Cryoballoon pulmonary vein isolation and left atrial appendage occlusion prior to atrial septal defect closure: A case report

lNTRODUCTlON

Pulmonary vein isolation (PVI) has been established as a treatment for patients with atrial fibrillation(AF)[1]. Cryoballoon PVI has become a relatively simple alternative for radiofrequency ablation[2]. Left atrial appendage (LAA) occlusion is performed as an alternative treatment to oral anticoagulation in patients with non-valvular AF[3]. Atrial septal defect (ASD), as the most common congenital heart disease, may lead to right heart dysfunction and paradoxical embolism[4]. In patients who suffer from both AF and ASD, cryoballoon PVI combined with ASD closure and the LAA occlusion combined with ASD closure have been reported[5-7]. However, there has been no report on the 3-in-1 procedure(cryoballoon PVI, LAA occlusion and ASD closure), which may be effective for preventing stroke and right heart failure. Here, we report a patient who underwent sequential cryoballoon PVI, LAA occlusion and ASD closure during the same operation.

CASE PRESENTATlON

Chief complaints

A 65-year-old man was admitted to our hospital due to recurrent episodes of palpitations and shortness of breath for 2 years.

History of present illness

The patient was subsequently treated with propafenone 150 mg three times a day for 3 mo. Antiplatelet and anticoagulation therapy (clopidogrel and rivaroxaban) was administered following the doctor's advice. Before discharge, correct device positions were confirmed by echocardiography (Figure 3C). A follow-up TEE was performed to confirm proper seating of the devices and to identify thrombi or residual leak at 3 mo (Figure 3D). Both devices were located in proper position, and neither thrombi nor leakage was present. Subsequently, the patient discontinued rivaroxaban and changed to aspirin and clopidogrel.

History of past illness

本研究采用堿法提取羊肚菌中可溶性膳食纖維，通過單因素試驗和響應面試驗對其工藝條件進行優化，得到各因素對羊肚菌SDF得率的影響順序為：提取溫度>料液比>堿液濃度>提取時間；提取的最佳工藝參數為：料液比1∶20 (g/mL)、提取液濃度0.75%、提取溫度63 ℃、提取時間60 min，在此工藝條件下羊肚菌SDF得率為33.06%。本試驗為綜合利用羊肚菌資源研究奠定了理論基礎。

Personal and family history

None.

對K-means算法中的最初分類個數k設定為2，從樣本對象集合中抽取k個樣本點，計算出樣本數據的原始分類點。對樣本中心進行再計算直到樣本中心不再變化，然后對聚類結果進行評價計算。若計算結果增加則說明得到了更優的聚類結果，讓k自增執行循環，直到二者成反比，即隨著k的增加得到負增加的計算結果，結束所有運算。可以通過計算數據分布相異值，防止類中出現樣本過多或過少的不平衡現象。數據分布相異值的計算公式為

Physical examination

We report an ASD patient with AF who underwent the cryoballoon PVI and LAA occlusion prior to ASD closure, which indicates that this 3-in-1 operation is feasible, but it is not recommended as a routine procedure. For patients with ASD complicated with poorly controlled AF and unable to tolerate long-term oral anticoagulants, this 3-in-1 procedure can be considered.

Laboratory examinations

On admission, his blood tests including routine blood test, renal function, liver function, thyroid function and coagulation function showed no abnormalities.

Imaging examinations

Pulmonary vein (PV) anatomy was assessed in detail by cardiac computed tomography (CT)(Figure 1A). Reconstruction and measurement of LAA and selection of suitable implantation angle and position were also completed by cardiac CT (Figure 1B-C). Electrocardiography showed AF with a ventricular rate of 76 bpm. Echocardiography showed normal left ventricular ejection fraction, moderate dilatation of the left atrium (50 mm), severe enlarged right atrium and right ventricle and moderate tricuspid regurgitation (estimated pulmonary arterial systolic pressure was 47 mmHg). Abnormal flow from the left to right atrium through the interatrial septum was found by color Doppler image. Echocardiography revealed a 25-mm secundum ASD with adequate margins for ASD closure. There were no obvious abnormalities on chest CT and abdominal color Doppler ultrasound.

Further diagnostic work-up: AF embolism and bleeding score

CHA2DS2VASc score was 3 (diabetes mellitus, vascular disease, age 65 years to 74 years) and HASBLED was 1 (age ≥ 65 years). He refused a long-term anti-coagulation treatment.

基于全面提升防滲層質量的目的，采用了兩種施工工藝，即C20變態混凝土和C20碾壓混凝土，以粗骨料粒徑為基準，兩類材料達到二級配標準，對應齡期均為90d；前者厚度為0.5m，后者介于2.0～4.5m范圍內，以確保抗滲等級達到W8水平。對于下游壩面亦采用上述兩種施工工藝，以粗骨料粒徑為基準，二者達到三級配標準，對應齡期均為90d，且厚度均為0.5m，最終確保抗滲等級達到W6水平。大壩基礎部分則采用C20常態混凝土工藝，此階段達到二級配標準，對應齡期為90d，以確保其抗滲等級達到W8水平。

FlNAL DlAGNOSlS

AF, ASD, coronary heart disease and diabetes.

TREATMENT

Cryoballoon PVI

The patient had recurrent AF, which was poorly controlled with antiarrhythmic drugs, so PVI was attempted. Under general anesthesia, a 12F FlexCath steerable sheath (Medtronic Inc., Minneapolis,MN, United States) was advanced into the left atrium without transseptal puncture. A cryoballoon catheter (Medtronic Inc.) was introduced inside the 12F sheath. Following good balloon occlusion, we applied two ablation freezes for 120-180 s (Figure 2A-D). PV mapping was performed following ablation of all four PVs with a 10-pole Lasso catheter (Biosense-Webster Inc., Diamond Bar, CA, United States).We used bidirectional conduction block between the left atrium and PVs[8] to conform the complete elimination of PV electrical activity. Preoperative and postoperative electrocardiograms are shown in Figure 2E-F.

His past illness included AF, ASD, coronary heart disease with stent implantation and diabetes.

LAA occlusion

Anticoagulant therapy was recommended, but the patient refused to take long-term oral anticoagulants,so LAA occlusion was selected. Following the cryoballoon PVI, the patient underwent LAA occlusion under transesophageal echocardiographic (TEE) monitoring[9]. A special sheathing canal was placed to perform LAA angiography, and a pigtail angiographic catheter was directed to the LAA with the following positions: Right anterior oblique 30° + cranial 20° and right anterior oblique 30° + caudal 20°.Suitable LAA occluder (Watchman, 3.0 cm) was selected following measurement of LAA orifice width and depth. The LAA occluder was introduced into the LAA along the sheathing canal. The position of the occluder was monitored by TEE. A pull test was conducted to determine the stability of the occluder. After suitable position of the occluder and good plugging effect were confirmed, the occluder was released (Figure 1D).

ASD closure

The indications and benefits of atrial septal occlusion are clear. Figure 3A shows a secundum ASD by echocardiography. After cryoballoon PVI and LAA occlusion, the diameter of the interatrial defect was measured on TEE images in various planes, and a 34-mm JIYI ASD occluder device (Shanghai Shape Memory Co., Ltd, Shanghai, China) was implanted[10]. Secured and stable positioning of the occluder was confirmed through a push-pull test (Figure 3B). After unscrewing the occluder from the cable, good positioning of the device was demonstrated by a final TEE examination.

OUTCOME AND FOLLOW-UP

His symptoms started 2 years ago with recurrent episodes of palpitations and shortness of breath, which had worsened over the last 48 h.

DlSCUSSlON

The patient’s temperature was 36.6 °C, heart rate was 74 bpm, respiratory rate was 16 breaths

minute, blood pressure was 120/70 mmHg and oxygen saturation in room air was 98%. There was no filling of jugular vein; cardiac auscultation showed arrhythmia and no cardiac murmur in each valve area; and no edema was found in both lower limbs.

All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Koermendy

[17] reported that LAA occlusion through ASD or patent foramen ovale was a feasible access. Cardiac tamponade and perforation of adjacent organs could be obviated by avoiding a transseptal puncture[18]. Another advantage is not to create an iatrogenic septal defect. It is not easy to perform LAA occlusion after ASD occlusion, as the ASD occluder makes it difficult to transseptal puncture[19]. Thus, before ASD occlusion, it is necessary to evaluate the indication for LAA occlusion carefully. According to the reported guidelines, a CHA2DS2VASc score of ≥ 2 point is considered as an indication for LAA occlusion[20]. Our case strictly followed this standard, and as this patient refused to take long-term anti-coagulants, LAA occlusion was conducted before ASD closure.

The authors thank Zhang B and Wu DH for their assistance in cardiac CT analysis.

CONCLUSlON

Cryoballoon PVI and LAA occlusion prior to ASD closure can be performed sequentially in ASD patients with AF, which may not be performed routinely. However, for ASD patients complicated with poorly controlled AF and unable to tolerate long-term oral anticoagulants, this 3-in-1 procedure can be considered.

ACKNOWLEDGEMENTS

Invasive and surgical procedures are becoming less frequent because of the improvement in percutaneous techniques, especially in cardiac interventions[21]. The present case report indicates that cryoballoon PVI and LAA occlusion prior to percutaneous ASD closure can be performed safely and can prevent several difficulties and complications. In addition, this 3-in-1 procedure was beneficial simultaneously to maintain sinus rhythm, reverse atrium remodeling and prevent embolism.

FOOTNOTES

Wu YC and Wang MΧ contributed to data collection, original draft preparation and writing;Chen GC and Ruan ZB contributed to operations and monitoring; Zhang QQ contributed to conceptualization,writing, reviewing and editing.

Taizhou People’s Hospital Scientific Research Start-Up Fund Project, No. QDJJ202113.

作為教師，要改變自己的教學，就必須從歷史本源入手。教師要常追問自己：這節課我要干什么？這節課的靈魂和主線是什么？它的教學價值到底是什么？教師通過深入思考，把握知識學習與思想價值的關系，用思想價值引領學生學習知識，用思想塑造學生的學習能力，這樣的歷史教學對學生才更有意義。

AF is the most common cardiac arrhythmia, which occurs in 1%-2% of the general population[11].Since PVs were demonstrated as major sources of ectopic beats, PVI has been considered as the cornerstone for AF procedures[12]. Cryoballoon AF ablation has been established as a useful and safe method in treating paroxysmal and persistent AF, providing an alternative approach to radiofrequency ablation[13]. The incidence of AF is strikingly high in patients with ASD, even after surgical closure[14].Furthermore, compared with the general population, patients with ASD suffer earlier from atrial arrhythmia[15]. Closure of the ASD could decrease the volume overload and reverse remodeling of the atrium[16]. In the present case, we performed cryoballoon ablation followed by closure of LAA and ASD, which we thought could maintain sinus rhythm, reverse atrium remodeling and prevent embolism.

The authors declared no potential conflicts of interest with respect to the research,authorship, and/or publication of this article.

5）機械類課程三維建模與仿真平臺可通過網絡實現區域共享甚至可以全國共享，不同地域的學校中的學生可以進行相同的虛擬實驗，彼此交流。

為了進一步提高區縣級電視臺專題節目的質量，在節目拍攝手段上要下功夫、創新拍攝手段，這樣才能夠讓更多的觀眾產生新的興趣點。中央電視臺的新聞因具有權威性，所以專題節目用詞精準，所表達的意思言簡意賅。而區縣級的觀眾從一定程度上來說，觀眾的文化水平以及專業素質相對較低，在拍攝手段上盡可能以簡單直觀的方式進行拍攝，這樣便于地方觀眾理解，容易引起觀眾的共鳴，一定程度上拉近節目與群眾之間的距離，吸引觀眾關注自己的節目。以普法為例，在劇本上以及人物講述角度上，可以采取第一人稱的拍攝手法，語言通俗易懂，鏡頭簡單明了，這樣觀眾就更容易理解和掌握法律知識。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

最早使用內部牽制手段的行業是美國鐵路公司，因其每天客運和貨運業務規模較大。公司規定企業的任何決定都必須由兩個或兩個以上部門參與，任何涉及資金收支的執行和審核崗位必須分離，強調崗位的相互制衡。但該階段由于內部控制思想處于萌芽階段，尚缺乏全局觀念。

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

傣族的新年被其他民族稱作“潑水節”。在新年這一天,人們彼此都會用橄欖枝或鮮花沾水灑向對方,借以表達相互的祝福。在灑水祝福的儀式結束后,人們就會潑水狂歡,沉醉于潑水嬉戲的歡樂中。筆者所調研的村子是一個傣族、拉祜族、佤族混居的村子，潑水節期間傣俗，佤族、拉祜族都會來村里一起過節，相當于農歷的新年，很熱鬧。

Yu-Cheng Wu 0000-0002-0963-6123; Mei-Χiang Wang 0000-0001-7112-0657; Ge-Cai Chen 0000-0003-4157-3190; Zhong-Bao Ruan 0000-0003-0337-4625; Qing-Qing Zhang 0000-0002-4895-0027.

Li Χ

Filipodia

Li Χ

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