LAA closure and AF ablation therapeutic option

Jacek BednarekOddział Elektrokardiologii

Krakowski Szpital Specjalistyczny im. Jana Pawła IIMarcin Kuniewicz

Krakowski Szpital Specjalistyczny im. Jana Pawła IIAnatomy Department UJ CM Kraków

The aim of AF ablation and LAA closure

• To decrease the risk of embolic complication in AF patients

• Atrial fibrillation ablation : protection of arrhythmia occurence in the paroxysmal forms, termination of chronic arrhythmia. The effects still non-satisfactory.

• Left atrial appendage (LAA) closure: protection of systemic embolism in the course of atrial fibrillation, since 95% of left atrial thrombus formation are found in LAA.

Hybrid left atrial appendage closure and

atrial fibrillation ablation

• Is it safe and efficient ?• Should one perform both procedures in the

same day?• Economic aspect

The basic types of atrial fibrillation ablation

• High-temperature radiofrequency pulmonary veins isolation (electrophysiological and anatomical circumferential subtypes)

• Low-temperature baloon cryoablation – pulmonary veins isolation

Circumferential pulmonary vein

isolation using RF energy and 3-D mapping system

Baloon cryoablation – pulmonary veins isolation

Types of left atrial appendage closure

• Intracardiac implantable device into the lumen of appendage. Watchman device, Amplatzer device, in Platoo device. The foreign body remain inside the heart. Performed in local anasthesia.

• Extracardiac loop appendage ligation. LARIAT system. There is no foreign body inside the heart. Performed under general anesthesia.

LARIAT system LAA ligationLARIAT system LAA ligation

FindrWIRZ LARIAT EndoCATH

LARIAT system LAA ligationLARIAT system LAA ligation

Swaans MJ et al., 2012 „Ablation for AF in combination with LAAC: first results of feasibility study”

• 30 AF patients with CHADS2VASc>3 and HAS-BLED>2

• Firstly RF CPVI ablation, next WATCHMAN closure • Total procedures duration time: 25-115, mean 97

min• In 30% of patients still AF afterwards• The hybrid procedures are safe method

Swaans MJ et al., 2011Cathether ablation in combination

with LAA closure for trial fibrillation

• 10 AF patients with CHADS2>1• Non-randomized clinical trial• Firstly CPVI ablation, next WATCHMAN closure• The hybrid procedures can be performed safely

Arguments for hybrid procedures

• Rafael Hernandez-Estefania et al., 2012: In 13% of PLAATO cases (Ostermayer et al 2005) and in 14% of WATCHMAN cases (PROTECT AF study, 2011) up to 5 mm leakage around the device since the LAA ostium in not round, but oval in shape.

• The effectiveness of ablation around 60 – 80%• Effectiveness of each procedure below 100%• High safety regarding WATCHMAN system closure.

Krzysztof Bartuś, Jacek Bednarek et al., observation of first LARIAT ligation cases,

Kraków 2009• 13 AF patients: LAA LARIAT closure and CPVI ablation in

the same day, general anesthesia• Significantly bigger hemorrhage to pericardial space

after the procedure in comparison to subsequent over 200 lone LARIAT ligation cases (probably due to high dose of heparine required for ablation)

• No verbal contact with patients during ablation• Limited time for more ligation procedures the same

day• Only one procedure can be reimbursed under our

circumstances – financial deficit for the hospital

Conclusions

• Intracardiac LAA closure device implantation can be safely performed with AF ablation as a hybrid procedure, although the financial benefit is questionable

• Extracardiac LAA ligation seems to be not recommended as the part of hybrid procedure with AF ablation the same day