Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
➤ Gửi thông báo lỗi ⚠️ Báo cáo tài liệu vi phạmNội dung chi tiết: Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
chapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ial fibrillation (Al’) currently affects up to 5 million Americans and remains the most common arrhythmia encountered ill clinical practice.1- With an aging population, the burden of AF is expected to rise 3-fold by 2050.’Among the several downstream consequences of AẸ the most feared is stroke due Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2to thromboembolism. The primary cause of thrombus formation is mechanical dysfunction in the atria, leading to impaired blood How and stasis. Al alsoEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
promotes endothelial dysfunction. inflammation, platelet activation, and hypercoagulability, which further contribute to thrombus formation*6Stroke rechapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2 a 5% annual stroke rate for all-comers.' Seen another way, the percentage of strokes attributable to Ar ranges from 1.5% in those aged 50 to 59 years to an impressive 23.5% in those aged 80 to 89 years.' While these statistics are dramatic, the influence of AF on stroke is almost certainly underest Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2imated as AF is commonly silent and underdiagnosed.8LEFT ATRIAL APPENDAGEJohnson and colleagues described the lell atrial appendage (I.AA) as “our mosEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
t lethal human attachment.”9 Derived from the embryonic left atrium, the LAA forms a blind pouch 2 to 4 cm long and most commonly lies on the anteriorchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ence of pectinate muscles. 1 his is in sharp contrast to the true left atrium, which is derived from venous tissue and has a smooth endocardial surface. The T.AA also has a variable number of lobes; an autopsy survey of 500 patients found that 20% had one lobe while 77%had two or three lobes.10Atrii Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2il Fibrillation. A Multidisciplinary Approach to farpxoving Patient Outcomes Í 2015 Juseph s. Alpert. Lxune T. Braun. Barbara J. r.elcher. Gerald neitEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
her. niilvrs-in-Chief. Cardiotext PublislwL’. ISBN: 978-1 -035395-95-0110 Section 1: Atrial Fibrillation: Background. Evaluation, and Managementrhe LAchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ies using magnetic resonance imaging (MRI) and transesophageal echocardiography (TEE) have suggested that larger l.AA ostia, more lobes, and greater length all predict higher risk of stroke.1 An important review of 23 studies found that 17% of patients with nonrheumatic AF had lell atrial thrombi, o Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2f which a striking 91% were located in the I.AA.I: It is now well-accepted that the vast majority of strokes caused by /V represent thromboembolism orEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
iginating from the LAA.1JM RATIONS OF ORAL ANTICOAGUIATIONStroke prevention is the foundation of AF management. Currently the standard of care is oralchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ne stroke risk in patients with otherwise low CHADSj scores.1- These scoring systems balance the bleeding risk from anlicoagulalion with the thromboembolic risk from untreated AF. Supported by decades of data, oral anticoagulation has been unequivocally effective in reducing stroke. Warfarin, still Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2the predominant anticoagulant, was demonstrated to reduce Al -related stroke by 64% in an extensive mcta-analysis.16However, the widespread use of sysEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
temic anlicoagulalion has highlighted several important limitations of this strategy Most importantly, systemic anticoagulation unavoidably increases chapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ing or an elevated risk of falls.1'1S The ĨĨAS-BĨ.ED score has helped quantify the bleeding risk of warfarin in a manner analogous to the CHADS, score for stroke risk. It is notable that several components of the 11 AS-BLED score—hyper tension, prior stroke, and advanced age—arc also found in the CH Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ADS, score. In other words, patients al high risk for stroke also happen to be patients at high risk for bleeding, illustrating the complexity in propEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
erly selecting patients for oral anticoagulalion.Aside from bleeding risk, warfarin use is further limited by the inconvenience of frequent blood testchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2AF patients.19 Even when patients are treated with warfarin, they spend up to half of the treatment time outside the therapeutic range.2”Motivated by the challenges of using warfarin, the newer oral anticoagulants dabigatian (a direct thrombin inhibitor), rivaroxaban (a factor Xa inhibitor), and api Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2xaban (a factor Xa inhibitor) were developed and are now m general clinicalChapters IAA Excision, ligation, and Occlusion Devices111use. These novel aEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
gents are comparably effective to warfarin with equivalent or lower bleeding risk? 'Theyhave the advantage of minimal food and drug interactions and achapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2bleeding risk; this risk is further heightened because, unlike warfarin, the new drugs are not easily reversible with blood-product transfusion. Finally, the new agents are more costly and, at present, it is unclear whether they are truly cost effective in comparison with warfarin.Even with improved Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2 oral anlicoagulalion options, there remains a more fundamental issue. Because AT-relatcd stroke appears to be largely a focal problem— thromboembolisEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
m from the LAA—a local approach would be preferable to the currently imprecise strategy of systemic anticoagulation. Theoretically, a procedure to excchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2anticoagulation. I.AA exclusion would be especially appealing for patients with cither intolerance or contraindications to anticoagulation, bl recent years, substantial progress has been made in developing techniques to exclude the 1.AA as a viable alternative for stroke prevention in Ar.LEFT ATRLAL Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2 APPENDAGE EXCLUSION: SURGICAL TECHNIQUESLAA exclusion was first reported ill 1949, when the surgeon Madden2 published a case series of 2 patients whoEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
underwent I -AA removal as a prophylaxis for recurrent arterial emboli. The high morbidity and mortality of the procedure prevented Ils widespread adchapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2' Surgical techniques have evolved along two lines: LAA exclusion (using various suture techniques) and I.AA excision (via surgical stapler or removal with oversew).Data for LAA surgery consist primarily of case reports and retrospective case series. Intepretation of the data is hampered by nonunifo Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2rm surgical techniques and nonstandardized outcomes measurements. The use of TEE, considered the gold standard for LAA visualization, is absent in manEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
y reports. A large review of existing literature found that surgical success was highly dependent on both operator and technique; complete LAA closurechapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2 surgical T AA closure versus oral anticoagu-lalion and demonstrated comparable stroke rales during follow-up?7 rhe results112 Section 1: Atrial Fibrillation: Background, Evaluation, and Managementpave (lie way lor a larger (rial lo answer (he critical question of whether surgical l.AA exclusion eff Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2ectively reduces stroke risk.Current ACC/AIIA guidelines limit surgical L.AA exclusion as an adjunctive procedure during mitral valve or Maze surgery1Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
- However, two recently developed devices may rekindle interest in stand-alone surgical I.AA exclusion. Ihe first, AtriClip LAA Exclusion system (Atrichapter 8Left Atrial Appendage Excision, ligation, and Occlusion Devicesfaral K Patel. MD and Bradley p. Knight, MDA TRIAL FIBRILLA HON AND STROKEAtri Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2al procedures in the United States. The device consists of a titanium ring covered by a woven polyester fabric. Under direct visualization, the clip is secured around the base of the IAA using a special deployment tool. In the largest trial to date. 70 patients undergoing open cardiac surgery in sev Ebook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2en US centers had the AlriClip successfully placed.-'’ of the 61 patients who underwent imaging at .3 months, 60 achieved persistent IAA exclusion. ThEbook Atrial fibrillation - A multidisciplinary approach to improving patient outcomes: Part 2
ere were no device-specific adverse events reported. Although this was a small study with short-rain follow-up, It demonstrated that the device couldGọi ngay
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