Experiência inicial com o novo amplatzerTM cardiac plug para oclusão percutânea do apêndice atrial esquerdo

Abstract

Background: Thrombus formation in the left atrial appendage (LAA) is the main cause of thromboembolic events in patients with non-valvular atrial fibrillation (AF). Oral anticoagulants are considered first-line therapy for stroke prevention in AF patients. Despite its proven efficacy, long-term oral anticoagulation is associated to innumerous limitations. Percutaneous LAA closure has emerged as a new strategy for stroke prevention in high risk AF patients who are not candidates for long term oral anticoagulation therapy. Methods: We report the initial experience with percutaneous occlusion of the LAA using the new Amplatzer TM Cardiac Plug (ACP -AGA Medical Corp., Golden Valley, USA) in patients with AF and CHADS2 score > 2 who were not eligible for anticoagulation therapy. Procedures were carried out under general anesthesia and 3D transesophageal echocardiography monitoring in real time. Results: Three male patients, mean age of 79 years and CHADS2 2, 3 and 5 scores had the device successfully implanted using a transeptal approach with no complications, resulting in immediate LAA occlusion and hospital discharge two days later. At the 50-day followup, all patients were clinically well with complete LAA occlusion and no complications at transthoracic echocardiography. Conclusions: Percutaneous LAA occlusion with the new ACP seems to be an attractive alternative to prevent thromboembolic events in patients with AF and contraindications or limitations for anticoagulation therapy.

Oclusão percutânea do apêndice atrial esquerdo com o Amplatzer Cardiac PlugTM na fibrilação atrial

“…But the device has shown to be promising in patients at high risk of embolism and limitations to the use of OAC. Although the importance of the learning curve cannot be underestimated 35,37,38 , the operators' familiarity with the devices Amplatzer TM might be an advantage in the initial experience with this intervention 28 . By the time of publication, there was no adverse endpoints on the 14 months follow-up.…”

“…The Amplatzer TM Cardiac Plug (ACP -St. Jude Medical Inc., Saint Paul, USA) was developed specifically for the LAA occlusion by percutaneous mean through transseptal puncture [26][27][28][29] . The device consists of a distal lobe and a proximal disk that are connected by an articulated beam.…”

“…The system allows repositioning and recapture; it has bends that facilitate catheterization of the LAA and has 13 French. The device (ACP) and its delivery system (TDS) have been approved for clinical use in Brazil by the National Health Surveillance Agency (ANVISA) 28 .…”

“…Despite this initial experiment, in a further series of 44 patients, three patients did not obtain the closure, one patient needed a new intervention and there were six events of embolization in the device 35 . Considering the fragility of the wall of the LAA, with approximately 1mm in thickness 38 , the manufacturer developed the ACP, a device designed for this intervention [26][27][28][29] . In our initial experience, considering the proven effectiveness of the OAC, we were concerned on establishing inclusion criteria regards the risk of embolism and bleeding.…”

Oclusão do apêndice atrial esquerdo com o Amplatzer Cardiac Plug em pacientes com fibrilação atrial

“…The flexibility of the central pin allows a misalignment between the disc and the lobe of the ACP after implantation, adapting the prosthesis to the LAA axis rather than distorting it 31 . Also, the more anatomic surface that derives from the occlusive disc implantation results in a rheology that is closer to normal and also in a more predictable endothelization 32 .…”