Background Persistent left atrial appendage (LAA) thrombosis in patents with contraindications or who are refractory to intensive antithrombotic therapy remains a clinical challenge. Although LAA closure with limited manipulation is performed in patients with small distal nonmobile thrombi, larger more proximal mobile thrombi are usually deemed a contraindication to percutaneous LAA closure due to the inherent risk of iatrogenic thromboembolism. In this population, percutaneous aspiration thrombectomy (AT) is a potential treatment modality. Objectives In this study the authors describe their experience with percutaneous AT. Methods This was a 4-center case series of 22 consecutive patients who underwent percutaneous LAA AT before closure for the presence of a persistent LAA thrombus. Large-bore (≥12-F) AT was performed either manually (n = 16 [a 60-mL syringe was used in 14 patients and AlphaVac System in 2 patients]) or mechanically using the pump-assisted Indigo system (n = 6). Results Percutaneous AT was technically successful in all patients, achieving evacuation of the LAA thrombus and allowing subsequent LAA closure with either a Watchman (n = 21) or Lariat (n = 1) device without AT-related complications. Conclusions Percutaneous AT followed by LAA closure is safe and feasible when performed by experienced operators proficient in left atrial interventional procedures. It may offer an alternative to surgery in patients with a proximally located persistent LAA thrombus.

Not applicable. Pulsed field ablation (PFA) has been increasingly adopted for catheter ablation of atrial fibrillation, owing to its increased procedural efficiency when compared to radiofrequency ablation. Due to its non-thermal and relatively tissue-selective mechanism of action, PFA does not carry many of the traditional risks associated with thermal ablation,but real-world experience has shown that other non-traditional, PFA-specific ablation risks can occur. Among these, hemolysis, coronary artery involvement (spasm and fibrosis), and profound vagal responses have been increasingly reported when using this technology. Herein, we will review the current understanding of the pathophysiology, clinical implications, and prevention or treatment strategies for these PFA-specific ablation risks.

BACKGROUND:Pulsed field ablation has emerged as a novel technique for atrial fibrillation ablation, offering myocardial preferential ablation and safety advantages over traditional thermal energy methods. Complications such as hemolysis, hemoglobinuria, and acute kidney injury have been reported, particularly with high-energy delivery and excessive applications. OBJECTIVE:To understand the underlying mechanisms and potential preventative strategies, and identifying at-risk populations, to optimize procedural safety and ensure consistent outcomes. METHODS:This narrative review explores current data on mechanisms, incidence, clinical biomarkers, and risk factors that contribute to these issues. RESULTS:While transient and subclinical hemolysis is common, large scale registry data demonstrate that clinically significant hemolysis-induced renal complications remain rare, with fewer than 0.05% of patients requiring intervention. As catheter design and technology continue to evolve, further research with long-term data is crucial to continue to better understand and standardize mitigation strategies. CONCLUSION:This paper provides an evidence-based framework and practical strategies, individual patient assessment, and postprocedural management to address and support safer integration of pulsed field ablation into clinical practice.

BACKGROUND:Hemolysis is a recognized side effect of pulsed field ablation (PFA). Severe hemolysis can lead to acute kidney injury, affecting the morbidity of patients undergoing PFA for atrial fibrillation. Here, we aimed to characterize the degree of hemolysis across different PFA technologies. METHODS:This is a retrospective cohort study of 552 PFA procedures performed in our center, where Hp (haptoglobin) was measured both at baseline and on postoperative day 1. The PFA catheters used were Farawave (59%), Sphere-9 (19%), Pulseselect (16%), and Varipulse (5.8%). RESULTS:Hemolysis (ie, reduction in Hp >10 mg/dL) was observed in the majority of cases (95%), with the lowest incidence observed in patients undergoing PFA with Sphere-9 (88%) compared with Farawave (97%), Varipulse (97%), and Pulseselect (100%). Significant and severe hemolysis (ie, Hp-postoperative day 1 ≤25 mg/mL and Hp-postoperative day 1 ≤10 mg/mL) occurred in 34% and 13%, with a different distribution across catheter types: Farawave 46% and 21%, Varipulse 29% and 9.7%, Pulseselect 23% and 1.2%, and Sphere-9 5.5% and 0%. Hp decreased by a mean of 76±40 mg/dL from baseline, with a significantly greater degree of reduction seen with Farawave (94±40 mg/dL) and Varipulse (85±32 mg/dL) compared with Pulseselect (62±25 mg/dL) or Sphere-9 (39±23 mg/dL). There is a linear relationship between Hp reduction and number of PFA applications, with a decrease of Hp per application of 0.47 mg/dL (95% CI, 0.22-0.71 mg/dL) for Farawave, 0.40 mg/dL (95% CI, 0.09-0.73 mg/dL) for Pulseselect, and 0.10 mg/dL (95% CI, 0.02-0.19 mg/dL) for Sphere-9. CONCLUSIONS:PFA-induced hemolysis is common, with different PFA technologies exhibiting variable degrees of hemolysis, lower with the focal PFA catheter Sphere-9 when compared with single-shot PFA catheters.

HomeCirculation: Arrhythmia and ElectrophysiologyAhead of PrintCardiac Perforation During High-Power Radiofrequency Ablation of the Left Lateral Ridge Using QDOT MICRO No AccessLetterRequest AccessAboutView PDFSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessLetterRequest AccessCardiac Perforation During High-Power Radiofrequency Ablation of the Left Lateral Ridge Using QDOT MICRO Carola Gianni, Matthew Dare, Javier E. Sanchez, Amin Al-Ahmad, Jason D. Zagrodzky, G. Joseph Gallinghouse, J. David Burkhardt, Robert C. Neely and Andrea Natale Carola GianniCarola Gianni Correspondence to: Carola Gianni, MD, PhD, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Ste 720, Austin, TX 78705. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8174-7207 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Matthew DareMatthew Dare Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Javier E. SanchezJavier E. Sanchez https://orcid.org/0000-0002-4488-9863 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Amin Al-AhmadAmin Al-Ahmad https://orcid.org/0000-0002-8547-025X Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Jason D. ZagrodzkyJason D. Zagrodzky https://orcid.org/0000-0002-0078-5309 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , G. Joseph GallinghouseG. Joseph Gallinghouse https://orcid.org/0000-0002-6233-9355 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , J. David BurkhardtJ. David Burkhardt https://orcid.org/0000-0003-1925-5241 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). , Robert C. NeelyRobert C. Neely Cardiothoracic and Vascular Surgeons, Austin, TX (R.C.N.). and Andrea NataleAndrea Natale https://orcid.org/0000-0002-5487-0728 Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX (C.G., M.D., J.E.S., A.A.-A., J.D.Z., G.J.G., J.D.B., A.N.). Interventional Electrophysiology, Scripps Clinic, La Jolla, CA (A.N.). MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (A.N.). Originally published17 Apr 2024https://doi.org/10.1161/CIRCEP.123.012643Circulation: Arrhythmia and Electrophysiology. 2024;0:e012643FootnotesFor Sources of Funding and Disclosures, see page XXX.Correspondence to: Carola Gianni, MD, PhD, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, 3000 N. IH-35, Ste 720, Austin, TX 78705. Email carola.gianni@gmail.com 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. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails Advertisement Article InformationMetrics © 2024 American Heart Association, Inc.https://doi.org/10.1161/CIRCEP.123.012643PMID: 38629294 Originally publishedApril 17, 2024 Keywordsatrial fibrillationcatheter ablationintraoperative complicationspericardial effusionthoracic surgeryPDF download Advertisement SubjectsAtrial FibrillationCatheter Ablation and Implantable Cardioverter-Defibrillator

Closure of peri-device leaks (PDL) is commonly performed using embolization coils deployed around or inside the left atrial appendage occlusion (LAAO) device and/or intravascular occluders deployed into the leak itself. In some circumstances, where large, crescent-shaped leaks are present in the setting of an undercompressed Watchman device, both approaches might fail to achieve complete PDL closure despite deployment of multiple leaks/occluders.

Two devices are currently available for percutaneous left atrial appendage occlusion (LAAO), Watchman FLX and Amplatzer Amulet. While in most cases LAAO is achieved by implanting the originally planned device, intra-procedural crossover from one type to the other might be necessary when LAAO is not satisfactory.

Aims Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. We aimed at reporting procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transoesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing. Methods and results Among 274 patients undergoing left atrial appendage occlusion (LAAO) with a Watchman FLX, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel (NUVISION (TM)) 3D-ICE one (54 patients). Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks >= 3 mm at follow-up TEE. 3D-ICE measurements of maximum landing zone correlated highly with pre-procedural TEE reference values [Pearson's: 0.94; P < 0.001; bias: -0.06 (-2.39, 2.27)]. The agreement between 3D-ICE-based device selection and final device size was 96.3% vs. 79.1% with 2D-ICE (P = 0.005). The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (P = 0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs. 44.5%; P = 0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients vs. 45.9% of 2D-ICE ones (P = 0.065). Conclusion Intracardiac echocardiography-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for FLX size selection and may provide better guidance during device deployment.

COVID-19 is a novel, highly contagious virus with a wide array of presentations. Initially characterized by symptoms in the respiratory tract, cardiovascular disease and associated complications often accompany COVID-19 infections thereby increasing morbidity and mortality. Current literature has reported an increased rate of cardiac arrhythmias in patients hospitalized with COVID-19. This retrospective medical analysis sought to evaluate the impact of atrial arrhythmias on morbidity and mortality in patients hospitalized with COVID-19.

Introduction: Vascular closure devices are commonly used for EP procedures to achieve rapid hemostasis. Different devices using different mechanisms of action are available, but the potential contribution of each type to the incidence of vascular complications is not clear. Methods: This is a single center, prospective study in which 138 contemporaneous patients undergoing EP procedures were categorized according to the vascular closure device type used: Vascade (collagen plug, n=57), Perclose (suture, n=41), and SiteSeal (external compression, n=40). The primary endpoint was access-related major vascular complications. Secondary endpoints included time to ambulation and delayed access-site bleeding requiring additional manual pressure. Results Mean age and BMI 68±11 years and 29.7±6.2 Kg/m 2 , 46 (33%) were female, 121 (88%) were on uninterrupted antithrombotic therapy (71% OAC, 14% OAC/APLT, 3% APLT). Femoral vein access was obtained in all, bilaterally in 113 (82%), with a mean of 3±1 access sites per patient and a sheath size ranging from 6- to 23-Fr. Femoral arterial access was obtained in 14 (10%), once per patient, with a sheath size ranging from 5- to 8-Fr. There were no arterial access complications. On the venous side, hematomas occurred in 3/57 (5%) of the Vascade group, 1/41 (2%) of the Perclose group, and 0/40 (0%) of the SiteSeal group (p=ns for all comparisons). Delayed access-site bleeding occurred in 5/57 (9%) of the Vascade group, 5/41 (12%) of the Perclose group, and 7/40 (18%) of the SiteSeal group (p=ns for all comparisons). Time to ambulation was comparable between groups (minutes: 139±51 Vascade, 137±34 Perclose, 123±11 SiteSeal, p=ns). Conclusion Vascade, Perclose, and SiteSeal are comparable in term of vascular complications and time to ambulation for patients undergoing EP procedures.

Purpose of Review Herein, we will describe our approach in the management of patients following LAA isolation. Summary With the increasing number of patients who undergo left atrial appendage isolation as part of their invasive treatment of atrial fibrillation, it is important to know that this patient population needs special care during follow-up. More specifically, owing to absent left atrial appendage contraction, these patients have an increased stroke risk despite persistent sinus rhythm and irrespective of their CHA(2)DS(2)-VASc score. Thus, the mainstay of management of patients following left atrial appendage isolation is stroke prevention, and life-long uninterrupted oral anticoagulation or left atrial appendage closure are essential in this population.