Search Results (86)

Background and Objectives: Left atrial appendage (LAA) closure is a Class I recommendation in patients with atrial fibrillation to reduce the risk of cardioembolic stroke. Achieving reliable and complete LAA exclusion during minimally invasive mitral valve surgery via right minithoracotomy remains technically challenging. We report here to our knowledge the largest series of a novel technique for LAA exclusion using an epicardial clip device applied via right minithoracotomy during minimally invasive mitral valve surgery. Materials and Methods: Between June 2023 and May 2026, 40 patients with atrial fibrillation underwent minimally invasive mitral valve surgery via right minithoracotomy with concomitant LAA exclusion. Cardiopulmonary bypass was established via percutaneous femoral cannulation. Following completion of the intracardiac procedure and prior to aortic cross-clamp removal, a suture was placed around the LAA base via the transverse sinus and used to guide clip deployment under direct vision. Successful closure was confirmed by intraoperative transesophageal echocardiography. Results: Mean patient age was 66.6 ± 8.0 years; 21 patients (53%) were female. Mitral valve repair was performed in 36 patients (90%) and replacement in 4 (10%). Concomitant cryoablation for AF was performed in 31 patients (78%). Successful LAA clip deployment was achieved in all 40 patients (100%). The 35 mm clip was used in 36 patients (90%), the 40 mm clip in 3 patients (8%), and the 45 mm clip in 1 patient (2%). Mean total operative time was 183 ± 58 min; mean CPB time was 134 ± 42 min; mean aortic cross-clamp time was 70 ± 27 min. In-hospital mortality was 0%. One patient (3%) required re-thoracotomy for bleeding, one developed a postoperative stroke, and two required ECMO support. Median hospital stay was 9 days. At discharge, 18 patients (45%) were in sinus rhythm; among the 31 who underwent concomitant cryoablation, 16 (52%) were discharged in sinus rhythm. Conclusions: Minimally invasive LAA exclusion is feasible and safe when performed via right minithoracotomy during minimally invasive mitral valve surgery. The technique achieves high rates of successful deployment and avoids the need for additional incisions or access sites. This approach represents a valuable addition to the armamentarium of concomitant stroke prevention strategies in patients with AF undergoing minimally invasive valvular surgery. Full article

Transseptal puncture (TSP) is a critical technique for accessing the left atrium in various structural and electrophysiological cardiac procedures. Originally introduced for diagnostic catheterization in the mid-20th century, it has evolved into a cornerstone of modern interventional cardiology. This article was designed as a targeted narrative review, rather than a systematic or comprehensive review, and synthesizes selected peer-reviewed evidence spanning 1955 to 2025, retrieved through a targeted literature search. We explore the anatomical foundations of TSP, its historical development, and modern refinements such as radiofrequency-assisted puncture, balloon septoplasty, and fluoroless or image-fusion-guided access. Clinical applications—including mitral valve interventions, left atrial appendage closure, and decompression during extracorporeal membrane oxygenation (ECMO)—are reviewed alongside safety considerations and complication management strategies. Advances in imaging modalities, including three-dimensional echocardiography and computed tomography, have enhanced precision and safety. Because of the narrative design, the review emphasizes clinical relevance, procedural applicability, and evidence synthesis without formal risk-of-bias scoring or quantitative evidence grading. Overall, TSP demonstrates a high success rate and low complication profile when performed with appropriate imaging and operator expertise. Ongoing innovation in technique and technology continues to expand its utility across cardiac disciplines. Full article

Introduction: In high-risk atrial fibrillation patients, the endocardial LAA closure technique is the most common approach. Epicardial ligation is not as widely spread despite the advantage of omitting all anticoagulation straight after ligation. This study retrospectively analyzes endo- and epicardial LAA occlusion techniques in regard to efficacy, safety and long-term data. Method: From November 2018 to August 2024, 112 patients underwent LAA occlusion, 69 with an epicardial approach using Lariat^® (epicardial group) and 43 patients with an endocardial plug Amulet^TM (endocardial group). Results: A total of 69 patients were treated with epicardial ligation and 43 patients with implantation of an endocardial plug. Procedure time (mean of 83 min vs. 62 min) and fluoroscopy time (17 min vs. 6.16 min) were significantly longer in the epicardial ligation group. Silent cerebral lesions (SCLs) in MRI were equally distributed in both groups (11.0% vs. 8%, p = 0.67). A 3-month FUP revealed five thrombi at the closure site in the epicardial group, which resolved with OAC therapy, and 0 in the endocardial group (8% vs. 0%), one central gap in the epicardial group and six peridevice leaks (PDLs) in the endocardial group (1% vs. 16%). A 12-month FUP revealed no thrombus in both groups, and six gaps in the endocardial group. Conclusions: Epicardial ligation of LAA is associated with a longer fluoroscopy time and procedure time compared to the endo approach. Early FUP revealed more thrombi in the epicardial group and more PDLs in the endocardial group. A 1-year FUP and long-term FUP showed comparable clinical results. Full article

Transcatheter structural heart interventions, including aortic, mitral and tricuspid valve replacement or repair, and patent foramen ovale, atrial septal defect, and left atrial appendage closure, have dramatically expanded over the past two decades, providing substantial improvements in both clinical outcomes and quality of life. These interventions are performed in a high-risk patient population, which is at risk for both thrombotic and bleeding complications. The introduction of prosthetic devices into the arterial or venous circulation under heterogeneous hemodynamic conditions inevitably increases the risk for thrombotic events and thromboembolic complications. Consequently, the selection of antithrombotic therapy (AT) regimen and its duration is complex and should be tailored to each patient’s risk profile, balancing the expected risk and benefits. This state-of-the-art review critically examines the thrombotic risks inherent to transcatheter structural heart interventions, synthesizes available evidence and current guidelines recommendations on antithrombotic management, and defines persisting gaps in knowledge while discussing the most relevant ongoing clinical trials. Full article

Background: Atrial fibrillation (AF) remains the most common cardiac arrhythmia, with pulmonary vein isolation (PVI) established as the cornerstone of interventional treatment. However, in patients with persistent AF (PersAF), the success rates of PVI alone tend to be limited. A promising additional target is the left atrial appendage (LAA). In recent years, cryoballoon (CB) technology has become a tool for achieving durable PVI. Its application for LAAI has been investigated as a potentially advantageous alternative to radiofrequency ablation, and a positive effect on long-term outcome has been reported. However, the available data is limited. This study sought to investigate the clinical impact of CB-based LAAI in addition to PVI. Methods: This is a prospective, interventional, single-centre study. Consecutive patients with symptomatic PersAF were prospectively enrolled. In total 23 patients with PersAF underwent PVI plus LAAI using the CB system. Percutaneous LAA closure was performed within 2–3 months in all patients by implanting an endocardial LAA-closure device. Prior to LAA closure, LAAI durability was systematically assessed by invasive remapping studies. Results: A total of 100% of PVs were successfully isolated using the CB only (n = 91/91). Concerning LAAIs, a total of 21/23 (91%) remained isolated at the end of the procedure. After the ablation procedure including LAAI, all patients were scheduled for TEE assessment and LAA closure. TEE was performed after a mean of 54 ± 19 days. In 6/23 (26%) patients, LAA thrombus formation was detected after LAAI. A total of 23/23 patients (100%) received LAAC after a mean of 72 ± 45 days. Durability of LAAI was assessed utilizing a spiral mapping catheter in 23/23 patients (100%). In a total of 17/23 (74%) patients, durable LAA isolation was detected. Durable PVI of all PVs was detected in 16/23 (70%) patients. During a mean follow-up of 13 ± 3.4 months, stable sinus rhythm was maintained in 15 (65%) patients. The LAA showed reconnection in 3/23 (13%) patients, with arrhythmia recurrence. During follow-up, one stroke (318 days after LAAC) and one device thrombus (56 days after LAAC) occurred. Conclusions: While CB-based LAAI may offer benefits in managing persistent AF, it presents a significant risk of thrombus formation in the LAA, even with appropriate OAC. Early closure of the LAA following LAAI appears promising in mitigating these risks, but further evidence is needed to establish clear best practices. Full article

Background: Atrial fibrillation (AF) and end-stage renal disease (ESRD) are closely related conditions that increase the risk of disability, stroke, and mortality. Anticoagulation management in patients with ESRD and AF is challenging due to the high risk of bleeding. Percutaneous left atrial appendage closure (LAAC) has emerged as an alternative to reduce thromboembolic events; however, evidence in this specific population remains limited. Therefore, we aimed to evaluate the frequency of thromboembolic events, bleeding complications and mortality in patients with AF and ESRD undergoing LAAC through a systematic review and meta-analysis. Methods: A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines and registered in PROSPERO (CRD420250640241). A structured search was performed in Medline, EMBASE, Web of Science, SCOPUS, LILACs and institutional repositories through September 2024, with no language restrictions. We included original studies reporting frequencies of thromboembolic events, bleeding and mortality in patients with AF and ESRD undergoing LAAC. A random-effects model was used and heterogeneity was assessed using the I² statistic. Results: Fourteen studies were included in the qualitative analysis and seven in the quantitative synthesis, comprising a total of 2433 patients with AF and ESRD undergoing LAAC. In the qualitative analysis, the mean age was 74 ± 7.6 years; the most common comorbidities were hypertension (74%), diabetes mellitus (47%), and dyslipidemia (53%). Watchman™ devices predominated in North America, whereas Amulet™ devices were more frequently used in Europe and Latin America. Procedural success was 98.4%, with infrequent periprocedural complications: major bleeding in 1.6% and device embolization in 0.5%. In the quantitative analysis, the pooled frequency of thromboembolic events was 3% (95% CI: 1–7%; I² = 81.1%), pooled bleeding frequency was 6% (95% CI: 4–10%; I² = 76.9%), and pooled mortality was 5% (95% CI: 1–22%; I² = 97.8%). After excluding studies with extreme values, adjusted mortality was 2% (95% CI: 1–5%; I² = 76.6%). Despite high heterogeneity, the findings suggest that LAAC may offer protection against embolic events with an acceptable bleeding risk. Conclusions: LAAC in patients with AF and ESRD is associated with a low frequency of thromboembolic events and bleeding when compared with standard anticoagulation therapy and no treatment. Overall mortality is moderate and appears to be primarily attributable to underlying comorbidity rather than the procedure itself. This meta-analysis provides evidence that LAAC may be a safe and effective therapeutic strategy in patients with contraindications or high risk for chronic anticoagulation. However, prospective and comparative clinical trials are needed to confirm these findings and inform future clinical practice guidelines. Full article

Background: Left atrial appendage closure (LAAC) is an established alternative to oral anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation who are at high risk of thromboembolic events or bleeding complications. Methods: In this single-center retrospective study, we analyzed 70 consecutive patients who underwent successful LAAC with the Watchman™ device between 2012 and 2024. Acute procedural outcomes, long-term thromboembolic and bleeding events, transfusion requirements and mortality were evaluated. Mean follow-up duration was 1210 days. Results: Procedural success was achieved in 98.6% of cases with a low periprocedural complication rate. Ischemic stroke/transient ischemic attack occurred in 2.8% of patients; no hemorrhagic strokes or stroke-related deaths were observed. LAAC resulted in a significant reduction in both the number (144 vs. 56 events; 2.36 vs. 1.55 events per patient, p < 0.05) and severity of bleeding events. Nonetheless, 42.9% of patients required bleeding-related hospitalization after implantation, predominantly within the first 6 months during dual antiplatelet therapy. Overall mortality was 40% with a 12% yearly mortality rate; heart failure and infections were leading causes of death. Pre- and postprocedural transfusion requirements were independently associated with a six-fold increase in mortality risk (HR = 5.97). Conventional risk scores (CHA₂DS₂-VASc, HAS-BLED) failed to predict transfusion needs; atrial enlargement, right ventricular dysfunction, smoking and alcohol consumption were associated with higher risk. Conclusions: LAAC is a safe and effective alternative to long-term anticoagulation, significantly reducing bleeding burden without increasing thromboembolic mortality. Persistent postprocedural bleeding remains a major determinant of long-term prognosis, underscoring the need for individualized, multidisciplinary post-implant management. Full article

Percutaneous left atrial appendage occlusion (LAAO), patent foramen ovale (PFO) closure, and atrial septal defect (ASD) closure rely on temporary antithrombotic therapy to prevent device-related thrombus during endothelialization, yet optimal regimens remain uncertain and vary widely across clinical practice. This review synthesizes contemporary evidence on postprocedural antithrombotic strategies, comparing efficacy and safety data and identifying key gaps in knowledge. After LAAO, therapeutic approaches range from short-term anticoagulation with vitamin K antagonists or direct oral anticoagulants to dual or single antiplatelet therapy in patients with high bleeding risk; observational data increasingly support DOAC-based regimens, although device-related thrombus remains a significant concern, and follow-up imaging protocols are inconsistent. Following PFO and ASD closure, antiplatelet-only regimens—typically brief dual antiplatelet therapy followed by aspirin—are widely used, with evidence suggesting that simplified or abbreviated strategies may be sufficient in selected patients. Despite extensive clinical experience, high-quality comparative trials are limited, and optimal therapy, duration, and surveillance remain debated. Standardized imaging definitions, randomized studies, and individualized risk-based frameworks are needed to optimize antithrombotic care after atrial structural interventions. Full article

Background: Echocardiographic imaging has become central to planning and guiding percutaneous left atrial appendage occlusion (LAAO), particularly in patient populations in whom long-term anticoagulation is unsuitable. This systematic review synthesizes current evidence on transesophageal (TEE) and intracardiac echocardiography (ICE) guidance during LAAO, with special emphasis on outcomes in high-risk cohorts, including chronic liver disease (CLD) and prior gastrointestinal (GI) bleeding. Methods: Following PRISMA 2020 guidelines, four databases (PubMed, Scopus, Web of Science, and Cochrane CENTRAL) were searched up to 5 December 2025. Eligible studies included adult patients with atrial fibrillation (AF) undergoing percutaneous LAAO with intraprocedural echocardiographic guidance. Eight studies (n = 1739 patients) met the inclusion criteria. Data were synthesized qualitatively due to heterogeneity across devices, imaging protocols, and outcomes. Results: TEE was the predominant imaging modality (62.5%), providing high spatial resolution for transseptal puncture, device positioning, and peri-device leak (PDL) assessment. ICE-guided LAAO (25.0%) was associated with high procedural success and favorable safety profiles in selected observational cohorts, while reducing anesthesia requirements and fluoroscopy time. Across all studies, procedural success ranged from 93 to 100%, with low rates of major complications. Reported follow-up durations varied substantially across studies and were predominantly short- to mid-term, limiting assessment of long-term device-related outcomes. Evidence specific to patients with chronic liver disease and prior gastrointestinal bleeding was limited, with only two included studies directly evaluating these populations, while remaining insights were extrapolated from broader LAAO cohorts. In high-risk groups, LAAO remained feasible: cirrhotic patients demonstrated high implantation success with acceptable bleeding profiles, while patients with prior GI bleeding showed low recurrence after closure. Conclusions: Both TEE and ICE provide reliable intraprocedural imaging for LAAO, with ICE offering workflow and safety advantages in patients unsuitable for general anesthesia. The available evidence suggests that LAAO is a feasible and potentially safe therapeutic option in selected patients with CLD and prior GI bleeding, although direct data remain limited. Future studies should compare imaging modalities prospectively in high-risk cohorts and evaluate emerging 3D/4D ICE technologies. Full article

Background: Percutaneous left atrial appendage closure (LAAC) provides an alternative to oral anticoagulation (OAC) in atrial fibrillation (AF) patients who are at high bleeding risk. Prior studies have suggested sex-related differences in procedural outcomes, with women demonstrating higher peri-procedural complication rates. Data on long-term outcomes, however, remain inconsistent. Methods: We analyzed 407 consecutive patients with AF who underwent LAAC between 2010 and 2023 in four Israeli medical centers participating in the LEADER registry. Baseline characteristics, procedural data, and clinical outcomes were compared between men and women. The primary efficacy endpoint was ischemic stroke or systemic embolism at 1 year. The primary safety endpoint was a composite of all-cause mortality, procedural complications, or major bleeding at 1 year. Results: Of 407 patients, 285 (70%) were men and 122 (30%) were women. The mean age was 77 ± 8.4 years with similar CHA₂DS₂-VASc and HAS-BLED scores across sexes. Device implantation exceeded 99% in both sexes. Major peri-procedural complications occurred in 6.4% overall, without significant sex-based differences (men 7.0%, women 4.9%, p = 0.51). At 1-year follow-up, Kaplan–Meier estimates for the primary efficacy endpoint of ischemic stroke/systemic embolism (2.6%), the primary safety endpoint (19.2%), major bleeding (8.9%), and all-cause mortality (9.3%) were comparable between men and women (all p > 0.1). Conclusions: In contrast to prior large registries reporting higher peri-procedural risk in women, this real-world multicenter experience demonstrated no significant sex differences in either peri-procedural or long-term outcomes following LAAC. These findings support LAAC as an effective and safe stroke-prevention strategy in AF, irrespective of sex. Full article

Intracardiac echocardiography (ICE) is increasingly recognized as a valuable imaging modality in structural heart interventions, offering high-resolution, real-time visualization from within the cardiac chambers. Originally developed for electrophysiologic procedures, ICE has expanded its use across a broad spectrum of structural interventions, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, left atrial appendage occlusion (LAAO), transseptal puncture guidance, transcatheter edge-to-edge repair (TEER), balloon mitral valvuloplasty, and both mitral and tricuspid valve therapies. This review outlines the current role and technical principles of ICE, with an emphasis on catheter design, image acquisition protocols, and the emerging potential of 3D ICE. Comparisons with transesophageal echocardiography (TEE) and fluoroscopy are discussed, highlighting ICE’s ability to support minimally invasive, sedation-sparing procedures while maintaining procedural precision. We provide a focused analysis of ICE-guided applications in specific clinical scenarios, emphasizing its role in anatomical assessment, device navigation, and intra-procedural monitoring. Data from recent clinical studies and registries are reviewed to assess safety, feasibility, and outcomes. Practical considerations including operator learning curve, workflow integration, and limitations such as cost and field of view are also addressed. Lastly, we explore future directions including advanced 3D imaging, fusion imaging, artificial intelligence integration, and robotic catheter systems. Full article

Background and objective: Evidence of percutaneous left atrial appendage closure (LAAC) and oral anticoagulants (OACs) in non-valvular atrial fibrillation (NVAF) patients with intermediate-to-borderline high stroke risk is scarce. We aimed to compare the efficacy and safety of these treatments in the latter clinical population. Methods: This retrospective cohort study included NVAF patients with CHA₂DS₂-VA scores of 1–2 and used 1:1 propensity score matching (184 patients per group) to compare efficacy and safety outcomes. The primary efficacy outcome was a composite of stroke, transient ischemic attacks, systemic embolism, and cardiovascular death during follow-up. Adverse safety events were categorized into peri-procedure (LAAC group) and non-procedural (both groups) events. Results: Over a mean follow-up of 48.93 ± 28.50 months, a total of 26 patients (7.07%) reached the primary composite efficacy endpoint. The LAAC group showed a significantly higher incidence of the efficacy endpoint compared to the OAC group (HR = 3.09; 95% CI 1.22–7.85; log-rank p = 0.01). Procedure-related events occurred in five LAAC patients (one contributing to primary endpoint), while non-procedural bleeding rates were similar (0.54% vs. 1.09%; p = 0.56). Subgroup analyses suggested concomitant ablation of NVAF in LAAC group did not significantly improve efficacy composite endpoints (HR = 0.47). Conclusions: In NVAF patients with intermediate-to-high stroke risk, OACs were more effective than LAAC in preventing thromboembolic events, with comparable rates of clinically relevant bleeding. Full article

Background: Positron emission tomography (PET) is a valuable tool in the diagnosis of cardiovascular infections. However, increased radiotracer uptake can also be observed in non-infectious inflammatory processes, leading to potential false positives. This study analyzed the uptake related to left atrial appendage closure devices (LAACD—AtriClip^®) to determine its association with infectious or inflammatory processes. Methods: We retrospectively analyzed 28 PET/CT scans from 20 patients with implanted LAACDs: 24 using ¹⁸F-fluorodeoxyglucose (FDG) and 4 using ¹⁸F-Choline (CHO). Clinical, laboratory, and imaging data were reviewed, and PET uptake was measured semi-quantitatively. All patients had at least 12 months of follow-up after PET imaging to assess for evidence of device-related infection. Results: Homogeneous PET uptake in the LAACD was observed in 93% (26/28) of the PET studies, regardless of the radiotracer used, clinical indication, or time since implantation. Clinical follow-up and laboratory findings revealed no signs of infection related to the LAACD in any case. SUV ratios did not differ significantly between the three PET indication groups (infection, neoplasia, or other; p = 0.46), nor between scans performed in patients with and without other confirmed infections unrelated to the LAACD (p = 0.37). Conclusions: FDG and CHO uptake in LAACDs appears to be a consistent and reproducible finding, most likely reflecting a sterile inflammatory response postoperative inflammatory uptake rather than true infection. Clear recognition of this uptake pattern is important to prevent misinterpretation and reduce the risk of false-positive PET/CT results in patients evaluated for suspected cardiovascular infections. Full article

The left atrial appendage (LAA) is a highly dynamic anatomical structure that plays a key role in left atrial reservoir function, pressure and volume modulation, and endocrine hormone secretion during sinus rhythm. However, its physiological contribution is profoundly altered in atrial fibrillation (AF). Electrical and structural remodeling, impaired contractility, and blood stasis within the LAA collectively transform this functional component into the principal cardiac source of thrombus formation and embolic events in patients with AF. This review focuses on the conceptual continuum from physiological LAA function in sinus rhythm to its pathological transformation in AF and the evolving rationale for progressively more complete (“radical”) anatomical exclusion A variety of strategies, including systemic anticoagulation therapy, percutaneous device-based exclusion, and surgical closure, are currently employed, each with specific indications, limitations, and procedure-related risks. Beyond summarizing available techniques, this review critically synthesizes mechanistic, anatomical, and clinical data to address unresolved controversies regarding patient selection, residual leaks, device-related thrombosis, and post-procedural antithrombotic management. Finally, emerging directions toward minimizing residual foreign material, reducing thrombogenicity, and achieving durable exclusion are discussed, supporting a more personalized and radical approach to stroke prevention in AF. Full article

Background: Left atrial appendage (LAA) closure is an alternative to oral anticoagulants (OAC) for stroke prevention in atrial fibrillation (AF), but comparative evidence remains inconsistent. This study systematically evaluates the efficacy and safety of LAA closure versus OAC in AF patients. Methods: We systematically searched PubMed, EmBase, Cochrane Library, and Web of Science for randomized controlled trials (RCTs) and propensity score-matched (PSM) studies published up to 30 September 2025. Treatment effects were estimated using relative risks (RR) with 95% confidence intervals (CI), and a random-effects model was applied for all analyses. Results: Fifteen studies (17,116 AF patients) were included, comprising 4 RCTs, 3 prospective PSM studies, and 8 retrospective PSM studies. Compared with OAC, LAA closure significantly reduced the composite endpoint (RR: 0.79; 95% CI: 0.66–0.95; p = 0.010), all-cause mortality (RR: 0.58; 95% CI: 0.49–0.69; p < 0.001), and cardiovascular mortality (RR: 0.55; 95% CI: 0.44–0.67; p < 0.001). Risks of any stroke (RR: 1.06; 95% CI: 0.86–1.31; p = 0.555), ischemic stroke (RR: 1.00; 95% CI: 0.85–1.17; p = 0.972), hemorrhagic stroke (RR: 0.96; 95% CI: 0.54–1.70; p = 0.879), and major bleeding (RR: 0.84; 95% CI: 0.67–1.04; p = 0.112) were not significantly different between groups. Conclusions: In AF patients, LAA closure significantly reduces mortality and a composite clinical endpoint compared to OAC, with similar risks of stroke and major bleeding. It is a favorable alternative for patients unsuitable for long-term anticoagulation. Full article