Author + information
- S1936879816313474-9bca65e32a4770c0612410384f9f149cJian-Fang Ren, MD∗ (, )
- S1936879816313474-618f7f6e2032796f787a5b680913c93bDavid J. Callans, MD and
- S1936879816313474-de5c3b14e1af761f2e107149872b093eFrancis E. Marchlinski, MD
- ↵∗University of Pennsylvania Health System, 111 North 9th Street, Philadelphia, Pennsylvania 19107-2452
In a recent issue of JACC: Cardiovascular Interventions, Koskinas et al. (1) reported that procedural success of left atrial appendage (LAA) closure using the Amplatzer device (St. Jude Medical, St. Paul, Minnesota) was high (97.8%), guided only by fluoroscopy without echocardiography. The authors indicated that angiographic LAA morphology, characterized as cauliflower (33%), cactus (32%), windsock (20%), or chicken wing (15%), was not associated with LAA closure procedural success or the occurrence of major adverse events (5.8%) in 500 patients with atrial fibrillation. There are significant insufficiencies in their methodology and analysis of adverse events that need to be clarified.
Left atrium morphology has been described as a narrow windsock-like body with different number of lobes (which might not be in the same plane) and size of the pectinate muscles or a hooked appendage by autopsy study (2). With routine clinical application of intracardiac echocardiography (ICE) in a baseline study in more than 3,500 cases of left heart ablation, a narrow windsock-like body of LAA with its ostium may be regularly imaged almost in every case when the ICE transducer is placed in the right ventricle or right ventricular outflow tract (Figure 1). We disagree with their complicated and confounded definition of different LAA morphologies instead of the windsock-like body. One might still note a dominant windsock-like body (the length may reach <4 cm) (3) especially in so-called cauliflower LAA, with limited projected views of the fluoroscopically angiographic imaging (1,3) or even with the magnetic resonance or computed tomographic imaging (4). For LAA closure procedures, accurate ICE or transesophageal echocardiography imaging and measurement of the LAA ostium and its immediately adjacent structure (not the secondary or even tertiary lobes or twigs) is critically important (more than the LAA surface shape) for successful LAA ostial closure using an Amplatzer or Watchman device (5). Therefore, it is meaningless to associate a complicated and confounded LAA morphology with the procedural success as study by the authors (1). Regarding a relatively high incidence of major adverse events (29 of 500, 5.8%), it is difficult to interpret or to clearly associate the occurrence of major complications with LAA morphologies, or procedural success. ICE monitoring may greatly reduce or prevent some of these complications, such as pericardial effusion (n = 33) and thrombus formation or embolization (n = 10). In addition, these complications should be also related to widely combined or concomitant procedures (e.g., percutaneous coronary intervention, closure of patent foramen ovale or atrial septal defect, transcatheter aortic valve replacement, mitral clip insertion, atrial fibrillation ablation, or transseptal catherization) and their procedures using only fluoroscopy and without guidance and monitoring of ICE or transesophageal echocardiography.
The investigators should be congratulated for presenting a large series of LAA closures and reported very early (1 week) outcomes. However, their methodology and analysis of major complications are inadequate and the LAA closure outcomes are also confounded mainly due to a complicated and impractical classification of LAA morphology and insufficiency of imaging technique.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
- Koskinas K.C.,
- Shakir S.,
- Fankhauser M.,
- et al.
- Veinot J.P.,
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- Ren J.F.,
- Callans D.J.,
- Marchlinski F.E.
- Ren J.F.