Post on 21-Aug-2015
Maurizio GentileCentro Cuore Morgagni - Pedara
CUORE E TECNOLOGIE: EVOLUZIONE DELLA
CARDIOLOGIA INTERVENTISTICA
CHIUSURA DELL’AURICOLA
E’ ben noto il ruolo dell’auricola sn nel tromboembolismodella malattia mitralica e della fibrillazione atriale (57-90%)
La chiusura dell’auricola sn: il ruolo del chirurgo
La chiusura chirurgica dell’auricola sn è una tecnicanota da molti anni, eseguita soprattutto nei pazienti mitralici sottoposti ad intervento cardiochirurgico.
Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.Blackshear JL, Odell JA. Ann Thorac Surg 1996.
Madden JL. Resection of left auricolar appendix: a prophylaxis for recurrent arterial emboli. JAMA 1949
La chiusura dell’auricola sn: il ruolo del chirurgo
Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis:
a transesophageal echocardiographic study.García-Fernández MA, ……, Moreno M, Silva J. , Madrid, Spain. J Am Coll Cardiol. 2003
CONCLUSIONS: LAA ligation during surgery of mitral valve replacement, performed in a high-risk population, is consistent with a reduction of the risk of late embolism and supports this technique.
La chiusura dell’auricola sn: il ruolo del chirurgo
J Am Coll Cardiol, 2006ACC/AHA 2006 Guidelines for the Management
of Patients With Valvular Heart Disease
Chirurgia conservativa della stenosi mitralica
..…amputation of the left atrial appendage is recommended to reduce the likelihood of postoperative thromboembolic events..….
La chiusura dell’auricola sn: il ruolo del chirurgo
-Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol. 2000 Katz ES, ……Kronzon I-Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. 2008 Kanderian AS, Gillinov AM-Mmcts.2010 Sacha P. Salzberg, Management of the left atrial appendage
Attualmente viene eseguita di routine durante chirurgia cardiaca solo da alcuni gruppi:
- Per insufficiente attenzione sull’importanza - Per risultati incerti (tecniche imperfette
e traumatiche) - Funzione dell’auricola
La chiusura dell’auricola sn: il ruolo del chirurgo
Indicazioni più recenti
•A complemento di ablazione di FA•Trattamento isolato in pz in FA
• Calkins H… et al HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2007
• Di Biase L,…..et all. Left atrial appendage: an underrecognized trigger site of atrial fibrillation. Circulation 2010• Takahashi Y, Haissaguerre M. Disconnection of left atrial appendage for elimination of foci maintaining atrial fibrillation.J Cardiov Electroph 2005
• L’auricola sn rappresenta un trigger per insorgenza di FA e di tachicardie atriali e ricorrenza di FA dopo ablazione. • La chiusura dell’auricola permette l’isolamento elettrico dell’auricola
La chiusura dell’auricola sn: il ruolo del chirurgo
HRS/EHRA/ECAS (2007) Expert Consensus Statement on
Catheter and Surgical Ablation of Atrial Fibrillation:
Surgical AF Ablation Concomitant to Other Heart Operations
all patients with AF undergoing other cardiac surgery should be considered for AF ablation ………………..………….. When it can be safely performed, complete occlusion of the LA appendage should be considered
La chiusura dell’auricola sn: il ruolo del chirurgo
Number of left atrial appendage publications in various periodsfrom 1948 to 2011
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter ExperiencesSubhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo
Nonostante il consenso sulla chiusura, è meno chiaroquale sia la miglior tecnica.
La letteratura chirurgica consiste in serie di pz con pregressa chiusura e segniclinici successivi(valutazione ETE)
Cardiology, 2005.
Surgical closure of the left atrial appendage – a beneficial procedure?Schneider B, Stollberger C, Sievers HH.
Klinik fur Kardiologie, Sana Kliniken Lubeck, Deutchland.
CONCLUSION: Surgical LAA closure was incomplete in most patients, resulting in blood stagnation and an increased likelihood of clot formation. Incomplete surgical LAA closure, therefore, may promote rather than reduce the risk of stroke.
La chiusura dell’auricola sn: il ruolo del chirurgo
L’anatomia dell’auricola è molto variabile
Three-dimensional anatomy of the left atrium by magnetic resonance angiography: implications for catheter ablation for atrial fibrillation Mansour M, …… Ruskin JN. J Cardiovasc Electrophysiol 2006
Tecniche chirurgiche di chiusura dell’auricola sn
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
Legatura-Sutura epicardica (a cuore chiuso)
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter ExperiencesSubhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
Sutura endocardica con sopragitto in CEC (paz valvolari)
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter ExperiencesSubhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
Escissione-sutura epicardica con stapling device
J Thorac Cardiovasc Surg 2005Stapled excision of the left atrial appendage A. Marc Gillinov, MD*….. Delos M. Cosgrove, III, MD Dept of Thor and Cardiovasc Surg, Cleveland, Ohio
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
Amputazione-sutura epicardica
Left Atrial Appendage Occlusion: Lessons Learned From Surgical and Transcatheter ExperiencesSubhasis Chatterjee, MD……., and Ted Feldman, MD Evanston, Illinois. Ann Thorac Surg 2011
La chiusura dell’auricola sn: il ruolo del chirurgo
Journal of the American College of Cardiology, 2008
Success of Surgical Left Atrial Appendage ClosureAssessment by Transesophageal Echocardiography
Anne S. Kanderian, MD,* A. Marc Gillinov, Eugene Blackstone, MD,Cleveland, Ohio
Conclusions:Of the various techniques (excision or exclusion by sutures or stapling), excision appears to be the most successful (73 %).
La chiusura dell’auricola sn: il ruolo del chirurgo
Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary
bypass surgery in patients at risk for stroke
Jeff S Healey,……….Stuart J Connolly - American Heart Journal, 2005
CONCLUSIONS: LAA occlusion ( stapler or epicardial suture)at the time of CABG (77 pts) …The rate of complete occlusion improves…… with the use of a stapling device (72% vs 45%). A large trial is needed to determine if LAA occlusion prevents stroke (2,6% vs 5,6%).
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
Clip epicardica (accesso standard o mini-inv)
AtriClip™ Gillinov-Cosgrove LAA Exclusion System, Standard
La chiusura dell’auricola sn: il ruolo del chirurgo
J of Thor and Cardiovasc Surgery, Nov 2011
Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial
Gorav Ailawadi, MD,…..Ralph J. Damiano, Jr, MD and Michael J. Mack, MDg
Concomitant cardiac operations performed in the EXCLUDE study
Surgical procedure Total % (n) (N ¼ 71)
CABG 77.5% (55)Mitral valve 23.9% (17) Repair 16.9% (12) Replacement 7.0% (5)Tricuspid valve 5.6% (4) Repair 5.6% (4)Aortic valve 40.8% (29) Replacement 40.8% (29)ASD/PFO closure 0.0% (0)Surgical (ablation or cut-and sew) Maze procedure 35.2% (25)
La chiusura dell’auricola sn: il ruolo del chirurgo
J of Thor and Cardiovasc Surgery, Nov 2011
Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial
Gorav Ailawadi, MD,…..Ralph J. Damiano, Jr, MD and Michael J. Mack, MDg
Conclusions: safe and atraumatic exclusion of the left atrial appendage can be performed during opencardiac surgery with the AtriClip device with greater than 95% success and appears to be durable in the short term by imaging.
La chiusura dell’auricola sn: il ruolo del chirurgo
Intraoperative TEE demonstrating (A) patent LAA before AtriClip device placement and(B) echocardiographic evidence of LAA exclusion after clip placement.
J of Thor and Cardiovasc Surgery, Nov 2011
Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial
Gorav Ailawadi, MD,…..Ralph J. Damiano, Jr, MD and Michael J. Mack, MDg
La chiusura dell’auricola sn: il ruolo del chirurgo
CT scan (A) preoperatively demonstrating patent LAA lumen and (B) postoperatively at 3 months after AtriClip deviceinsertion demonstrating endovascular exclusion of the LAA.
J of Thor and Cardiovasc Surgery, Nov 2011
Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial
Gorav Ailawadi, MD,…..Ralph J. Damiano, Jr, MD and Michael J. Mack, MDg
La chiusura dell’auricola sn: il ruolo del chirurgo
Thoracoscopic appendage exclusion with an atriclip device as a solo treatment for
focal atrial tachycardia.Stefano Benussi, ……… and Paolo Della Bella
Circulation (2011)
Appendage clip implantation as a solo procedure
La chiusura dell’auricola sn: il ruolo del chirurgo
Tecniche chirurgiche di chiusura dell’auricola sn
La chiusura dell’auricola sn: il ruolo del chirurgo
•Tecniche diverse endo - epicardiche (chiusura incompleta – residuo)
• Possibile su qualunque anatomia
• Accesso mini-invasivo
• Non necessità di TAO
• L’occlusione dell’auricola sn è un punto essenziale nella prevenzione dello Stroke nei pazienti in FA
• La chiusura dell’auricola sn va considerata:
-nei pz cardiochirurgici (FA cronica-megaatrio)
-nei pz sottoposti ad ablazione chirurgica concomitante a chir cardiaca (FA parossistica?)
CONCLUSIONI Iindicazioni
• Il successo della chiusura dell’auricola dipende dalla tecnica (evoluzione delle tecniche)
• Le tecniche chirurgiche epicardiche sembrano le più dirette, efficaci e sicure (escissione-sutura, clip)
•La completa chiusura dell’auricola va documentata (rischio chiusura incompleta)
CONCLUSIONI IItecnica
CONCLUSIONI III
Le tecniche chirurgiche mini-invasive ed i nuovi devices (chirurgici e percutanei) possono portare a nuove indicazioni di chiusura dell’auricola
-chirurgia della FA isolata -”sole therapy” (controindicazione a percutane e a
anticoagulazione orale)
-interventi ibridi (chirurgo - elettrofisiologo)
Studi randomizzati percutanea vs chirurgia