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1。事前手続きの準備<ol><li>事前の手順を実行するために、患者とプロシージャのリスクと利点を説明し、署名した同意書を取得します。 3.0から2.0の国際標準化率を達成するために、患者のビタミンK拮抗薬の投与量を調整します。アップ手順の時に抗不整脈薬治療を続けています。 </li><li>前日またはプロシージャの日か、LAA内血栓の有無を記録するために経食道心エコー（TEE）を行い、（参照LAAの機能と種類を評価し、移植するために適切な夜警デバイスのサイズを決定する詳細については、メビウス·ウィンクラーらによる2012 Joveの記事）22。 </li><li>手順については、適切な診断およびイメージング機器と電気生理学ラボで結合されたカテーテルアブレーションと夜警のLAA閉鎖デバイスの配置手順を実行します。 </li><li>仰臥位の患者、administe付き制度上のプロトコルに従ってR麻酔。 </li></ol> 2。カテーテルアブレーション<ol><li>電気生理学的記録システム（バード社、ローウェル、マサチューセッツ州）は100から500 kHzおよび5000の信号増幅のフィルタ設定を使用していることを確認します。 </li><li>患者は完全に麻酔したら、脚の付け根の領域における局所麻酔としてリドカイン1％の20ミリリットルを管理します。直ちに、清潔で準備カニュレーション用の鼠径部。 </li><li>大腿静脈の位置を確認し、静脈8フレンチ（8F）シースを挿入します。ペーシングの目的のために冠状静脈洞に四極カテーテルを導入する。その後、長いガイドワイヤーを挿入し、シースを除去します。標準静脈経アクセスシースをご紹介します。 </li><li>長いワイヤーを外し、12.5F-outer-diameter/9.5F-inner-diameter操縦可能なシースと経RF Brockenbrough針（ベイリス·メディカルカンパニーインク、モントリオール、ケベック、カナダ）（チャンネル、吟遊詩人、ローウェル、マサチューセッツ州の挿入）および経中隔punctuを実行再。 </li><li>心房中隔を渡った後、左心房の中心にあるピグカテーテルを配置し、3D回転血管造影を行う。 </li><li>肺静脈アブレーションカテーテル（PVAC：メドトロニック/アブレーションフロンティア株式会社、カールスバッド、カリフォルニア州）は、遠位先端に25mmの直径を持つ配列9F、オーバー·ザ·ワイヤー、円形、decapolarマッピングおよびアブレーションカテーテルです。 PVAC、マッピング、アブレーションと肺静脈隔離の検証を有効にニチノールのフレームに10個の電極を持っています。 PVACに0.032インチのガイドワイヤーを挿入します。 </li><li>次に、静脈シースにシステム全体を挿入します。 PVACによって収集された情報は、表示されたカテーテルの位置が患者の心臓の3D画像を生成するためにモニターに表示されます。 </li><li>手順の結果として凝固を防ぐために10.000IEヘパリンのボーラスをお届けします。肺静脈の枝の一つにワイヤーを置き、その後、肺静脈の前庭にPVACを進める。 </li><li> fluoroscopiを使用PVAcの位置を評価し、電極の全てで最高のコンタクトを得るためにそれを調整するには、c指導、電位図、および3D電気信号イメージング（ESI）の再建。 </li><li>満足カテーテル位置が達成されると、RFエネルギーの送達のために適切な電極対を選択することにより、無線周波数（RF）アブレーションを開始。 </li><li>選択されたペアの各電極に60℃の目標温度を達成するために電力を調整するために発電機を設定します。ほとんどの場合、すべての電極対は、病変リングを重複作成する最初のアプリケーションの間に活性化されます。 </li><li> 60秒のために切除する。アブレーション時の条件については、モニターをチェックしてください。温度が15秒以内に50℃以上に上昇しない場合は、アプリケーションを中止電極の位置を調整し、再度起動します。 </li><li>円周肺静脈の病変を作成するPVACカテーテルを移動し、回転させます。 </li><li>すべての肺静脈について、この手順を繰り返します。 </li><li> CR後のすべての肺静脈のための周病変を食べて、直流除細動（DCCV）により洞調律を回復。 </li><li>冠状静脈洞から操縦をペーシングと組み合わせる各静脈内側PVACマッピングと局所ポテンシャル（入り口と出口ブロック）の有無をチェックすることで分離を確認してください。 </li><li>隔離された電極対上の残留電位、それだけと隣接するペアのターゲットアブレーションが目標温度に到達容易にするために。 </li></ol> 3。夜警デバイスの移植<ol><li>カテーテルアブレーションの手順が完了したら、夜警デバイスが注入される。 </li><li> PVAC及びガイドワイヤの位置を維持しながら、左上肺静脈内のガイドワイヤ。PVACを外した位置に0.035 &quot;スティッフガイドワイヤー（ 例えば Amplatzスーパースティッフ260センチメートル）を進める。 </li><li>アブレーションは、移植前に行われなかった場合は、活性化凝固時間oを取得するために100 IU / kg体重でヘパリンを投与fは200から300秒。それはまだ200から250秒であることを確認するために活性化凝固時間のレベルをチェックします。必要に応じて、この30分ごとに継続的に監視します。 </li><li>無菌条件下での包装から夜警アクセスシステム及び拡張器を取り外します。慎重に損傷がないか点検します。 </li><li>生理食塩水60CC注射器を埋めると夜警アクセスシースのサイドポートをフラッシュします。ダイレータをフラッシュするために、残りの生理食塩水を使用します。夜警アクセスシースにダイレータを挿入します。 </li><li>左心房にガイドワイヤ上夜警アクセスシースとダイレータを前進させます。夜警アクセスシースが左心房の中心に近づくと、拡張器を保持し、左心房のみの初期位置に夜警アクセスシースを前進させます。 </li><li>ダイレータとガイドワイヤを外します。止血弁を締める前に、戻って空気を導入するための可能性を最小限に抑えるために出血を許可します。生理食塩水で夜警アクセスシースをフラッシュします。 </li><li>アクセスシースのバルブを締めます。 </li><li> CONに会社のLAA寸法は、0°、45°、90°、135°で4ビューの最大のLAAの寸法を測定するためにTシャツを使用しています。 </li><li>生理食塩水でピグカテーテルをフラッシュし、ワイヤ上と夜警アクセスシースを介してそれを進める。その後、ガイドワイヤを削除して、ピグに造影剤と注射器を接続してください。 </li><li> TEEを見ながら、シースはもっと前に整列し、LAAの遠位部で所望の位置にピグを進めるために、反時計回り夜警アクセスシースを回します。 </li><li>ピグテールカテーテルがLAAに達した後、20〜30℃、尾20〜30°の（RAO）右前斜位で血管造影を得る。その後、0から135°掃引の最小値とTEEを実行します。シースは壁やLAAの頂点付近に進んでいるときに、任意の解剖で、より遠位に進めながら、これが最も重要です。 </li><li>慎重に最も優れた葉のピグテールカテーテル経由でアクセスシースを前進さ：血管造影では、これはLAAローブsituatですEDで2時の周りの右前斜（RAO）20〜30℃の、尾20〜30℃、TEE、それは135°でLAAローブ最も正しいです。 </li><li>透視下で、適切なサイズに対応するマーカ帯域に基づいて、LAAで所望の深さまで夜警アクセスシースを前進させます。 </li><li>ピグは、できるだけ遠位になったら、造影剤を注入します。 </li><li>最大LAA口寸法やサイジング22に基づいて、適切な見張りデバイスのサイズを選択します。 </li><li>無菌条件下で、損傷がないか点検し包装から夜警デバイスを削除します。デバイスが芯線に接続されていることを確認するには、止血弁を開き、デバイス約1cmを撤回。 </li><li>マーカーバンドを持つデバイスの遠位先端部の位置を合わせます。夜警デバイスが突出していないはずです。 </li><li>生理食塩水を含む大規模な60 ccシリンジを取り付けます。空気を除去するために、システムを数回洗浄してください。その後、水没でデリバリーカテーテルの先端生理食塩水と気泡を除去するために、それをタップします。 </li><li>血管造影によるアクセスシースの位置を再確認。アクセスシースバルブを緩め、ゆっくりと鞘からピグテールカテーテルを除去します。シースはブリードをバックアップできるようになります。 </li><li>それが送達カテーテルから滴りよう空気を導入することを避けるためには、フラッシュポートを介して生理食塩水を注入し、その後、夜警装置システムを導入。 </li><li>透視下で、ゆっくりとデリバリーカテーテル上のマーカーバンドが付いているアクセスシースライン上の最遠位マーカーバンドまで、アクセスシースにデリバリーカテーテルを前進させ、デリバリーカテーテルを安定させる。 </li><li>アクセスシースを引っ込めるとデリバリーカテーテル上にはめ込みます。 X線透視を使用して、デリバリーカテーテル先端の位置を再確認する。デリバリーシステムがそれにスナップされた後、アクセスシースを進めない。 </li><li>再配置が必要な場合は、デリバリーシステムを取り外し、挿入し直しピグテールカテーテルとPRにアクセスシースを進めるOPER位置。 </li><li>デリバリーシステムが配置されると、夜警デリバリーカテーテルのバルブを緩めます。口への前進前進または再配置相対が発生しないことを確実にするためにデバイスの遠位端を観察します。 </li><li>次に、デバイスを展開するためには、デプロイメント·ノブが静止したまま、ゆっくり3から5秒の期間にわたって安定した低速の動きでアクセスシース/デリバリーカテーテルアセンブリを引っ込める。 </li><li>アクセスシース/デリバリーカテーテルアセンブリ装置から数センチの芯線を接続したまま、LAAに揃え撤回。 </li><li>装置が配備された後、再びコントラストを注入します。その後、透視やTEEを使って、位置を確認し、アンカー、サイズ及びシール（PASS）デバイスのリリース基準は、次のように満たされている： </li><li> 位置 ：デバイスが正しくデバイスの最大径の平面がLAAの口にまたがり、LAAのオリフィスから遠位で、または単にであることを確実にすることによって、配置されていることを確認します。 </li> &lt;LI&gt; アンカー： -優しくして、デバイス後退に直面してから2cmと展開ノブを解除装置を確認し、アクセスシース/デリバリーカテーテル組立体1を引き出すことによって、所定の位置に固定されている。 LAAとデバイスが一斉に移動する必要があります。 </li><li> サイズ：デバイスは0°、45°、90°、135°、ネジ付きインサートを確保するが表示されている標準的な4ビューでTEEを使用して、デバイスの最大径の平面を測定することにより、適切な大きさであることを確認します。デバイスは、元のサイズの80から92パーセントでなければなりません。 </li><li> シール：カラードプラを用いた場合は、デバイスに対して遠位のローブの全てが封印されていることを確認する。色の流れは、デバイスの近く検出されるべきではない。 5ミリメートルより大きいデバイスの周りに隙間やジェットがある場合は、デバイスが再配置または完全に奪還し、交換する必要があります。 </li><li>すべてのリリース条件が満たされている場合は、デバイスの顔にアクセスシース/デリバリーカテーテルを上に移動および回転展開ノブ3-5解除し、反時計回りになります。 </li><li>リリース後、デバイスが所定の場所に残っていることを文書化するために造影剤で血管造影を行う。その後、TEE、再チェックサイズやシールを使用。左心房からシースアセンブリを取り外します。 </li><li>デバイスがあまりにも遠位またはLAAまたはデバイスの基準が満たされていない中で近接している場合は、部分的または完全装置（詳細はメビウス·ウィンクラーらによる2012年のJoveの記事を参照してください）22を奪還する必要があるかもしれません。 </li></ol> 4。処置後<ol><li>装置の適切な配置が確認された後、シースを除去します。大腿静脈は、その後、数時間のために圧縮されるべきであり、患者には慎重に血圧と心拍数のモニタリングで少なくとも6時間を監視する必要があります。 </li><li>制度上のガイドラインに従って定期的な間隔で血腫および/または出血を確認してください。患者が目につき抗生物質の予防的投与を投与すべきである電子アメリカ心臓協会のガイドライン。注：POSTプロシージャヘパリンは推奨されません。 </li><li>患者が覚醒したら、神経学的検査を行う。 </li><li>患者は、インプラントの手順（内部標準比= 2.0から3.0）の後45日以上ワルファリンおよび81 mgのアスピリンに残るはずです。 </li><li>患者は一晩入院し、翌日に排出する必要があります。経胸壁心エコー（TTE）または胸部X線は心嚢液貯留の有無を確認するために実行することができる。 </li><li> 45日目には、TEEを使って夜警デバイス配置を評価する。 LAAを完全に閉じていると、デバイス上の血栓が除外された場合はワルファリンを中止し、医師の裁量に委ねられる。流れが5mm以上装置の周りに指摘されている場合はそれが5mm未満に減少するまで、配慮がワルファリンで患者を維持するために与えられるべきである。 </li><li>ワルファリンを中止する患者は6ヵ月後にインプラントを介して毎日75mgのクロピドグレルを開始し、撮影を続行する必要があり毎日の無期限スピーリン。 </li><li>移植後6ヶ月に適した心内膜炎の予防を処方する。 6ヶ月を超えて心内膜炎の予防を継続すると医師の裁量に委ねられる。 </li></ol>

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	<li>Wolowacz, S. E., Samuel, M., Brennan, V. K., Jasso-Mosqueda, J. G., 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=The+cost+of+illness+of+atrial+fibrillation:+a+systematic+review+of+the+recent+literature.+Europace+:+European+pacing,+arrhythmias,+and+cardiac+electrophysiology.">The cost of illness of atrial fibrillation: a systematic review of the recent literature. Europace : European pacing, arrhythmias, and cardiac electrophysiology.</a> Journal of the Working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology. 13, 1375-1385 (2011).</li><li>Miyasaka, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Secular+trends+in+incidence+of+atrial+fibrillation+in+Olmsted+County,+Minnesota,+1980+to+2000,+and+implications+on+the+projections+for+future+prevalence.">Secular trends in incidence of atrial fibrillation in Olmsted County, Minnesota, 1980 to 2000, and implications on the projections for future prevalence.</a> Circulation. 114, 119-125 (2006).</li><li>Psaty, B. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incidence+of+and+risk+factors+for+atrial+fibrillation+in+older+adults.">Incidence of and risk factors for atrial fibrillation in older adults.</a> Circulation. 96, 2455-2461 (1997).</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>Bin Salih, S. A., A, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+characteristics+of+patients+with+atrial+fibrillation+at+a+tertiary+care+hospital+in+the+central+region+of+Saudi+Arabia.">Clinical characteristics of patients with atrial fibrillation at a tertiary care hospital in the central region of Saudi Arabia.</a> J. Family Community Med. 18, 80-84 (2011).</li><li>Lloyd-Jones, D. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lifetime+risk+for+development+of+atrial+fibrillation:+the+Framingham+Heart+Study.">Lifetime risk for development of atrial fibrillation: the Framingham Heart Study.</a> Circulation. 110, 1042-1046 (2004).</li><li>Hart, R. G., Pearce, L. A., Aguilar, M. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis:+antithrombotic+therapy+to+prevent+stroke+in+patients+who+have+nonvalvular+atrial+fibrillation.">Meta-analysis: antithrombotic therapy to prevent stroke in patients who have nonvalvular atrial fibrillation.</a> Ann. Intern. Med. 146, 857-867 (2007).</li><li>Nieuwlaat, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Atrial+fibrillation+management:+a+prospective+survey+in+ESC+member+countries:+the+Euro+Heart+Survey+on+Atrial+Fibrillation.">Atrial fibrillation management: a prospective survey in ESC member countries: the Euro Heart Survey on Atrial Fibrillation.</a> European Heart Journal. 26, 2422-2434 (2005).</li><li>Gage, B. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Adverse+outcomes+and+predictors+of+underuse+of+antithrombotic+therapy+in+medicare+beneficiaries+with+chronic+atrial+fibrillation.">Adverse outcomes and predictors of underuse of antithrombotic therapy in medicare beneficiaries with chronic atrial fibrillation.</a> Stroke: A Journal of Cerebral Circulation. 31, 822-827 (2000).</li><li>Hylek, E. M., Evans-Molina, C., Shea, C., Henault, L. E., Regan, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+hemorrhage+and+tolerability+of+warfarin+in+the+first+year+of+therapy+among+elderly+patients+with+atrial+fibrillation.">Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation.</a> Circulation. 115, 2689-2696 (2007).</li><li>Sudlow, M., Thomson, R., Thwaites, B., Rodgers, H., Kenny, R. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prevalence+of+atrial+fibrillation+and+eligibility+for+anticoagulants+in+the+community.">Prevalence of atrial fibrillation and eligibility for anticoagulants in the community.</a> Lancet. 352, 1167-1171 (1998).</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>Echt, D. S., et al. <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> The New England Journal of Medicine. 324, 781-788 (1991).</li><li>Cappato, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Updated+worldwide+survey+on+the+methods,+efficacy,+and+safety+of+catheter+ablation+for+human+atrial+fibrillation.+Circulation.">Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circulation.</a> Arrhythmia and Electrophysiology. 3, 32-38 (2009).</li><li>Kumagai, K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Catheter+ablation+of+atrial+fibrillation.">Catheter ablation of atrial fibrillation.</a> Circ. J. 75, 2305-2311 (2011).</li><li>Reynolds, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Health+outcomes+with+catheter+ablation+or+antiarrhythmic+drug+therapy+in+atrial+fibrillation:+results+of+a+propensity-matched+analysis.">Health outcomes with catheter ablation or antiarrhythmic drug therapy in atrial fibrillation: results of a propensity-matched analysis.</a> Circulation. Cardiovascular Quality and Outcomes. 5, 171-181 (2012).</li><li>Blackshear, J. L., Odell, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Appendage+obliteration+to+reduce+stroke+in+cardiac+surgical+patients+with+atrial+fibrillation.">Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.</a> The Annals of Thoracic Surgery. 61, 755-759 (1996).</li><li>Holmes, D. R., et al. <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>Singh, I. M., 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=Left+atrial+appendage+closure.">Left atrial appendage closure.</a> Current Cardiology Reports. 12, 413-421 (2010).</li><li>Velthuis, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+Atrial+Appendage+Closure+for+Stroke+Prevention+in+Patients+with+Atrial+Fibrillation+and+Hereditary+Hemorrhagic+Telangiectasia.">Left Atrial Appendage Closure for Stroke Prevention in Patients with Atrial Fibrillation and Hereditary Hemorrhagic Telangiectasia.</a> Case Reports in Cardiology. 3, (2012).</li><li>Swaans, M. J., Post, M. C., Rensing, B. J., Boersma, L. V. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Percutaneous+left+atrial+appendage+closure+for+stroke+prevention+in+atrial+fibrillation.">Percutaneous left atrial appendage closure for stroke prevention in atrial fibrillation.</a> Netherlands Heart Journal: Monthly Journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation. 20, 161-166 (2012).</li><li>Mobius-Winkler, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+WATCHMAN+left+atrial+appendage+closure+device+for+atrial+fibrillation.">The WATCHMAN left atrial appendage closure device for atrial fibrillation.</a> J. Vis. Exp. (60), e3671 (2012).</li><li>Garcia-Fernandez, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Role+of+left+atrial+appendage+obliteration+in+stroke+reduction+in+patients+with+mitral+valve+prosthesis:+a+transesophageal+echocardiographic+study.">Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study.</a> Journal of the American College of Cardiology. 42, 1253-1258 (2003).</li><li>Blackshear, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thoracoscopic+extracardiac+obliteration+of+the+left+atrial+appendage+for+stroke+risk+reduction+in+atrial+fibrillation.">Thoracoscopic extracardiac obliteration of the left atrial appendage for stroke risk reduction in atrial fibrillation.</a> Journal of the American College of Cardiology. 42, 1249-1252 (2003).</li><li>Block, P. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Watching+the+watchman.">Watching the watchman.</a> Journal of the American College of Cardiology. 49, 1496-1497 (2007).</li><li>Block, P. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=+Percutaneous+left+atrial+appendage+occlusion+for+patients+in+atrial+fibrillation+suboptimal+for+warfarin+therapy:+5-year+results+of+the+PLAATO+(Percutaneous+Left+Atrial+Appendage+Transcatheter+Occlusion)+Study."> Percutaneous left atrial appendage occlusion for patients in atrial fibrillation suboptimal for warfarin therapy: 5-year results of the PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) Study.</a> JACC. Cardiovascular. 2, 594-600 (2009).</li><li>Viles-Gonzalez, J. F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Incomplete+occlusion+of+the+left+atrial+appendage+with+the+percutaneous+left+atrial+appendage+transcatheter+occlusion+device+is+not+associated+with+increased+risk+of+stroke.">Incomplete occlusion of the left atrial appendage with the percutaneous left atrial appendage transcatheter occlusion device is not associated with increased risk of stroke.</a> Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing. 33, 69-75 (2012).</li><li>Cappato, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Worldwide+survey+on+the+methods,+efficacy,+and+safety+of+catheter+ablation+for+human+atrial+fibrillation.">Worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation.</a> Circulation. 111, 1100-1105 (2005).</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><li>Oral, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Pulmonary+vein+isolation+for+paroxysmal+and+persistent+atrial+fibrillation.">Pulmonary vein isolation for paroxysmal and persistent atrial fibrillation.</a> Circulation. 105, 1077-1081 (2002).</li><li>Biase, L. D. i., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Left+atrial+appendage:+an+underrecognized+trigger+site+of+atrial+fibrillation.">Left atrial appendage: an underrecognized trigger site of atrial fibrillation.</a> Circulation. 122, 109-118 (2010).</li></ol>

聖アントニウス病院（ニューウェハイン、オランダ）の心臓部はAtritech /ボストン·サイエンティフィックからトレーニング/教育サービスのための試験監督料を受け取ります。 この記事への生産とフリーアクセスがボストン·サイエンティフィック社が主催しています。

上記のテキストは、AFのための治療と関連した血栓塞栓症の予防のような複合カテーテルアブレーションと左心耳の閉塞のための手順を説明します。予備的なデータは、この手順を安全に脳卒中のリスクが高い患者で行うことができることを示している。技術的な難しさは、結合された手順を実行する際に遭遇されていません。彼らはお互いに影響を与えませんので、どちらの方法にも改善が期待できない一方で、結合された手順は、別途手順を実行するよりもいくつかの利点を提供することができる。組み合わせの手順では、AFによって影響を受けた人々の生活の質の向上、AFの症状と脳卒中リスクの低減の同時処理を可能にします。それはまたそれらがその後のワルファリン治療せずに夜警デバイスの移植を受けることを許容することによって、薬物難治性·患者の治療法の選択肢を提示することができる。さらに、の必要性、および関連するリスク、繰り返し左心房LAAの閉鎖はフォローアップの間に、所望になるべき介入や経穿刺が低減されます。 CAはAFの症状のための確立された治療法ですが、最近のデータは、それはまた、脳卒中を減少させるのに有効であることを示唆している。マッチのAF患者のペアのレトロスペクティブ分析では、レイノルズらは抗不整脈薬療法を受けている16と比べてアブレーションを施行した患者のうち、脳卒中や一過性脳虚血発作イベントの相対リスクの有意な減少を見た。また、データは配置が効果的に塞栓症を減少させる外科的結紮またはデバイスを介してLAAまたは閉塞のその切断を示します。これらのメソッドは、有望な表示されます。僧帽弁置換術を受けた患者の研究では外科的結紮を受けたものは、19（3対17％）23を大幅に少ないストロークを持っていた。ループのスネア·プロシージャを使用して、低侵襲、胸腔鏡下結紮は15の14で正常に実行された次の42ヶ月19,24の上に2例（4％）で発生した脳卒中患者。 いくつかの経皮的カテーテルLAA閉塞デバイスはAmplatzer心臓プラグ（AGAの医療）、塞栓パッチ（カスタム医療機器）、皮のLAA塞栓閉塞（PLAATO）システム、および夜警LAA閉塞デバイスを含む開発されてきた。現時点では、安全性と有効性に関する臨床試験が唯一PLAATO（利用できなくなっている）と見張りのために発行されます。 PLAATOは、安全性と有効性を実証し、ニチノールフィルタベースのデバイスを使用してLAAの閉鎖のための概念の証拠を提供しています。デバイスは、LAA 25に入るから血を防止ポリテトラフルオロエチレンで覆われた自己拡張ニチノールケージでした。 &gt; 2のCHADS 2を搭載した64人の患者の非無作為化研究では、患者の98％以上で完全閉塞を認めた。 5年後、一過性/虚血性脳卒中ATTAC誘電率は人口26で期待される6.6％に比べて3.8％減少した。 ワルファリンによる治療に夜警装置の有効性を比較し、PROTECT AFの研究18から得られたデータはさらに、LAA閉塞のデバイスベースのアプローチをサポートしています。この無作為化試験では、手続きが最終的に患者の慢性ワルファリン療法の代替として使用される可能性を高め、その注入夜警がOACの適格患者における全死因脳卒中および全死因死亡率の面で非劣性であることが判明したことを示した薬物率18人です。 2012 21年にオランダ·ハート·ジャーナルに発表された研究では、我々は正常に同時CAを受けた9人の10人の患者に装置を移植した。残留流れはフォローアップ45日間で3例に見られたものの、Viles-Gonzalezと同僚は装置の周りこの残留流れが関連付けられていないことを示していることに注意してください27血栓塞栓症のリスクの増加。 入手可能なデータはAFのための効果的な治療法として夜警デバイスを使用してCAとLAAオクルージョンの両方をサポートしていますが、両方の手続きが合併症に関連付けられています。 2010年にカリフォルニアの世界的な調査では、合併症は、患者14の4.5％に起こることを示した。最も重大な合併症は、次のとおり死、脳血栓塞栓症、extrapericardial肺静脈穿孔、タンポナーデ、狭窄、新規発症（医原性）14、15、28の非定型フラッターを。夜警デバイス配置手順に起因するかもしれない処置合併症は深刻な心嚢液貯留、デバイス塞栓、手技関連ストローク18を含む。どちらのケースでも、合併症の発生率は、オペレータの経験15、29に依存することが見出されている。 結合された手順については、安全性に関するデータは、当社の2012年の研究に限定されているCOMのplicationsは、1つのデバイス·塞栓症に限られていました。患者の半数は、3ヶ月のフォローアップでAFの再発を文書化していなかった。患者の残りの半分は、少なくとも一つの直流電気的除細動を必要とした。一人の患者はリピートアブレーションを施行し、それが21成功しました。この研究では、小集団であったと他の治療方法との直接の比較を提供していない、独立した手順29のそれぞれの安全性の研究、30は治療オフセットの潜在的な利点のある安全上のリスクの増加を示唆している。けれども考慮すべきその他の安全性の問題は長い夜警の配置を添付しなければならない手続き回、全身麻酔のための要件、およびティーのモニタリングと、GI管出血のリスクの増加である。 本明細書で説明する手順は、警備員の配置やPV CAの複合手順を説明しているが、それは警備員の配置がstrategすることを妨げるものではないことに注意することが重要であるLAAの電気的絶縁のy。ディBiaseらによる最近の研究では、再発性AFと選択された患者群では、27％が巣を最適に完全な円周のLAA分離31を介して処理された初期のアブレーション後LAAから生じる示したことを明らかにした。 LAAの電気的分離はそれがより血栓作り、洞調律時にもLAAの停滞につながる可能性があるため、この患者群は、特に閉鎖のLAAの恩恵を受ける可能性があります。 AFのアブレーションとLAAの閉鎖が検討されている人に、まずは可能LAAを検出して切除するために薬理学的課題に電気生理学的検査を行うことができるための患者では夜警装置31の移植の前にトリガされます。 10ハイリスク患者をフォローアップする本研究は無作為ではなく、45日間に限定されて与えられた、数多くの質問が対処されずに残っている：ストロークPRでより効果的な複合カリフォルニア/夜警移植手順です単独方法よりもAFの症状のeventionと安堵？手続きの順番を逆にした場合はどのように手続きのメリットは、LAA閉塞最初に、比較するのですか？どのように手続きの安全性は、デバイスの移植またはCA単独と比べてどうですか？これは低リスク患者では効果的ですか？結合されたプロシージャの影響を受け、将来の切除の必要はありますか？手順は、ワルファリンを服用していない患者で同等の成功を行うことができますか？今後の研究では、これらの技術を組み合わせることで、これらの患者において患者の転帰と生活の質を改善するかどうかを検討する無作為化対照研究が含まれます。 この手順を実行するときには、デバイスのサイズを選択する際は慎重にLAAの解剖を評価するために、徹底的にそれを解放する前に、デバイスの配置を確認することが重要であることに注意してください。それは、デバイス用のランディングゾーンの深さは目の幅の最大値と同じかそれ以上であることを確認することも非常に重要です電子LAA口。これらのステップは、患者の安全と手順の有効性に重要である。

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.

In a preliminary study of WATCHMAN implantation in 10 patients that had a high risk of stroke and bleeding, 9 of the patients received the device after a catheter ablation. The data from this study is published in the Netherlands Heart Journal, and is presented here with permission 21. All patients included in the study were fully informed about the procedure and signed a consent form. The study was approved by the hospital's ethics committee and all procedures were performed in accordance with the hospital's ethics standards and the Helsinki Declaration of 1975 (revised in 2008).
The characteristics of these patients are summarized in Table 1. All patients had documented AF with a high stroke risk (CHADS2 &gt;1) and all but one of the patients had history of stroke. LAA closure was indicated as an alternative to OAC for the following reasons: stroke during OAC therapy (3/10), severe bleeding during OAC therapy (2/10) and patient preference (5/10). Prior to the procedure all patients were taking a vitamin K antagonist. The median CHADS2 score for this group was 3, with a median CHA2DS2-VASc score of 3.5 and a median HAS-BLED score of 1.5. Prior to the procedure, all patients underwent TEE to exclude LAA thrombus and to rule out structural cardiac abnormalities. Among patients, the average maximum LAA diameter was 20.2&plusmn;2.2 mm with an average depth of 27.9&plusmn;5.4 mm. 40% of the patients had a multi-lobular atrial appendage.
Table 2 outlines procedural characteristics. The WATCHMAN LAA closure device was successfully placed in all 10 patients. Based on patient anatomy determined during preliminary TEE, three different device sizes were used. The median total procedure time was 104 min (range 75-167 min), including a median 56 min (range 38-137 min) for LAA occlusion. During the procedure, an asymptomatic catheter thrombus occurred in one patient. The thrombus was aspirated and the patient received an extra bolus of heparin. Prolonged femoral vein bleeding in this patient necessitated a blood transfusion and extended hospitalization. All other patients were discharged from the hospital on the day following the procedure (Table 2). OAC was continued at least until TEE was performed at 45 days, at which point the device position and closure rate was assessed.
The findings at the 45-day patient follow-up are summarized Table 3. Successful device implantation was defined as long-term sealing of the LAA as measured by TEE 45 days after the procedure without major adverse events. Residual flow (&lt; 5 mm) around the device was allowed after the procedure (according to the PROTECT-AF study). Importantly, no thromboembolic cerebral events occurred. Minimal residual flow was observed in 3 patients. TEE revealed asymptomatic embolization of the device in one patient, and the device was percutaneously retrieved via the femoral vein. Thrombus was not seen on the device in any cases. One patient required a redo-ablation procedure 3 months after the initial procedure, in which pulmonary vein isolation was successful. The implanted LAA device was not affected by and did not interfere with the procedure. Three of the 10 patients were able to discontinue warfarin treatment at 45 days. In the PROTECT-AF18 and Continues Access Registry29 device embolization occurred in 3 patients out of the 1,002 patients implanted.
Figure 2 shows a TEE screen capture of the LAA in one example patient in which no residual flow is observed 45 days post-procedure. In contrast, flow around the device, as evidenced by color Doppler, is seen for another patient (Figure 3).
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Baseline Characteristics</td>
		</tr>
		<tr>
			<td>Number, n</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Age (years)</td>
			<td>61.6 +/9.6</td>
		</tr>
		<tr>
			<td>Sex (%female)</td>
			<td>5 (50)</td>
		</tr>
		<tr>
			<td>Median CHADS2</td>
			<td>3 (2-4)</td>
		</tr>
		<tr>
			<td>2</td>
			<td>4 (40)</td>
		</tr>
		<tr>
			<td>3</td>
			<td>4 (40)</td>
		</tr>
		<tr>
			<td>4</td>
			<td>2 (20)</td>
		</tr>
		<tr>
			<td>CHA2DS2-VASc</td>
			<td>3.5 (2-6)</td>
		</tr>
		<tr>
			<td>HAS-BLED</td>
			<td>1.5 (1-4)</td>
		</tr>
		<tr>
			<td>Vitamin K antagonist, n(%)</td>
			<td>10 (100)</td>
		</tr>
		<tr>
			<td colspan="2">Indication, n(%)</td>
		</tr>
		<tr>
			<td>Bleeding with OAC</td>
			<td>2 (20)</td>
		</tr>
		<tr>
			<td>Stroke using OAC</td>
			<td>3 (30)</td>
		</tr>
		<tr>
			<td>Patient Preference</td>
			<td>5 (50)</td>
		</tr>
		<tr>
			<td colspan="2">LAA, mm</td>
		</tr>
		<tr>
			<td>LAA width</td>
			<td>20.2+/2.2</td>
		</tr>
		<tr>
			<td>LAA length</td>
			<td>27.9+/-5.4</td>
		</tr>
		<tr>
			<td>Multilobular</td>
			<td>4 (40)</td>
		</tr>
	</tbody>
</table>
Table 1. Baseline characteristics of patients enrolled in the study. Data reprinted with permission from the Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, OAC=oral anticoagulation, LAA=left atrial appendage.
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Procedural characteristics</td>
		</tr>
		<tr>
			<td>PVAC, n(%)</td>
			<td>9 (90)</td>
		</tr>
		<tr>
			<td>Size device (mm)</td>
			<td>24 (21-27)</td>
		</tr>
		<tr>
			<td>21</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>24</td>
			<td>8 (80)</td>
		</tr>
		<tr>
			<td>27</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>LAA Occlusion Time (min)</td>
			<td>56 (38-137)</td>
		</tr>
		<tr>
			<td>Total procedural time (min)</td>
			<td>104 (75-167)</td>
		</tr>
		<tr>
			<td>Devices, n</td>
			<td>2 (1-3)</td>
		</tr>
		<tr>
			<td colspan="2">Complications, n(%)</td>
		</tr>
		<tr>
			<td>Catheter thrombus</td>
			<td>1 (10)*</td>
		</tr>
		<tr>
			<td>Inguinal bleeding</td>
			<td>1 (10)*</td>
		</tr>
		<tr>
			<td>Pericardial effusion</td>
			<td>0 (0)*</td>
		</tr>
		<tr>
			<td colspan="2">TEE</td>
		</tr>
		<tr>
			<td>Successful implantation</td>
			<td>10 (100)</td>
		</tr>
		<tr>
			<td>Residual Flow</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>Hospitalization, days</td>
			<td>2 (2-7)</td>
		</tr>
	</tbody>
</table>
Table 2. Procedural characteristics. Data reprinted with permission from the Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, PVAC=pulmonary vein ablation catheter, TEE=Transesophageal echocardiography. *Both in the same patient.
<table border="1">
	<tbody>
		<tr>
			<td colspan="2">Follow-up characteristics at 45 days</td>
		</tr>
		<tr>
			<td>Number, n (%)</td>
			<td>10</td>
		</tr>
		<tr>
			<td>TEE, n (%)</td>
			<td>&nbsp;</td>
		</tr>
		<tr>
			<td>Residual flow</td>
			<td>3 (33)</td>
		</tr>
		<tr>
			<td>Device embolization</td>
			<td>1 (10)</td>
		</tr>
		<tr>
			<td>Thrombus on device</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Vitamin K antagonist, n(%)</td>
			<td>6 (67)</td>
		</tr>
		<tr>
			<td colspan="2">Complications during follow-up, n(%)</td>
		</tr>
		<tr>
			<td>Death</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Stroke or TIA</td>
			<td>0 (0)</td>
		</tr>
		<tr>
			<td>Bleeding</td>
			<td>1 (10)</td>
		</tr>
	</tbody>
</table>
Table 3. 45-day follow-up. Data reprinted with permission from Netherlands Heart Journal 21. All data are presented as mean +/- standard deviation, as number with percentage (n(%)) or median with lower and upper range, N=number, mm=millimeters, TEE=Transesophageal echocardiography, TIA=transient ischemic attack.
<img alt="Figure 1" src="/files/ftp_upload/3818/3818fig1.jpg" /> 
 Figure 1. The WATCHMAN Device. The WATCHMAN device is a nitinol cage covered with a Polyethyl terephthalate membrane. Fixation barbs around the perimeter secure the device in the LAA.
<img alt="Figure 2" src="/files/ftp_upload/3818/3818fig2.jpg" /> 
 Figure 2. A complete LAA isolation or occlusion. TEE with color Doppler demonstrating proper positioning and occlusion at 45 days post-procedure from different TEE-angulations in a single patient. As the TEE probe looks at the device between 0-180 &deg;, there is no flow in the appendage and that the device is appropriately placed in all views.
<img alt="Figure 3" src="/files/ftp_upload/3818/3818fig3.jpg" /> 
 Figure 3. An incomplete LAA occlusion. TEE with color Doppler 45 days post-procedure demonstrating flow (leak) around the device. As the TEE probe looks at the device between 0-180 &deg;, a small gap (&lt;5 mm) with color flow is seen around the device. These findings still can be qualified as successful sealing. Therefore OAC can be stopped. All images are from the same patient.

Watch this Scientific Journal Video about Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation at JoVE.com

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

カテーテルアブレーションは、非弁膜症性心房細動患者における虚血性脳卒中を防ぐために心耳閉鎖デバイスを左見張りの配置と組み合わされています。

心房細動に対する左心耳閉鎖との組み合わせでカテーテルアブレーション

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

catheter-ablation-combination-with-left-atrial-appendage-closure-for

Universidad de Cartagena UDEC

Research

JoVE Journal

Medicine

33.2K ビュー.  St. Antonius Hospital, The Netherlands. カテーテルアブレーションは、非弁膜症性心房細動患者における虚血性脳卒中を防ぐために心耳閉鎖デバイスを左見張りの配置と組み合わされています。

ビデオ: Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation

High-Resolution Endocardial and Epicardial Optical Mapping in a Sheep Model of Stretch-Induced Atrial Fibrillation

Atrial fibrillation (AF) is a complex cardiac arrhythmia with high morbidity and mortality.1,2 It is the most common sustained cardiac rhythm disturbance seen in clinical practice and its prevalence is expected to increase in the coming years.3 Increased intra-atrial pressure and dilatation have been long recognized to lead to AF,1,4 which highlights the relevance of using animal models and stretch to study AF dynamics. Understanding the mechanisms underlying AF requires visualization of the cardiac electrical waves with high spatial and temporal resolution. While high-temporal resolution can be achieved by conventional electrical mapping traditionally used in human electrophysiological studies, the small number of intra-atrial electrodes that can be used simultaneously limits the spatial resolution and precludes any detailed tracking of the electrical waves during the arrhythmia. The introduction of optical mapping in the early 90's enabled wide-field characterization of fibrillatory activity together with sub-millimeter spatial resolution in animal models5,6 and led to the identification of rapidly spinning electrical wave patterns (rotors) as the sources of the fibrillatory activity that may occur in the ventricles or the atria.7-9 Using combined time- and frequency-domain analyses of optical mapping it is possible to demonstrate discrete sites of high frequency periodic activity during AF, along with frequency gradients between left and right atrium. The region with fastest rotors activates at the highest frequency and drives the overall arrhythmia.10,11 The waves emanating from such rotor interact with either functional or anatomic obstacles in their path, resulting in the phenomenon of fibrillatory conduction.12 Mapping the endocardial surface of the posterior left atrium (PLA) allows the tracking of AF wave dynamics in the region with the highest rotor frequency. Importantly, the PLA is the region where intracavitary catheter-based ablative procedures are most successful terminating AF in patients,13 which underscores the relevance of studying AF dynamics from the interior of the left atrium. Here we describe a sheep model of acute stretch-induced AF, which resembles some of the characteristics of human paroxysmal AF. Epicardial mapping on the left atrium is complemented with endocardial mapping of the PLA using a dual-channel rigid borescope c-mounted to a CCD camera, which represents the most direct approach to visualize the patterns of activation in the most relevant region for AF maintenance.

This report provides a detailed description of the methodology and results of simultaneous endocardial and epicardial optical mapping of electrical excitation in the intact left atrium of a Langendorff-perfused sheep heart during stretch-induced atrial fibrillation.

ストレッチ誘発性心房細動の羊のモデルで高解像度の心内膜と心外膜光学マッピング

 Atrial fibrillation (AF) is a complex cardiac arrhythmia with high morbidity and mortality.1,2 It is the most common sustained cardiac rhythm disturbance ...

医学

The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting an estimated 6 million people in the United States 1. Since AF affects primarily elderly people, its prevalence increases parallel with age. As such, it is expected that 15.9 million Americans will be affected by the year 2050 2. Ischemic stroke occurs in 5% of non-anticoagulated AF patients each year. Current treatments for AF include rate control, rhythm control and prevention of stroke 3.
The American College of Cardiology, American Heart Association, and European Society of Cardiology currently recommended rate control as the first course of therapy for AF 3. Rate control is achieved by administration of pharmacological agents, such as &beta;-blockers, that lower the heart rate until it reaches a less symptomatic state 3. Rhythm control aims to return the heart to its normal sinus rhythm and is typically achieved through administration of antiarrhythmic drugs such as amiodarone, electrical cardioversion or ablation therapy. Rhythm control methods, however, have not been demonstrated to be superior to rate-control methods 4-6. In fact, certain antiarrhythmic drugs have been shown to be associated with higher hospitalization rates, serious adverse effects 3, or even increases in mortality in patients with structural heart defects 7. Thus, treatment with antiarrhythmics is more often used when rate-control drugs are ineffective or contraindicated. Rate-control and antiarrhythmic agents relieve the symptoms of AF, including palpitations, shortness of breath, and fatigue 8, but don't reliably prevent thromboembolic events 6.
Treatment with the anticoagulant drug warfarin significantly reduces the rate of stroke or embolism 9,10. However, because of problems associated with its use, fewer than 50% of patients are treated with it. The therapeutic dose is affected by drug, dietary, and metabolic interactions, and thus requires detailed monitoring. In addition, warfarin has the potential to cause severe, sometimes lethal, bleeding 2. As an alternative, aspirin is commonly prescribed. While aspirin is typically well tolerated, it is far less effective at preventing stroke 10. Other alternatives to warfarin, such as dabigatran 11 or rivaroxaban 12 demonstrate non-inferiority to warfarin with respect to thromboembolic events (in fact, dabigatran given as a high dose of 150 mg twice a day has shown superiority). While these drugs have the advantage of eliminating dietary concerns and eliminating the need for regular blood monitoring, major bleeding and associated complications, while somewhat less so than with warfarin, remain an issue 13-15.
Since 90% of AF-associated strokes result from emboli that arise from the left atrial appendage (LAA) 2, one alternative approach to warfarin therapy has been to exclude the LAA using an implanted device to trap blood clots before they exit. Here, we demonstrate a procedure for implanting the WATCHMAN Left Atrial Appendage Closure Device. A transseptal cannula is inserted through the femoral vein, and under fluoroscopic guidance, inter-atrial septum is crossed. Once access to the left atrium has been achieved, a guidewire is placed in the upper pulmonary vein and the WATCHMAN Access Sheath and dilator are advanced over the wire into the left atrium. The guidewire is removed, and the access sheath is carefully advanced into the distal portion of the LAA over a pigtail catheter. The WATCHMAN Delivery System is prepped, inserted into the access sheath, and slowly advanced. The WATCHMAN device is then deployed into the LAA. The device release criteria are confirmed via fluoroscopy and transesophageal echocardiography (TEE) and the device is released.

The accompanying video describes a procedure for percutaneous placement of the WATCHMAN Left Atrial Appendage (LAA) Device. The WATCHMAN is a nitinol device designed to be permanently implanted at, or slightly distal to, the opening of the left atrial appendage (LAA) to trap blood clots before they exit the LAA, preventing thromboembolic stroke.

警備員は、心房細動のために心耳の閉鎖デバイスの左

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

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.

心房細動のロボットアブレーション

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

Reduction of Iatrogenic Atrial Septal Defects with an Anterior and Inferior Transseptal Puncture Site when Operating the Cryoballoon Ablation Catheter

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical transseptal puncture site is the fossa ovalis (FO) &#8211; the atrial septum&#8217;s thinnest section. A potentially beneficial transseptal site, for the cryoballoon, is near the inferior limbus (IL). This study examines an alternative transseptal site near the IL, which may decrease the frequency of acute iatrogenic atrial septal defect (IASD). Also, the study evaluates the acute pulmonary vein isolation (PVI) success rate utilizing the IL location. 200 patients were evaluated by retrospective chart review for acute PVI success rate with an IL transseptal site. An additional 128 IL transseptal patients were compared to 45 FO transseptal patients by performing Doppler intracardiac echocardiography (ICE) post-ablation to assess transseptal flow after removal of the transseptal sheath. After sheath removal and by Doppler ICE imaging, 42 of 128 (33%) IL transseptal patients demonstrated acute transseptal flow, while 45 of 45 (100%) FO transseptal puncture patients had acute transseptal flow. The difference in acute transseptal flow detection between FO and IL sites was statistically significant (P &#60;0.0001). Furthermore, 186 of 200 patients (with an IL transseptal puncture) did not need additional ablation(s) and had achieved an acute PVI by a &#8220;cryoballoon only&#8221; technique. An IL transseptal puncture site for cryoballoon AF ablations is an effective location to mediate PVI at all four PVs. Additionally, an IL transseptal location can lower the incidence of acute transseptal flow by Doppler ICE when compared to the FO. Potentially, the IL transseptal site may reduce later IASD complications post-cryoballoon procedures.

The goal of this study is to demonstrate the preferential location of transseptal puncture during a cryoballoon catheter ablation procedure for the treatment of atrial fibrillation.

前部と劣る経中隔穿刺部位との医原性心房中隔欠損の減少Cryoballoonアブレーションカテーテルの操作

The cryoballoon catheter ablates atrial fibrillation (AF) triggers in the left atrium (LA) and pulmonary veins (PVs) via transseptal access. The typical ...

Isolation of Atrial Cardiomyocytes from a Rat Model of Metabolic Syndrome-related Heart Failure with Preserved Ejection Fraction

In this article, we describe an optimized, Langendorff-based procedure for the isolation of single-cell atrial cardiomyocytes (ACMs) from a rat model of metabolic syndrome (MetS)-related heart failure with preserved ejection fraction (HFpEF). The prevalence of MetS-related HFpEF is rising, and atrial cardiomyopathies associated with atrial remodeling and atrial fibrillation are clinically highly relevant as atrial remodeling is an independent predictor of mortality. Studies with isolated single-cell cardiomyocytes are frequently used to corroborate and complement in vivo findings. Circulatory vessel rarefication and interstitial tissue fibrosis pose a potentially limiting factor for the successful single-cell isolation of ACMs from animal models of this disease.
We have addressed this issue by employing a device capable of manually regulating the intraluminal pressure of cardiac cavities during the isolation procedure, substantially increasing the yield of morphologically and functionally intact ACMs. The acquired cells can be used in a variety of different experiments, such as cell culture and functional Calcium imaging (i.e., excitation-contraction-coupling).
We provide the researcher with a step-by-step protocol, a list of optimized solutions, thorough instructions to prepare the necessary equipment, and a comprehensive troubleshooting guide. While the initial implementation of the procedure might be rather difficult, a successful adaptation will allow the reader to perform state-of-the-art ACM isolations in a rat model of MetS-related HFpEF for a broad spectrum of experiments.

Here, we describe an optimized, Langendorff-based procedure for the isolation of single-cell atrial cardiomyocytes from a rat model of metabolic syndrome-related heart failure with preserved ejection fraction. A manual regulation of intraluminal pressure of cardiac cavities is implemented to yield functionally intact myocytes suitable for excitation-contraction-coupling studies.

保存された駆出率とメタボリック症候群関連心不全ラットモデルから心房の心筋細胞の単離

In this article, we describe an optimized, Langendorff-based procedure for the isolation of single-cell atrial cardiomyocytes (ACMs) from a rat model of ...

Left Atrial Stenosis Induced Pulmonary Venous Arterialization and Group 2 Pulmonary Hypertension in Rat

The mechanism of mitral stenosis-induced pulmonary venous arterialization and group 2 pulmonary hypertension (PH) is unclear. There is no rodent model of group 2 PH, due to mitral stenosis (MS), to facilitate the investigation of disease mechanisms and potential therapeutic strategies. We present a novel rat model of pulmonary venous congestion-induced pulmonary venous arterialization and group 2 PH caused by left atrial stenosis (LAS). LAS is achieved by constricting the left atrium using a half-closed titanium clip. After the LAS surgery, a rat model with a transmitral inflow velocity greater than or equal to 2.0 m/s on echocardiography gradually develops pulmonary venous arterialization and group 2 PH over an 8- to 10-week period. In this protocol, we provide the step-by-step procedure of how to perform the LAS surgery. The presented LAS rat model mimics MS in humans and is useful for studying the underlying molecular mechanism of pulmonary venous arterialization and for the preclinical evaluation of therapies for group 2 PH.

Left atrial stenosis (LAS) is a novel surgical technique used for studying group 2 pulmonary hypertension (PH) and mechanisms underlying pulmonary venous arterialization. Here, we present a protocol to constrict the left atrium using a titanium clip to cause pulmonary venous arterialization and moderate PH in a rat.

左心房狭窄による肺静脈動脈化術とグループ 2 肺高血圧症ラット

The mechanism of mitral stenosis-induced pulmonary venous arterialization and group 2 pulmonary hypertension (PH) is unclear. There is no rodent model of ...

Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most frequent type of cardiac ablation procedure performed. Although generally safe, collateral injury to surrounding structures, particularly the esophagus, remains a concern. Cooling or warming the esophagus to counteract the heat from RF ablation, or the cold from cryoablation, is a method that is used to reduce thermal esophageal injury, and there are increasing data to support this approach. This protocol describes the use of a commercially available esophageal temperature management device to cool or warm the esophagus to reduce esophageal injury during left atrial ablation. The temperature management device is powered by standard water-blanket heat exchangers, and is shaped like a standard orogastric tube placed for gastric suctioning and decompression. Water circulates through the device in a closed-loop circuit, transferring heat across the silicone walls of the device, through the esophageal wall. Placement of the device is analogous to the placement of a typical orogastric tube, and temperature is adjusted via the external heat-exchanger console.

The goal of this protocol is to describe the use of esophageal temperature modulation to counteract esophageal thermal injury from left atrial ablation for the treatment of atrial fibrillation.

心房細動治療における左心房切除中の食道損傷を軽減する食道の冷却または温暖化

Ablation of the left atrium using either radiofrequency (RF) or cryothermal energy is an effective treatment for atrial fibrillation (AF) and is the most ...

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;

経カテーテル閉鎖前の心房通信の心エコー検査

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

Sterile Pericarditis in Aachener Minipigs As a Model for Atrial Myopathy and Atrial Fibrillation

Atrial fibrillation (AF) is the most common arrhythmia caused by structural remodeling of the atria, also called atrial myopathy. Current therapies only target the electrical abnormalities and not the underlying atrial myopathy. For the development of novel therapies, a reproducible large animal model of atrial myopathy is necessary. This paper presents a model of sterile pericarditis-induced atrial myopathy in Aachener minipigs. Sterile pericarditis was induced by spraying sterile talcum and leaving a layer of sterile gauze over the atrial epicardial surface. This led to inflammation and fibrosis, two crucial components of the pathophysiology of atrial myopathy, making the atria susceptible to the induction of AF. Two pacemaker electrodes were positioned epicardially on each atrium and connected to two pacemakers from different manufacturers. This strategy allowed for repeated non-invasive atrial programmed stimulation to determine the inducibility of AF at specified time points after surgery. Different protocols to test AF inducibility were used. The advantages of this model are its clinical relevance, with AF inducibility and the rapid induction of inflammation and fibrosis-both present in atrial myopathy-and its reproducibility. The model will be useful in the development of novel therapies targeting atrial myopathy and AF.

We describe a sterile pericarditis model in minipigs to study atrial myopathy and atrial fibrillation (AF). We present surgical and anesthetic techniques, strategies for vascular access, and a protocol to study the inducibility of AF.

心房ミオパチーおよび心房細動のモデルとしてのAachenerミニブタにおける滅菌心膜炎

Atrial fibrillation (AF) is the most common arrhythmia caused by structural remodeling of the atria, also called atrial myopathy. Current therapies only ...

Transesophageal Atrial Burst Pacing for Atrial Fibrillation Induction in Rats

Animal studies have brought important insights into our understanding regarding atrial fibrillation (AF) pathophysiology and therapeutic management. Reentry, one of the main mechanisms involved in AF pathogenesis, requires a certain mass of myocardial tissue in order to occur. Due to the small size of the atria, rodents have long been considered 'resistant' to AF. Although spontaneous AF has been shown to occur in rats, long-term follow-up (up to 50 weeks) is required for the arrhythmia to occur in those models. The present work describes an experimental protocol of transesophageal atrial burst pacing for rapid and efficient induction of AF in rats. The protocol can be successfully used in rats with healthy or remodeled hearts, in the presence of a wide variety of risk factors, allowing the study of AF pathophysiology, identification of novel therapeutic targets, and evaluation of novel prophylactic and/or therapeutic strategies.

The present work describes an experimental protocol of transesophageal atrial burst pacing for efficient induction of atrial fibrillation (AF) in rats. The protocol can be used in rats with healthy or remodeled hearts, allowing the study of AF pathophysiology, identification of novel therapeutic targets, and evaluation of new therapeutic strategies.

ラットにおける心房細動誘導のための経食道心房バーストペーシング

Animal studies have brought important insights into our understanding regarding atrial fibrillation (AF) pathophysiology and therapeutic management. ...