| Background and objectiveAtrial fibrillation(AF)is a common arrhythmia in clinical practice,which can lead to an increased risk of stroke.In recent years,with the development of radiofrequency catheter ablation(RFCA)technology,the success rate of the treatment of AF has been gradually improved.According to the guidelines of the European and American for the treatment of AF,the recommended level of RFCA in the treatment of AF increased.Specifically,this technology is mainly applied to the patients with paroxysmal AF or persistent AF which last less time,but not to patients with long-standing persistent AF and obvious atrial enlargement due to the recurrence rate of AF is increased if they are treated with RFCA.In addition,for patients with permanent AF,RECA is not a suitable treatment,while prevention of thromboembolism is highly recommended.The meta-analysis showed that warfarin reduces the risk of thromboembolism in patients with AF,the effect of new anticoagulant drugs are as good as warfarin.But all the medicines comes along with several drawbacks,like frequent monitoring of blood coagulation is required,poor compliance,high price and higher risk of hemorrhagic stroke.The study of PREVAIL and PROTECT confirmed that the effect of left atrial appendage occlusion in the prevention of thromboembolism is no less than warfarin,which affirmed the status of the left atrial appendage occlusion in treatment of AF thrombosis.With the approval of the FDA of American,Europe and China for the closure of the left atrial appendage,the left atrial appendage occlusion has been developed rapidly in the prevention of AF thrombosis,but there are still many problems need to be further studied.Firstly,what is the effect of left atrial appendage occlusion on the structure and function of the left atrium? Then,how to choose the best antithrombotic therapy after left atrial appendage occlusion? And how to choose interventional therapy for atrial septal defect combined with persistent atrial fibrillation? How to apply 3D printing technology in left atrial appendage occlusion? There is no solution related to these questions being reported.Based on the above background,our study focused on the left atrial appendage occlusion.Start with observing the effect of left atrial appendage occlusion on left atrial structure and function,we investigated antithrombotic treatment after left atrial appendage occlusion later on,and explored the safety of carrying out left atrial appendage occlusion and closure of atrial septal defect at the same time,then the application of 3D printing technology in the left atrial appendage occlusion.Methods1.140 patients with persistent non valvular AF who were admitted to our hospital from August 3,2014 to February 15,2017 were selected as the research subjects;2.Inclusion Criteria:(1)Patients with nonvalvular persistent AF;(2)Patients are older than 18 years old;(3)The CHADS2 VASc score is more than 2 points;(4)The HASBLED score is more than 3 points;(5)Patients who have a contraindication to Warfarin or are unwilling to use Warfarin for long-term.Exclusion criteria:(1)Heart valve disease complicated with AF;(2)Preoperative transesophageal echocardiography showed that the left atrium or left atrial appendage had a suspicious or definite thrombus;(3)Severe heart failure(NYHA IV)and severe liver and renal insufficiency;(4)Patients with acute myocardial infarction;(5)1 months after stroke;3.Influence of left atrial appendage occlusion on left atrial structure and function:(1)85 patients were enrolled in this study;(2)The preoperative and postoperative 48 h and postoperative 45-60 days,conduct ocardiac ultrasound to measure the inner diameter of left atrium,right atrium,left ventricle and right ventricular,and left atrial area(systolic and diastolic)and volume(systolic and diastolic);(3)The transesophageal echocardiography to check if left atrial and left atrial appendage have spontaneous contrast and thrombosis or not,and to observe and measure the left atrial appendage depth and diameter from four angles,such as 0 degrees,45 degrees,90 degrees and 135 degrees;(4)The levels of NT-proBNP were measured before operation,6 hours,24 hours,48 hours and 45-60 days after operation;(5)Complete left atrial appendage occlusion under general anesthesia;(6)The 45-60 days after operation,transesophageal echocardiography was used to examine there is residual shunt and thrombosis on occluder or not.4.Study on antithrombotic therapy for patients with left atrial appendage occlusion;(1)The 75 patients enrolled,randomly divided into anticoagulant warfarin group,new oral anticoagulants(dabigatran)group and dual antiplatelet group(aspirin and clopidogrel);(2)The echocardiography of left atrium,right atrium,left ventricle and right ventricular diameter;transesophageal echocardiography of left atrial and left atrial appendage without spontaneous contrast or thrombosis,and at 0 degrees,45 degrees,90 degrees and 135 degrees from four angles of observation and measurement of left atrial appendage depth and diameter;(3)Complete left atrial appendage occlusion under general anesthesia;(4)According to the preoperative randomization principle,Warfarin,new anticoagulant drugs or dual antiplatelet therapy were given;(5)After operation 3 days,15 days,45 days,60 days,6 months,12 months,we do follow-ups.Then follow-up visits were paid per year.The follow-ups focused on if the patients have stroke,TIA attack,bleeding complications such as gastrointestinal bleeding,oral warfarin INR standards(2.0-3.0);(6)The 45-60 days after operation,transesophageal echocardiography was used to examine there is residual shunt and thrombosis on occluder or not.5.The feasibility study of one-stop occlusion in patients with atrial septal defect combined with persistent atrial fibrillation:(1)15 patients with atrial septal defect and persistent atrial fibrillation were enrolled in this study;(2)The echocardiography atrial septal defect diameter and edge;transesophageal echocardiography of left atrial and left atrial appendage without spontaneous contrast or thrombosis,and in the four angles of 0 degrees,45 degrees,90 degrees and 135 degrees were observed and measured the largest diameter and depth,to determine whether the closure of atrial septal defect and left atrial appendage occlusion indications;(3)Under general anesthesia,the one-stop occlusion was performed by the order of the left atrial appendage firstly,then atrial septal defect by order.(4)After operation,warfarin was used.Six months later,Aspirin Enteric-coated Tablets was prescribed instead.(5)The patients were followed up regularly after the operation,and the patients were checked TIA,stroke or not and INR(2.0-3.0)and so on;(6)The 45-60 days after operation,transesophageal echocardiography was used to examine the condition of the occluder and there is residual shunt and thrombosis on occluder or not.6.Application of 3D printing in the occlusion of left atrial appendage(1)42 patients were enrolled in this study were randomly divided into 3D printing group and non 3D pringting group;(2)The transesophageal echocardiography was conducted to check left atrial and left atrial appendage have spontaneous contrast andthrombosis or not,and to observe and measure the maximum inner diameter and depth in the four angles of 0 degrees,45 degrees,90 degrees and 135 degrees;(3)Cardiac CTA examination was performed to determine the size and depth of the left atrial appendage;(4)The 3D printing group made the left atrial appendage model according to the preoperative cardiac CTA image,and then print out the left atrial appendage in vitro model,tried plugging in the model to the left atrial appendage,got familiar with the LAA occluder size before surgery,to choose the suitable intraoperative occluder;(5)The left atrial appendage occlusion was performed under general anesthesia.The maximum inner diameter and depth of left atrial appendage was measured by left atrial appendage angiography;(6)The 45-60 days after operation,transesophageal echocardiography was used to examine the condition of the occluder and there is residual shunt and thrombosis on occluder or not.Results1.A total of 140 patients were enrolled in this study.Among them,62 cases were male,78 were female,means of age was 68.2±8.6 years(51-83 years),the duration of AF was 3.1±3.7 years,CHA2DS2 VASc scores were 4.2±1.4,HASBLED scores were 3.2±0.4;2.140 patients underwent left atrial appendage occlusion,including 138 cases of closure,closure of the success rate is 98.6%,a total of 138(including the Watchman occluder implantation device 135,ACP 3,average occluder)occluder diameter: 26.5±3.2mm occluder;the compression rate is 21.2±4.9%(8-30%),the average follow-up time was 15.9±7.9month,4 cases of postoperative patients with thrombosis of occluder.3.Study on the effect of 85 cases of left atrial structure and function in patients with left atrial appendage occlusion,postoperative 48 h and 45-60 days,left atrial diameter,left atrial diastolic volume and systolic diameter,end diastolic area and systolic area decreased(P<0.05);NT-proBNP in left atrial appendage after transcatheter closure of 6h and 24 h was significantly increased(P<0.05),48 h after the return to normal,to further reduce the postoperative 45-60d(P<0.05);4.For patients with left atrial appendage occlusion after antithrombotic therapy in 75 cases,dual antiplatelet group,anticoagulant warfarin group and new oral anticoagulants group each have 1 cases occurred in patients with occluder thrombosis,which occurred thrombosis were prolonged anticoagulation after six month,thrombus disappeared,three were not statistically significant compared(P>0.05);5.15 cases of atrial septal defect with persistent AF patients were adults,age 67.5±6.8 years,the duration of atrial fibrillation was 3.5±1.5 years;TTE measurement of atrial septal defect with an average diameter of 17±7.2mm,TEE measured left atrial maximum opening diameter of 21.4±3.2 mm,the maximum depth diameter of 27.4±3.8mm.15 patients were treated with left atrial appendage occlusion and atrial septal defect occlusion successfully.Watchman occluder was implanted in 15 cases,with an average diameter of 27.6±3.2mm.Atrial septal defect(ASD)occluder was implanted in 16 cases with an average diameter of the occluder was 26.8±8.5mm.After oral anticoagulation with warfarin,the value of INR was 2.2± 0.18,with an average follow-up of 10.5±6.9 months.After TEE,the left atrial appendage and ASD occluder were normal.6.A total of 42 patients were enrolled in the study of 3D printing in the left atrial appendage occlusion,were randomly divided into 3D pringting group and control group.TEE,left atrial appendage angiography and cardiac CTA measured two groups of patients with left atrial diameter were 20.4±2.5mm vs 20.1±3.3mm,19.6±2.2mm vs 19.5±2.8mm and 20.8±2.1mm vs 20.2±3.0mm,the two groups showed no significant difference(P>0.05),but the comparison group,the maximum diameter measured was cardiac CTA and minimum diameter measured was left atrial appendage angiography(P<0.05).All patients were successfully occluded with Watchman occluder.The diameter of the occluder used in 3D group and control group was 26.5±2.8mm and 26.3±3.4mm.TEE detection showed that there was a small amount of gap shunt in 3 cases in the control group,but there was no residual shunt in the 3D printing group.7.Compared with the control group,the operation time,X-ray exposure and contrast agent dosage of 3D pringting group were significantly reduced(P<0.05).The mean follow-up was 17.8±2.7 months,and in the control group,the residual shunt was found in all the patients in the treatment group in 2 cases and disappeared in the postoperative period of 45 days,and in the control group,1 cases disappeared in the postoperative 3 months.There were no complications,thrombosis and ischemic events.Conclusions:1.140 cases of patients with left atrial appendage occlusion,138 cases were successful,the success rate of 98.6%.When follow-up,4 cases have occluder thrombosis,and no serious complications and death cases.All the data shown left atrial appendage occlusion is safe and effective in preventing stroke of non valvular atrial fibrillation;2.After left atrial appendage occlusion,left atrial diameter,left atrial end diastolic volume,end systolic volume,end diastolic area,and end systolic phase were reduced,which means this operation improved the structure of atrium;3.6h and 24 h after left atrial appendage occlusion,the serum level of NT-proBNP in patients increased,and returned to normal after 48 h.The serum level of NT-proBNP was lower than normal after 45-60 days,which indicated that it could affect the secretion of NT-proBNP and improve the function of left atrium;4.45 days after left atrial appendage occlusion operation,warfarin,new oral anticoagulants and dual antiplatelet therapy are feasible;5.It is safe and effective to treat patients with atrial septal defect and persistent atrial fibrillation with one-stop occlusion;6.TEE,cardiac CTA and left atrial appendage angiography can be used to evaluate the width and depth of the left atrial appendage.The data of the left atrial appendage angiography is the smallest,and the CTA data is the largest;7.3D printing guidance left atrial appendage occlusion can shorten the operation time,reduce the amount of exposure and the amount of contrast agent,the residual flow is less.All the benefits suggest there is a certain clinical value. |
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