Application Of Echocardiography In Percutaneous Left Atrial Appendage Closure In Patients With Non-valvular Atrial Fibrillation

Background:Atrial fibrillation(AF)is one of the common types of arrhythmia in the clinic.Thrombosis and shedding are more common in patients with atrial fibrillation,which directly leads to an increased risk of death in patients with AF.Due to the special structure,the left atrial appendage is more prone to thrombosis.Therefore,occlusion of the left atrial appendage is important to reduce the formation of left atrial appendage thrombus,thereby reducing the occurrence of thromboembolic events.Percutaneous left atrial appendage closure(LAAC)is a new technology to prevent thromboembolism in patients with AF in recent years.Although this technology has been successfully carried out in many clinical research centers across the country,its safety is still controversial.The focus of the current controversy is on the occurrence of postoperative complications and changes in cardiac cavity size and cardiac function.Because venous emboli can enter the arterial system through abnormal atrial communication,ASD and PFO become independent high risk factors for stroke.At present,in some adult patients with atrial septal defect(ASD)or patent foramen ovale(PFO),the incidence of atrial fibrillation is 31%,which is closely related to advanced age,and the risk of thromboembolism is higher.Active treatment and intervention for patients with ASD or PFO complicated with atrial fibrillation can reduce the incidence and mortality of systemic embolism events and reduce hospitalization costs.The "one-stop" interventional therapy,LAAC and atrial traffic occlusion are performed at the same time,cannot only reduce the number of hospitalization and surgery,but also medical cost of patients.However,there are few reports on whether "one-stop" interventional therapy can be performed in patients with ASD or PFO complicated with atrial fibrillation,and whether "one-stop" interventional therapy is safe and effective.Both transthoracic echocardiography(TTE)and transesophageal echocardiography(TEE)can display the cardiac structure in real time,measure the parameters related to the cardiac cavity,evaluate the cardiac function and diagnose the complications related to cardiac surgery.Among them,TEE has the advantages of clear image,clear and complete display of intracardiac structures such as left atrial appendage and atrial septum,which can not be fully demonstrated by conventional TTE,and does not interfere with the visual field of operation,so it plays an irreplaceable role in preoperative monitoring,intraoperative guidance and postoperative follow-up of LAAC and atrial traffic occlusion.Purposes:1)TTE and TEE were used to evaluate the safety and efficacy of LAAC and the changes of cardiac function before and after operation.2)TTE and TEE were used to evaluate the safety and efficacy of simultaneous closure of ASD/PFO and LAAC,as well as the changes of cardiac function before and after operation.Methods:This topic is divided into the following two parts:1.Application of echocardiography in percutaneous left atrial appendage closure in patients with non-valvular atrial fibrillationThe images and data of echocardiography(TTE and TEE)before,during and after percutaneous LAAC in our hospital from August 2014 to July 2018 were retrospectively analyzed,the process of intraoperative guidance of TTE and TEE was analyzed,and the types and incidence of complications were summarized.At the same time,the values of cardiac chamber size(end systolic left atrial anteroposterior diameter(LAD)、 left ventricular end-diastolic diameter(LVDd),right atrial transverse diameter(RAT),right ventricular internal diameter(RVD))and cardiac function indexes(left ventricular ejection fraction(LVEF),left ventricular shortening score(LVFS),end diastolic volume(EDV)and stroke volume(SV))were collected before percutaneous LAAC,48 hours after operation,3-6 months after operation and 1 year after operation,and the differences of corresponding parameters before and after operation were analyzed.2.Application value of echocardiography in simultaneous percutaneous left atrial appendage closure and ASD or PFO atrial traffic occlusionThe clinical and echocardiographic data of 18 patients with ASD and 12 patients with PFO complicated with atrial fibrillation who received transcatheter closure in our hospital from August 2014 to July 2018 were analyzed retrospectively.During the operation,occlusions of left atrial appendage and atrial traffic were performed under the guidance of transesophageal echocardiography.The effect of occlusion was evaluated immediately after operation,and echocardiography was followed up at 48 hours and 3-6 months after operation.The changes of cardiac chamber size and cardiac function indexes were analyzed before and after operation.At the same time,the complications such as residual shunt around the occluder,occluder-related thrombus,and transposition of occluder and pericardial effusion were observed.Results:1.Echocardiography showed successful completion of LAAC in 202 patients(98.5%,202/205),postoperative occluder-related thrombosis in 17 patients(8.4%,17/202),and pericardial effusion in 4 patients(2.0%,4/202),29 cases(14.4%,29/202,both <5mm)had residual shunt around the occluder.No occluder detachment and displacement occurred in all patients.Compared with preoperative,LVEF,LVFS and SV increased slightly at 48 hours after operation(all P<0.05).LAD,RAT,RVD,LVDd,LVEF,LVFS,EDV and SV were not significantly different from those before surgery(P>0.05)at 3 to 6 months after operation and 1 year after operation.2.Watchman left atrial appendage occluder was successfully inserted in 30 patients under the guidance of transesophageal echocardiography during the operation.Twelve patients underwent PFO occlusion at the same time,and 18 patients underwent ASD occlusion at the same time.The postoperative follow-up found that 1 case of occluder-related thrombosis occurred,with an incidence of 3.3%(1/30);11 cases of residual shunt around the occluder,the shunt beam width were all <5mm,the incidence was36.7%(11/30);1 case of pericardial effusion,the incidence was 3.3%(1/30),all patients had no occluder displacement.In the patients who underwent LAAC and PFO occlusion at the same time(12/30),there was no statistically significant difference in cardiac chamber size and cardiac function parameters compared with those before surgery(P>0.05).Patients who underwent concurrent LAAC and ASD occlusion(18/30),the right ventricular outflow tract diameter(RVOT),RVD,RAT,the internal pulmonary artery diameter(MPAD),and pulmonary valve velocity(PV)at 48 hours and 3-6 months were lower than before surgery.LVDd,SV,EDV were higher than before surgery,and the differences were statistically significant(all P <0.05).Conclusion:1.LAAC and "one-stop" interventional therapy for atrial traffic occlusion at the same time have the advantages of safety and low incidence of postoperative complications.The main postoperative complications of LAAC are occluder-related thrombus,a small amount of shunt around the occluder and pericardial effusion.2.There was no significant change in cardiac chamber size and cardiac function indexes 3 to 6 months and 1 year after LAAC alone.In patients with simultaneous percutaneous LAAC and PFO occlusion,there was no significant change in the size of cardiac chambers and cardiac function parameters 48 hours and 3 to 6 months after operation.In patients with simultaneous LAAC and ASD occlusion,48 hours and 3-6months after operation,the size of right atrium and right ventricle and the flow velocity of systolic pulmonary valve were lower than those before operation,while the size of left ventricle and stroke volume were significantly higher than those before operation.3.The combined application of TTE and TEE can play an important clinical value in preoperative detection,intraoperative guidance and postoperative follow-up of LAAC and "one-stop" interventional therapy in the same period.