Grosset-Janin D, Barth E, Bertrand B, Detante O
Stroke unit, neurology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France.
Cardiology, university hospital, boulevard de la Chantourne, 38043 Grenoble cedex 9, France.
Rev Neurol (Paris). 2015 May;171(5):426-32. doi: 10.1016/j.neurol.2014.11.009. Epub 2015 Apr 23.
Stroke, as the third cause of death in developed countries, is a public health issue. Atrial fibrillation is an important cause of ischemic stroke and its prevention is efficient with oral anticoagulation. However, oral anticoagulation can be contraindicated because of hemorrhagic risk related to these treatments. Percutaneous left atrial appendage occlusion is a new alternative of oral anticoagulation for patients with atrial fibrillation and high risk of cardio-embolic stroke but contraindicated for oral anticoagulation.
We describe in this paper the procedure of left atrial appendage occlusion with the Amplatzer cardiac plug device, used in our center in Grenoble university hospital, for the first three patients who have been treated with this device. These three patients (one man and two women) have all atrial fibrillation with neurological complication of this arrhythmia, as ischemic stroke. Oral anticoagulation is indicated to prevent another ischemic stroke. However, they all have a high risk of cerebral bleeding for different reasons (cavernomatosis, history of intracerebral hemorrhage and aneurysm of the polygon of Willis). Consequently, they have a high risk of cardio-embolic complication but contraindication for oral anticoagulation. They have been treated by left atrial appendage occlusion with Amplatzer cardiac plug device by percutaneous and trans-septal access. Then, they have been followed by neurologist and cardiologist, with clinical and paraclinical evaluation by echocardiography.
Our three first patients have been successfully implanted, without periprocedural complication. No latest adverse event was observed, and particularly no cardiac or neurologic adverse event.
The technique of left atrial appendage occlusion is a very interesting and promising technique for ischemic stroke prevention in patient with high risk of cardio-embolic complication because of atrial fibrillation, but high risk of bleeding and contraindication for oral anticoagulation. Because of frequency of both atrial fibrillation and contraindication for oral anticoagulation, occlusion of the left atrial appendage should become an interesting alternative for many patients. However, it remains an invasive procedure and efficacy and indications need to be evaluated in further clinical trials. Risk/benefit ratio must be carefully assessed and compared to that of the new anticoagulant drugs.
中风作为发达国家的第三大死因，是一个公共卫生问题。心房颤动是缺血性中风的重要病因，口服抗凝治疗对其预防有效。然而，由于这些治疗相关的出血风险，口服抗凝治疗可能存在禁忌。经皮左心耳封堵术是心房颤动且有高心源性栓塞性中风风险但口服抗凝治疗禁忌患者的一种新型口服抗凝替代方法。
本文描述了在格勒诺布尔大学医院中心使用Amplatzer心脏封堵器进行左心耳封堵的过程，该装置用于首批接受此治疗的三名患者。这三名患者（一名男性和两名女性）均患有心房颤动且伴有该心律失常的神经系统并发症，如缺血性中风。口服抗凝治疗用于预防再次发生缺血性中风。然而，由于不同原因（海绵状血管瘤、脑出血病史和Willis环动脉瘤），他们均有高脑出血风险。因此，他们有高心源性栓塞并发症风险但口服抗凝治疗禁忌。他们通过经皮和经房间隔途径使用Amplatzer心脏封堵器进行了左心耳封堵治疗。然后，由神经科医生和心脏病专家对他们进行随访，并通过超声心动图进行临床和辅助检查评估。
我们的首批三名患者均成功植入，无围手术期并发症。未观察到近期不良事件，特别是无心脏或神经方面的不良事件。
左心耳封堵技术对于因心房颤动而有心源性栓塞并发症高风险但出血风险高且口服抗凝治疗禁忌的患者预防缺血性中风是一项非常有趣且有前景的技术。由于心房颤动的发生率以及口服抗凝治疗的禁忌情况，左心耳封堵术对许多患者而言应成为一个有吸引力的替代方法。然而，它仍是一种侵入性手术，其疗效和适应证需要在进一步的临床试验中进行评估。必须仔细评估风险/获益比，并与新型抗凝药物的风险/获益比进行比较。
