Clin Res Cardiol DOI 10.1007/s00392-014-0724-0
LETTER TO THE EDITORS
Thromboembolic stroke after cardioversion with incomplete left atrial appendage closure Koji Hanazawa • Michele Brunelli J. Christoph Geller
•
Received: 18 March 2014 / Accepted: 28 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Sirs: A 73-year-old man with persistent Atrial Fibrillation (AF) and a CHA2DS2VASc Score of 3 underwent uneventful percutaneous left atrial appendage (LAA) closure (WatchmanTM, 21 mm, Atritech, Inc., Plymouth, Minnesota) guiding fluoroscopy and transesophageal echocardiogram (TEE) in 2011 because of the inability to keep the INR within the therapeutic range (Fig. 1). TEE revealed residual flow into the LAA after implantation and also during follow-up, no flow was seen directly around the device. Warfarin was stopped 6 weeks and clopidogrel 3 months after implantation, aspirin was continued. Due to progressive arrhythmia symptoms, 15 months after implantation, successful electrical cardioversion was performed on aspirin alone after exclusion of intracardiac thrombi with TEE. The following day, the patient developed right-sided weakness and aphasia, cerebral computed tomography (CT) showed ischemia in the territory of the left medial cerebral artery. Repeat analysis of the previous TEE
Electronic supplementary material The online version of this article (doi:10.1007/s00392-014-0724-0) contains supplementary material, which is available to authorized users. K. Hanazawa (&) M. Brunelli J. C. Geller Arrhythmia and Electrophysiology Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany e-mail: [email protected]
images revealed residual narrow flow (speed [40 cm/s) in the lateral portion of the LAA (Fig. 2). On cardiac CT, the occluder was positioned in one of the two LAA lobes and the other lobe was not occluded (Fig. 3). There was no evidence of intracardiac thrombus. The neurologic symptoms resolved quickly, and oral anticoagulation (Dabigatran, 2 9 150 mg/day) was started. Interventional LAA closure is as effective as oral anticoagulation in patients with non-valvular AF [1–6], and some case reports [7, 8] pointed out that a combined mitral valve treatment and interventional LAA closure in patients with AF and mitral valve disease is effective in reducing thromboembolic complications. In one analysis, residual peri-device flow was not associated with an increased risk of thromboembolism in PROTECT-AF [9]. However, the risk of thromboembolic complications in patients undergoing cardioversion is unknown, and there is no clear evidence that cardioversion can be performed without anticoagulant treatment after mechanical LAA occlusion. In this case, there are several important points: (1) the cause of ischemia was presumably cardiac embolic in origin (although the TEE before cardioversion did not show any thrombus). Therefore, as suggested in the guidelines, effective anticoagulant treatment is mandatory for 4 weeks after cardioversion despite closure of the LAA. The role of residual flow into the LAA after interventional LAA occlusion in increasing the risk of thromboembolic complications after cardioversion is unknown. In addition, thrombi might also evolve in the left atrium cavity due to atrial stunning after cardioversion. (2) The CT (Fig. 3) revealed a more complex 3D anatomy of the LAA, which was not seen with TEE or fluoroscopy (Fig. 1) during the procedure. Therefore, it is recommended to assess LAA anatomy with different two-dimensional views (preferably with 3D) in
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Clin Res Cardiol Fig. 1 LAA angiography in RAO 30° (the contrast were injecting from the delivery system) showed the shape of LAA (Panel A). The fluoroscopy demonstrated the final position of Watchman device (white arrow), TEE (dotted arrow) and LCX stents (small white arrow) (Panel B). LAA left atrial appendage, RAO right anterior oblique, TEE transesophageal echocardiogram, LCX left circumflex coronary artery
Fig. 2 Transesophageal echocardiogram (TEE, 104°, Panel A) demonstrating positioning of the device (red circle) within the left atrial appendage, but color-Doppler in a 73° angulation (Panel
B) demonstrates significant peri-device flow (white arrows). LIPV left pulmonary vein, MV mitral valve, LV left ventricle, LA left atrium, LAA left atrial appendage
every case before and after interventional LAA occlusion to evaluate LAA lobuli and exclude incomplete closure.
References
Fig. 3 The 3D reconstruction of the left atrium in the right anterior oblique projection shows incomplete occlusion of the left atrial appendage. The inferior-lateral lobe is not occluded (yellow arrow) due to suboptimal positioning of the device into the superior lobe
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1. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised noninferiority trial. Lancet 374:534–542 2. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minguez JR, Meerkin D, Valde´s M, Ormerod O, Leitha¨user B (2011) Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv 77:700–706 3. Lam YY, Yip GW, Yu CM, Chan WW, Cheng BC, Yan BP, Clugston R, Yong G, Gattorna T, Paul V (2012) Left atrial appendage closure with AMPLATZER cardiac plug for stroke prevention in atrial fibrillation: initial Asia-Pacific experience. Catheter Cardiovasc Interv 79:794–800 4. Meier B, Palacios I, Windecker S, Rotter M, Cao QL, Keane D, Ruiz CE, Hijazi ZM (2003) Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv 60:417–422
Clin Res Cardiol 5. Ostermayer SH, Reisman M, Kramer PH, Matthews RV, Gray WA, Block PC, Omran H, Bartorelli AL, Della Bella P, Di Mario C, Pappone C, Casale PN, Moses JW, Poppas A, Williams DO, Meier B, Skanes A, Teirstein PS, Lesh MD, Nakai T, Bayard Y, Billinger K, Trepels T, Krumsdorf U, Sievert H (2005) Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials. J Am Coll Cardiol 46:9–14 6. Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S (2011) 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 123:417–424 7. Jabs A, Hink U, Warnholtz A (2012) Stephan von Bardeleben R, Nikolai P, Mu¨nzel T, Gori T. Left atrial appendage occlusion in
valvular atrial fibrillation following MitraClip implantation. Clin Res Cardiol 101(5):393–396 8. Sedaghat A, Nickenig G, Hammerstingl C (2014) Left atrial appendage closure in a patient with atrial fibrillation after mechanical mitral valve replacement and cardio-embolic stroke despite effective oral anticoagulant therapy: a case report. Clin Res Cardiol 103:10–12 9. Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY (2012) The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) Substudy. J Am Coll Cardiol 59:923–929
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LETTER TO THE EDITORS
Thromboembolic stroke after cardioversion with incomplete left atrial appendage closure Koji Hanazawa • Michele Brunelli J. Christoph Geller
•
Received: 18 March 2014 / Accepted: 28 April 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Sirs: A 73-year-old man with persistent Atrial Fibrillation (AF) and a CHA2DS2VASc Score of 3 underwent uneventful percutaneous left atrial appendage (LAA) closure (WatchmanTM, 21 mm, Atritech, Inc., Plymouth, Minnesota) guiding fluoroscopy and transesophageal echocardiogram (TEE) in 2011 because of the inability to keep the INR within the therapeutic range (Fig. 1). TEE revealed residual flow into the LAA after implantation and also during follow-up, no flow was seen directly around the device. Warfarin was stopped 6 weeks and clopidogrel 3 months after implantation, aspirin was continued. Due to progressive arrhythmia symptoms, 15 months after implantation, successful electrical cardioversion was performed on aspirin alone after exclusion of intracardiac thrombi with TEE. The following day, the patient developed right-sided weakness and aphasia, cerebral computed tomography (CT) showed ischemia in the territory of the left medial cerebral artery. Repeat analysis of the previous TEE
Electronic supplementary material The online version of this article (doi:10.1007/s00392-014-0724-0) contains supplementary material, which is available to authorized users. K. Hanazawa (&) M. Brunelli J. C. Geller Arrhythmia and Electrophysiology Section, Division of Cardiology, Zentralklinik Bad Berka, Bad Berka, Germany e-mail: [email protected]
images revealed residual narrow flow (speed [40 cm/s) in the lateral portion of the LAA (Fig. 2). On cardiac CT, the occluder was positioned in one of the two LAA lobes and the other lobe was not occluded (Fig. 3). There was no evidence of intracardiac thrombus. The neurologic symptoms resolved quickly, and oral anticoagulation (Dabigatran, 2 9 150 mg/day) was started. Interventional LAA closure is as effective as oral anticoagulation in patients with non-valvular AF [1–6], and some case reports [7, 8] pointed out that a combined mitral valve treatment and interventional LAA closure in patients with AF and mitral valve disease is effective in reducing thromboembolic complications. In one analysis, residual peri-device flow was not associated with an increased risk of thromboembolism in PROTECT-AF [9]. However, the risk of thromboembolic complications in patients undergoing cardioversion is unknown, and there is no clear evidence that cardioversion can be performed without anticoagulant treatment after mechanical LAA occlusion. In this case, there are several important points: (1) the cause of ischemia was presumably cardiac embolic in origin (although the TEE before cardioversion did not show any thrombus). Therefore, as suggested in the guidelines, effective anticoagulant treatment is mandatory for 4 weeks after cardioversion despite closure of the LAA. The role of residual flow into the LAA after interventional LAA occlusion in increasing the risk of thromboembolic complications after cardioversion is unknown. In addition, thrombi might also evolve in the left atrium cavity due to atrial stunning after cardioversion. (2) The CT (Fig. 3) revealed a more complex 3D anatomy of the LAA, which was not seen with TEE or fluoroscopy (Fig. 1) during the procedure. Therefore, it is recommended to assess LAA anatomy with different two-dimensional views (preferably with 3D) in
123
Clin Res Cardiol Fig. 1 LAA angiography in RAO 30° (the contrast were injecting from the delivery system) showed the shape of LAA (Panel A). The fluoroscopy demonstrated the final position of Watchman device (white arrow), TEE (dotted arrow) and LCX stents (small white arrow) (Panel B). LAA left atrial appendage, RAO right anterior oblique, TEE transesophageal echocardiogram, LCX left circumflex coronary artery
Fig. 2 Transesophageal echocardiogram (TEE, 104°, Panel A) demonstrating positioning of the device (red circle) within the left atrial appendage, but color-Doppler in a 73° angulation (Panel
B) demonstrates significant peri-device flow (white arrows). LIPV left pulmonary vein, MV mitral valve, LV left ventricle, LA left atrium, LAA left atrial appendage
every case before and after interventional LAA occlusion to evaluate LAA lobuli and exclude incomplete closure.
References
Fig. 3 The 3D reconstruction of the left atrium in the right anterior oblique projection shows incomplete occlusion of the left atrial appendage. The inferior-lateral lobe is not occluded (yellow arrow) due to suboptimal positioning of the device into the superior lobe
123
1. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P (2009) Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised noninferiority trial. Lancet 374:534–542 2. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minguez JR, Meerkin D, Valde´s M, Ormerod O, Leitha¨user B (2011) Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv 77:700–706 3. Lam YY, Yip GW, Yu CM, Chan WW, Cheng BC, Yan BP, Clugston R, Yong G, Gattorna T, Paul V (2012) Left atrial appendage closure with AMPLATZER cardiac plug for stroke prevention in atrial fibrillation: initial Asia-Pacific experience. Catheter Cardiovasc Interv 79:794–800 4. Meier B, Palacios I, Windecker S, Rotter M, Cao QL, Keane D, Ruiz CE, Hijazi ZM (2003) Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv 60:417–422
Clin Res Cardiol 5. Ostermayer SH, Reisman M, Kramer PH, Matthews RV, Gray WA, Block PC, Omran H, Bartorelli AL, Della Bella P, Di Mario C, Pappone C, Casale PN, Moses JW, Poppas A, Williams DO, Meier B, Skanes A, Teirstein PS, Lesh MD, Nakai T, Bayard Y, Billinger K, Trepels T, Krumsdorf U, Sievert H (2005) Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials. J Am Coll Cardiol 46:9–14 6. Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S (2011) 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 123:417–424 7. Jabs A, Hink U, Warnholtz A (2012) Stephan von Bardeleben R, Nikolai P, Mu¨nzel T, Gori T. Left atrial appendage occlusion in
valvular atrial fibrillation following MitraClip implantation. Clin Res Cardiol 101(5):393–396 8. Sedaghat A, Nickenig G, Hammerstingl C (2014) Left atrial appendage closure in a patient with atrial fibrillation after mechanical mitral valve replacement and cardio-embolic stroke despite effective oral anticoagulant therapy: a case report. Clin Res Cardiol 103:10–12 9. Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY (2012) The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) Substudy. J Am Coll Cardiol 59:923–929
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