Characterization of Pleural Effusion After Left Atrial Appendage Exclusion Using the Lariat Procedure SAMPATH GUNDA, M.D., M.H.A.,∗ ARUN KANMANTHAREDDY, M.D.,∗ AJAY VALLAKATI, M.D.,† PRAMOD JANGA, M.B.B.S.,∗ MUHAMMAD RIZWAN AFZAL, M.D.,∗ JAYASREE PILLARISETTI, M.D.,∗ SUDHARANI BOMMANA, M.Phil.,∗ DONITA ATKINS, R.N.,∗ MATTHEW EARNEST, M.D., F.A.C.C., F.S.C.A.I.,∗ JAYANT NATH, M.D.,∗ NAGARAJ HOSAKOTE, M.D., F.A.C.C.,‡ LUIGI DI BIASE, M.D., F.A.C.C., F.H.R.S., Ph.D.,§ ANDREA NATALE, M.D., F.A.C.C., F.H.R.S.,§ MADHU REDDY, M.D., F.A.C.C., F.H.R.S.,∗ RANDALL LEE, M.D., F.A.C.C., F.H.R.S., Ph.D.,¶ and DHANUNJAYA LAKKIREDDY, M.D., F.A.C.C., F.H.R.S.∗ From the ∗ Mid-America Cardiology and University of Kansas Medical Center, Kansas City, Kansas, USA; †Case Western Reserve University/Metrohealth Medical Center, Cleveland, Ohio, USA; ‡Nebraska Heart Institute, Lincoln, Nebraska, USA; §Texas Cardiac Arrhythmia Institute, Austin, Texas, USA; and ¶University of California, San Francisco, California, USA

Pleural Effusions After the Lariat Procedure. Background: The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdotal reports of pleural effusions after the Lariat procedure. However, the incidence, demographics, and pathophysiology of these effusions are largely unknown. Objective: Characterization of pleural effusions in patients who underwent LAA exclusion using the Lariat procedure. Methods: We report the incidence, demographics, and clinical and laboratory characteristics of patients from a multicenter prospective registry who underwent the Lariat procedure and subsequently developed pleural effusions. Results: A total of 10 out of 310 (3.2%) patients developed significant pleural effusions after the Lariat procedure. The mean age of these patients was 67 ± 9, ranging from 52 to 78 years and included 5 (50%) males. Nine patients had persistent AF with median CHADS2 score of 2.7 ± 1.2. The LAA was successfully ligated in all these patients. Post-Lariat procedure, 6 patients developed bilateral and 4 patients developed left-sided pleural effusions. Pleural tap revealed transudative in 2 and exudative in 6 patients. The remaining 2 patients responded to active diuresis and behaved clinically like transudative effusions. There is a statistically significant difference between the onset of pleural effusion after the Lariat procedure between tPLE versus ePLE groups (14 ± 1.2 vs. 6 ± 6, P = 0.05). Conclusion: Incidence of clinically significant pleural effusion is uncommon after the Lariat procedure and can be either exudative or transudative in nature depending on the underlying mechanisms. More prospective studies are needed to study the pathophysiologic basis of development of pleural effusions after the Lariat procedure. (J Cardiovasc Electrophysiol, Vol. 26, pp. 515-519, May 2015) atrial fibrillation, Lariat procedure, left atrial appendage, pleural effusions, atrial natriuretic peptide, stroke, anticoagulation Introduction Atrial fibrillation (AF) is the most common arrhythmia in the clinical cardiovascular practice. AF affects around L. Di Biase serves as a consultant/advisory board member of Biosense Webster, St. Jude Medical, Hansen, and Boston Scientific; he received speaker honoraria from Biosense Webster and Medtronic. A. Natale reports honoraria from and serving as consultant/advisory board member to Biosense Webster, Janssen, Boston Scientific, Medtronic, and St. Jude Medical. R. Lee is a consultant for SentreHEART Inc., with equity in the company. D. Lakkireddy received modest speaker’s honorarium from SentreHEART. Other authors: No disclosures. Address for correspondence: Dhanunjaya (DJ) Lakkireddy, M.D., F.A.C.C., F.H.R.S., Professor of Medicine, Mid America Cardiology, University of Kansas Hospital, Kansas City, KS 66160. Fax: 913-588-9770; E-mail: [email protected] Manuscript received 27 October 2014; Revised manuscript received 3 January 2015; Accepted for publication 27 January 2015. doi: 10.1111/jce.12648

6.1 million adults in the United States and 4.5 million in Europe.1 AF contributes to approximately 23% of thromboembolic strokes, which is the major cause of morbidity and mortality.2 It is thought that the left atrial appendage (LAA) is the primary source for thromboembolism in these patients.3 Appropriate use of antithrombotic therapy, mainly oral anticoagulants (OACs), substantially decreases this stroke risk.4 Around 20–50% of patients are not candidates for OACs due to age, frequent falls, physician–patient barriers, and systemic disorders that preclude the use of OAC.5,6 With more than 90% of strokes in patients with AF originating from the LAA,3 it became the obvious target for closure to decrease the risk of systemic thromboembolism over the last 2 decades.7 The Lariat device has been increasingly used for LAA exclusion in patients with AF in the United States. Ligation of the LAA using the Lariat device causes both mechanical and electrical exclusion from the rest of left atrium (LA).8 It has been shown that the LAA tissue undergoes ischemic necrosis after successful ligation. LAA seems to be the major


Journal of Cardiovascular Electrophysiology

Vol. 26, No. 5, May 2015

TABLE 1 Comparison of Baseline Characteristics of Patients in Transudative Pleural Effusion (tPLE) versus Exudative Pleural Effusions (ePLE)

Clinical Characteristics Age, mean (years) Males (%) BMI, mean (kg/m2 ) Caucasian (%) Persistent AF (%) CHADS2 score CHADS2 VASc score HAS-BLED score Antiarrhythmic use (%) Oral anticoagulation use (%) Diuretic use (%) Hypertension (%) Chronic kidney disease (%) Heart failure with reduced EF ࣘ40% (HFrEF) (%) Heart failure with preserved EF (HFpEF) Mean LVEF % Mean LA size in cm (range) LAA length (mm) Preligation LAA volume (mL) Acute leak post-Lariat procedure

No Effusion Group (N = 300)

Effusion Group (N = 10)

tPLE (N = 4)

69 ± 11 170 (56) 30 ± 7 283 (96) 105 (35) 2.6 ± 1.3 3.3 ± 1.6 3.4 ± 1.1 NA 254 (84) 13 (5) 183 (61) 45 (15) 26 ± 5 56 ± 5 54 ± 9 6±7 NA NA 51 (20)

67 ± 9 5 (50) 31 ± 8 9 (90) 9 (90) 2.7 ± 1.2 3.4 ± 1.4 2.6 ± 1.2 5 (50) 7 (70) 4 (40) 10 (100) 2 (20) 3 (30) 1 (10) 51 ± 11 5.1 ± 0.5 48 ± 8 1.71 ± 1 0

68 ± 12 2 (50) 33 ± 12 4 (44) 4 (44) 3.25 ± 0.5 4.5 ± 0.5 3.25 ± 0.5 3 (60) 4 (57) 4 (100) 4 (40) 1 (50) 2 (66) 0 48 ± 10 5 ± 0.7 51 ± 7 1.75 ± 0.5 0

source of atrial natriuretic peptide (ANP)9 and is thought to act as a reservoir in accommodating increasing stroke volume during physiologic stress.10,11 Impact of LAA exclusion on the secretory function of ANP and other physiologic aspects is largely unknown. Pleural effusion has been reported as a potential side effect of the Lariat procedure.12 However, the incidence, demographics, and pathophysiology of these pleural effusions after LAA exclusion are largely unknown. Here we report our observations on pleural effusions after successful LAA ligation using the Lariat device from a multicenter registry. Methods and Materials This is an observational study of patients from a prospective data base registry from January 2012 to June 2014, who developed pleural effusions after successful LAA exclusion using the Lariat device at the participating institutions. The study was approved by the institutional review board. Baseline demographics, laboratory parameters, procedural characteristics, and complications were collected. The Lariat procedure was performed as previously described.8 Post-procedure, pericardial drain was left in place for 12–24 hours or until the pericardial drain output was minimal (

Characterization of pleural effusion after left atrial appendage exclusion using the Lariat procedure.

The Lariat procedure is increasingly used for the exclusion of the left atrial appendage (LAA) in atrial fibrillation (AF) patients. There are anecdot...
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