ABC | Volume 114, Nº1, January 2019

Statement Position Statement of the Brazilian Cardiology Society and the Brazilian Society of Hemodynamics and Interventional Cardiology on Training Centers and Professional Certification in Hemodynamics and Interventional Cardiology – 2020 Arq Bras Cardiol. 2020; 114(1):137-193 Chart 3 – Absolute and relative contraindications to the use of oral anticoagulation • Previous significant bleeding • Previous intracranial bleeding • Symptomatic bleeding in a critical organ (e.g., ocular, pericardial, medullary) • High risk of bleeding • Frailty/frequent falls • Comorbidities (e.g., intestinal angiodysplasia, renal failure, blood dyscrasia) • Lack of adherence to treatment • Labile INR • Anticoagulant intolerance • Use of double antiplatelet therapy • Refusal to use the medication • Occupational risk INR: international normalized ratio. post-infarction IVC, cardiac perforation, arrhythmias/ atrioventricular block, coronary occlusion, etc.). • Immediate and long-term post-procedural care. 6.2.2.11. Left Atrial Appendage Occlusion Oral anticoagulation is indicated as a class I recommendation, level of evidence A, for prevention of thromboembolic stroke in patients with non-valvular atrial fibrillation (NVAF) and CHA 2 DS 2 -VASc scores ≥ 2, in both Brazilian 30 and international 31,32 guidelines. There are, however, several absolute and relative contraindications to the use of this therapy, either with the use of vitamin K antagonists or direct action oral anticoagulants 33 (Chart 3). Based on the rationale that more than 90% of intracardiac thrombi that are formed as a result of NVAF are localized in the left atrial appendage (LAA), 34 percutaneous left atrial appendage occlusion (LAAO) has proven to be a non-inferior alternative, in relation to the occurrence of thromboembolism, and it is superior in terms of late mortality, when compared to oral anticoagulation with warfarin. 35,36 The II Brazilian Guidelines for Atrial Fibrillation recommend LAAO for patients with high risks of thromboembolic phenomena and contraindications to the use of oral anticoagulants (class IIa, level of evidence B), and for patients sustaining a ischemic stroke of cardioembolic origin occurring in the presence of adequate oral anticoagulant use (class IIa, level of evidence C). 30 Notwithstanding its growing utilization, LAAO is not yet an intuitive procedure for interventional surgeons, which is reflected by the slower and more gradual learning curve and by the potential associated complications. In addition to technical abilities for the intervention itself, LAAO requires proficiency in several stages of management for these patients who are generally elderly and complex, including proper indication for the procedure, interpretation of cardiac angiography and pre- and trans-operative echocardiography imaging, and management of specific protocols of medication and late follow-up. In this manner, with the aim of obtaining better safety and effectiveness in the intervention, and in accordance with international propositions, 36-38 these guidelines recommend the establishment of prerequisites for institutions and professionals who wish to dedicate themselves to LAAO, in addition to a consistent model for acquiring competence in this intervention. 6.2.2.11.1. Institutional Prerequisites The institution should have an established service for structural or congenital heart diseases and/or electrophysiology equipped with an infrastructure that includes, among other things, a hybrid room or a cardiac catheterization laboratory with fixed hemodynamic equipment; it is considered not adequate performing these procedures with a C-arm. There should be a local echocardiography service, with a capacity for performing transthoracic and transesophageal exams with an experienced operator. Anesthesiologists experienced in complex cardiovascular interventions should be part of the local team. The institution should also have a structured cardiac surgery service. It is not considered necessary to keep a cardiac surgery team on stand-by during the procedure; it should, nonetheless, be possible to activate this team rapidly, if necessary. 6.2.2.11.2. Basic Knowledge • Basic knowledge about management of patients with atrial fibrillation, including mastery of tools for assessing risk of stroke and bleeding. • Detailed understanding of cardiac anatomy, surrounding structures, and the anatomical variability of the LAA, with the ability to interpret invasive pressure curves, fluoroscopy, echocardiography, and cardiac angiotomography images related to the procedure and its possible complications. • Interpretation and familiarity with different imaging exams related to the LAA: TTE, TEE, CT, MR, and angiography. • Knowledge of current guidelines for LAAO. • Therapeutic options and outcomes. • Indications for intervention. 6.2.2.11.3. Interventional Cardiologists’ Abilities • Interpretation of LAA images. • Selective transseptal puncture. • Safe access to the LAA. • Sheaths, wires, and catheters utilized. • Proper technical knowledge of the different devices available, their characteristics, sizes, forms of release, and contraindications. • Recognition and rapid management of complications (vascular occlusions, dissections, thromboembolism, hemodynamic collapse, cardiac perforations, cardiac tamponade, device embolism, arrhythmias/atrioventricular blocks, coronary occlusion etc.). • Immediate and long-term post-procedural care. 152