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Optical Coherence Tomography to Visualize Endothelialization in Left Atrial Appendage Closure: Optical Reality or Illusion?

2023; Wiley; Volume: 13; Issue: 1 Linguagem: Inglês

10.1161/jaha.123.032974

2047-9980

Arun Narayanan, Haider Al Taii, Muhie Dean Sabayon,

Cardiac Arrhythmias and Treatments

HomeJournal of the American Heart AssociationAhead of PrintOptical Coherence Tomography to Visualize Endothelialization in Left Atrial Appendage Closure: Optical Reality or Illusion? Open AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessEditorialPDF/EPUBOptical Coherence Tomography to Visualize Endothelialization in Left Atrial Appendage Closure: Optical Reality or Illusion? Chockalingam Arun Narayanan, Haider Al Taii and Muhie Dean Sabayon Chockalingam Arun NarayananChockalingam Arun Narayanan * Correspondence to: Chockalingam Arun Narayanan, MD, Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, 5.106 John Sealy Annex, Galveston, TX. Email: E-mail Address: [email protected] https://orcid.org/0009-0008-3325-8928 , Division of Cardiology, Department of Internal Medicine, , University of Texas Medical Branch, , Galveston, , TX, , USA, , Haider Al TaiiHaider Al Taii , Division of Cardiology, Department of Internal Medicine, , University of Texas Medical Branch, , Galveston, , TX, , USA, and Muhie Dean SabayonMuhie Dean Sabayon , Division of Cardiology, Department of Internal Medicine, , University of Texas Medical Branch, , Galveston, , TX, , USA, Originally published29 Dec 2023https://doi.org/10.1161/JAHA.123.032974Journal of the American Heart Association. 2023;0:e032974Atrial fibrillation (AF) is associated with a 3‐ to 5‐fold increased risk of ischemic stroke.1 AF‐related strokes are often more severe and fatal, making stroke prevention an integral component to AF management.2 Oral anticoagulation (OAC) is the foundation of thromboembolic prevention in AF; however, many patients are unable to tolerate its long‐term use. Left atrial appendage closure (LAAC) is a nonpharmacologic, mechanical option for patients with AF to prevent embolic events in those who necessitate an alternative to OAC. With growing experience and technical improvements, LAAC has been adopted worldwide and considered a safe and effective modality (PREVAIL [Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy], PROTECT AF [Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation], PRAGUE‐17 [Left Atrial Appendage Closure vs. Novel Anticoagulation Agents in Atrial Fibrillation]).3, 4, 5 However, device‐related thrombus (DRT) is a recognized complication of LAAC and is associated with an increased risk of ischemic events.6 Incomplete endothelialization of the LAAC device is thought to be the underlying pathophysiology of DRT, given the prothrombotic surface that persists.7 Transesophageal echocardiography, computed tomography, and intracardiac echography are being used to evaluate peridevice leak, which is considered a predictor of incomplete endothelialization; however, poor spatial resolution makes direct visualization of endothelialization challenging.8In this issue of the Journal of the American Heart Association (JAHA), Chen et al have analyzed the feasibility of optical coherence tomography (OCT) to assess for complete endothelialization of LAAC devices.9 OCT applies infrared light (≈1300‐nm wavelength) that reflects off microstructures within tissue with the echo time delay used to create spatial image data with a resolution of approximately 15 μm.10 The technology is commonly used in coronary interventions to evaluate the presence and extent of atherosclerotic plaque, as well as assessment following stent placement.11 This was the first‐in‐man study to evaluate OCT as an imaging modality for assessment of LAAC endothelialization.They evaluated 14 patients with a mean age of 72.8±9.4 years who were undergoing pulmonary vein isolation with a previously implanted LAAC device (Watchman 2.5 or Amulet) with OCT to directly visualize the surface layer and categorized patients as no, early, or late/complete endothelialization. The average CHADS2VASc score was 3.5±1.2, and average HAS‐BLED score was 2.3±1.2. The mean time from LAAC to OCT was 2.4 years. Ten patients were taking single antiplatelet therapy, and 4 patients continued OAC due to a history of stroke on OAC prior to LAAC. No DRT was noted in any patients with preprocedural transesophageal echocardiography. The results were subdivided based on device type. Of the 5 patients with the Watchman device, 2 had no endothelialization, 2 had early endothelialization, and 1 had complete endothelialization. Among 9 patients with the Amulet device, 2 showed no endothelialization, 3 had early endothelialization, and 4 had late endothelialization. In addition, in vitro imaging of the Watchman and Amulet devices immersed in contrast medium were performed to establish baseline pattern of no endothelialization.These findings bring us back to a few fundamental questions that must be answered: what is the risk of DRT in LAAC? What is the underlying cause of DRT? What are the clinical impacts of DRT? And, most importantly, are we misguided in attempting to answer these questions at this time given the lack of high‐quality imaging available to evaluate DRT? Previous trials have shown significant variability in the rate of DRT, as well as clinical impacts of DRT.12, 13 The decision to resume OAC in patients with LAAC is largely dependent on postprocedural transesophageal echocardiography after 45 days to evaluate peridevice leak more so than direct visualization of DRT.14 Although peridevice leak is a known predictor of thrombotic risk, are we potentially missing a major cohort of patients with elevated stroke risk who may have DRT or incomplete endothelialization that we are unable to accurately visualize with current imaging modalities?Chen and colleagues are to be congratulated for their efforts in evaluating OCT in vivo as a potential solution to this conundrum. The high spatial resolution offered by OCT, more than 10 times that of intravascular ultrasound and validated in coronary interventions, has the potential to provide accurate assessment of DRT and degree of endothelialization, as well as help cater antithrombotic management. It is important to note the several limitations of this study. Without further tissue processing, OCT is only able to evaluate surface features within the imaging depth. In addition, a catalogue of imaging with pathological specimens used for confirmation is necessary to validate the findings associated with level of endothelialization noted on OCT. Given the small cohort studied and lack of comparison imaging, it is challenging to truly appreciate the specificity of findings presented when comparing minor differences between devices. The limited size of the study also hindered the ability to establish cause and effect relationships between potential predictors of DRT and findings on OCT. The presence of permanent atrial fibrillation, CHA2DS2VASc score, left atrial appendage size and emptying velocity, deep implantation, excessive device compression, and post‐implantation anticoagulant or antiplatelet regimen are all critical risk factors for DRT and warrant more in‐depth study in relation to OCT findings. Furthermore, OCT was used in the setting of an invasive procedure in combination with pulmonary vein isolation and required large volume contrast injections for visualization. As a novel approach to better assess endothelialization and risk of DRT in patients following LAAC, OCT has the potential to be a game changer in the field. Nevertheless, it is necessary to validate its accuracy and establish the practicality of using the technology in this patient population.Chen et al have succeeded in their goal to establish the feasibility of OCT for assessment of LAAC device endothelialization following implant in this first‐in‐human study; however, further long‐term, larger, prospective study is necessary.DisclosuresMuhie Sabayon reports consulting fees from Biosense Webster and Boston Scientific, and speaker fees from Abbot and Boston Scientific. The remaining authors have no disclosures to report.Footnotes* Correspondence to: Chockalingam Arun Narayanan, MD, Division of Cardiology, Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, 5.106 John Sealy Annex, Galveston, TX. Email: canaraya@utmb.eduThis article was sent to Hani Jneid, MD, Associate Editor, for editorial decision and final disposition.See Article by Chen et al.For Disclosures, see page 2.References1 Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991; 22:983–988. doi: 10.1161/01.str.22.8.983LinkGoogle Scholar2 Lin HJ, Wolf PA, Kelly‐Hayes M, Beiser AS, Kase CS, Benjamin EJ, D'Agostino RB. Stroke severity in atrial fibrillation. The Framingham Study. Stroke. 1996; 27:1760–1764. doi: 10.1161/01.str.27.10.1760LinkGoogle Scholar3 Holmes DR, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long‐term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014; 64:1–12. doi: 10.1016/j.jacc.2014.04.029CrossrefMedlineGoogle Scholar4 Reddy VY, Doshi SK, Sievert H, Buchbinder M, Neuzil P, Huber K, Halperin J, Holmes D, PROTECT AF InvestigatorsPercutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3‐year follow‐up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation. 2023; 127:720–729. doi: 10.1161/CIRCULATIONAHA.112.114389LinkGoogle Scholar5 Osmancik P, Herman D, Neuzil P, Hala P, Taborsky M, Kala P, Poloczek M, Stasek J, Haman L, Branny M, et al. Left atrial appendage closure versus direct oral anticoagulants in high‐risk patients with atrial fibrillation. J Am Coll Cardiol. 2020; 75:3122–3135. doi: 10.1016/j.jacc.2020.04.067CrossrefMedlineGoogle Scholar6 Dukkipati SR, Kar S, Holmes DR, Doshi SK, Swarup V, Gibson DN, Maini B, Gordon N, Main M, Reddy VY. Device‐related thrombus after left atrial appendage closure: incidence, predictors, and outcomes. Circulation. 2018; 138:874–885. doi: 10.1161/CIRCULATIONAHA.118.035090LinkGoogle Scholar7 Sedaghat A, Vij V, Al‐Kassou B, Gloekler S, Galea R, Fürholz M, Meier B, Valgimigli M, O'Hara G, Arzamendi D, et al. Device‐related thrombus after left atrial appendage closure: data on thrombus characteristics, treatment strategies, and clinical outcomes from the EUROC‐DRT‐registry. Circ Cardio Inter. 2021; 14:e010195. doi: 10.1161/CIRCINTERVENTIONS.120.010195LinkGoogle Scholar8 Granier M, Laugaudin G, Massin F, Cade S, Winum PF, Freitag C, Pasquie J. Occurrence of incomplete endothelialization causing residual permeability after left atrial appendage closure. J Invasive Cardiol. 2018; 30:245–250.MedlineGoogle Scholar9 Chen J, Chiu F, Chang S, Cheng H, Huang P, Wu C, Wang Y, Hwang J, Tsai C. Pattern of endothelialization in left atrial appendage occluder by optic coherence tomography: a pilot study. J Am Heart Assoc. 2023; 12:e030080. doi: 10.1161/JAHA.123.030080LinkGoogle Scholar10 Terashima M, Kaneda H, Suzuki T. The role of optical coherence tomography in coronary intervention. Korean J Intern Med. 2012; 27:1–12. doi: 10.3904/kjim.2012.27.1.1CrossrefMedlineGoogle Scholar11 Araki M, Park SJ, Dauerman HL, Uemura S, Kim JS, Di Mario C, Johnson TW, Guagliumi G, Kastrati A, Joner M, et al. Optical coherence tomography in coronary atherosclerosis assessment and intervention. Nat Rev Cardiol. 2022; 19:684–703. doi: 10.1038/s41569-022-00687-9CrossrefMedlineGoogle Scholar12 Simard T, Jung RG, Lehenbauer K, Piayda K, Pracoń R, Jackson GG, Alkhouli M. Predictors of device‐related thrombus following percutaneous left atrial appendage occlusion. J Am Coll Cardiol. 2021; 78:297–313. doi: 10.1016/j.jacc.2021.04.098CrossrefMedlineGoogle Scholar13 Lempereur M, Aminian A, Freixa X, Gafoor S, Kefer J, Tzikas A, Legrand V, Saw J. Device‐associated thrombus formation after left atrial appendage occlusion: a systematic review of events reported with the Watchman, the Amplatzer Cardiac Plug and the Amulet. Catheter Cardiovasc Interv. 2017; 90:E111–E121. doi: 10.1002/ccd.26903CrossrefMedlineGoogle Scholar14 Viles‐Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY. The clinical impact of incomplete left atrial appendage closure with the Watchman device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol. 2012; 59:923–929. doi: 10.1016/j.jacc.2011.11.028CrossrefMedlineGoogle Scholar eLetters(0) eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. 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Published on behalf of the American Heart Association, Inc., by Wiley BlackwellThis is an open access article under the terms of the Creative Commons Attribution‐NonCommercial‐NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non‐commercial and no modifications or adaptations are made.https://doi.org/10.1161/JAHA.123.032974PMID: 38156595 Manuscript receivedNovember 10, 2023Manuscript acceptedNovember 16, 2023Originally publishedDecember 29, 2023 KeywordsEditorialsatrial fibrillationdevice‐related thrombusleft atrial appendageoptical coherence tomographystrokePDF download Subjects Atrial Fibrillation Cerebrovascular Disease/Stroke Electrophysiology Imaging Optical Coherence Tomography (OCT)