Thoracoscopic Appendage Exclusion With an Atriclip Device As a Solo Treatment for Focal Atrial Tachycardia
2011; Lippincott Williams & Wilkins; Volume: 123; Issue: 14 Linguagem: Inglês
10.1161/circulationaha.110.005652
ISSN1524-4539
AutoresStefano Benussi, Patrizio Mazzone, Giuseppe Maccabelli, Pasquale Vergara, Antonio Grimaldi, Alberto Pozzoli, Pietro Spagnolo, Ottavio Alfieri, Paolo Della Bella,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 123, No. 14Thoracoscopic Appendage Exclusion With an Atriclip Device As a Solo Treatment for Focal Atrial Tachycardia Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBThoracoscopic Appendage Exclusion With an Atriclip Device As a Solo Treatment for Focal Atrial Tachycardia Stefano Benussi, MD, PhD, Patrizio Mazzone, MD, Giuseppe Maccabelli, MD, Pasquale Vergara, MD, PhD, Antonio Grimaldi, MD, Alberto Pozzoli, MD, Pietro Spagnolo, MD, Ottavio Alfieri, MD and Paolo Della Bella, MD Stefano BenussiStefano Benussi From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Patrizio MazzonePatrizio Mazzone From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Giuseppe MaccabelliGiuseppe Maccabelli From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Pasquale VergaraPasquale Vergara From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Antonio GrimaldiAntonio Grimaldi From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Alberto PozzoliAlberto Pozzoli From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Pietro SpagnoloPietro Spagnolo From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. , Ottavio AlfieriOttavio Alfieri From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. and Paolo Della BellaPaolo Della Bella From the San Raffaele University Hospital, Cardiac Surgery Division (S.B., A.G., A.P., O.A.), Arrhythmia Unit and Electrophysiology Laboratories (P.M., G.M., P.V., P.D.B.), and Centre for Cardiovascular Prevention (P.S.), Milan, Italy. Originally published12 Apr 2011https://doi.org/10.1161/CIRCULATIONAHA.110.005652Circulation. 2011;123:1575–1578A 15-year-old boy with incessant drug-refractory atrial tachycardia was referred to our department for an ablation procedure. The tachycardia was diagnosed at 13 years of age during routine medical screening for soccer competition. Despite the administration of metoprolol, verapamil, and flecainide, the arrhythmia persisted and ventricular response was not controlled. Physical examination was normal except for a heart rate of 130 bpm; no signs of congestive heart failure were found.Blood examinations revealed normal thyroid function. Twelve-lead ECG showed a narrow QRS tachycardia with positive P waves in II-III-aVF-V1-V2 leads, negative P waves in I-aVL leads, and a short PR interval (Figure 1), suggesting a left atrial origin.1,2 Transthoracic echocardiography showed normal left ventricular size with normal systolic function and normal atrial volumes.Download figureDownload PowerPointFigure 1. Twelve-lead ECG showed a narrow QRS tachycardia with positive P waves in II-III-aVF-V1-V2 leads, negative P waves in I-aVL leads, and a short PR interval, suggesting a left atrial origin.During electrophysiological study, the earliest atrial activation during tachycardia was located on the distal bipole of the coronary sinus catheter, confirming a lateral left atrial origin.1–3 Left atrial access was obtained by transseptal approach with a Brockenbrough needle. Electroanatomic mapping, performed with the CARTO 3 mapping system (Biosense-Webster Diamond Bar, CA), showed a normal left atrial morphology and an eccentric atrial activation from the distal portion of the left atrial appendage (Figure 2).1–3Download figureDownload PowerPointFigure 2. Focal atrial tachycardia originating from the left atrial appendage by electroanatomic mapping (CARTO 3).Radiofrequency was delivered at the site where the earliest local electrogram preceded atrial activation on the distal coronary sinus by 48 milliseconds. However, tachycardia relapsed despite 2 percutaneous ablation attempts (Figure 3).Download figureDownload PowerPointFigure 3. Electroanatomic map generated by the CARTO 3 system showing the Local Activation Time (LAT) of the focal atrial tachycardia originating from the left atrial appendage.To eliminate the arrhythmia, epicardial exclusion of the appendage with a minimally invasive occlusion device (Atriclip, AtriCure Inc) was decided. The clip is composed of 2 parallel, straight, rigid titanium tubes covered with a knit-braided polyester sheath. It is designed to be implanted from outside the heart through a thoracoscopic approach.4In January 2010, the patient underwent the thoracoscopic procedure under general anesthesia with dual-lumen intubation. Three ports were positioned: 1 (5 mm) in the third intercostal space, 1 (10 mm) in the sixth space at the median axillary level, and 1 (10 mm) in the fifth space on the posterior axillary line. Pericardiotomy was performed parallel and posterior to the phrenic pedicle to expose the left atrial appendage. The Marshall ligament was interrupted with diathermy. Through the inferior port (enlarged to 3 cm), a 35-mm clip was deployed with immediate interruption of the arrhythmia (Figure 4). Electric conduction from the excluded left atrial appendage, as assessed by pacing at 20 mA with a bipolar surgical stimulator (Affirm, Estech Inc), was lost seconds after clip deployment.Download figureDownload PowerPointFigure 4. Left atrial appendage clip closure and consequent immediate interruption of tachycardic beats.After an uneventful postoperative course, the patient was discharged on day 5 in sinus rhythm with no medical treatment. One month after the procedure, a computed tomographic scan and echocardiogram showed correct and stable positioning of the Atriclip with no residual flow distal to the clip (Figures 5 and 6). Twenty-four–hour Holter monitoring performed at 1, 3, and 6 months showed stable sinus rhythm with a mean heart rate of 70 bpm and without a single premature beat. The patient is asymptomatic and has now resumed his soccer training.Download figureDownload PowerPointFigure 5. A, Preoperative computed tomographic scan control. B, One-month computed tomographic scan monitoring shows the positioning of the Atriclip and exclusion of the left appendage.Download figureDownload PowerPointFigure 6. One-month echocardiogram control. No residual flow was detected through the left atrial appendage (Au).To the best of our knowledge, this is the first case of appendage clip implantation as a solo procedure.DisclosuresDr Benussi has a financial relationship with St. Jude Medical Inc., AtriCure Inc., Medtronic Inc., CryoCath Inc., and Edwards Lifesciences Inc. The other authors report no conflicts.AcknowledgmentsWe would like to express our thanks to Paola Cardano, MSc and to Ylenia Adelaide Privitera, MSc for their ardent support to the development of the study.FootnotesCorrespondence to Stefano Benussi, San Raffaele University Hospital, Via Olgettina 60, 20132 Milan, Italy. E-mail benussi.[email protected]itReferences1. 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Ailawadi G, Gerdisch M, Harvey R, Hooker R, Damiano R, Salamon T and Mack M (2011) Exclusion of the left atrial appendage with a novel device: Early results of a multicenter trial, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2011.07.052, 142:5, (1002-1009.e1), Online publication date: 1-Nov-2011. April 12, 2011Vol 123, Issue 14 Advertisement Article InformationMetrics © 2011 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.110.005652PMID: 21482976 Originally publishedApril 12, 2011 PDF download Advertisement SubjectsArrhythmiasCardiovascular SurgeryCatheter Ablation and Implantable Cardioverter-DefibrillatorComputerized Tomography (CT)EchocardiographyElectrocardiology (ECG)Electrophysiology
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