Long-term outcomes of left atrial appendage occlusion in patients with atrial fibrillation and end stage renal disease.

OBJECTIVE: In patients with atrial fibrillation (AF) and end-stage renal disease (ESRD), oral anticoagulants are contraindicated, and left atrial appendage occlusion (LAAO) is an alternative treatment. However, the efficacy of thromboembolic prevention using LAAO in these patients has rarely been reported in Asian populations. To our knowledge, this is the first long-term LAAO study in patients with AF undergoing dialysis in Asia. METHODS: In this study, 310 patients (179 men) with a mean age of 71.3 ± 9.6 years and mean CHA2DS2-VASc 4.2 ± 1.8 were consecutively enrolled at multiple centers in Taiwan. The outcomes of 29 patients with AF and ESRD undergoing dialysis who underwent LAAO were compared to those without ESRD. The primary composite outcomes were stroke, systemic embolization, or death. RESULTS: No difference in mean CHADS-VASc score was noted between patients with versus without ESRD (4.1 ± 1.8 vs. 4.6 ± 1.9, p = 0.453). After a mean follow-up of 38 ± 16 months, the composite endpoint was significantly higher in patients with ESRD (hazard ratio, 5.12 [1.4-18.6]; p = 0.013) than in those without ESRD after LAAO therapy. Mortality was also higher in patients with ESRD (hazard ratio, 6.6 [1.1-39.7]; p = 0.038). The stroke rate was numerically higher in patients with versus without ESRD, but the difference was not statistically significant (hazard ratio, 3.2 [0.6-17.7]; p = 0.183). Additionally, ESRD was associated with device-related thrombosis (odds ratio, 6.15; p = 0.047). CONCLUSION: Long-term outcomes of LAAO therapy may be less favorable in patients with AF undergoing dialysis, possibly because of the poor condition of patients with ESRD.

Pattern of Endothelialization in Left Atrial Appendage Occluder by Optic Coherence Tomography: A Pilot Study.

BACKGROUND: Implantation of the left atrial appendage occluder (LAAO) has been proven to prevent stroke effectively in patients with atrial fibrillation who cannot tolerate anticoagulants. Incomplete endothelization of LAAO may cause device-related thrombus, and currently no good image modality exists to clearly see LAAO endothelialization. We aimed to use coronary optic coherence tomography (OCT) to visualize LAAO endothelialization. METHODS AND RESULTS: We enrolled 14 patients (72.8±9.4 years old) undergoing pulmonary vein isolation with a preexisting LAAO implanted more than 1 year ago (5 Watchman and 9 Amulet). After pulmonary vein isolation, we did OCT via steerable sheath and coronary guiding catheter to adjust OCT probe location and injected contrast medium to visualize the LAAO surface. In vitro testing was also performed to see the bare occluder. In vitro OCT showed the surface of the bare device as an interrupted granule pattern, which included the Watchman surface polytetrafluoroethylene membrane string, Amulet disc metal strut, and inner polytetrafluoroethylene membrane string. In the implanted Watchman, OCT showed endothelialization as a smooth surface layer with noninterrupted coarser granules. In the implanted Amulet, OCT showed endothelialization as thin (early) or thick (late) endothelialization layer covering struts with OCT shadows. Among patients with Watchman, 2 showed no, 2 early, and 1 complete endothelialization. Among patients with Amulet, 2 showed no, 3 early, and 4 late endothelialization. CONCLUSIONS: We demonstrated the feasibility of OCT to visualize LAAO endothelization with high resolution. Further studies are needed to determine antithrombotic regimens if incomplete endothelization is detected. A new OCT catheter may be designed specifically for LAAO.

Impact of pre-existing left atrial appendage occluder on catheter ablation of atrial fibrillation.

BACKGROUND: Patients with drug-refractory atrial fibrillation (AF) and pre-existing left atrial appendage occluder (LAAO) device may need pulmonary vein isolation (PVI). In this pioneer study, we investigated the impact of pre-existing LAAO on AF substrates and outcomes of PVI. METHODS: From our AF registry, 65 drug-refractory patients with LAAO (72.1±11.4 years old; CHA2DS2-VASc score 3.7±2.1) were included for PVI. A balanced control group with 124 patients without LAAO receiving PVI (70.9±10.2 years old, CHA2DS2-VASc 3.6±1.9) were included for comparison. RESULTS: We found PVI is feasible in patients with AF with pre-existing LAAO without new peridevice leak. Two patients with LAAO and one without LAAO had stroke during the procedure (2/65 vs 1/124, p=0.272). Complete isolation of left-sided PVs might not be achieved if the device covered the ridge joining the left atrial (LA) appendage to the body of LA. Local electrogram could be detected over LAAO and there was propagation of conduction over the occluder either under sinus rhythm or under atrial arrhythmia. LAAO might modulate LA substrate and induce peridevice fibrosis, peridevice LA flutter and complex fractionate atrial electrogram. The AF recurrent rate at 1 year was similar between the two groups (9.2% vs 8.8%). CONCLUSIONS: This pioneer study first showed impacts of LAAO on LA substrate and PVI procedure.

Bailout left atrial appendage occluder for pulmonary vein isolation and electrical cardioversion in patients with atrial fibrillation and left atrial appendage thrombus: a pilot study.

BACKGROUND: Cardioversion and catheter-based circumferential pulmonary vein isolation (CPVI) are established rhythm control treatment strategies for patients with atrial fibrillation (AF). However, these treatments are contraindicated for AF patients with a left atrial appendage (LAA) thrombus. METHODS: We conducted the first-in-man case series study to evaluate the feasibility and safety of performing cardioversion or CPVI in AF patients with LAA thrombus immediately after implantation of LAA Occluder (LAAO) in a combined procedure. In our multi-center LAAO registry of 310 patients, 27 symptomatic and drug-refractory AF patients underwent a combined procedure of LAAO and CPVI, among whom 10 (mean age 68 ± 16 years, 6 men) having anticoagulant-resistant LAA thrombus received a bailout procedure of LAAO implantation first then CPVI, and the other 17 patients without LAA thrombus received CPVI first then LAAO for comparison. RESULTS: The mean CHA2DS2-VASc score and HAS-BLED score were comparable between these two groups. In patients with LAA thrombus, we put carotid filters and did a no-touch technique, neither advancing the wire and sheath into the LAA nor performing LAA angiography. After LAAO implantation, the connecting cable was still connected to the occluder when cardioversion was performed. During CPVI, the occluder location was registered in the LA geometry by three-dimensional mapping to guide the catheter not to touch the LAAO. The procedure was successful in all the patients without intra-procedural complications. After a mean follow-up of 1.7 ± 0.7 years, there was no device embolization, peri-device leak ≧ 5 mm or stroke event in both groups. The AF recurrence rate was also similar between the two groups (P = 0.697). CONCLUSION: We demonstrated that cardioversion or CPVI is doable in symptomatic AF patients with LAA thrombus if LAA was occluded ahead as a bailout procedure.

First-in-Human Experience of Using a Universal Steerable Sheath in Implanting Left Atrial Appendage Closure Devices.

Left atrial appendage (LAA) closure (LAAC) device implantation may be challenging in cases with difficult LAA anatomy. A deflectable sheath to approach multiple LAA positions may be helpful. We used a deflectable sheath to implant LAAC devices in 20 patients and included 60 cases using the standard sheaths for comparison. The procedures were successful in all patients without peri-procedural complications. After a median follow-up of 1.52 (IQR: 0.76-2.33) years, none of the patients in the deflectable sheath group had peri-device leak ≥3 mm and experienced thromboembolic stroke. In the standard sheath group, after follow-up of 2.03 (IQR: 0.87-3.19) years, 2 had peri-device leak ≥3 mm and 1 experienced thromboembolic stroke. We first proved the idea of using a universal steerable sheath for LAAC device implantation in difficult LAA anatomy, which also allows rapid switching of different LAAC devices.

Peri-device leakage not CHA2DS2-VASc is associated with post-left atrial appendage closure cardiovascular event.

OBJECTIVE: In patients with non-valvular atrial fibrillation (NVAF), the left atrial appendage occluder (LAAO) is an alternative treatment for stroke prevention. However, thromboembolic event still occur, and the predictors are unknown. METHODS: The first Asian long-term follow-up study consisted of 308 patients with mean age 71.9±9.5 years, mean CHA2DS2-VASc 4.1 ± 1.8 since 2013. Primary outcome was defined as any type of ischemic stroke/transient ischemic attack (TIA), systemic embolization and cardiovascular death. RESULTS: There was no procedural-related TIA or stroke. After a mean follow-up of 38±16 months, the ischemic stroke/TIA rate was 1.9 and cardiovascular death rate 0.3 per 100 patient-year. The rate of peri-device leak (PDL) was 11.9% and device-related thrombus (DRT) 2.6%. In the multivariable analyses, PDL was the only independent predictor of stroke/TIA (hazard ratio 5.5, p=0.008). CHA2DS2-VASc score, prior history of stroke, DRT and post-procedural anti-thrombotic regimen/duration were not associated with outcomes. Implantation of Watchman was associated with PDL (odds ratio 4.35, p=0.001). CONCLUSIONS: PDL is the only independent predictor of post-LAAO stroke. The risk of stroke for patients with NVAF may be controllable after LAA is occluded, because PDL is preventable and treatable.

Neuroprotective effects of intraoperative dexmedetomidine versus saline infusion combined with goal-directed haemodynamic therapy for patients undergoing cranial surgery: A randomised controlled trial.

BACKGROUND: By inhibiting neuroinflammation dexmedetomidine may be neuroprotective in patients undergoing cranial surgery, but it reduces cardiac output and cerebral blood flow. OBJECTIVE: To investigate whether intra-operative dexmedetomidine combined with goal-directed haemodynamic therapy (GDHT) has neuroprotective effects in cranial surgery. DESIGN: A double-blind, single-institution, randomised controlled trial. SETTING: A single university hospital, from April 2017 to April 2020. PATIENTS: A total of 160 adults undergoing elective cranial surgery. INTERVENTION: Infusion of dexmedetomidine (0.5 µg kg-1 h-1) or saline combined with GDHT to optimise stroke volume during surgery. MAIN OUTCOME MEASURES: The proportion who developed postoperative neurological complications was compared. Postoperative disability was assessed using the Barthel Index at time points between admission and discharge, and also the 30-day modified Rankin Scale (mRS). Postoperative delirium was assessed. The concentration of a peri-operative serum neuroinflammatory mediator, high-mobility group box 1 protein (HMGB1), was compared. RESULTS: Fewer patients in the dexmedetomidine group developed new postoperative neurological complications (26.3% vs. 43.8%; P = 0.031), but the number of patients developing severe neurological complications was comparable between the two groups (11.3% vs. 20.0%; P = 0.191). In the dexmedetomidine group the Barthel Index reduction [0 (-10 to 0)] was less than that in the control group [-5 (-15 to 0)]; P = 0.023, and there was a more favourable 30-day mRS (P = 0.013) with more patients without postoperative delirium (84.6% vs. 64.2%; P = 0.012). Furthermore, dexmedetomidine induced a significant reduction in peri-operative serum HMGB1 level from the baseline (222.5 ±â€Š408.3 pg ml-1) to the first postoperative day (152.2 ±â€Š280.0 pg ml-1) P = 0.0033. There was no significant change in the control group. The dexmedetomidine group had a lower cardiac index than did the control group (3.0 ±â€Š0.8 vs. 3.4 ±â€Š1.8 l min-1 m-2; P = 0.0482) without lactate accumulation. CONCLUSIONS: Dexmedetomidine infusion combined with GDHT may mitigate neuroinflammation without undesirable haemodynamic effects during cranial surgery and therefore be neuroprotective. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT02878707.

Scalp Block Is Associated With Improved Recurrence Profiles in Patients Undergoing Primary Glioma Resection Surgery.

BACKGROUND: Glioma is associated with high recurrence and poor survival, despite the success of tumor resection surgery. This may be partly because the immune microenvironment within a glioma is susceptible to perioperative immunosuppression. Therefore, intraoperative anesthesia-related immunomodulators, such as scalp block, intravenous anesthesia, the opioid dosage administered, and transfusions, may influence oncological outcomes among patients with glioma. The aim of this retrospective study was to investigate the influence of anesthetic techniques on oncological outcomes after craniotomy for glioma resection, particularly the effects of scalp block, intravenous anesthesia, and inhalation anesthesia. METHODS: Consecutive patients who underwent primary glioma resection surgeries between January 2010 and December 2017 were analyzed to compare postcraniotomy oncological outcomes (progression-free survival [PFS] and overall survival) by using the Kaplan-Meier method and multivariate Cox regression analysis. A propensity score-matched regression analysis including prognostic covariates was also conducted to analyze the selected relevant anesthetic factors of the unmatched regression model. RESULTS: A total of 230 patients were included in the final analysis. No analyzed anesthetic factor was associated with overall survival. Patients who received scalp block had a more favorable median (95% confidence interval [CI]) PFS (55.37 [95% CI, 12.63-62.23] vs. 14.07 [95% CI, 11.27-17.67] mo; P=0.0053). Scalp block was associated with improved PFS before (hazard ratio, 0.465; 95% CI, 0.272-0.794; P=0.0050) and after (hazard ratio, 0.367; 95% CI, 0.173-0.779; P=0.0091) propensity score-matched Cox regression analysis. By contrast, intravenous anesthesia, amount of opioid consumed, and transfusion were not associated with PFS. CONCLUSIONS: The study results suggest that the scalp block improves the recurrence profiles of patients receiving primary glioma resection.

Mini-fluid challenge test predicts stroke volume and arterial pressure fluid responsiveness during spine surgery in prone position: A STARD-compliant diagnostic accuracy study.

The study was designed to verify if mini-fluid challenge test is more reliable than dynamic fluid variables in predicting stroke volume (SV) and arterial pressure fluid responsiveness during spine surgery in prone position with low-tidal-volume ventilation.Fifty patients undergoing spine surgery in prone position were included. Fluid challenge with 500 mL of colloid over 15 minutes was given. Changes in SV and systolic blood pressure (SBP) after initial 100 mL were compared with SV, pulse pressure variation (PPV), SV variation (SVV), plethysmographic variability index (PVI), and dynamic arterial elastance (Eadyn) in predicting SV or arterial pressure fluid responsiveness (15% increase or greater).An increase in SV of 5% or more after 100 mL predicted SV fluid responsiveness with area under the receiver operating curve (AUROC) of 0.90 (95% confidence interval [CI], 0.82 to 0.99), which was significantly higher than that of PPV (0.71 [95% CI, 0.57 to 0.86]; P = .01), and SVV (0.72 [95% CI, 0.57 to 0.87]; P = .03). A more than 4% increase in SBP after 100 mL predicted arterial pressure fluid responsiveness with AUROC of 0.86 (95% CI, 0.71-1.00), which was significantly higher than that of Eadyn (0.52 [95% CI, 0.33 to 0.71]; P = .01).Changes in SV and SBP after 100 mL of colloid predicted SV and arterial pressure fluid responsiveness, respectively, during spine surgery in prone position with low-tidal-volume ventilation.

Multi-timescale phase-amplitude couplings in transitions of anesthetic-induced unconsciousness.

Under general anesthesia (GA), advanced analysis methods enhance the awareness of the electroencephalography (EEG) signature of transitions from consciousness to unconsciousness. For nonlinear and nonstationary signals, empirical mode decomposition (EMD) works as a dyadic filter bank to reserve local dynamical properties in decomposed components. Moreover, cross-frequency phase-amplitude coupling analysis illustrates that the coupling between the phase of low-frequency components and the amplitude of high-frequency components is correlated with the brain functions of sensory detection, working memory, consciousness, and attentional selection. To improve the functions of phase-amplitude coupling analysis, we utilized a multi-timescale approach based on EMD to assess changes in brain functions in anesthetic-induced unconsciousness using a measure of phase-amplitude coupling. Two groups of patients received two different anesthetic recipes (with or without ketamine) during the induction period of GA. Long-term (low-frequency) coupling represented a common transitional process of brain functions from consciousness to unconsciousness with a decay trend in both groups. By contrast, short-term coupling reflected a reverse trend to long-term coupling. However, the measures of short-term coupling also reflected a higher degree of coupling for the group with ketamine compared with that without ketamine. In addition, the coupling phase is a factor of interest. The phases for different combinations of coupling components showed significant changes in anesthetic-induced unconsciousness. The coupling between the delta-band phase and the theta-band amplitude changed from in-phase to out-phase coupling during the induction process from consciousness to unconsciousness. The changes in the coupling phase in EEG signals were abrupt and sensitive in anesthetic-induced unconsciousness.

Pretreatment serum lactate level as a prognostic biomarker in patients undergoing supratentorial primary brain tumor resection.

INTRODUCTION: Malignant primary brain tumors are one of the most aggressive cancers. Pretreatment serum nonneuronal biomarkers closely associated with postoperative outcomes are of high clinical relevance. The present study aimed to identify potential pretreatment serum biomarkers that may influence oncological outcomes in patients with primary brain tumors. METHODS: A total of 74 patients undergoing supratentorial primary brain tumor resection were enrolled. Before tumor resection, serum neuronal biomarkers, namely neuron-specific enolase (NSE), S100ß, and glial fibrillary acidic protein (GFAP), and serum nonneuronal biomarkers, namely neutrophil gelatinase-associated lipocalin (NGAL), lactate dehydrogenase (LDH), and lactate, were measured and associated postoperative oncological outcomes, including brain tumor grading, progression-free survival (PFS), and overall survival (OS), were compared. RESULTS: Patients with high-grade brain tumors had significantly higher pretreatment serum lactate levels (p = 0.011). By contrast, other biomarkers were comparable between patients with high-grade and low-grade brain tumors. Receiver operating characteristic curve analysis of serum lactate levels yielded an area under the curve of 0.71 for differentiating between high-grade and low-grade brain tumors. Kaplan-Meier survival analysis revealed patients with high serum lactate levels (≧2.0 mmol/L) had shorter PFS and OS (p = 0.021 and p = 0.093, respectively). In a multiple regression model, only elevated serum lactate levels were associated with poor PFS and OS (p = 0.021 and p = 0.048, respectively). CONCLUSIONS: An elevated pretreatment serum lactate level is a prognostic biomarker of high-grade primary brain tumors and is significantly associated with poor PFS in patients with supratentorial brain tumors undergoing tumor resection. By contrast, other serum biomarkers are not significantly associated with oncological outcomes.

Transcatheter aortic valve implantation: Anesthetic experience of retrograde transfemoral approach with CoreValve ReValving System.

OBJECTIVES: Valvular aortic stenosis (AS) is a major cardiac valvular disease in geriatric people. Conventional treatment for severe AS is aortic valve replacement through surgery. However, many geriatric patients are considered inoperable due to higher risks for surgery and anesthesia. Transcatheter aortic valve implantation (TAVI), a less invasive procedure, has rapidly developed in recent years as an alternative management option for high-risk AS patients. Herein, we describe our anesthetic experience in the TAVI procedure. METHODS: We included 11 patients who consecutively received transfemoral TAVI in the period from September 2010 to January 2011. All patients received general anesthesia with endotracheal intubation; arterial line placement and central venous catheter insertion were carried out for monitoring hemodynamics. Transesophageal echocardiography was applied for valve evaluation, hemodynamic monitoring, and intraoperative guidance. Patients were transferred to the intensive care unit for further care after surgery. The periprocedural events were recorded. RESULTS: The mean age of these patients was 82 years. Morphology of the aortic valve in all patients was tricuspid, and the etiology of AS was degenerative calcification. During TAVI, all patients received bolus injections of 5-10 µg norepinephrine just before the rapid pacing stage in order to increase the mean arterial pressure. Only one patient needed continuous infusion of dopamine because of severe preoperative congestive heart failure, and another patient needed continuous infusion of norepinephrine due to relatively old age and suspected low systemic vascular resistance. After TAVI, all patients had the endotracheal tube extubated within 7 hours, except one because of preoperative ventilator dependence. Another male patient stayed in the intensive care unit for 8 days due to postoperative complete atrioventricular block, and he received permanent pacemaker implantation. There was no early mortality. CONCLUSION: TAVI is another choice for AS patients who have a high perioperative risk. General anesthesia with endotracheal intubation and application of transesophageal echocardiography can facilitate the use of this new technique by cardiologists. Complete preprocedural evaluation and good intraprocedural cooperation are still the gold standards to achieve successful TAVI and patient safety.

Anterior mitral leaflet perforation identified by real time three-dimensional transesophageal echocardiography.

With its unique en face view, real time three-dimensional transesophageal echocardiography has been reported to be more precise than conventional two-dimensional studies in evaluating mitral regurgitation etiology, and can locate diseased segments correctly. We present a case with severe mitral regurgitation due to anterior mitral leaflet perforation. Intraoperative real time three-dimensional transesophageal echocardiography demonstrated its value in diagnosis and surgical planning for this perforation, which had not been identified preoperatively. This technique should be applied more widely for dedicated mitral valve assessment in clinical practice.