Berg Jan, Preda Alberto, Fierro Nicolai, Marzi Alessandra, Radinovic Andrea, Della Bella Paolo, Mazzone Patrizio
Division of Arrhythmology, San Raffaele Hospital, 20132 Milan, Italy.
Division of Cardiology, Cantonal Hospital of Aarau, 5001 Aarau, Switzerland.
J Clin Med. 2023 Feb 16;12(4):1549. doi: 10.3390/jcm12041549.
Cerebral protection devices (CPD) are designed to prevent cardioembolic stroke and most evidence that exists relates to TAVR procedures. There are missing data on the benefits of CPD in patients that are considered high risk for stroke undergoing cardiac procedures like left atrial appendage (LAA) closure or catheter ablation of ventricular tachycardia (VT) when cardiac thrombus is present.
This work aimed to examine the feasibility and safety of the routine use of CPD in patients with cardiac thrombus undergoing interventions in the electrophysiology (EP) lab of a large referral center.
The CPD was placed under fluoroscopic guidance in all procedures in the beginning of the intervention. Two different CPDs were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed over a 6F sheath from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over an 8F femoral sheath. Retrospective periprocedural and safety data were obtained from procedural reports and discharge letters. Long-term safety data were obtained by clinical follow-up in our institution and telephone consultations.
We identified 30 consecutive patients in our EP lab who underwent interventions (21 LAA closure, 9 VT ablation) with placement of a CPD due to cardiac thrombus. Mean age was 70 ± 10 years and 73% were male, while mean LVEF was 40 ± 14%. The location of the cardiac thrombus was the LAA in all 21 patients (100%) undergoing LAA-closure, whereas, in the 9 patients undergoing VT ablation, thrombus was present in the LAA in 5 cases (56%), left ventricle (n = 3, 33%) and aortic arch (n = 1, 11%). The capture device was used in 19 out of 30 (63%) and the deflection device in 11 out of 30 cases (37%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CPD-related complications comprised the vascular access and were as follows: two cases of pseudoaneurysm of the femoral artery not requiring surgery (7%), 1 hematoma at the arterial puncture site (3%) and 1 venous thrombosis (3%) resolved by warfarin. At long-term follow-up, 1 TIA and 2 non-cardiovascular deaths occurred, with a mean follow-up time of 660 days.
Placement of a cerebral protection device prior to LAA closure or VT ablation in patients with cardiac thrombus proved feasible, but possible vascular complications needed to be taken into account. A benefit in periprocedural stroke prevention for these interventions seemed plausible but has yet to be proven in larger and randomized trials.
脑保护装置（CPD）旨在预防心源性栓塞性卒中，现有的大多数证据都与经导管主动脉瓣置换术（TAVR）相关。对于存在心脏血栓且被认为在进行诸如左心耳（LAA）封堵或室性心动过速（VT）导管消融等心脏手术时发生卒中风险较高的患者，关于CPD益处的数据尚不完整。
本研究旨在探讨在一家大型转诊中心的电生理（EP）实验室中，对存在心脏血栓的患者常规使用CPD的可行性和安全性。
在所有手术中，于干预开始时在透视引导下放置CPD。根据医生的判断使用两种不同的CPD：（1）一种捕获装置，由用于头臂动脉和左颈总动脉的两个过滤器组成，通过桡动脉置于6F鞘管上；或（2）一种覆盖所有三根主动脉弓血管的偏转装置，通过股动脉8F鞘管放置。从手术报告和出院小结中获取围手术期回顾性数据和安全性数据。通过本机构的临床随访和电话咨询获取长期安全性数据。
我们在EP实验室中确定了30例连续患者，他们因心脏血栓接受了干预（21例LAA封堵，9例VT消融）并放置了CPD。平均年龄为70±10岁，73%为男性，平均左心室射血分数（LVEF）为40±14%。在所有21例接受LAA封堵的患者（100%）中，心脏血栓位于LAA，而在9例接受VT消融的患者中，5例（56%）血栓位于LAA，3例（33%）位于左心室，1例（11%）位于主动脉弓。30例中有19例（63%）使用了捕获装置，30例中有11例（37%）使用了偏转装置。围手术期无卒中或短暂性脑缺血发作（TIA）。与CPD相关的并发症包括血管通路问题，具体如下：2例股动脉假性动脉瘤，无需手术（7%），1例动脉穿刺部位血肿（3%），1例静脉血栓形成（3%），通过华法林治疗后缓解。在长期随访中，发生了1例TIA和2例非心血管死亡，平均随访时间为660天。
对于存在心脏血栓的患者，在LAA封堵或VT消融之前放置脑保护装置证明是可行的，但需要考虑可能的血管并发症。对于这些干预措施，围手术期预防卒中的益处似乎合理，但尚未在更大规模的随机试验中得到证实。
