Pelissero Elisa, Giuggia Marco, Todaro Maria Chiara, Trapani Giuseppe, Giordano Benedetta, Senatore Gaetano
Dipartimento di Cardiologia, Ospedale Civile di Ciriè, Ciriè (TO).
Dipartimento di Cardiologia, Ospedale Civile di Ivrea, Ivrea (TO) - Dipartimento di Medicina Clinica e Sperimentale, Università degli Studi, Messina.
G Ital Cardiol (Rome). 2017 Dec;18(12 Suppl 1):11S-17S. doi: 10.1714/2835.28627.
We evaluated long-term safety and efficacy of concomitant left atrial appendage (LAA) closure and atrial fibrillation (AF) ablation.
From February 2013 to June 2017, all patients referred for AF ablation and LAA closure (group 1) were enrolled in the study and compared with a matched control group undergoing AF ablation only (group 2). Pulmonary vein isolation was achieved in all cases with radiofrequency or cryoballoon. LAA was occluded with Watchman or Amplatzer Cardiac Plug or Amulet (ACP) devices. All patients were treated with oral anticoagulation therapy for at least 3 months after the procedure ("blanking period"), and then switched to dual antiplatelet therapy with aspirin and clopidogrel for other 3 months, and then to single antiplatelet therapy with aspirin in case of LAA closure, while group 2 was treated with long-term oral anticoagulation therapy according to CHA2DS2-VASc score. Follow-up was performed with transesophageal echocardiography and clinical visit at 3, 6 and 12 months after the procedure. AF burden was evaluated by loop recorder or pacemaker interrogation in all patients.
Overall, 42 patients were enrolled, 21 in each group. Mean age was 66.86 ± 10.35 years in group 1 vs 68.42 ± 10.61 in group 2 (p=NS); mean CHA2DS2-VASc score was 2.8 ± 1.22 in group 1 vs 2.01 ± 0.93 in group 2 (p=NS), mean HAS-BLED score was 3.2 ± 0.83 in group 1 vs 3.1 ± 0.95 in group 2 (p=NS). Persistent AF was present in 80% of patients in group 1 and in 85% in group 2. LAA closure was successful in all cases (14 Watchman, 7 ACP devices). Procedural and fluoroscopy times were shorter in group 2 (68 ± 17 vs 52 ± 15 min, p <0.05; 23 ± 5 vs 18 ± 3 min, p <0.05, respectively). No procedural complications were observed in group 2, while in group 1 one case of self-terminating pericardial effusion and one arteriovenous fistula were observed. At a mean follow-up of 14.93 ± 10.05 months, complete seal of LAA was documented in all patients, with neither dislocations nor thromboembolic events. Similarly, no long-term complications were observed in group 2. Maintenance of sinus rhythm was overlapping, with an AF relapse rate of 36% in group 1 vs 38% in group 2 (p=NS).
Combined LAA percutaneous closure and AF ablation appears to be feasible in high-risk patients.
我们评估了同期进行左心耳（LAA）封堵和心房颤动（AF）消融的长期安全性和有效性。
2013年2月至2017年6月，所有因AF消融和LAA封堵而转诊的患者（第1组）均纳入本研究，并与仅接受AF消融的匹配对照组（第2组）进行比较。所有病例均通过射频或冷冻球囊实现肺静脉隔离。使用Watchman、Amplatzer心脏封堵器或Amulet（ACP）装置封堵LAA。所有患者术后接受至少3个月的口服抗凝治疗（“空白期”），然后改用阿司匹林和氯吡格雷的双联抗血小板治疗3个月，若进行了LAA封堵则随后改用阿司匹林单药抗血小板治疗，而第2组根据CHA2DS2-VASc评分接受长期口服抗凝治疗。术后3、6和12个月通过经食管超声心动图和临床访视进行随访。所有患者均通过环路记录器或起搏器问询评估房颤负荷。
总体而言，共纳入42例患者，每组21例。第1组平均年龄为66.86±10.35岁，第2组为68.42±10.61岁（p=无显著性差异）；第1组平均CHA2DS2-VASc评分为2.8±1.22，第2组为2.01±0.93（p=无显著性差异），第1组平均HAS-BLED评分为3.2±0.83，第2组为3.1±0.95（p=无显著性差异）。第1组80%的患者存在持续性房颤，第2组为85%。所有病例的LAA封堵均成功（14个Watchman，7个ACP装置）。第2组的手术时间和透视时间较短（分别为68±17分钟对52±15分钟，p<0.05；23±5分钟对18±3分钟，p<0.05）。第2组未观察到手术并发症，而第1组观察到1例自限性心包积液和1例动静脉瘘。平均随访14.93±10.05个月时，所有患者的LAA均记录到完全封堵，无移位或血栓栓塞事件。同样，第2组未观察到长期并发症。窦性心律维持情况相似，第1组房颤复发率为36%，第2组为38%（p=无显著性差异）。
对于高危患者，联合经皮LAA封堵和AF消融似乎是可行的。
