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Left atrial appendage closure for stroke prevention in patients with atrial fibrillation and hereditary hemorrhagic telangiectasia.

Velthuis S, Swaans MJ, Mager JJ, Rensing BJ, Boersma LV, Post MC - Case Rep Cardiol (2012)

Bottom Line: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide, and a major risk factor for disabling cerebral embolic stroke.Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder, characterized by vascular abnormalities with high-bleeding tendency and therefore intolerance for oral anticoagulation.We report a case of percutaneous closure of the left atrial appendage, which might be a good alternative strategy instead of chronic oral anticoagulation to protect patients with high-risk AF and HHT from cerebral embolic strokes.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands.

ABSTRACT
Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide, and a major risk factor for disabling cerebral embolic stroke. Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder, characterized by vascular abnormalities with high-bleeding tendency and therefore intolerance for oral anticoagulation. We report a case of percutaneous closure of the left atrial appendage, which might be a good alternative strategy instead of chronic oral anticoagulation to protect patients with high-risk AF and HHT from cerebral embolic strokes.

No MeSH data available.


Related in: MedlinePlus

Real-time three-dimensional transoesophageal echocardiographic imaging of the left atrial appendage as seen from the left atrial perspective. (a) Preprocedural view of LAA. (b) LAA closure device deployed. (LAA: left atrial appendage; AoV; aortic valve; MV; mitral valve).
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fig1: Real-time three-dimensional transoesophageal echocardiographic imaging of the left atrial appendage as seen from the left atrial perspective. (a) Preprocedural view of LAA. (b) LAA closure device deployed. (LAA: left atrial appendage; AoV; aortic valve; MV; mitral valve).

Mentions: We present a 79-year-old man who had been previously diagnosed with HHT, based on the clinical Curaçao criteria [1]; his family history revealed numerous first-degree relatives with HHT, physical examination demonstrated several telangiectasia on hands, face, lips, and ears, and he suffered from recurrent epistaxis. DNA analysis confirmed the clinical diagnosis with an ALK-1 gene mutation on chromosome 12. Visceral AVMs in the brain, lungs, liver, or gastro-intestinal tract were excluded with magnetic resonance imaging, echocardiography, computed-tomography, and endoscopy. In addition to HHT, the patient was known with arterial hypertension, a recent cerebral ischemic stroke, and permanent AF. His CHADS2-score of four indicated a high risk of recurrent stroke (8.5%/year) [2]. Since visceral sources of life-threatening hemorrhages were ruled out, a trial of OAC (warfarin) was started. This resulted in extensive epistaxis, requiring repeated blood transfusions despite treatment with iron supplements and nasal cauterizations. Because of this clinical dilemma, the patient was referred to our HHT-specialized cardiology department and was accepted for percutaneous LAA closure to protect against recurrent stroke, while avoiding the need for long-term OAC. A 27 mm Watchman LAA Occlusion Device (Atritech Inc., Plymouth, Minnesota) was implanted in the LAA using biplane fluoroscopy and 3D-transoesophageal echocardiography (TEE) guidance, according to the recent literature (Figure 1) [3]. Because of the patient's high-bleeding risk, postprocedural anticoagulation was limited to aspirin for at least six weeks to allow for device endothelialization and to prevent thrombotic complications. Control TEE at 45 days demonstrated successful closure of the LAA without thrombus formation on the atrial surface of the device (Figure 2), and aspirin was discontinued. During one-year followup, no thromboembolic complications or severe HHT-related bleedings occurred.


Left atrial appendage closure for stroke prevention in patients with atrial fibrillation and hereditary hemorrhagic telangiectasia.

Velthuis S, Swaans MJ, Mager JJ, Rensing BJ, Boersma LV, Post MC - Case Rep Cardiol (2012)

Real-time three-dimensional transoesophageal echocardiographic imaging of the left atrial appendage as seen from the left atrial perspective. (a) Preprocedural view of LAA. (b) LAA closure device deployed. (LAA: left atrial appendage; AoV; aortic valve; MV; mitral valve).
© Copyright Policy - open-access
Related In: Results  -  Collection

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getmorefigures.php?uid=PMC4008176&req=5

fig1: Real-time three-dimensional transoesophageal echocardiographic imaging of the left atrial appendage as seen from the left atrial perspective. (a) Preprocedural view of LAA. (b) LAA closure device deployed. (LAA: left atrial appendage; AoV; aortic valve; MV; mitral valve).
Mentions: We present a 79-year-old man who had been previously diagnosed with HHT, based on the clinical Curaçao criteria [1]; his family history revealed numerous first-degree relatives with HHT, physical examination demonstrated several telangiectasia on hands, face, lips, and ears, and he suffered from recurrent epistaxis. DNA analysis confirmed the clinical diagnosis with an ALK-1 gene mutation on chromosome 12. Visceral AVMs in the brain, lungs, liver, or gastro-intestinal tract were excluded with magnetic resonance imaging, echocardiography, computed-tomography, and endoscopy. In addition to HHT, the patient was known with arterial hypertension, a recent cerebral ischemic stroke, and permanent AF. His CHADS2-score of four indicated a high risk of recurrent stroke (8.5%/year) [2]. Since visceral sources of life-threatening hemorrhages were ruled out, a trial of OAC (warfarin) was started. This resulted in extensive epistaxis, requiring repeated blood transfusions despite treatment with iron supplements and nasal cauterizations. Because of this clinical dilemma, the patient was referred to our HHT-specialized cardiology department and was accepted for percutaneous LAA closure to protect against recurrent stroke, while avoiding the need for long-term OAC. A 27 mm Watchman LAA Occlusion Device (Atritech Inc., Plymouth, Minnesota) was implanted in the LAA using biplane fluoroscopy and 3D-transoesophageal echocardiography (TEE) guidance, according to the recent literature (Figure 1) [3]. Because of the patient's high-bleeding risk, postprocedural anticoagulation was limited to aspirin for at least six weeks to allow for device endothelialization and to prevent thrombotic complications. Control TEE at 45 days demonstrated successful closure of the LAA without thrombus formation on the atrial surface of the device (Figure 2), and aspirin was discontinued. During one-year followup, no thromboembolic complications or severe HHT-related bleedings occurred.

Bottom Line: Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide, and a major risk factor for disabling cerebral embolic stroke.Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder, characterized by vascular abnormalities with high-bleeding tendency and therefore intolerance for oral anticoagulation.We report a case of percutaneous closure of the left atrial appendage, which might be a good alternative strategy instead of chronic oral anticoagulation to protect patients with high-risk AF and HHT from cerebral embolic strokes.

View Article: PubMed Central - PubMed

Affiliation: Department of Cardiology, St. Antonius Hospital, 3435 CM Nieuwegein, The Netherlands.

ABSTRACT
Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting millions of individuals worldwide, and a major risk factor for disabling cerebral embolic stroke. Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant inherited disorder, characterized by vascular abnormalities with high-bleeding tendency and therefore intolerance for oral anticoagulation. We report a case of percutaneous closure of the left atrial appendage, which might be a good alternative strategy instead of chronic oral anticoagulation to protect patients with high-risk AF and HHT from cerebral embolic strokes.

No MeSH data available.


Related in: MedlinePlus