Vol 25, No 2 (2018)
Original articles — Interventional cardiology
Published online: 2017-08-24

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Left atrial appendage closure for “primary primary” prevention during percutaneous closure of septal defects in patients with large atria but no atrial fibrillation

Shingo Kuwata1, Juliane Vierecke2, Steffen Gloekler3, Francesco Maisano1, Bernhard Meier2, Fabian Nietlispach1
Pubmed: 28840592
Cardiol J 2018;25(2):179-187.


Background: Percutaneous atrial septal defect (ASD) closure is a routine procedure to prevent right ventricular failure, pulmonary hypertension, or paradoxical embolism. The latter is the typical reason for percutaneous patent foramen ovale (PFO) closure. Atrial enlargement represents a risk for develop­ing atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) closure is emerging as a preven­tive therapy for patients in AF who suffered from a previous stroke or bleeding (secondary prevention) or patients without previous stroke or bleeding (primary prevention). Percutaneous septal closure, particularly that of large ASDs, may inhibit future percutaneous left atrial access when required for LAA closure. Reported herein is the feasibility and safety of concomitant percutaneous closure of the LAA and a septal shunt, mostly large ASDs, in patients without AF, in the sense of “primary primary” preventive LAA closure. The first “primary” relates to “in anticipation of AF” and potentially also for “for prevention of AF”. The second “primary” relates to “prevention of stroke or bleeding”.

Methods: Thirteen consecutive patients, older than 40 years without any clinical or electrocardio­graphic evidence of AF, underwent percutaneous closure of large ASDs or PFOs in the presence of enlarged atria at the university hospitals of Bern and Zurich between April 2013 and June 2015. They concomitantly received “primary primary” preventive LAA closure after informed consent.

Results Mean patient age was 58 ± 9 years (46% male). Procedural success was achieved in all pa­tients and no major adverse events occurred acutely or during the following 2.0 ± 0.8 years. No patient developed AF.

Conclusions: Concomitant closure of ASD or PFO in the presence of enlarged atria and LAA for “primary primary” prevention appears feasible and safe but has yet to prove its justification.

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  1. Hoffman J, Kaplan S. The incidence of congenital heart disease. J Am Coll of Cardiol. 2002; 39(12): 1890–1900.
  2. Gatzoulis MA, Freeman MA, Siu SC, et al. Atrial Arrhythmia after Surgical Closure of Atrial Septal Defects in Adults. N Engl J Med. 1999; 340: 839–846.
  3. Konstantinides S, Geibel A, Olschewski M, et al. A Comparison of Surgical and Medical Therapy for Atrial Septal Defect in Adults. N Engl J Med. 1995; 333(8): 469–473.
  4. Gatzoulis M, Redington A, Somerville J, et al. Should atrial septal defects in adults be closed? Ann Thorac Surg. 1996; 61(2): 657–659.
  5. Akula V, Durgaprasad R, Velam V, et al. Right Ventricle before and after Atrial Septal Defect Device Closure. Echocardiography. 2016; 33(9): 1381–1388.
  6. Du ZD, Hijazi Z, Kleinman C, et al. Comparison between transcatheter and surgical closure of secundum atrial septal defect in children and adults: results of a multicenter nonrandomized trial. J Am Coll Cardiol. 2002; 39(11): 1836–1844.
  7. Fischer G, Stieh J, Uebing A, et al. Experience with transcatheter closure of secundum atrial septal defects using the Amplatzer septal occluder: a single centre study in 236 consecutive patients. Heart. 2003; 89(2): 199–204.
  8. Omeish A, Hijazi Z. Transcatheter Closure of Atrial Septal Defects in Children & Adults Using the Amplatzer Septal Occluder. J Interv Cardiol. 2001; 14(1): 37–44.
  9. Spies C, Khandelwal A, Timmermanns I, et al. Incidence of Atrial Fibrillation Following Transcatheter Closure of Atrial Septal Defects in Adults. Am J Cardiol. 2008; 102(7): 902–906.
  10. Wagdi P. Incidence and predictors of atrial fibrillation following transcatheter closure of interatrial septal communications using contemporary devices. Clin Res Cardiol. 2010; 99(8): 507–510.
  11. Schneeberger Y, Schaefer A, Conradi L, et al. Minimally invasive endoscopic surgery versus catheter-based device occlusion for atrial septal defects in adults: reconsideration of the standard of care. Interact Cardiovasc Thorac Surg. 2016: ivw366.
  12. Burow A, Schwerzmann M, Wallmann D, et al. Atrial Fibrillation following Device Closure of Patent Foramen Ovale. Cardiology. 2008; 111(1): 47–50.
  13. Holmes D, Reddy V, Turi Z, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009; 374(9689): 534–542.
  14. Tzikas A, Shakir S, Gafoor S, et al. Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug. EuroIntervention. 2016; 11(10): 1170–1179.
  15. Nietlispach F, Gloekler S, Krause R, et al. Amplatzer left atrial appendage occlusion: Single center 10-year experience. Catheter Cardiovasc Interv. 2013; 82(2): 283–289.
  16. Ghenzi RA, Obeid S, Maisano F, et al. The evolving role of left atrial ­appendage occlusion: a high-volume single-centre experience. Cardiovasc Med. 2016; 19(11): 288–295.
  17. Holmes D, Doshi S, Kar S, et al. Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation. J Am Coll Cardiol. 2015; 65(24): 2614–2623.
  18. Reddy V, Sievert H, Halperin J, et al. Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation. JAMA. 2014; 312(19): 1988–1998.
  19. Wagdi P, Alkadhi H. Can computer tomography help predict feasibility of transseptal puncture after percutaneous closure of an interatrial septal communication? J Interv Card Electrophysiol. 2012; 34(2): 167–172.
  20. Zaker-Shahrak R, Meier B. Transseptal puncture for catheter ablation of atrial fibrillation after device closure of patent foramen ovale. Catheter Cardiovasc Interv. 2008; 71(4): 551–552.
  21. Nyboe C, Olsen MS, Nielsen-Kudsk JE, et al. Atrial fibrillation and stroke in adult patients with atrial septal defect and the long-term effect of closure. Heart. 2015; 101(9): 706–711.
  22. Praz F, Wahl A, Schmutz M, et al. Safety, feasibility, and long-term results of percutaneous closure of atrial septal defects using the Amplatzer septal occluder without periprocedural echocardiography. J Invasive Cardiol. 2015; 27(3): 157–162.
  23. Meier B, Blaauw Y, Khattab AA, et al. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion. Europace. 2014; 16(10): 1397–1416.
  24. Kappetein AP, Head SJ, Généreux P, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. J Am Coll Cardiol. 2012; 60: 1438–1454.
  25. Go A, Hylek E, Phillips K, et al. Prevalence of diagnosed atrial fibrillation in adults: national implications for rhythm management and stroke prevention: the AnTicoagulation and Risk Factors in Atrial Fibrillation (ATRIA) Study. JAMA. 2001; 285(18): 2370–2375.
  26. De Backer O, Arnous S, Ihlemann N, et al. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart. 2014; 1(1): e000020.
  27. Rigatelli G, Pedon L, Zecchel R, et al. Long-Term Outcomes and Complications of Intracardiac Echocardiography-Assisted Patent Foramen Ovale Closure in 1,000 Consecutive Patients. J Interv Cardiol. 2016; 29(5): 530–538.
  28. Giardini A, Donti A, Sciarra F, et al. Long-term incidence of atrial fibrillation and flutter after transcatheter atrial septal defect closure in adults. Int J Cardiol. 2009; 134(1): 47–51.
  29. Landmesser U, Holmes DR. Left atrial appendage closure: a percutaneous transcatheter approach for stroke prevention in atrial fibrillation. Eur Heart J. 2012; 33(6): 698–704.
  30. Fountain R, Holmes D, Chandrasekaran K, et al. The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) Trial. Am Heart J. 2006; 151(5): 956–961.