Leon H. Charney Division of Cardiology New York University Langone Medical Center, New York, New York.
Cleveland Clinic, Cleveland, Ohio.
J Am Soc Echocardiogr. 2018 Apr;31(4):454-474. doi: 10.1016/j.echo.2017.09.014. Epub 2017 Nov 20.
Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. In this article, the authors describe the crucial role of two- and three-dimensional transesophageal echocardiography in the pre- and postprocedural assessment and intraprocedural guidance of percutaneous left atrial appendage (LAA) occlusion procedures. Although recent advances have been made in the field of systemic anticoagulation with the novel oral anticoagulants, these medications come with a significant risk for bleeding and are contraindicated in many patients. Because thromboembolism in atrial fibrillation typically arises from thrombi originating in the LAA, surgical and percutaneous LAA exclusion/occlusion techniques have been devised as alternatives to systemic anticoagulation. Currently, surgical LAA exclusion is typically performed as an adjunct to other cardiac surgical procedures, which limits the number of eligible patients. Recently, several percutaneously delivered devices for LAA exclusion from the systemic circulation have been developed, some of which have been shown in clinical trials to reduce the risk for thromboembolism. These devices use an either purely endocardial LAA occlusion approach, such as the Watchman and Amulet procedures, or both an endocardial and a pericardial (epicardial) approach, such as the Lariat procedure. In the Watchman and Amulet procedures, a transseptally delivered structure composed of nitinol is placed in the LAA orifice, thereby excluding the LAA from the systemic circulation. In the Lariat procedure, a magnet link is created between a transseptally delivered endocardial wire and epicardially delivered pericardial wire, followed by epicardial suture ligation of the LAA.
心房颤动是全球最常见的心律失常，也是栓塞性中风的主要危险因素。本文作者描述了二维和三维经食管超声心动图在经皮左心耳（LAA）封堵术的术前、术后评估和术中指导中的关键作用。尽管新型口服抗凝剂在全身抗凝领域取得了进展，但这些药物存在明显的出血风险，在许多患者中被禁用。由于房颤中的血栓栓塞通常源自起源于 LAA 的血栓，因此设计了外科和经皮 LAA 排除/封堵技术作为全身抗凝的替代方法。目前，外科 LAA 排除术通常作为其他心脏外科手术的辅助手段，这限制了适合该手术的患者数量。最近，已经开发出几种用于从体循环中排除 LAA 的经皮输送装置，其中一些在临床试验中已被证明可降低血栓栓塞风险。这些装置采用完全心内膜 LAA 闭塞方法，例如 Watchman 和 Amulet 手术，或同时采用心内膜和心包（心外膜）方法，例如 Lariat 手术。在 Watchman 和 Amulet 手术中，通过经房间隔输送的由镍钛诺制成的结构放置在 LAA 口，从而将 LAA 排除在体循环之外。在 Lariat 手术中，经房间隔输送的心内膜线和心外膜输送的心包线之间形成磁链接，随后进行心外膜结扎 LAA。
