CC BY
8
II. ХИРУРГИЯ
LEFT ATRIAL APPENDAGE CLOSURE FOR STROKE PREVENTION IN PATIENTS WITH ATRIAL FIBRILLATION. CASE REPORT.
A.K. Baimbetov1, K.B. Abzaliev2, K.A. Yergeshov1, K.A. Bizhanov1, I.A. Yakupova1
1Department of X-Ray surgery, Interventional cardiology and Arrythmology, National Scientific Centre of Surgery named after A.N. Sizganov, Almaty, Kazakhstan 2Department of Cardiothoracic Surgery,
National Scientific Centre of Surgery named after A.N. Sizganov, Almaty, Kazakhstan
УДК 636.831-616.125
ABOUT THE AUTHORS
Baimbetov A.K. - Head of the department X-ray surgery, interventional cardiology and arrhythmology of JSC "NSCS named after A.N. Syzganov", MD, PhD e-mail: [email protected]
Abzaliev K.B. - Head of the department of management research AO NNTSH them. AN Syzganova, MD, Professor. e-mail: [email protected]
Summary
This article describes the first clinical case of the left atrial appendage closure using the Amplatzer Amulet. Usually we use oral anticoagulant therapy for primary and secondary stroke prevention associated with atrial fibrillation. However, nowadays the left atrial appendage closure procedure with occluder was introduced in clinical practice as a valuable alternative to the continuous reception of oral anticoagulants for the patients who cannot take anticoagulants or when anticoagulation is ineffective.
Журекшелердщ булкшдеу1мен пациенттердщ инсульт ауруын алдын алу ушш сол жагындагы журекше кулакшасын эндоваскулярлык жабу.
Байымбетов А.К.1, Абзалиев К.Б.2, Ергешов К.А.1, Бижанов К.А.1, Якупова И.А.1
А.Н.Сь№анов атындаш Улттык, шлыми хирургия орталышньщ рентгенохирургия, интервенциялык, кардиология жэне аритмология бел1мшесГ
А.Н.Сь^анов атындаш Улттык, шлыми хирургия орталышныщ кардиохирургия бел1мшесР Ацдатпа
Аталмыш макалада журекшелерд!^ булк'шдеу'шен пациент^н инсульт ауруын алдын алу максатында, сол жатнын журекше кулакшасына Amplatzer Amulet окклюдерд! сэттi имплантаттау бойынша алгашкы клиникалык окма сипатталады. Журекшелердщ булк!лдеу!мен байланысты, инсульттар мен тромбоэмболиялыкаскынулардын бастапкы жэне ек!ншi профилактикасы уш'н антикоагулянтты терапия колданылады. Дегенмен, сонгы уакытта сол жатнын журекше кулакшасын окклюдтер аркылы эндоваскулярлык жабу, антикоагулянттердi тутыну ти!мс!з болеан кезде, пациенттер антикоагулянттарды кабылдай алмайтындар уш'н пероралды антикоагулянттердi туракты тутынып туру баеалы балама рет!нде клиникалык тэж!рибеге енпзлген.
Keywords:
atrial fibrillation, stroke prevention, left atrial appendage occlusion, amplatzer amulet
АВТОРЛАР ТУРАЛЫ
Байымбетов дд!л Кудайбергенулы - А.Н.Сызеанов атындаеы Улттыкшлыми хирургия орталышнын рентгенохирургия, интервенциялык кардиология жэне аритмология бол!мшес1н1н менгеруш!с1, e-mail: [email protected]
Абзалиев Куат Баяндыулы -А.Н.Сызеанов атындаеы Улттыкшлыми хирургия орталыеы ышыми -зерттеу менеджментi бол!мшес!н!н менгеруш!с1. e-mail: [email protected]
Туйш сездер
журекшелердн булк'1лдеу'1, инсульттын профилактикасы, сол жатынын журекше кулакшасынын окклюзиясы, амплатцер, амулет.
Эндоваскулярное закрытие ушка левого предсердия окклюдером для профилактики инсульта у пациентов с фибрилляцией предсердий.
Баимбетов А.К.1 , Абзалиев К.Б.2, Ергешов К.А.1, Бижанов К.А.1, Якупова И.А.1
Национальный научный центр хирургии им. А.Н. Сызганова,
отделения рентгенохирургии, интервенционной кардиологии и аритмологии1
Национальный научный центр хирургии им. А.Н. Сызганова, отделения кардиохирургии2
Аннотация
В данной статье описывается первый клинический случай успешной имплантации окклюдера Amplatzer Amulet в ушко левого предсердия, с целью профилактики инсульта пациенту с фибрилляцией предсердий. Обычно для первичной и вторичной профилактики инсультов и тромбоэмболических осложнений, связанных с фибрилляцией предсердий применяется антикоагулянтная терапия. Однако, в последнее время эндоваскулярное закрытие ушка левого предсердия окклюдером введен в клиническую практику в качестве ценной альтернативы постоянному приему пероральных антикоагулянтов для пациентов, которые не могут принимать антикоагулянты или в случае, когда прием антикоагулянтов неэффективен.
ОБ АВТОРАХ
Баимбетов Адиль Кудайбергенович -Национальный научный центр хирургии имени А.Н. Сызганова, заведующий отделением рентгенохирургии, интервенционной кардиологии и аритмологии, e-mail: [email protected]
Абзалиев Куат Баяндыевич -Национальный научный центр хирургии имени А.Н. Сызганова, заведующий отделом менеджмента научных исследований., e-mail: [email protected]
Ключевые слова:
фибрилляция предсердий, профилактика инсульта, окклюзия ушка левого предсердия, амплатцер амулет
Atrial fibrillation (AF) is the most common type of heart rhythm disorder and is the cause of up to 30% of all ischemic strokes [1]. The annual risk of stroke in the patients with atrial fibrillation increases with age dramatically, from 1.5% for those aged 50-59 years to 23.5% among those aged 80-89 years [2]. Standard therapy for primary and secondary prevention of stroke and thromboembolic complications associated with atrial fibrillation is an oral anticoagulant therapy [3]. Echocardiographic studies have shown that in 90% of patients with non-valvular AF, the clot is in the left atrial appendage (LAA) [4].
Currently, closing the LAA with occluder introduced in clinical practice as a valuable alternative to the continuous reception of oral anticoagulants for the patients who cannot take anticoagulants or when anticoagulation is ineffective.
Results of a randomized clinical trial- PROTECT AF for the WATCHMAN device and register data for the Amplatzer Cardiac Plug (ACP) have been promising that the occlusion of the LAA has been included in the latest revision of the recommendations of the European Society of Cardiology (ESC) for the treatment of patients with atrial fibrillation (II b recommendation grade, level of evidence B) [5]. The device Amplatzer Amulet (Figure 1) (AGA-St. Jude Medical, Minnesota, USA) is the successor of ACP. This article describes the first clinical case of the closure of the LAA with occluder by endovascular access using the Amplatzer Amulet in Kazakhstan.
Clinical case
A male patient of 74 years with persistent AF was admitted to our hospital in a planned manner and was directed to the procedure of closing the LAA with occluder for the prevention of stroke and
thromboembolic complications. It was identified from history that there is a presence of diabetes mellitus, hypertension, peripheral vascular disease, coronary heart disease and 2 underwent cases of coronary angioplasty procedure. Considering all these factors the risk on a scale of CHA2DS2VASc constitutes 6 units meaning the annual risk of death of patient due to thromboembolic complications may be about 19.2%. With careful selection of doses of warfarin it was not possible to achieve stability index of international normalized ratio (INR) of the therapeutic range.
According to the international guidelines for the prevention of stroke and thromboembolic complications as an alternative to anticoagulant therapy, it is indicated to implant LAA occluder with endovascular method. After clarifying the essence of the operation and possible risks, the consent of the patient is obtained,. The absence of a blood clot in the appendage of Left Atrium was confirmed by transesophageal echocardiog-raphy. The procedure for endovascular closure of the LAA was performed under fluoroscopy (Siemens Artis Zee) and transesophageal echocardiography. Passage from the right atrium to the left atrium was achieved with the help of transseptal puncture, by accessing via the right femoral vein, using a long transducer SL1 and transseptal needle BRK-1 (St. Jude Medical, Minnesota, United States). Continuous intravenous infusion of heparin was provided, maintaining indicator activated clotting time of more than 300 seconds, which was monitored every 30 minutes. Angiographic image was recorded in 30 ° RAO and 15 ° CRAN projections. The size of the isthmus of LAA was 18.9 mm with the diameter of the body from 17.2 to 19.7 mm. Based on the
Figure 1.
The Amplatzer Amulet device. Schema of device implantation for LAA.
measurements performed with angiography and echocardiography it was decided to implant Am-platzer Amulet. The device was implanted using specific delivery system which comes in set with device (Figure 2). During procedure it was confirmed on angiography and Doppler echocardiography that there is no shunt between LAA and LA, and complete occlusion is achieved. After thorough testing of device stabillity, delivery system was detached from the device and removed from the cavities of the heart and blood vessels (Figure 3). In total, procedure time was 57 minutes with no complications registered. The patient was prescribed 20 mg of Rivaroxaban for 3 months and 100 mg of Aspirin continuously. After 3 months, under echocardiography the complete closure of LAA was confirmed and thus anticoagulation therapy was canceled and patient was transferred only to Aspirin.
Discussion
Nowadays, it is recommended for all patients with AF who have more than one risk factor, to use Warfarin or new oral anticoagulant drugs such as Rivaroxaban, Dabigatran and Apixa-ban for the prevention of stroke. However, due to the contraindications applied for the use of anticoagulant therapies as of increased risk of bleeding, physicians and patients are generally reluctant to use anticoagulant drugs [6]. Therefore, endovascular closure of the LAA with oc-cluder is considered as a new treatment option for primary and secondary prevention of stroke in patients with non-valvular AF. Recent results of PROTECT AF have demonstrated the superiority of LAA closure with WATCHMAN device compared to warfarin in terms of the primary efficacy and mortality [7]. The LAA occlusion procedure itself requires a very high experience of the operator. The PROTECT AF study showed that the main problems were associated with a frequency of complications, specifically - pericardial effusion and tamponade, stroke due to air embolism, and device embolization occurring in 7.7%. Fortunately, the complication rate decreased to 3.7% by the completion of PROTECT AF study, which is directly correlated with the skill of the operating physician. [8]. Similar results were published in a study of ACP Registry [9]. Adequate training and careful selection of patients are required in order to avoid complications. In addition, knowledge of LAA anatomy is essential. As in other endo-vascular interventions on the heart, the role of high-quality imaging is a prerequisite. During the procedure, the use echocardiography facilitates transseptal puncture as well as can be used to
assess the total closure of the LAA and device stability.
Amplatzer Amulet (Figure 4) is the second generation of LAA occlusion device, and in comparison with the (ACP) has a long blade and a larger disk. Amplatzer Amulet also has a stiffer stabilizing wire around the base and delivery cable with inner wire that is used to evaluate the end position of the system. The implantation procedure of Amplatzer Amulet is practically the same. The aim of technique is
to completely cover the orifice of LAA with a device disk, creating a smooth transition to the wall of Left Atrium. Complete endothelialization takes place over 1-3 months, with an average of 45 days. Therefore, it is recommended to provide antithrombotic support after the procedure with a dose of 100 mg of Aspirin and Clopidogrel of 75 mg for 1-3 months, and then transfer only to Aspirin of 100 mg continuously.
Endovascular closure of the LAA with oc-cluder, is now considered as a good alternative to the conservative anticoagulant therapy to prevent stroke in patients with AF. At the same time, it requires careful patient selection and appropriate training of doctors is mandatory in order to ensure the safety and effectiveness of the proposed procedure.
References
1. Wolf PA, D'Agostino RB, Belanger AJ. Probability of stroke: A risk profile from the Framingham Study. Stroke 1991;22:312-31.
2. Chesebro JH, Fuster V, Halperin JL: Atrial fibrillation: Risk marker for stroke. N Engl J Med 1990;323: 1556-1558.
3. Baimbetov A.K., Bekbossynova M.S., Gainutdinov R.G. et al. Conservative treatment of atrial fibrilla-taion. Astana medicine journal. № 1, 2011: 19-23.
4. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996; 61: 755-759.
5. Kirchhof P., Benussi S., Kotecha D. et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS uropean Heart Rhythm Association. Eur Heart J. 2016; 33: 2719-2747.
6. Kirley K, Qato DM, Kornfield R et al; National trends in oral anticoagulant use in the United States, 2007
to 2011. Circ Cardiovasc Qual Outcomes. 2012; 5: 615-621.
7. Reddy VY, Holmes D, Doshi SK et al; Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation. 2011; 123: 417-424.
8. Reddy VY, Doshi SK, Sievert H. et al; Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial. Circulation. 2013;127:720-729.
9. Freixa X, Chan JL, Tzikas A, Garceau P, Basmadjian A, Ibrahim R. The Amplatzer^ Cardiac Plug 2 for left atrial appendage occlusion: novel features and first-in-man experience. Eurointervention. 2013; 8: 10941098
