1/24 This month’s #EHJCaseReports #tweetorial focuses on percutaneous left atrial appendage occlusion.

Is #LAAO the exact solution for preventing stroke & embolism in #AF pts who can’t tolerate #OAC?
Or, a new problem while seeking a solution?
doi.org/10.1093/ehjcr/…
#CardioEd
2/24
🎯 The rationale of #LAAO
🔸 In non-valvular #AF patients, 90% of thrombus is located in the #LAA
🔸 These thrombi embolise to the 🧠 & cause #stroke
🎯 Don't miss the ‘#EHRA_ESC #EAPCI expert consensus document on catheter-based #LAAO –an update’ doi.org/10.1093/europa…
3/24
#LAA closure devices should be safe, efficent and easy to deploy.

📌 Currently available catheter-based devices for #LAAO have different principles.

A- Plug ➡️ Watchman
B- Pacifier ➡️ Amplatzer Amulet
C- Ligation ➡️ Lariat

doi.org/10.1093/europa…
4/24
#LAA has different morphologies based on Wang’s classification.

Cactus (∼30%)
Chicken-wing (∼48%)
Windsock (∼19%)
Cauliflower (∼3%)

journals.plos.org/plosone/articl…
5/24
🎯 Pre- & peri- & post-procedural imaging w/ #TEE and #yesCT is key for:

👉 Ruling out #LAA thrombus
👉 #LAA anatomy & dimensions
👉 Equipment (device) selection
👉 Guiding procedural device implantation
👉 Device surveillance post-implantation

doi.org/10.1093/europa…
6/24 Persistent large (≥5 mm) peri-device leaks detected w/ post-procedural imaging deserve long-term #OAC or a second occlusion attempt.
🎯 As an alternative strategy, this case shows successful percutaneous leak closure w/ an Amplatzer Vascular Plug II doi.org/10.1093/ehjcr/…
7/24
📌 Imaging w/ #TEE is essential during transseptal puncture.

📌 For most #LAA, where the body is superior-anterior directed, a standard infer-posterior puncture of the fossa ovalis is recommended to provide a direct vector towards the superior-anterior LAA.
8/24
#LAAO is still possibile in patients w/ a previous atrial septal device.

📌 In this case report you will find out how #LAAO was performed w/ a LAmbre device in a patient w/ previously implanted #PFO occluder. doi.org/10.1093/ehjcr/…
9/24
📌 Pericardial tamponade rates during the #LAAO is ~ 1 %.

👉 This case shows cardiac tamponade due to high PSI injection during #LAA angiography and sealing the perforation w/ Watchman device.
doi.org/10.1093/ehjcr/…
10/24
#yesCT #TEE & fluoroscopic measurements for the appropriate size of Amulet device:

🎯 #LAA orifice ➡️ yellow lines

🎯 Landing zone ➡️ 10-12 mm inside the orifice (red lines)

🔑 For appropriate measurements mean left atrial pressure should be >12 mmHg
11/24

🔑 The appropriate size of the Amulet device is decided according to the ‘maximum landing zone’, which is 10-12 mm from the ostium of the #LAA.

🔑 For an #LAA w/ a landing zone of 16 mm 👉 20 mm Amulet device is recommended.
12/24
#LAAO is performed under #TEE & fluoroscopic guidance.

🎯 RAO 30/cranial 20 👉 proximal #LAA

🎯 RAO 30/caudal 20 👉 distal #LAA

🔑🕵️‍♂️
RAO 30/cranial 20 ↩️ #TEE 45
RAO 30/caudal 20 ↩️ #TEE 135

eurointervention.pcronline.com/article/left-a…
13/24
📌Amulet device deployment has 4️⃣ steps:

1 > Unsheat for ‘ball’ configuration
2-3 > Advance delivery cable for ‘triangle’ configuration and ‘lobe’ unfolded
4 > Unsheat for ‘Disc’ unfolded

🎯 Lobe of the device should sit landing zone.

doi.org/10.1093/europa…
14/24
📌 Please find step by step Amulet device deployment + tug test in the ⬇️ videos.

1st video ➡️ ‘ball’ & ‘triangle’ configuration of the ‘lobe’
2nd video ➡️ ‘disc’ deployment
3rd video ➡️ tug test

doi.org/10.1093/europa…
15/24
🎯 Before release, 5️⃣ signs of device stability need to be verified.

1️⃣ Slightly compressed ‘lobe’
2️⃣ Orientation between the ‘lobe’ and #LAA orifice
3️⃣ Concave shaped ‘disc’
4️⃣ Separated ‘disc’ & ‘lobe’
5️⃣ The midpoint of the ‘lobe’ should be distal to the LCx.
16/24
⁉️ Despite all efforts, embolisation of the device can still occur.

🎯 In this case report, the embolised #LAAO device was retrieved using a double snaring technique.

doi.org/10.1093/ehjcr/…
17/24
#LAAO to who?

🎯 High-risk non-valvular #AF patients who ‘ve contraindications or can't tolerate long-term #OAC.

🎯 Patients w/elevated bleeding risk

🎯 Patients suffering from stroke while on #OAC

🎯 Patients unwilling to receive #OAC

doi.org/10.1093/europa…
18/24
⁉️ Optimal post #LAAO antithrombotic 💊 & duration remain controversial.

The results of ongoing
📌 ANDES
📌 ADRIFT
📌 SAFE-LAAC
trials comparing different post #LAAO antithrombotic regimens will shed light on this issue.

doi.org/10.1093/europa…
19/24

⁉️ Device-related thrombus (3.75%) is related to concurrent #OAC or #DAPT 💊 and is associated w/ ⬆️ risk of ischemic stroke.

👉 See the following case report for how device-related thrombus was managed in an 85 yo 👴 w/ a history of #LAAO

doi.org/10.1093/eurhea…
20/24
⁉️Another question to be answered:
🤔 Is #LAAO better than, or at least as safe and effective as antithrombotic agents?

Without a doubt, ongoing studies

📌 OCCLUSION-AF
📌 STROKE-CLOSE
📌 CLOSURE-AF
📌 ASAP-TOO

will provide essential insights.

doi.org/10.1093/europa…
21/24

🎯 The results of PRAGUE-17 trial, which compares NOACs w/ #LAAO in high-risk #AF patients (CHA2DS2-VASC ≥3), showed #LAAO was non-inferior to NOACs in preventing major AF-related cardiovascular, neurological, and bleeding events.

eurointervention.pcronline.com/trials/left-at…
22/24
⁉️ Which device is better ⁉️

🎯 AMULET-IDE study (Hot Line #ESCCongress2021) compared Amulet vs WATCHMAN device in high-risk #AF patients.

🎯 The Amulet device was associated w/

⬆️ #LAA occlusion
↔️ Safe & effective for stroke prev.

compared to the Watchman device.
23/24
🤔 Do we have alternative venous access sites for #LAAO ?

🙂 The answer is YES.

🎯 See the ⬇️ case report, which demonstrates transhepatic access in a patient w/ poor femoral access for implantation of the #LAAO device.

doi.org/10.1093/ehjcr/…
24/24
We hope you enjoyed our #tweetorial on #LAAO

Let's say goodbye with a poll.

⁉️ Which #LAAO device has the ‘8’ image on #TTE ?

⬇️ Please vote ⬇️

Thank you to our fabulous Twitter Editors: @aayshacader @FarhanaAra @KardiologieHH @TJ_Yeo @ANazmiCalik

#EHJCaseReports
⁉️ Which #LAAO device has the ‘8’ image on #TTE ?

#EHJCaseReports #cardiotwitter @johncamm @cfcamm

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More from @ESC_Journals

Jul 25, 2022
1/25
How would you tackle this heavily calcified LAD with calcified #nodule that was appropriately identified by intravascular imaging? #OCT
doi.org/10.1093/ehjcr/…

In this #EHJCaseReports #tweetorial we take a deep dive into the Rx of #calcified coronary lesions.
#Cardiotwitter
2/25
Calcified lesions are top of the totem pole of complex PCI
Main armamentaria are balloon-based #IVL & ablation-based (rotational/orbital) techniques, while ancillary tools eg guide extension catheters are useful too. eurointervention.pcronline.com/article/intrav…

#EHJCaseReports #tweetorial
3/25
What do you see with this non-compliant balloon in this calcified RCA?
What would you do next? Poll in next tweet! doi.org/10.1093/ehjcr/…
Read 25 tweets
May 14, 2021
1. This month's #EHJCaseReports #tweetorial focuses on a cardiac condition that can result in these findings 👇 on #echofirst. What could it be?
1 Hypertension
2 Hypertrophic cardiomyopathy
3 Aortic stenosis
4 Cardiac amyloidosis
doi.org/10.1093/ehjcr/…
#CardioTwitter @EHJCREiC
2. It’s cardiac amyloidosis! Here is a great resource from @escardio WG on Myocardial and Pericardial Diseases to start with
doi.org/10.1093/eurhea…
3. First, what is amyloidosis?

Amyloidosis occurs when abnormal proteins misfold and deposit in tissues as beta-pleated sheets. These disrupt tissue structure and can cause damage to many different organs.
Read 27 tweets
Apr 1, 2021
1/24
A picture is worth a thousand words. This month's #EHJCaseReports tweetorial focuses on intravascular imaging in coronary intervention.

For starters, what do you see on this #OCT image of an intracoronary honeycomb🐝?

academic.oup.com/ehjcr/article/…

Poll 👇

#cardiotwitter
2/24
The intracoronary honeycomb on the image above is ⬇️

Find out the answer in #EHJCaseReports:

academic.oup.com/ehjcr/article/…
3/24
Honeycomb-like structure, a rare cause of myocardial ischaemia has multiple communicating channels divided by thin septa. Angiographically fuzzy & hazy appearance often without significant stenosis, they're best detected on high-resolution IVUS/OCT
academic.oup.com/ehjcr/article/…
Read 24 tweets
Mar 10, 2021
1. Hot off the press - #EHJACVC Issue 1/2021 tweetorial 🔽

The issue opens with an editorial by new EiC @VranckxPascal, highlighting the aims of the journal, presenting the new editorial board and thanking @cvrints, former EiC academic.oup.com/ehjacc/article…

#ACVC_ESC #cardiotwitter
2. Issue focus: #CardiogenicShock (CS) management.

In the new "Sciencepulse", chaired by @ingo_ahrens, David Morrow from @BrighamWomens and @thiele_holger discuss differences and commonalities in CS management in Europe and North America academic.oup.com/ehjacc/article…
3. In an editorial titled "Potential growth in cardiogenic shock research though an international registry collaboration", @seanvandiepen and Dave Morrow call for a Hub-of-Spokes model in #CardiogenicShock research academic.oup.com/ehjacc/article…

#EHJACVC #CardioEd
Read 16 tweets

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