Recently, under the leadership of Professor Xu Wei, head of the atrial fibrillation center of Gulou Hospital Affiliated to Nanjing University Medical College, the electrophysiological team of Cardiology successfully completed the double umbrella kissing watchman left atrial appendage occlusion for a patient with high bleeding risk, which is also the first case of kissing watchman left atrial appendage occlusion in Jiangsu Province. This operation is an innovative one in the left atrial appendage blocking operation. It can easily solve the very complex double lobed left atrial appendage. It can simplify the complex problems, decompose the steps for the operation, ensure the safety of the patient's operation, and guarantee the prognosis of the patient to the greatest extent. However, it needs experienced clinicians to fully evaluate the patient's operation conditions. The successful completion of double umbrella kissing watchman's left atrial appendage occlusion marked a new step in the comprehensive treatment of atrial fibrillation in the Department of Cardiology of Nanjing Gulou Hospital.
On April 7, Professor Xu Wei, head of the atrial fibrillation center of Gulou Hospital Affiliated to Nanjing University Medical College, led the electrophysiological team to perform left atrial appendage occlusion for a patient with high bleeding risk. The patient was a 64 year old male patient with persistent atrial fibrillation. The left atrium was 58 mm in diameter and 49% in EF value. The related score of admission atrial fibrillation: cha2ds2-vasc 3 points, has-bled bleeding 3 points. Because the left atrium diameter of the patient is more than 50 mm, the expected 5-year recurrence rate of ablation operation is more than 50%, and stroke is at high risk, requiring anticoagulation treatment for life, Professor Xu Wei's team decided to perform simple left atrial appendage occlusion for the patient with atrial fibrillation, in order to solve the high risk of stroke and bleeding caused by the patient's atrial fibrillation, and improve the long-term quality of life of the patient.
During the operation, it was found that the opening of the left atrial appendage of the patient was "underpants with early lobes", the largest opening diameter was 40 mm, the upper lobe was wind bag type, and the lower lobe was cauliflower type. So here comes the question...!
Is it to choose a huge occluder to block the outer port or to go up and down the leaves in two steps?
Analysis of Professor Xu Wei:
1. The area of left atrial appendage occluder exposed to left atrium should not be too large. The smaller the exposure area is, the faster the endothelialization speed is. Because of the repeated bleeding of anticoagulant drugs, it is more appropriate to choose the occluder of plug type to reduce the oral anticoagulation time during the perioperative period. 2. The diameter of the external opening of the left atrial appendage is 36 mm, the internal opening is 40 mm, the distance between the crest of the upper lobe and the external opening is 20 mm, the inferior lobe and the axial direction are not good. Therefore, Professor Xu Wei's team immediately changed the operation strategy, divided it into two parts, reduced the difficulty of operation, and used two small plug occluders for operation.
Two occluders were put into the patients' auricle at one time to block the mouth of the auricle side by side, that is, the killing plugging technology of left auricle plugging. As the patient's auricle is of early lobulated underpants, the opening of upper lobe is 20 mm, the depth is 26 mm, and the opening of lower lobe is 20 mm (the opening of lower lobe is reduced after being squeezed by upper lobe occluder), the depth is 23 mm. During the operation, two plug occluders (24mm watchman device) were sent into the upper and lower lobes respectively to block. The 24mm watchman of the upper leaf occluder is located at the mouth of the upper leaf, with a compression ratio of 13.8% - 21.6%. There is no residual shunt at all angles, and the pull is stable. The 24mm watchman of the lower leaf occluder is located at the mouth of the lower leaf, with a compression ratio of 15% - 17.5%. There is no residual shunt at all angles, and the pull is stable. Both occluders conform to the pass principle. Intraoperative imaging
Summary of surgical techniques:
1. [big and small, split in two] when the left atrial appendage with large opening is divided into early leaves, we can try to decompose the left atrial appendage according to the shape of the left atrial appendage, and block them respectively. 2. In this case, the two occluders were independent and stable, meeting the pass principle, and had some interaction, increasing the stability. Although the cost and difficulty of operation are increased, the safety of operation is ensured. 3. [low shallow cauliflower type auricle] the lower leaf is shallow cauliflower type auricle. During plugging, 2mm depth is borrowed outside the body. Smoke is emitted continuously when entering the sheath clockwise to observe the available space at the far end. After positioning is completed, the second borrowing depth is borrowed when opening the packer to complete the flat sealing.
4. [judgment of stability] the stability of watchman's left atrial appendage occluder depends on two points: active fixation of barb and radial support of shoulder. When judging the stability of this case of kissing watchman, it was observed that the fixation of the barb on the septal crest was firm. Professor Xu Wei suggested:
There is not much experience in the clinical application of kissing watchman technology, but this practice proves that it can be simplified into a simple and effective way to solve the problem of super large auricle. Its advantage is that it can reduce the area of occluder exposed in the atrium. The area of occluder finally exposed in the atrium of this patient is less than 839mm?, which theoretically shortens the time of endothelialization. At the same time, because two occluders are fixed separately, it also increases the stability of occluder to a certain extent, which provides guarantee for the patients with atrial fibrillation to stop using anticoagulants and reduce the risk of stroke and bleeding.
This patient is a non valvular atrial fibrillation, stroke high-risk patients, because of taking oral anticoagulant repeated bleeding, choose to block the left atrial appendage operation to prevent stroke. According to the existing evidence-based medical evidence, oral anticoagulants can be stopped 45 days to 3 months after left atrial appendage occlusion. The 2-year follow-up results show that the risk of stroke and bleeding in patients with left atrial appendage occlusion is not significantly different from noac. The long-term follow-up results show that the economic benefits of left atrial appendage occlusion operation are prolonged with time.
There are not many cases of kissing watchman in China. Up to now, there are only more than 20 cases of surgical experience, which are only suitable for special form of auricular closure. Due to the large exposure area of the occluder, the process of endothelialization and residual shunt need to be closely monitored, especially the residual shunt between the two occluders, so as to determine the time node of discontinuation of oral anticoagulants.
The successful completion of kissing watchman's left atrial appendage occlusion is one of the achievements that Nanjing Gulou Hospital has been exploring and breaking through in the construction of China's atrial fibrillation center. It also further overcomes the technical difficulties of special left atrial appendage occlusion for patients with atrial fibrillation, and brings new options for more patients with atrial fibrillation to prevent stroke and stay away from bleeding.
Introduction to experts
Xu Wei
Nanjing Gulou Hospital
Chief physician, MD, FHRS, FESC; deputy director of Cardiology Department of Gulou Hospital Affiliated to Nanjing University Medical College and director of arrhythmia training base of cardiovascular intervention diagnosis and treatment technology of national health and Health Commission.
Vice chairman of rhythm Professional Committee of Chinese Medical Association, vice chairman of atrial fibrillation stroke prevention working committee of National Health Committee, vice chairman of heart failure device treatment Committee of electrophysiology and pacing branch of Chinese Medical Association, vice chairman of cardiac telemedicine Professional Committee of electrophysiology and pacing branch of Chinese Medical Association, Jiangsu Medical Association He is the chairman designate of the electrophysiology and pacing branch, the head of the arrhythmia group of the cardiovascular disease branch of Jiangsu Medical Association, the president of the China Association of county cardiac rhythm physicians and the president of Jiangsu Association. The deputy editor in chief of the cardiology channel of the medical reference newspaper of the National Health Committee and the editorial board of several professional academic journals such as the Chinese Journal of arrhythmias, the Chinese Journal of cardiac pacing and electrophysiology, and the Chinese Journal of general medicine.
LAN Rong Fang
Nanjing Gulou Hospital
Nanjing Gulou Hospital, deputy chief physician of cardiovascular medicine, MD. He is a young member of the electrophysiology and pacing branch of the Chinese Medical Association, a young member of the rhythm Professional Committee of the Chinese Medical Association, a vice chairman of the Youth Committee of the electrophysiology and pacing branch of the Jiangsu Medical Association, and a member of the electrophysiology and pacing branch of the Nanjing Medical Association. Professional direction: cardiac pacing electrophysiology, especially good at heart failure device treatment, Xipu system physiological pacing, pacing system removal, etc., has obtained ehra pacing qualification certification, and is now the instructor of arrhythmia intervention training base of national health and Family Planning Commission.
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