Grossi Stefano, Bianchi Francesca, Blandino Alessandro, Pintor Chiara, Tomasello Antonino, Mabritto Barbara, Musumeci Giuseppe
Cardiology Department, AO Ordine Mauriziano, Turin, Italy.
Biosense Webster Italy, Johnson&Johnson MedTech Italy, Pomezia (RM), Italy.
Front Cardiovasc Med. 2023 Oct 9;10:1224924. doi: 10.3389/fcvm.2023.1224924. eCollection 2023.
Atrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure.
We describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.All procedures were concluded without complications.At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred.
The combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.
心房颤动（AF）是心源性栓塞性卒中的主要原因。在高出血风险患者中，不允许进行长期抗凝治疗，可考虑进行左心耳（LAA）封堵。LAA也是AF的关键基质。心外膜LAA封堵有几个优点：LAA结扎可导致有利的心房电重构和结构重构，从而降低AF复发率。单纯心内膜消融对所有患者并不都有效，新证据表明，对于持续性AF患者，联合心内膜-心外膜消融后的效果更好。考虑到这些技术的协同潜力，在本病例系列中，将这两种技术在同一次手术中联合应用。
我们描述了5例因难治性AF消融和LAA封堵而转诊患者的治疗情况。所有患者均有高血栓形成风险且既往有大出血史，相对禁忌长期抗凝治疗。计划采用短期抗凝进行LAA结扎和心内膜-心外膜消融联合手术。使用LARIAT系统经心外膜途径进行LAA封堵。然后，先经心内膜、再经心外膜进行左心房标测和消融。所有手术均顺利完成，无并发症。随访时，所有患者经食管超声心动图显示LAA完全闭塞；因此，中断抗凝治疗。所有患者均无症状，处于窦性心律，未发生出血或缺血事件。
经皮LAA结扎与心内膜-心外膜消融联合应用被证明是可行且安全的，可能代表了一种治疗有LAA封堵指征的难治性AF患者的新方法。
