Die Autoren danken Frau Maggie Wallner (Atritech Inc. / Boston Scientific) für die kritische Durchsicht des Artikels. Die Autoren möchten Herrn Mahesh Deshpanade (Boston Scientific) für seine administrative Unterstützung und Organisation von Copyright-Berechtigungen zu danken. Das Video wurde von einen nicht zweckgebundenen Zuschuss von Boston Scientific unterstützt.

<ol>
	<li>Miyasaka, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Time+trends+of+ischemic+stroke+incidence+and+mortality+in+patients+diagnosed+with+first+atrial+fibrillation+in+1980+to+2000:+report+of+a+community-based+study.">Time trends of ischemic stroke incidence and mortality in patients diagnosed with first atrial fibrillation in 1980 to 2000: report of a community-based study.</a> Stroke. 36, 2362-2366 (2005).</li><li>Holmes, D. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+closure+of+the+left+atrial+appendage+versus+warfarin+therapy+for+prevention+of+stroke+in+patients+with+atrial+fibrillation:+a+randomised+non-inferiority+trial.">Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.</a> Lancet. 374, 534-542 (2009).</li><li>Schweizer, P. A., Becker, R., Katus, H. A., Thomas, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dronedarone:+current+evidence+for+its+safety+and+efficacy+in+the+management+of+atrial+fibrillation.">Dronedarone: current evidence for its safety and efficacy in the management of atrial fibrillation.</a> Drug. 5, 27-39 (2011).</li><li>Wyse, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+rate+control+and+rhythm+control+in+patients+with+atrial+fibrillation.">A comparison of rate control and rhythm control in patients with atrial fibrillation.</a> N. Engl. J. Med. 347, 1825-1833 (2002).</li><li>Carlsson, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Randomized+trial+of+rate-control+versus+rhythm-control+in+persistent+atrial+fibrillation:+the+Strategies+of+Treatment+of+Atrial+Fibrillation+(STAF)+study.">Randomized trial of rate-control versus rhythm-control in persistent atrial fibrillation: the Strategies of Treatment of Atrial Fibrillation (STAF) study.</a> J. Am. Coll. Cardiol. 41, 1690-1696 (2003).</li><li>Van Gelder, I. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+comparison+of+rate+control+and+rhythm+control+in+patients+with+recurrent+persistent+atrial+fibrillation.">A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation.</a> N. Engl. J. Med. 347, 1834-1840 (2002).</li><li>Echt, D. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mortality+and+morbidity+in+patients+receiving+encainide,+flecainide,+or+placebo.+The+Cardiac+Arrhythmia+Suppression+Trial.">Mortality and morbidity in patients receiving encainide, flecainide, or placebo. The Cardiac Arrhythmia Suppression Trial.</a> N. Engl. J. Med. 324, 781-788 (1991).</li><li>Ames, A., Stevenson, W. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cardiology+patient+page.+Catheter+ablation+of+atrial+fibrillation.">Cardiology patient page. Catheter ablation of atrial fibrillation.</a> Circulation. 113, e666-e668 (2006).</li><li>. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stroke+Prevention+in+Atrial+Fibrillation+Study.+Final+results.">Stroke Prevention in Atrial Fibrillation Study. Final results.</a> Circulation. 84, 527-539 (1991).</li><li>Singer, D. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Antithrombotic+therapy+in+atrial+fibrillation:+American+College+of+Chest+Physicians+Evidence-Based+Clinical+Practice+Guidelines+(8th+Edition).">Antithrombotic therapy in atrial fibrillation: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition).</a> Chest. 133, 546S-592S (2008).</li><li>Connolly, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dabigatran+versus+warfarin+in+patients+with+atrial+fibrillation.">Dabigatran versus warfarin in patients with atrial fibrillation.</a> N. Engl. J. Med. 361, 1139-1151 (2009).</li><li>Patel, M. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rivaroxaban+versus+warfarin+in+nonvalvular+atrial+fibrillation.">Rivaroxaban versus warfarin in nonvalvular atrial fibrillation.</a> N. Engl. J. Med. 365, 883-891 (2011).</li><li>Albers, G. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ximelagatran+vs+warfarin+for+stroke+prevention+in+patients+with+nonvalvular+atrial+fibrillation:+a+randomized+trial.">Ximelagatran vs warfarin for stroke prevention in patients with nonvalvular atrial fibrillation: a randomized trial.</a> JAMA. 293, 690-698 (2005).</li><li>Fiessinger, J. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ximelagatran+vs+low-molecular-weight+heparin+and+warfarin+for+the+treatment+of+deep+vein+thrombosis:+a+randomized+trial.">Ximelagatran vs low-molecular-weight heparin and warfarin for the treatment of deep vein thrombosis: a randomized trial.</a> JAMA. 293, 681-689 (2005).</li><li>Schulman, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Dabigatran+versus+warfarin+in+the+treatment+of+acute+venous+thromboembolism.">Dabigatran versus warfarin in the treatment of acute venous thromboembolism.</a> N. Engl. J. Med. 361, 2342-2352 (2009).</li><li>Sick, P. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Initial+worldwide+experience+with+the+WATCHMAN+left+atrial+appendage+system+for+stroke+prevention+in+atrial+fibrillation.">Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation.</a> J. Am. Coll. Cardiol. 49, 1490-1495 (2007).</li><li>Reddy, V. Y., Holmes, D., Doshi, S. K., Neuzil, P., Kar, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=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.">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.</a> Circulation. 123, 417-424 (2011).</li></ol>

Dr. Möbius-Winkler, Dr. Dähnert und Prof. Schuler nahmen an der Protect AF-Studie. Dr. Möbius-Winkler arbeitet als Wachmann für Proctor Implantation für Atritech Inc. und Boston Scientific.

Das Verfahren für die perkutane Implantation des Wächters linke Herzohr Schließung hier beschriebene Gerät, wurde in klinischen Studien wurde gezeigt, dass 16 machbar sein, nicht unterlegen Warfarin-Therapie 2, 17 und sichere. Obwohl in allen Studien gab es eine höhere Komplikationsrate in der Gruppe, die das Implantat 2,16,17, schlägt Daten aus dem PROTECT AF-Studie und die GAP-Registry-Studie, die Sicherheit zu beurteilen, dass die Komplikationen mit der Implantation des Wächters assoziiert sein kann weitgehend auf Betreiber Unerfahrenheit zurückzuführen. Die Häufigkeit der Sicherheit Ereignisraten war anfangs hoch, verringerte sich jedoch im Laufe der Zeit 17. Die hier vorgestellte Methode hebt mehrere wichtige Schritte bei der Vorbeugung von Komplikationen. Während der Pilot-Studie gab es drei Veranstaltungen zur Sicherheit als Folge der Ausfall des Geräts. In zwei Fächern das Gerät embolisiert, und in einem Fach der Draht gebrochen während der Implantationrens. Obwohl diese Ereignisse traten in der ersten Generation-Geräte und sind nicht in der zweiten Generation Gerätes aufgetreten ist, sollte das System WATCHMAN immer vor Gebrauch gründlich 16 untersucht werden. Die häufigsten Komplikationen mit dem Verfahren verbunden sind Perikardergüsse brauchen Intervention und Luftembolie. Analyse der Bilddaten legt nahe, dass die schweren Perikardergüsse im PROTECT AF-Studie von Fehlbedienungen während transseptale Punktion, durch die Manipulation der Vorrichtung Wachmann oder durch Manipulation im LAA mit der Hülle, um eine optimale Implantation zu erreichen verursacht wurden. Durch die Verwendung eines Pigtail-Katheter das Risiko für die Perforation des LAA von der Spitze der Hülle kann stark reduziert werden. Ein Perikarderguss höchstwahrscheinlich von einem kräftigen &quot;Ruck-Test&quot; durchgeführt, um die Stabilität des Gerätes in der LAA überprüfen geführt. Aus diesem Grund ist es wichtig, T und Fluoroskopie während des gesamten Verfahrens zu verwenden, um die i überwachenmplantation Prozess. Bei der Suche nach Stabilität sollten dagegen in die LAA injiziert werden, um die Kammer zu visualisieren, oder der Prozess kontinuierlich mit TEE überwacht werden. Mit der Beobachtung, wurden keine weiteren Schlepper-bezogenen Ergüsse beobachtet worden. Verfahren im Zusammenhang mit Schlaganfall in 3 Fällen als Folge einer Luftembolie aus der großen 12F transseptalen Zugangsschleuse aufgetreten ist. Daher ist es wichtig, sorgfältig sein, korrekt Spülen der Hülle sicherzustellen, dass Luft nicht in der Ummantelung 17 eingeschlossen. Außerdem kann das Fasten vor dem Eingriff der Entwässerung was zu einer niedrigen linken atrialen Druck während der Implantation, die Luftembolie verursachen kann. Deshalb vor dem Einsatz des Gerätes ist darauf Kochsalzlösung infundiert, um den Patienten linksatrialen Druck auf etwa 10 mmHg zu erhöhen. Trotz der höheren Rate von sicherheitsrelevanten Ereignissen mit LAA Okklusion im Vergleich zu Warfarin-Behandlung war das Gesamtergebnis in Bezug auf Morbidität / Mortalität mit LAA Okklusion imerwiesen 17. Schließung der linke Herzohr ist daher eine vielversprechende Alternative zu Warfarin kontinuierliche Therapie bei Patienten mit nicht-Vorhofflimmern.

the watchman left atrial appendage closure device for atrial fibrillation

Vorhofflimmern (VHF) ist die häufigste Herzrhythmusstörung unter der schätzungsweise 6 Millionen Menschen in den Vereinigten Staaten ein. Seit AF betrifft vor allem ältere Menschen, steigt die Prävalenz parallel mit dem Alter. Als solche wird erwartet, dass 15,9 Millionen Amerikaner im Jahr 2050 zwei betroffen sein werden. Der ischämische Schlaganfall tritt in 5% der Nicht-AF antikoagulierten Patienten pro Jahr. Gegenwärtige Behandlungen für AF zählen Rate Control, Rhythmus Kontrolle und Prävention von Schlaganfällen 3. Das American College of Cardiology, American Heart Association und European Society of Cardiology aktuell empfohlenen Rate Control als erstes Verlauf der Therapie für die AF-3. Bewerten Kontrolle wird durch die Verabreichung von pharmakologischen Wirkstoffen, wie z. B. β-Blocker, dass niedriger die Herzfrequenz erreicht, bis sie einen weniger symptomatische Zustand 3 erreicht. Rhythm Kontrolle zielt darauf ab, das Herz zu seiner normalen Sinusrhythmus zurück und ist in der Regelerreicht durch Gabe von Antiarrhythmika wie Amiodaron, elektrische Kardioversion oder Ablationstherapie. Rhythm Kontrollmethoden haben jedoch nicht nachgewiesen überlegen zu sein Rate-Control-Methoden 6.4. In der Tat haben einige Antiarrhythmika wurde gezeigt, dass mit höheren Krankenhausaufenthalte, schwerwiegende Nebenwirkungen 3 oder auch Erhöhungen der Mortalität bei Patienten mit struktureller Herzfehler 7 zugeordnet werden. So wird die Behandlung mit Antiarrhythmika mehr oft verwendet, wenn Rate-Control-Medikamente unwirksam oder kontraindiziert sind. Rate-Steuerung und Antiarrhythmika lindern die Symptome von Vorhofflimmern, einschließlich Herzklopfen, Kurzatmigkeit, Müdigkeit und 8, aber nicht zuverlässig verhindern, thromboembolische Ereignisse 6. Die Behandlung mit dem Antikoagulans Warfarin Medikament reduziert signifikant die Rate an Schlaganfällen oder Embolien 9,10. Aufgrund der Probleme mit seiner Verwendung verbunden sind, weniger als 50%der Patienten, die damit behandelt. Die therapeutische Dosis wird durch Arzneimittel, diätetische und metabolische Interaktionen betroffen sind, und erfordert deshalb eine detaillierte Überwachung. Darüber hinaus hat Warfarin die Gefahr schwerer, manchmal tödlich zu bewirken, Blutungen 2. Als Alternative wird häufig verschriebenen Aspirin. Während Aspirin wird in der Regel gut vertragen, ist es weit weniger effektiv bei der Prävention von Schlaganfällen 10. Andere Alternativen zu Warfarin, wie Dabigatran oder Rivaroxaban 11 12 demonstrieren die Nicht-Unterlegenheit zu Warfarin im Hinblick auf thromboembolische Ereignisse (in der Tat, Dabigatran als eine hohe Dosis von 150 mg zweimal pro Tag hat gezeigt Überlegenheit gegeben). Während diese Medikamente den Vorteil, dass Anliegen und diätetische wodurch die Notwendigkeit für regelmäßige Blutuntersuchungen Überwachung, schwere Blutungen und die damit verbundenen Komplikationen, während haben etwas weniger als mit Warfarin, ein Thema, 13-15 bleiben. Da 90% der AF-assoziierten Schlaganfälle resultieren aus Embolien, dass arisich von der linken Herzohrs (LAA) 2, hat einer alternativen Ansatz zur Warfarin bereits in die LAA unter Verwendung eines implantierten Vorrichtung von Blutgerinnseln einzufangen, bevor sie zu verlassen auszuschließen. Hier zeigen wir ein Verfahren für die Implantation der Wächter linke Herzohr Closure Device. Ein transseptalen Kanüle wird durch die Oberschenkelvene eingeführt und unter fluoroskopischer Führung, inter-atriale Septum überschritten wird. Wenn in den linken Vorhof zu übersetzen erreicht worden ist, einen Führungsdraht in der oberen Lungenvene angeordnet ist und der Wächter Zugang Mantel und dem Dilatator werden über die Leitung in den linken Vorhof vorgeschoben. Der Führungsdraht wird entfernt und der Zugangsschleuse wird sorgfältig in den distalen Abschnitt des LAA über einen Pigtailkatheter vorgeschoben. The Watchman Delivery System wird vorbereitet, eingefügt in die Scheide Zugang, und langsam fortgeschritten. Die WATCHMAN Vorrichtung wird dann in der LAA bereitgestellt. Das Gerät entfällt Kriterien werden über Fluoroskopie und transösophageale Echokardiographie (TEE) und dem Gerät bestätigt is veröffentlicht.

Watch this Scientific Journal Video about The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation at JoVE.com

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

Das dazugehörige Video beschreibt ein Verfahren zur perkutanen Plazierung des Wächters linke Herzohr (LAA) Device. Die Wächter ist ein Nitinol-Einrichtung, die dauerhaft an implantiert werden oder etwas distal, der Öffnung des linken Herzohrs (LAA) Blutgerinnsel einzufangen, bevor sie die LAA verlassen, Verhütung von thromboembolischen Schlaganfall.

The Watchman linke Herzohr Verschlusseinrichtung für Vorhofflimmern

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily ...

the-watchman-left-atrial-appendage-closure-device-for-atrial

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

83.3K Aufrufe.  University of Leipzig Heart Center. Das dazugehörige Video beschreibt ein Verfahren zur perkutanen Plazierung des Wächters linke Herzohr (LAA) Device. Die Wächter ist ein Nitinol-Einrichtung, die dauerhaft an implantiert werden oder etwas distal, der Öffnung des linken Herzohrs (LAA) Blutgerinnsel einzufangen, bevor sie die LAA verlassen, Verhütung von thromboembolischen Schlaganfall.

Serie: The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

A New Single Chamber Implantable Defibrillator with Atrial Sensing: A Practical Demonstration of Sensing and  Ease of Implantation

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect patients from sudden cardiac death (SCD). However, inappropriate shocks may occur if tachycardias are misdiagnosed. Inappropriate shocks are harmful and impair patient quality of life. The risk of inappropriate therapy increases with lower detection rates programmed in the ICD. Single-chamber detection poses greater risks for misdiagnosis when compared with dual-chamber devices that have the benefit of additional atrial information. However, using a dual-chamber device merely for the sake of detection is generally not accepted, since the risks associated with the second electrode may outweigh the benefits of detection. Therefore, BIOTRONIK developed a ventricular lead called the LinoxSMART S DX, which allows for the detection of atrial signals from two electrodes positioned at the atrial part of the ventricular electrode. This device contains two ring electrodes; one that contacts the atrial wall at the junction of the superior vena cava (SVC) and one positioned at the free floating part of the electrode in the atrium. The excellent signal quality can only be achieved by a special filter setting in the ICD (Lumax 540 and 740 VR-T DX, BIOTRONIK). Here, the ease of implantation of the system will be demonstrated.

Dual-chamber implantable cardioverter-defibrillators (ICDs) may improve detection of atrial fibrillation as well as differentiation of tachycardias. However, this advantage is undermined by complications associated with the second electrode, which is required in conventional dual chamber devices. Therefore, BIOTRONIK has developed a new electrode called the LinoxSMART S DX that, when used in conjunction with the Lumax DX ICD, offers dual-chamber detection without the risks associated with the second electrode.

A New Single Chamber implantierbarer Defibrillator mit Atrial Sensing: eine praktische Demonstration der Fernerkundung und Einfache Implantation

Implantable cardioverter-defibrillators (ICDs) terminate ventricular tachycardia (VT) and ventricular fibrillation (VF) with high efficacy and can protect ...

Forschung

Medizin

Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and disordered electrical activity in the atria gives rise to palpitations, fatigue, dyspnea, chest pain and dizziness with or without syncope 4, 5. Patients with AF have a five-fold higher risk of stroke 6.
Oral anticoagulation (OAC) with warfarin is commonly used for stroke prevention in patients with AF and has been shown to reduce the risk of stroke by 64% 7. Warfarin therapy has several major disadvantages, however, including bleeding, non-tolerance, interactions with other medications and foods, non-compliance and a narrow therapeutic range 8-11. These issues, together with poor appreciation of the risk-benefit ratio, unawareness of guidelines, or absence of an OAC monitoring outpatient clinic may explain why only 30-60% of patients with AF are prescribed this drug 8.
The problems associated with warfarin, combined with the limited efficacy and/or serious side effects associated with other medications used for AF 12,13, highlight the need for effective non-pharmacological approaches to treatment. One such approach is catheter ablation (CA), a procedure in which a radiofrequency electrical current is applied to regions of the heart to create small ablation lesions that electrically isolate potential AF triggers 4. CA is a well-established treatment for AF symptoms 14, 15, that may also decrease the risk of stroke. Recent data showed a significant decrease in the relative risk of stroke and transient ischemic attack events among patients who underwent ablation compared with those undergoing antiarrhythmic drug therapy 16.
Since the left atrial appendage (LAA) is the source of thrombi in more than 90% of patients with non-valvular atrial fibrillation 17, another approach to stroke prevention is to physically block clots from exiting the LAA. One method for occluding the LAA is via percutaneous placement of the WATCHMAN LAA closure device. The WATCHMAN device resembles a small parachute. It consists of a nitinol frame covered by fabric polyethyl terephthalate that prevents emboli, but not blood, from exiting during the healing process. Fixation anchors around the perimeter secure the device in the LAA (Figure 1). To date, the WATCHMAN is the only implanted percutaneous device for which a randomized clinical trial has been reported. In this study, implantation of the WATCHMAN was found to be at least as effective as warfarin in preventing stroke (all-causes) and death (all-causes) 18. This device received the Conformit&eacute; Europ&eacute;enne (CE) mark for use in the European Union for warfarin eligible patients and in those who have a contraindication to anticoagulation therapy 19.
Given the proven effectiveness of CA to alleviate AF symptoms and the promising data with regard to reduction of thromboembolic events with both CA and WATCHMAN implantation, combining the two procedures is hoped to further reduce the incidence of stroke in high-risk patients while simultaneously relieving symptoms. The combined procedure may eventually enable patients to undergo implantation of the WATCHMAN device without subsequent warfarin treatment, since the CA procedure itself reduces thromboembolic events. This would present an avenue of treatment previously unavailable to patients ineligible for warfarin treatment because of recurrent bleeding 20 or other warfarin-associated problems.
The combined procedure is performed under general anesthesia with biplane fluoroscopy and TEE guidance. Catheter ablation is followed by implantation of the WATCHMAN LAA closure device. Data from a non-randomized trial with 10 patients demonstrates that this procedure can be safely performed in patients with a CHADS2 score of greater than 1 21. Further studies to examine the effectiveness of the combined procedure in reducing symptoms from AF and associated stroke are therefore warranted.

Catheter ablation is combined with placement of the WATCHMAN Left Atrial Appendage Closure Device to prevent ischemic stroke in a patient with non-valvular atrial fibrillation.

Katheterablation in Kombination mit linken Herzohr Closure für Vorhofflimmern

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, affecting millions of individuals worldwide 1-3. The rapid, irregular, and ...

Robotic Ablation of Atrial Fibrillation

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between pulmonary vein (PV) and left atrium (LA) is created. This conduction block prevents AF, which is triggered by irregular electric activity originating from the PV. However, transmural atrial lesions are required which can be challenging. Re-conduction and AF recurrence occur in 20 - 40% of the cases. Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new remote catheter system (RCS), is presented. Objective of this article is to show feasibility of robotic AF ablation with a novel system. Materials and Methods: After interatrial trans-septal puncture is performed using a long sheath and needle under fluoroscopic guidance. The needle is removed and a guide wire is placed in the left superior PV. Then an ablation catheter is positioned in the LA, using the sheath and wire as guide to the LA. LA angiography is performed over the sheath. A circular mapping catheter is positioned via the long sheath into the LA and a three-dimensional (3-D) anatomical reconstruction of the LA is performed. The handle of the ablation catheter is positioned in the robotic arm of the Amigo system and the ablation procedure begins. During the ablation procedure, the operator manipulates the ablation catheter via the robotic arm with the use of a remote control. The ablation is performed by creating point-by-point lesions around the left and right PV ostia. Contact force is measured at the catheter tip to provide feedback of catheter-tissue contact. Conduction block is confirmed by recording the PV potentials on the circular mapping catheter and by pacing maneuvers. The operator stays out of the radiationfield during ablation. Conclusion: The novel catheter system allows ablation with high stability on low operator fluoroscopy exposure.

Pulmonary vein isolation (PVI) with an ablation catheter is a curative treatment for atrial fibrillation (AF). Robotic catheter systems aim to improve catheter steerability. Here, a procedure with a new robotic catheter system is presented. The goal of the procedure is electrical block between pulmonary vein and left atrium.

Robotic Ablation von Vorhofflimmern

Background: Pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). During PVI an electrical conduction block between ...

Non-fluoroscopic Catheter Tracking for Fluoroscopy Reduction in Interventional Electrophysiology

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that the application of this non-fluoroscopic catheter visualization system (NFCV) reduces fluoroscopy time and dose by 90-95% in a variety of electrophysiology (EP) procedures. This can be of relevance not only to the patients, but also to the nurses and physicians working in the EP lab. Furthermore, in a subset of indications such as supraventricular tachycardias, NFCV enables a fully non-fluoroscopic procedure and allows the lab staff to work without wearing lead aprons. With this protocol, we demonstrate that even complex procedures such as ablations of atrial fibrillation, that are typically associated with fluoroscopy times of &#62;30 min in conventional settings, can safely be performed with a reduction of &#62;90% in fluoroscopy exposure by the additional use of NFCV.

Radiation exposure is an underestimated risk in complex ablation procedures. Here, we describe a protocol to significantly decrease fluoroscopy time and dosage for both the patient and the lab staff by using a novel non-fluoroscopic catheter visualization system.

Non-Durchleuchtungs Catheter Tracking für Fluoroskopie Reduction in Interventional Elektrophysiologie

A technological platform (MediGuide) has been recently introduced for non-fluoroscopic catheter tracking. In several studies, we have demonstrated that ...

Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale (PFO) detection, for patient selection for transcatheter ASD/PFO closure,&#160;for intraoperative guidance and for long-term follow-up. The size, shape, location and the number of the atrial communications schould be determined. The accuracy of PFO detection can be improved by using agitated saline together with maneuvers to transiently increase the right atrial (RA) pressure. The appearance of microbubbles in the left atrium (LA) within 3 cardiac cycles after opacification of the RA is considered positive for the presence of an intracardiac shunt. Three dimensional TEE identifies further septal fenestrations and describes the dynamic morphology of ASD/PFO and atrial septal aneurysm. Follow-up evaluations with TTE is recommended at 1, 6, and 12 months after the procedure, with a subsequent evaluation every year. Previous studies showed an increased incidence of atrial arrhythmias early after device closure. Speckle tracking analysis may help to understand functional left atrial remodeling following percutaneous closure and its impact on atrial arrhythmias.

Transthoracic (TTE) and transesophageal (TEE) echocardiography represent the basic imaging tools for interatrial septum examination. Three dimensional (3D) TEE provides incremental information in the assessment of the interatrial septum. Further advanced echocardiography techniques using speckle tracking echocardiography are applied for sensitive volumetric and functional assessment of the heart chambers.&#160;

Echokardiographische Auswertung der Atrialkommunikation vor dem Transkatheterverschluss

Transthoracic (TTE) and transesophageal echocardiography (TEE) is the standard imaging method for atrial septal defect (ASD) and patent foramen ovale ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

Verwendung eines perkutanen ventrikulären Unterstützungsgeräts / linker Vorhof zu Femurarterien-Bypass-System für kardiogenen Schock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

Cox-Maze IV Procedure Concomitant with Valvular Surgery In Situs Inversus Dextrocardia: A Single-Center Experience in China

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically easier, faster, becoming the gold standard for the surgical treatment of AF. However, the efficacy and safety of CMP-IV in situs inversus dextrocardia are largely unknown. This paper summarizes the CMP-IV procedure performed concomitantly with valvular surgery in patients with situs inversus dextrocardia at this institution.
From February 2016 to September 2020, three dextrocardia patients with persistent AF and valvular diseases were referred to this institution for valvular and CMP-IV surgery. CMP-IV was performed using either cryoablation with a nitrous oxide (N2O)-based cryoprobe or a bipolar radiofrequency clamp and bipolar radiofrequency pen. Mechanical valve replacement or mitral vavuloplasty was performed in another patient in addition to tricuspid annuloplasty. Transmurality of the ablated atrial tissues was evaluated by electron microscopy. Heart function was assessed by transthoracic echocardiography. Cardiac rhythm was monitored by 24 h Holter at 3, 6, 12, 18, 24, and 48 months follow-up. 
All the AF was successfully eliminated in the ablation procedure without recurrence or other complications during hospitalization. The mean bypass and crossclamp times were similar in all the patients. The postoperative ventilator support time, the duration of stay in the ICU, and postoperative residence time were also not significantly different among the patients. Transmural atrial necrosis was detected in the ablated atrial tissues. Sinus rhythm maintenance was achieved at 3, 6, 12, 18, 24, and 48 months follow-up in all the patients. All valve protheses switched freely; no tricuspid regurgitation was observed. The results of the present study demonstrate that the CMP-IV is safe and effective in eliminating AF in dextrocardia patients concomitant with valvular surgery.

We summarize the Cox-Maze IV procedure concomitant with valvular surgery performed in patients with situs inversus dextrocardia at this institution.

Cox-Maze IV Verfahren Begleitend mit Klappenchirurgie in Situs Inversus Dextrokardie: Eine Single-Center-Erfahrung in China

Atrial fibrillation (AF) is the most common cardiac arrhythmia. The use of ablation technologies made the Cox-Maze IV procedure (CMP-IV) technically ...

Closure of a Patent Foramen Ovale (PFO): An Intervention Sequence

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young adults. PFO can be easily diagnosed by transthoracic contrast and/or transesophageal echocardiography. Interventional closure of the PFO via the femoral vein is a commonly used cardiological procedure since several trials have demonstrated the superiority of PFO closure over standard medical therapy in patients with PFO and who have experienced post ischemic, cardioembolic, or cryptogenic stroke. The current paper and video show the procedure of PFO closure in a step-by-step manner.

Closure of a Patent Foramen Ovale PFO: An Intervention Sequence

The closure of a patent foramen ovale (PFO) is a catheter-based intervention to prevent PFO-associated stroke. The PFO-occlusion device is advanced through the femoral vein and deployed across the interatrial septum using transesophageal echocardiography (TEE) and fluoroscopic guidance. The following protocol provides a step-by-step guide for the PFO-closure intervention using a double-disc device.

Verschluss eines offenen Foramen ovale (PFO): Eine Interventionssequenz

A patent foramen ovale (PFO) persists in about one-quarter of people and is the source of up to 25% of all ischemic strokes, especially strokes in young ...

Benefits of Cardiac Resynchronization Therapy in an Asynchronous Heart Failure Model Induced by Left Bundle Branch Ablation and Rapid Pacing

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac resynchronization therapy (CRT), and LBBB has become one of the important predictors for CRT response. The conventional tachypacing-induced HF model has several major limitations, including absence of stable LBBB and rapid reversal of left ventricular (LV) dysfunction after cessation of pacing. Hence, it is essential to establish an optimal model of chronic HF with isolated LBBB for studying CRT benefits. In the present study, a canine model of asynchronous HF induced by left bundle branch (LBB) ablation and 4 weeks of rapid right ventricular (RV) pacing is established. The RV and right atrial (RA) pacing electrodes via the jugular vein approach, together with an epicardial LV pacing electrode, were implanted for CRT performance. Presented here are the detailed protocols of radiofrequency (RF) catheter ablation, pacing leads implantation, and rapid pacing strategy. Intracardiac and surface electrograms during operation were also provided for a better understanding of LBB ablation. Two-dimensional speckle tracking imaging and aortic velocity time integral (aVTI) were acquired to validate the chronic stable HF model with LV asynchrony and CRT benefits. By coordinating ventricular activation and contraction, CRT uniformed the LV mechanical work and restored LV pump function, which was followed by reversal of LV dilation. Moreover, the histopathological study revealed a significant restoration of cardiomyocyte diameter and collagen volume fraction (CVF) after CRT performance, indicating a histologic and cellular reverse remodeling elicited by CRT. In this report, we described a feasible and valid method to develop a chronic asynchronous HF model, which was suitable for studying structural and biologic reverse remodeling following CRT.

The establishment of a chronic asynchronous heart failure (HF) model by rapid pacing combined with left bundle branch ablation is presented. Two-dimensional speckle tracking imaging and aortic velocity time integral are applied to validate this stable HF model with left ventricular asynchrony and the benefits of cardiac resynchronization therapy.

Vorteile der kardialen Resynchronisationstherapie in einem asynchronen Herzinsuffizienz Modell induziert durch linke Bundle Branch Ablation und schnellen Tempo

It is now well recognized that heart failure (HF) patients with left bundle branch block (LBBB) derive substantial clinical benefits from cardiac ...

Biologie

<meta charset="utf8"></head><body>Effiziente Reparatur von Spenderdefekten des linken Vorhofs mit Rotation des hinteren Lappens

Donor Posterior Atrial Flap Rotation for Left Atrial Cuff Reconstruction in Lung Transplantation

We describe in detail a novel surgical technique for repairing donor anterior left atrial wall defect in vivo by rotating the posterior atrial flap during lung transplantation. This method can safely and effectively address the most common type of donor left atrial cuff defect: the anterior wall defect, with the intact posterior wall, typically retained when the donor heart is also used. During atrial cuff anastomosis in lung transplantation, the excess donor posterior atrial wall is trimmed into an atrial flap. After the posterior wall anastomosis is completed, the atrial flap is rotated 180&#176; and used as a patch for anterior wall reconstruction anastomosis. 
After restoring blood flow, the flow rate of the pulmonary vein is normal and smooth as confirmed by transesophageal echocardiography. Compared with the traditional patch reconstruction method, the new method effectively reduces the atrial cuff anastomosis time. Our results showed no significant difference in pulmonary vein obstruction after reconstruction. Pulmonary artery systolic blood pressure was significantly lower and pulmonary function improved postoperatively in all groups, with no significant differences among the groups. The new technique provides a feasible strategy for the reconstruction of left atrial cuff defects and can improve the effective utilization rate of donor lungs.

<meta charset="utf8"></head><body>Rotation des hinteren Vorhoflappens des Spenders für die Rekonstruktion der linken Vorhofmanschette bei Lungentransplantation

This protocol describes a new method for effectively reconstructing donor atrial cuff anterior wall defects during lung transplantation through the rotation of the donor posterior atrial flap.

Rotation des hinteren Vorhoflappens des Spenders für die Rekonstruktion der linken Vorhofmanschette bei Lungentransplantation

We describe in detail a novel surgical technique for repairing donor anterior left atrial wall defect in vivo by rotating the posterior atrial flap during ...