Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias

Rillig, Andreas; Tilz, Roland Richard; Lin, Tina; Fink, Thomas; Heeger, Christian-H.; Arya, Anita; Metzner, Andreas; Mathew, Shibu; Wißner, Erik; Makimoto, Hisaki; Wohlmuth, Peter; Kuck, Karl‐Heinz; Ouyang, Feifan

doi:10.1161/circep.115.003461

Cited by 179 publications

(138 citation statements)

References 21 publications

Supporting

Mentioning

129

Contrasting

Unclassified

Order By: Relevance

“…Second, regarding the technique of LAAI in our study population, 2 we fully agree with Briceno et al that a wide-area LAAI is different from the LAAI technique described by Di Biase et al, 3,4 which is more or less restricted to local ablation close to the base of the LAA and may have a lower chance of persistent isolation of the LAA. The risk of LAA thrombus formation using this technique might be lower, as was shown in the recently presented data from the BELIEF trial.…”

Section: In Responsesupporting

confidence: 86%

Response by Rillig et al to Letter Regarding Article, “An Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias”

Rillig

Tilz

Lin

et al. 2016

Circ: Arrhythmia and Electrophysiology

Self Cite

View full text Add to dashboard Cite

In Response:We are grateful for the letter from Briceno et al 1 and their interest in our published data. We take this opportunity to clarify some of the issues raised in their response letter.First, our nonrandomized study presented findings that demonstrated the high incidence of left atrial appendage (LAA) thrombi after wide-area LAA isolation (LAAI). The mechanism of this high incidence of thrombus formation within the LAA remains unclear whether due purely to the isolation itself or to the combined effect of disease progression and the wide area of LAAI. This needs further investigation in subsequent studies. Because of the potentially significant clinical implications, we felt that these important findings must not be withheld from other electrophysiologists.Second, regarding the technique of LAAI in our study population, 2 we fully agree with Briceno et al that a wide-area LAAI is different from the LAAI technique described by Di Biase et al, 3,4 which is more or less restricted to local ablation close to the base of the LAA and may have a lower chance of persistent isolation of the LAA. The risk of LAA thrombus formation using this technique might be lower, as was shown in the recently presented data from the BELIEF trial. 4 We have emphasized that the difference between these 2 techniques in isolating the LAA may play a critical role in the subsequent risk of thromboembolic stroke.2 Also, we agree that wide-area LAAI might be one of the most critical factors that leads to the high rate of LAA thrombi in our study.Third, the patient population in both studies was different. Our patients may have more diseased left atrium, with extensive areas of low amplitude in the left atrium, with larger left atrial volumes, and with more attempts at previous ablation compared with their patient population. A randomized study will be required to answer this question. Given that LAAI can occur by chance and unintentionally during ablation of complex fractionated atrial electrograms, we emphasize that this information is even more important to disseminate, and we conclude that LAA conduction should be closely monitored during extensive complex fractionated atrial electrogram ablation.Importantly, there was no significant difference between the LAA flow velocities of patients with and without LAA thrombus after LAAI, but flow velocity was significantly reduced in the overall LAAI group as compared with the matched control group.1 Unfortunately, left atrial mechanical function of the isolated area was not determined in our study. This might be of interest in future studies and potentially give further insights in the definite mechanism of LAA thrombus formation after LAAI. Thus far, wide-area LAAI does not absolutely lead to LAA thrombus formation in every case but remains a significant risk factor for development of LAA thrombus.In regards to the anticoagulation regimen, there was some heterogeneity in the study population. Of note, patients on oral anticoagulants were either continuously on novel oral anticoagulants or ...

show abstract

Section: In Responsesupporting

confidence: 86%

Response by Rillig et al to Letter Regarding Article, “An Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias”

Rillig

Tilz

Lin

et al. 2016

Circ: Arrhythmia and Electrophysiology

Self Cite

View full text Add to dashboard Cite

show abstract

“…There are ethical concerns about the extensive ablation strategy used by Rillig et al, 7 particularly in patients with paroxysmal AF (40% of patients who underwent LAA isolation). After pulmonary vein isolation, the majority of patients with LAA isolation received a mitral isthmus line (94%) and an anterior line (90%).…”

Section: See Article By Rillig Et Almentioning

confidence: 99%

“…More work is required to delineate the risks, benefits, and hemodynamic impact of LAA isolation, and the methods to achieve this. We must thank Rillig et al 7 for reporting what had been a more theoretical risk with electric LAA isolation, and their work should serve as an important guide and resource to the reader.…”

Section: See Article By Rillig Et Almentioning

confidence: 99%

Electrical Isolation of the Left Atrial Appendage: Is It Safe?

Thompson

Jaı̈s

2016

Circ: Arrhythmia and Electrophysiology

View full text Add to dashboard Cite

of the journal, corrections were needed.The authors apologize for this error.On p 1, left column, lines 11-13 of the second paragraph, the sentence that read "Of the 3 cerebrovascular events, 1 did not receive OCA, whereas of the 10 patients who had LAA clot detected, 1 did not receive OCA" has been corrected to read, "Of the 3 cerebrovascular events, 1 did not receive oral anticoagulation, whereas of the 10 patients who had LAA clot detected, 1 did not receive oral anticoagulation."These corrections have been made to the current version of the article, which is available at

show abstract

“…In contrast, Rillig et al found that 21% of patients developed an LAA thrombus after LAA ablation despite 90% of patients receiving oral anticoagulation at the time. However, LAA ablation in this study included electrical isolation of the LAA base using bidirectional block of both an anterior and mitral isthmus line, which may explain the increased stroke risk 42. On the other hand, all studies included in this meta‐analysis made use of distal LAA isolation.…”

Section: Discussionmentioning

confidence: 99%

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

AlTurki

Huynh

Dawas

et al. 2018

Journal of Arrhythmia

View full text Add to dashboard Cite

A significant proportion of patients’ experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random‐effects meta‐analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow‐up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10‐0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25‐0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long‐term risk of stroke.

show abstract

Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias

Abstract: After LAAI, an unexpectedly high incidence of LAA thrombus formation and stroke was observed despite OAC therapy.

Cited by 179 publications

References 21 publications

Response by Rillig et al to Letter Regarding Article, “An Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias”

Response by Rillig et al to Letter Regarding Article, “An Unexpectedly High Incidence of Stroke and Left Atrial Appendage Thrombus Formation After Electrical Isolation of the Left Atrial Appendage for the Treatment of Atrial Tachyarrhythmias”

Electrical Isolation of the Left Atrial Appendage: Is It Safe?

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta‐analysis

Contact Info

Product

Resources

About