure with AF ablation the same day