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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Cryoballoon-Based Left Atrial Appendage Isolation and Closure in Patients with Atrial Fibrillation-The LALALAND Pilot
Christian-H Heeger1,2,3, Samuel Reincke1, Sorin Stefan Popescu1
1University Heart Center Lübeck, Department of Rhythmology, University Hospital Schleswig-Holstein, 23538 Lübeck, Germany.
Insights
Cryoballoon ablation for persistent atrial fibrillation (AF) combined with left atrial appendage isolation (LAAI) shows promise but carries a risk of thrombus formation. Early left atrial appendage closure (LAAC) may mitigate risks, but further research is needed.
Area of Science:
- Cardiology
- Electrophysiology
- Medical Devices
Background:
- Atrial fibrillation (AF) is the most common cardiac arrhythmia.
- Pulmonary vein isolation (PVI) is standard for AF treatment, but success rates are limited in persistent AF (PersAF).
- Left atrial appendage (LAA) is a potential target for ablation, with cryoballoon (CB) technology showing promise for durable PVI and LAA isolation (LAAI).
Purpose of the Study:
- To investigate the clinical impact of CB-based LAAI in addition to PVI for patients with symptomatic PersAF.
- To assess the durability of LAAI and PVI after CB ablation.
- To evaluate the safety and efficacy of combining CB-based LAAI with percutaneous LAA closure (LAAC).
Main Methods:
- Prospective, interventional, single-centre study enrolling 23 patients with symptomatic PersAF.
- Patients underwent PVI plus LAAI using the CB system.
- Percutaneous LAA closure (LAAC) was performed 2-3 months post-ablation, with LAAI durability assessed by invasive remapping prior to LAAC.
Main Results:
- 100% PVI success and 91% initial LAAI success were achieved with CB.
- LAA thrombus formation occurred in 26% of patients post-LAAI.
- Durable LAA isolation was achieved in 74% and durable PVI in 70% of patients.
- At 13-month follow-up, 65% maintained sinus rhythm, but LAA reconnection occurred in 13%, leading to recurrence.
- One stroke and one device thrombus occurred during follow-up post-LAAC.
Conclusions:
- CB-based LAAI combined with PVI may improve outcomes in PersAF but carries a significant risk of LAA thrombus formation.
- Early LAAC following LAAI appears promising for risk mitigation.
- Further evidence is required to establish optimal practices for this combined approach.
Abstract:
Background: Atrial fibrillation (AF) remains the most common cardiac arrhythmia, with pulmonary vein isolation (PVI) established as the cornerstone of interventional treatment. However, in patients with persistent AF (PersAF), the success rates of PVI alone tend to be limited. A promising additional target is the left atrial appendage (LAA). In recent years, cryoballoon (CB) technology has become a tool for achieving durable PVI. Its application for LAAI has been investigated as a potentially advantageous alternative to radiofrequency ablation, and a positive effect on long-term outcome has been reported. However, the available data is limited. This study sought to investigate the clinical impact of CB-based LAAI in addition to PVI. Methods: This is a prospective, interventional, single-centre study. Consecutive patients with symptomatic PersAF were prospectively enrolled. In total 23 patients with PersAF underwent PVI plus LAAI using the CB system. Percutaneous LAA closure was performed within 2-3 months in all patients by implanting an endocardial LAA-closure device. Prior to LAA closure, LAAI durability was systematically assessed by invasive remapping studies. Results: A total of 100% of PVs were successfully isolated using the CB only (n = 91/91). Concerning LAAIs, a total of 21/23 (91%) remained isolated at the end of the procedure. After the ablation procedure including LAAI, all patients were scheduled for TEE assessment and LAA closure. TEE was performed after a mean of 54 ± 19 days. In 6/23 (26%) patients, LAA thrombus formation was detected after LAAI. A total of 23/23 patients (100%) received LAAC after a mean of 72 ± 45 days. Durability of LAAI was assessed utilizing a spiral mapping catheter in 23/23 patients (100%). In a total of 17/23 (74%) patients, durable LAA isolation was detected. Durable PVI of all PVs was detected in 16/23 (70%) patients. During a mean follow-up of 13 ± 3.4 months, stable sinus rhythm was maintained in 15 (65%) patients. The LAA showed reconnection in 3/23 (13%) patients, with arrhythmia recurrence. During follow-up, one stroke (318 days after LAAC) and one device thrombus (56 days after LAAC) occurred. Conclusions: While CB-based LAAI may offer benefits in managing persistent AF, it presents a significant risk of thrombus formation in the LAA, even with appropriate OAC. Early closure of the LAA following LAAI appears promising in mitigating these risks, but further evidence is needed to establish clear best practices.
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