Editorial comment
Combined MitraClip implantation and left atrial appendage occlusion - “because it's there” revisited
Implantação simultânea de MitraClip e encerramento do apêndice auricular esquerdo – “because it's there” revisitado?
Duarte Nuno Cacela
Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
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"itemAnterior" => array:20 [ "pii" => "S2174204917302040" "issn" => "21742049" "doi" => "10.1016/j.repce.2016.11.015" "estado" => "S300" "fechaPublicacion" => "2017-07-01" "aid" => "1028" "copyright" => "Sociedade Portuguesa de Cardiologia" "documento" => "article" "crossmark" => 1 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "fla" "cita" => "Rev Port Cardiol. 2017;36:525-32" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 2872 "formatos" => array:3 [ "EPUB" => 217 "HTML" => 2206 "PDF" => 449 ] ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>" "titulo" => "Combined MitraClip implantation and left atrial appendage occlusion using the Watchman device: A case series from a referral center" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "pt" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "525" "paginaFinal" => "532" ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Implantação simultânea de <span class="elsevierStyleItalic">MitraClip</span> e encerramento do apêndice auricular esquerdo com <span class="elsevierStyleItalic">Watchman</span>: a experiência de um centro de referência" ] ] "contieneResumen" => array:2 [ "en" => true "pt" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1372 "Ancho" => 2000 "Tamanyo" => 262583 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Procedure steps: (1) transseptal puncture guided by transesophageal echocardiography (TEE) (1a) and fluoroscopy (1b); (2) the Watchman 14F double curve sheath is advanced over an Amplatzer stiff wire positioned in the left superior pulmonary vein; (3) the left atrial appendage is measured by angiography (3a) and TEE (3b); (4) the Watchman is implanted guided by fluoroscopy (4a) and good apposition and absence of leaks and complications are confirmed by TEE (4b); (5) the Watchman 14F double curve sheath is exchanged for a 24F MitraClip guide catheter, over an Amplatzer support wire; (6) the clip delivery system is directed to the mid scallops of the anterior and posterior mitral valve leaflets, and guided by three-dimensional TEE, the clip is positioned above the origin of the mitral regurgitation (MR) jet; (7) leaflet insertion, MR reduction, and absence of significant mitral valve stenosis are confirmed by TEE (7a and 7b); (8) additional clips are deployed if necessary.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Ana Rita G. Francisco, Eduardo Infante de Oliveira, Miguel Nobre Menezes, Pedro Carrilho Ferreira, Pedro Canas da Silva, Ângelo Nobre, Fausto J. Pinto" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Ana Rita G." "apellidos" => "Francisco" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Infante de Oliveira" ] 2 => array:2 [ "nombre" => "Miguel" "apellidos" => "Nobre Menezes" ] 3 => array:2 [ "nombre" => "Pedro" "apellidos" => "Carrilho Ferreira" ] 4 => array:2 [ "nombre" => "Pedro" "apellidos" => "Canas da Silva" ] 5 => array:2 [ "nombre" => "Ângelo" "apellidos" => "Nobre" ] 6 => array:2 [ "nombre" => "Fausto J." "apellidos" => "Pinto" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S0870255117304456" "doi" => "10.1016/j.repc.2016.11.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255117304456?idApp=UINPBA00004E" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2174204917302040?idApp=UINPBA00004E" "url" => "/21742049/0000003600000078/v1_201707290050/S2174204917302040/v1_201707290050/en/main.assets" ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial comment</span>" "titulo" => "Combined MitraClip implantation and left atrial appendage occlusion - “because it's there” revisited" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "533" "paginaFinal" => "534" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Duarte Nuno Cacela" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Duarte" "apellidos" => "Nuno Cacela" "email" => array:1 [ 0 => "dcacela@hotmail.com" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Hospital de Santa Marta, Centro Hospitalar de Lisboa Central, Lisboa, Portugal" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Implantação simultânea de MitraClip e encerramento do apêndice auricular esquerdo – “because it's there” revisitado?" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In an interview with the New York Times in 1923, George Mallory, who was to die on his third attempt to climb Mount Everest (his body was not found until in 1999), was asked why he wanted to climb the mountain. His reply was “Because it's there”.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This phrase has since become iconic, used to justify any action or ambition that otherwise has no justification.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In their article published in this issue of the <span class="elsevierStyleItalic">Journal</span> on their experience with simultaneous MitraClip implantation and left atrial appendage occlusion,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Francisco et al. describe five patients who underwent this combined procedure, with excellent results, both procedural and in a mean follow-up of 243±70.7 days.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The rationale for combining the two procedures is attractive, since both require transseptal access. MitraClip implantation is one of the few interventional cardiology procedures that do not require administration of contrast, reducing the likelihood of contrast overload, an important factor in patients with multiple comorbidities that often include renal dysfunction.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Combining the two procedures also has the advantages of reducing costs, the time that patients must suspend or change their anticoagulant therapy, vascular complications (since only a single vascular access is required), and total fluoroscopy time, as well as avoiding the additive effect of two residual interatrial septal communications. The main disadvantage is longer procedure time.</p><p id="par0030" class="elsevierStylePara elsevierViewall">If, as the authors show, the reference transseptal puncture for the MitraClip – which differs from the ideal puncture site for left atrial appendage (LAA) closure – does not hinder implantation of the Watchman device, the combination appears to make even more sense.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Given all this, what is the weakest point in this combined procedure? In my opinion it is the indication for LAA closure, which, as the authors point out, is only a class IIb indication in the European Society of Cardiology guidelines. The procedure is the subject of ongoing controversy, the most famous example of which was John Mandrola's article “Left atrial appendage closure should stop now”<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> in November 2016.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In this regard the approach of Francisco et al. was flawless, restricting LAA closure to patients with firm indications for the procedure: comorbidities directly affecting bleeding risk associated with anticoagulant therapy (liver cirrhosis, previous stroke under oral anticoagulation, chronic anemia with intestinal angiodysplasia, documented labile INR, and chronic use of non-steroidal anti-inflammatory drugs due to degenerative osteoarticular disease). The patients selected for this approach were clearly those with a worse risk profile: three were ineligible for the EVEREST II trial<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> due to ejection fraction (EF) <25% (in EVEREST II the mean EF was 60%, compared to 26% in the series under discussion) and, more directly relevant to LAA closure, a mean CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score of 4.5±0.6 and mean HAS-BLED score of 3.5±0.6. In the largest series published to date on the Watchman device, a meta-analysis<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> of 2406 patients from the PROTECT AF and PREVAIL trials and their respective registries, the CHA<span class="elsevierStyleInf">2</span>DS<span class="elsevierStyleInf">2</span>-VASc score ranged between 3.5±1.6 and 4.3±1.3, while the proportion of patients with a HAS-BLED score ≥3 varied between 19.9 and 36.2%. In the series by Francisco et al., all had a HAS-BLED score ≥3.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In the only published study comparing the combined procedure with standalone MitraClip implantation, Kuwata et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> drew similar conclusions to the Portuguese authors in terms of safety, feasibility and short-term efficacy. In the series by Kuwata et al., in a population with mean EF of 54% and using Amplatzer and Amulet devices, procedure time (90 min vs. 66 min) and fluoroscopy time (32 min vs. 18 min) were the only parameters that differed significantly. The short follow-up in both series is perhaps their greatest limitation, since it leaves open the question of medium- and long-term clinical benefit, including survival, particularly regarding LAA closure, which is the more controversial intervention.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In view of the above, considering the low probability of a randomized trial being conducted between the standalone and combined approaches, I believe that the study by Francisco et al., with its scrupulous selection of patients for this combined procedure, provides good evidence that associating MitraClip implantation and LAA closure with the Watchman device is feasible, safe and, at least in the short term, effective. In the cases they present, it was not simply “Because it's there”, but rather “and last but not least, because it's there”, and for this they are to be congratulated.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Nuno Cacela D. Implantação simultânea de MitraClip e encerramento do apêndice auricular esquerdo – “because it's there” revisitado? Rev Port Cardiol. 2017;36:533–534.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Combined MitraClip implantation and left atrial appendage occlusion using the Watchman device: a case series from a referral center" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Francisco" 1 => "E. Oliveira" 2 => "M. Menezes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2016.11.012" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2017" "volumen" => "36" "paginaInicial" => "525" "paginaFinal" => "532" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28673783" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0040" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "November 10" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial appendage closure should stop now (www.medscape.com/viewarticle/871678)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J. Mandrola" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Theheartorg on Medscape" "fecha" => "2016" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Percutaneous repair or surgery for mitral regurgitation" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "for the EVEREST II Investigators" "etal" => true "autores" => array:3 [ 0 => "FeldmanT" 1 => "E. Foster" 2 => "D. Glower" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1009355" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2011" "volumen" => "364" "paginaInicial" => "1395" "paginaFinal" => "1406" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21463154" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "D. Holmes" 1 => "S. Doshi" 2 => "S. Kar" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2015.04.025" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "65" "paginaInicial" => "2614" "paginaFinal" => "2623" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26088300" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Jaa-068 2016" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Feasibility of concomitant MitraClip and left atrial appendage occlusion" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "S. Kuwata" 1 => "M. Taramasso" 2 => "M. Zuber" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4244/EIJ-D-16-00784" "Revista" => array:2 [ "tituloSerie" => "Euro Intervention" "fecha" => "2016" ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0060" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left atrial appendage closure to reduce the risk of thromboembolic complications in atrial fibrillation; Pay now and possibly pay later?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Waks" 1 => "W. Manning" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jacc.2015.03.593" "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2015" "volumen" => "65" "paginaInicial" => "2624" "paginaFinal" => "2627" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26088301" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21742049/0000003600000078/v1_201707290050/S217420491730168X/v1_201707290050/en/main.assets" "Apartado" => array:4 [ "identificador" => "9917" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21742049/0000003600000078/v1_201707290050/S217420491730168X/v1_201707290050/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S217420491730168X?idApp=UINPBA00004E" ]
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| 2022 December | 33 | 26 | 59 |
| 2022 November | 31 | 34 | 65 |
| 2022 October | 73 | 31 | 104 |
| 2022 September | 60 | 29 | 89 |
| 2022 August | 69 | 45 | 114 |
| 2022 July | 81 | 40 | 121 |
| 2022 June | 66 | 31 | 97 |
| 2022 May | 42 | 31 | 73 |
| 2022 April | 29 | 33 | 62 |
| 2022 March | 28 | 45 | 73 |
| 2022 February | 23 | 34 | 57 |
| 2022 January | 35 | 29 | 64 |
| 2021 December | 20 | 34 | 54 |
| 2021 November | 32 | 33 | 65 |
| 2021 October | 29 | 41 | 70 |
| 2021 September | 23 | 28 | 51 |
| 2021 August | 33 | 32 | 65 |
| 2021 July | 20 | 26 | 46 |
| 2021 June | 17 | 22 | 39 |
| 2021 May | 22 | 33 | 55 |
| 2021 April | 50 | 39 | 89 |
| 2021 March | 59 | 18 | 77 |
| 2021 February | 40 | 20 | 60 |
| 2021 January | 28 | 14 | 42 |
| 2020 December | 33 | 14 | 47 |
| 2020 November | 21 | 13 | 34 |
| 2020 October | 20 | 16 | 36 |
| 2020 September | 44 | 11 | 55 |
| 2020 August | 19 | 12 | 31 |
| 2020 July | 41 | 6 | 47 |
| 2020 June | 38 | 15 | 53 |
| 2020 May | 26 | 7 | 33 |
| 2020 April | 39 | 17 | 56 |
| 2020 March | 46 | 9 | 55 |
| 2020 February | 74 | 20 | 94 |
| 2020 January | 49 | 12 | 61 |
| 2019 December | 33 | 8 | 41 |
| 2019 November | 35 | 7 | 42 |
| 2019 October | 44 | 8 | 52 |
| 2019 September | 19 | 3 | 22 |
| 2019 August | 32 | 8 | 40 |
| 2019 July | 47 | 14 | 61 |
| 2019 June | 34 | 11 | 45 |
| 2019 May | 32 | 8 | 40 |
| 2019 April | 14 | 11 | 25 |
| 2019 March | 159 | 9 | 168 |
| 2019 February | 83 | 8 | 91 |
| 2019 January | 22 | 8 | 30 |
| 2018 December | 46 | 10 | 56 |
| 2018 November | 92 | 15 | 107 |
| 2018 October | 145 | 18 | 163 |
| 2018 September | 30 | 14 | 44 |
| 2018 August | 33 | 6 | 39 |
| 2018 July | 25 | 11 | 36 |
| 2018 June | 40 | 9 | 49 |
| 2018 May | 51 | 16 | 67 |
| 2018 April | 77 | 8 | 85 |
| 2018 March | 113 | 11 | 124 |
| 2018 February | 70 | 10 | 80 |
| 2018 January | 91 | 21 | 112 |
| 2017 December | 120 | 24 | 144 |
| 2017 November | 63 | 20 | 83 |
| 2017 October | 48 | 26 | 74 |
| 2017 September | 58 | 35 | 93 |
| 2017 August | 103 | 33 | 136 |
| 2017 July | 24 | 12 | 36 |
Show all
