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• W2552897441 abstract "HomeCirculation: Arrhythmia and ElectrophysiologyVol. 9, No. 12Late Dehiscence of Left Atrial Appendage Closure Device Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBLate Dehiscence of Left Atrial Appendage Closure Device Santosh K. Padala, MD, Parikshit S. Sharma, MD, MPH, Walter H.J. Paulsen, MD, Vigneshwar Kasirajan, MD, John D. Grizzard, MD, Matthew Sackett, MD and Kenneth A. Ellenbogen, MD Santosh K. PadalaSantosh K. Padala From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author , Parikshit S. SharmaParikshit S. Sharma From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author , Walter H.J. PaulsenWalter H.J. Paulsen From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author , Vigneshwar KasirajanVigneshwar Kasirajan From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author , John D. GrizzardJohn D. Grizzard From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author , Matthew SackettMatthew Sackett From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author and Kenneth A. EllenbogenKenneth A. Ellenbogen From the Division of Cardiology, Pauley Heart Center (S.K.P., P.S.S., W.H.J.P., K.A.E.), Division of Cardiothoracic Surgery, Pauley Heart Center (V.K.), and Department of Radiology (J.D.G.), Virginia Commonwealth University, Richmond; and Division of Cardiology, Centra Lynchburg General Hospital, VA (M.S.). Search for more papers by this author Originally published18 Nov 2016https://doi.org/10.1161/CIRCEP.116.004291Circulation: Arrhythmia and Electrophysiology. 2016;9:e004291A 68-year-old male with history of hypertension, diabetes mellitus, and persistent atrial fibrillation (AF) refractory to amiodarone (CHA2DS2-VASc score of 3) underwent a successful total thoracoscopic surgical ablation of AF (mini-maze) procedure in August 2011. A transesophageal echocardiogram (TEE) performed before the procedure revealed no evidence of thrombus in the left atrial appendage (LAA). The base of the LAA measured 45 mm. The mini-maze procedure involved bilateral thoracoscopic, minimally invasive bilateral pulmonary vein antral isolation with bipolar radiofrequency, creation of roof and floor lines to isolate the posterior left atrium using bipolar radiofrequency, and exclusion of LAA with AtriCure Gillinov-Cosgrove clip of 45 mm size. Intraoperative TEE after clip deployment showed near-complete occlusion of the LAA. Dabigatran was discontinued after 3 months. A year later, patient was referred for electrophysiology study for symptomatic left-sided atrial tachycardia. A cardiac magnetic resonance imaging performed before the ablation revealed persistent occlusion of the LAA with the AtriClip with only a small portion of the proximal LAA remaining patent without any flow. All 4 pulmonary veins remained isolated from the previous ablation. An area between the anterior ridge and the LAA clip was ablated using radiofrequency energy. Four and half years after the AtriClip implant, patient developed recurrent symptomatic atrial tachycardia for which he underwent a preprocedural coronary computed tomographic angiography that revealed an increase in size of the patent portion of the LAA with apparent change in the orientation of the clip. Figures 1A, 1B, 2A, and 2B compare the preablation magnetic resonance imaging images with the computed tomographic angiography images showing dehiscence of the AtriClip. This was confirmed on TEE, which also revealed a widely patent LAA with normal emptying velocity (Movie I in the Data Supplement; Figure 3). There was no evidence of LAA clot or thrombus. Anticoagulation was restarted given these findings.Download figureDownload PowerPointFigure 1. Magnetic resonance axial image (A) performed preablation shows left atrial appendage excluder clip (red arrows in A and B) in place, with only a small portion of the proximal left atrial appendage remaining patent. Follow-up axial computed tomographic angiography image (B) at a similar level shows increase in the diameter of the patent portion of the left atrial appendage from 7 to 16 mm (green line in A and B).Download figureDownload PowerPointFigure 2. Initial magnetic resonance (A) and later computed tomographic angiography (B) spatially matched 2-chamber views show the left atrial appendage (blue arrows) and the excluder clip (red arrows) in place. Note the increase in size of the patent portion of the left atrial appendage in (B) and the apparent change in orientation of the clip.Download figureDownload PowerPointFigure 3. Transesophageal echocardiographic image demonstrating significant patency of the left atrial appendage.LAA occlusion is recommended for stroke prevention in patients with AF undergoing concomitant cardiac surgery or in those who have contraindications to anticoagulation. Suture ligation or stapler excision of LAA has historically been used for patients with AF undergoing concurrent cardiac surgery for stroke prevention. However, in the first randomized LAA occlusion study involving 72 patients, a TEE performed 8 weeks postoperatively showed complete occlusion of LAA in only 72% of patients with staples and in 42% of patients with suture ligation.1 These suboptimal results led to the development of an epicardially placed AtriClip (AtriCure, Westchester, OH) at the base of the appendage for exclusion of blood flow into the LAA. The US Food and Drug Administration approved AtriClip in 2010 based on the results of a multicenter, nonrandomized EXCLUDE trial (Exclusion of Left Atrial Appendage with AtriClip Exclusion Device in Patients Undergoing Concomitant Cardiac Surgery) conducted in the United States.2 In this study, 70 patients with a history of AF or a CHADS2 score of ≥2 undergoing elective coronary artery bypass grafting, valve surgery, or maze procedures had this device placed for LAA exclusion. The trial demonstrated an excellent safety profile and at a short-term follow-up of 3 months, 60 of 61 patients (98.4%) had successful LAA exclusion by computed tomographic angiography or TEE imaging.2 To date, the only trial reporting the long-term durability of this device was a 40 patient European study in which AtriClip was implanted during cardiac surgery.3 Of 32 patients available for long-term follow-up (8 had nondevice-related deaths), none of them had dislocation of the clip, intracardiac thrombus, or LAA reperfusion on CT imaging over a mean duration of 3.5 years.3In the case above, complete dehiscence of the AtriClip was noted 4.5 years after the implant. A device mismatch at the time of surgical implantation could have led to migration of the clip. Device embolization with endocardial LAA occlusion devices because of mismatch in size has also been reported.4 Anticoagulation should be continued, especially in patients with higher stroke risk after the LAA exclusion5 because dehiscence of the occluder raises a great concern for thromboembolic phenomenon. This case highlights the need for long-term durability data in a larger cohort with LAA occlusion devices. The results of the ongoing largest, multicenter, randomized LAA occlusion study (LAAOS III) with a planned mean follow-up of 4 years will provide a better understanding of the safety and efficacy of the surgical LAA occlusion in patients with AF.6DisclosuresDr Kasirajan received honoraria and research support from AtriCure, SynCardia, Thoratec, and Abiomed. Dr Ellenbogen received honoraria from AtriCure, Biosense Webster, Medtronic, Boston Scientific, and St. Jude Medical. The other authors report no conflicts.FootnotesGuest Editor for this case report was Gerhard Hindricks, MD.The Data Supplement is available at http://circep.ahajournals.org/lookup/suppl/doi:10.1161/CIRCEP.116.004291/-/DC1.Correspondence to Santosh K. Padala, MD, Virginia Commonwealth University, Gateway Bldg, 3rd Floor, 3-216, 1200 E Marshall St, Richmond, VA. E-mail [email protected] or [email protected]References1. Healey JS, Crystal E, Lamy A, Teoh K, Semelhago L, Hohnloser SH, Cybulsky I, Abouzahr L, Sawchuck C, Carroll S, Morillo C, Kleine P, Chu V, Lonn E, Connolly SJ.Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke.Am Heart J. 2005; 150:288–293. doi: 10.1016/j.ahj.2004.09.054.CrossrefMedlineGoogle Scholar2. Ailawadi G, Gerdisch MW, Harvey RL, Hooker RL, Damiano RJ, Salamon T, Mack MJ.Exclusion of the left atrial appendage with a novel device: early results of a multicenter trial.J Thorac Cardiovasc Surg. 2011; 142:1002–1009, 1009.e1. doi: 10.1016/j.jtcvs.2011.07.052.CrossrefMedlineGoogle Scholar3. Emmert MY, Puippe G, Baumüller S, Alkadhi H, Landmesser U, Plass A, Bettex D, Scherman J, Grünenfelder J, Genoni M, Falk V, Salzberg SP.Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial.Eur J Cardiothorac Surg. 2014; 45:126–131. doi: 10.1093/ejcts/ezt204.CrossrefMedlineGoogle Scholar4. Aminian A, Lalmand J, Tzikas A, Budts W, Benit E, Kefer J.Embolization of left atrial appendage closure devices: a systematic review of cases reported with the watchman device and the Amplatzer cardiac plug.Catheter Cardiovasc Interv. 2015; 86:128–135. doi: 10.1002/ccd.25891.CrossrefMedlineGoogle Scholar5. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, van Putte B, Vardas P; Authors/Task Force Members; Document Reviewers. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS [published online ahead of print August 27, 2016].Eur Heart J. doi: 10.1093/europace/euw295. http://europace.oxfordjournals.org/content/18/11/1609. Accessed November 5, 2016.Google Scholar6. Whitlock R, Healey J, Vincent J, Brady K, Teoh K, Royse A, Shah P, Guo Y, Alings M, Folkeringa RJ, Paparella D, Colli A, Meyer SR, Legare JF, Lamontagne F, Reents W, Böning A, Connolly S.Rationale and design of the Left Atrial Appendage Occlusion Study (LAAOS) III.Ann Cardiothorac Surg. 2014; 3:45–54. doi: 10.3978/j.issn.2225-319X.2013.12.06.MedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails December 2016Vol 9, Issue 12 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.116.004291PMID: 27864311 Manuscript receivedApril 24, 2016Manuscript acceptedSeptember 28, 2016Originally publishedNovember 18, 2016 Keywordsleft atrial appendage occlusioncoronary artery bypassatrial fibrillationPDF download Advertisement SubjectsAtrial FibrillationImaging" @default.
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