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Junarta J, Siddiqui MU, Abaza E, Zhang P, Roshandel A, Barbhaiya CR, Jankelson L, Park DS, Holmes D, Chinitz LA, Aizer A. Catheter ablation alone versus catheter ablation with combined percutaneous left atrial appendage closure for atrial fibrillation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2024:10.1007/s10840-024-01915-7. [PMID: 39230634 DOI: 10.1007/s10840-024-01915-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/25/2024] [Indexed: 09/05/2024]
Abstract
BACKGROUND Combined catheter ablation (CA) with percutaneous left atrial appendage closure (LAAC) may produce comprehensive treatment for atrial fibrillation (AF) whereby rhythm control is achieved and stroke risk is reduced without the need for chronic oral anticoagulation. However, the efficacy and safety of this strategy is still controversial. METHODS This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. The risk of bias was assessed using the Modified Newcastle-Ottawa scale and Cochrane risk of bias tool. Eligible studies reported outcomes in patients with AF who underwent combined CA and LAAC vs CA alone. Studies performing CA without pulmonary vein isolation were excluded. RESULTS Eight studies comprising 1878 patients were included (2 RCT, 6 observational). When comparing combined CA and LAAC vs CA alone, pooled results showed no difference in arrhythmia recurrence (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.82-1.33), stroke or systemic embolism (RR 0.78; 95% CI 0.27-2.22), or major periprocedural complications (RR 1.28; 95% CI 0.28-5.89). Total procedure time was shorter with CA alone (mean difference 48.45 min; 95% CI 23.06-74.62). CONCLUSION Combined CA with LAAC for AF is associated with similar rates of arrhythmia-free survival, stroke, and major periprocedural complications when compared to CA alone. A combined strategy may be as safe and efficacious for patients at moderate to high risk for bleeding events to negate the need for chronic oral anticoagulation.
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Affiliation(s)
- Joey Junarta
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA.
| | - Muhammad U Siddiqui
- Jefferson Heart Institute, Thomas Jefferson University Hospitals, Philadelphia, USA
| | - Ehab Abaza
- Department of Internal Medicine, New York University Langone Health, New York, USA
| | - Peter Zhang
- Department of Internal Medicine, New York University Langone Health, New York, USA
| | - Aarash Roshandel
- Department of Internal Medicine, New York University Langone Health, New York, USA
| | - Chirag R Barbhaiya
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
| | - Lior Jankelson
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
| | - David S Park
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
| | - Douglas Holmes
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
| | - Larry A Chinitz
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
| | - Anthony Aizer
- Leon H. Charney Division of Cardiology, New York University Langone Health, 550 1st Ave, New York, New York, 10016, USA
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2
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Reinhardt SW, Gibson DN, Hsu JC, Kapadia SR, Yeh RW, Price MJ, Piccini JP, Nair DG, Christen T, Allocco DJ, Freeman JV. Anticoagulation Alone vs Anticoagulation Plus Aspirin or DAPT Following Left Atrial Appendage Occlusion. J Am Coll Cardiol 2024; 84:889-900. [PMID: 39197978 DOI: 10.1016/j.jacc.2024.05.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/29/2024] [Indexed: 09/01/2024]
Abstract
BACKGROUND The prevalence of and outcomes associated with different antithrombotic strategies after left atrial appendage occlusion (LAAO) are not well described. OBJECTIVES This study sought to evaluate patterns of antithrombotic medication strategies at discharge following LAAO with the Watchman FLX device in real-world practice and to compare the risk of adverse events among the different antithrombotic regimens. METHODS The authors evaluated patients in the NCDR (National Cardiovascular Data Registry) LAAO Registry who underwent LAAO with the second-generation LAA closure device between 2020 and 2022. They grouped patients by mutually exclusive discharge antithrombotic strategies and compared the rates of adverse events at 45 days and 6 months using multivariable Cox proportional hazards regression. RESULTS Among 53,878 patients undergoing successful LAAO with the second-generation LAA closure device, the most common antithrombotic discharge regimens were direct oral anticoagulant (DOAC) plus aspirin (48.3%), DOAC alone (22.6%), dual antiplatelet therapy (8.1%), warfarin plus aspirin (7.7%), and DOAC plus P2Y12 inhibitor (4.9%). In multivariate analysis, DOAC alone had a lower rate of major adverse events and major bleeding at 45 days of follow-up compared with DOAC plus aspirin (major adverse events: HR: 0.78; 95% CI: 0.68-0.91; major bleeding: HR: 0.69; 95% CI: 0.60-0.80). These differences persisted at 6 months. Warfarin without aspirin also showed lower rates of major bleeding at both time points. No differences were seen in stroke/transient ischemic attack or device-related thrombus. CONCLUSIONS In real-world U.S. practice, discharge on DOAC alone or warfarin alone was associated with a lower rate of adverse events compared with DOAC plus aspirin.
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Affiliation(s)
- Samuel W Reinhardt
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Devi G Nair
- Department of Cardiac Electrophysiology, St Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | | | | | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA.
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3
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Zeitler EP, Johnson AE, Cooper LB, Steinberg BA, Houston BA. Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction: New Assessment of an Old Problem. JACC. HEART FAILURE 2024; 12:1528-1539. [PMID: 39152985 DOI: 10.1016/j.jchf.2024.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 05/30/2024] [Accepted: 06/04/2024] [Indexed: 08/19/2024]
Abstract
Atrial fibrillation (AF) and heart failure (HF)-specifically, heart failure with reduced ejection fraction (HFrEF)-often coexist, and each contributes to the propagation of the other. This relationship extends from the mechanistic and physiological to clinical syndromes, quality of life, and long-term cardiovascular outcomes. The risk factors for AF and HF overlap and create a critical opportunity to prevent adverse outcomes among patients at greatest risk for either condition. Increasing recognition of the linkages between AF and HF have led to widespread interest in designing diagnostic, predictive, and interventional strategies targeting all aspects of disease, from identifying genetic predisposition to addressing social determinants of health. Advances across this spectrum culminated in updated multisociety guidelines for management of AF, which includes specific consideration of comorbid AF and HF. This review expands on these guidelines by further highlighting relevant clinical trial findings and providing additional context for the evolving recommendations for management in this important and growing population.
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Affiliation(s)
- Emily P Zeitler
- Section of Cardiovascular Medicine, Dartmouth Health and The Dartmouth Institute, Lebanon New Hampshire, USA.
| | - Amber E Johnson
- Section of Cardiology, Department of Medicine, Pritzker School of Medicine of the University of Chicago, Chicago, Illinois, USA
| | - Lauren B Cooper
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Benjamin A Steinberg
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, Utah, USA
| | - Brian A Houston
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
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4
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Hagendorff A, Stöbe S, Helfen A, Knebel F, Altiok E, Beckmann S, Bekfani T, Binder T, Ewers A, Hamadanchi A, Freyhaus HT, Groscheck T, Haghi D, Knierim J, Kruck S, Lenk K, Merke N, Pfeiffer D, Dorta ER, Ruf T, Sinning C, Wunderlich NC, Brandt R, Ewen S. Echocardiographic assessment of left atrial appendage morphology and function-an expert proposal by the German Working Group of Cardiovascular Ultrasound. Clin Res Cardiol 2024:10.1007/s00392-024-02492-5. [PMID: 39196343 DOI: 10.1007/s00392-024-02492-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2024] [Accepted: 07/04/2024] [Indexed: 08/29/2024]
Abstract
The left atrial appendage is a blind ending cardiac structure prone to blood stasis due to its morphology. This structure is a preferred region of thrombogenesis in relation to reduced myocardial contractility of the atrial wall. Blood stasis occurs primarily in low flow conditions. One of the tasks of echocardiography is the analysis of morphology and function of the left atrial appendage. The detection of thrombi by echocardiography is difficult and must be carried out thoroughly and carefully to avoid potential complications-especially in the context of rhythm control. The assessment of thromboembolic risk, especially in patients with unknown and presumed atrial fibrillation is a second challenge by characterizing atrial function and flow conditions in the left atrial appendage. Thus, this proposal focuses on the obvious problems of echocardiography when assessing left atrial appendage and the role of this method in planning a potential interventional closure of left atrial appendage.
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Affiliation(s)
- Andreas Hagendorff
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany.
| | - Stephan Stöbe
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Andreas Helfen
- Department of Kardiologie, Katholische St. Paulus Gesellschaft, St.-Marien-Hospital Lünen, Lünen, Germany
| | - Fabian Knebel
- Department of Internal Medicine II, Cardiology, Sana Klinikum Lichtenberg, Berlin, Germany
| | - Ertunc Altiok
- Department of Cardiology, Angiology, and Intensive Medicine, University Hospital Aachen, Aachen, Germany
| | - Stephan Beckmann
- Privatpraxis Kardiologie, Beckmann Ehlers Und Partner, Berlin-Grunewald, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Thomas Binder
- Department of Cardiology, University Hospital AKH, Vienna, Austria
| | - Aydan Ewers
- Department of Cardiology and Angiology, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Ali Hamadanchi
- Department of Cardiology, University of Jena, Jena, Germany
| | - Henrik Ten Freyhaus
- Department of Internal Medicine III, Cardiology, University of Cologne, Cologne, Germany
| | - Thomas Groscheck
- Department of Cardiology and Angiology, University Hospital Magdeburg AöR, Magdeburg, Germany
| | - Dariush Haghi
- Kardiologische Praxisklinik Ludwigshafen-Akademische Lehrpraxis of the University of Mannheim, Ludwigshafen, Germany
| | - Jan Knierim
- Department of Internal Medicine and Cardiology, Paulinenkrankenhaus Berlin, Berlin, Germany
| | - Sebastian Kruck
- Praxis Für Kardiologie Cardio Centrum Ludwigsburg, Ludwigsburg, Germany
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig AöR, Leipzig, Germany
| | - Nicolas Merke
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Charité Berlin, Berlin, Germany
| | | | - Elena Romero Dorta
- Department of Cardiology, Angiology and Intensive Care Medicine, University of Berlin, Deutsches Herzzentrum Charité Berlin, Campus Mitte, Berlin, Germany
| | - Tobias Ruf
- Department of Cardiology, Center of Cardiology, Heart Valve Center, University Medical Center Mainz, University of Mainz, Mainz, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart and Vascular Center Hamburg, German Centre of Cardiovascular Research (DZHK), Hamburg, Germany
| | | | - Roland Brandt
- Department of Cardiology, Kerckhoff Klinik GmbH, Bad Nauheim, Germany
| | - Sebastian Ewen
- Department Cardiology and Intensive Care Medicine, Schwarzwald-Baar Klinik, Villingen-Schwenningen, Germany
- University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
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5
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 276] [Impact Index Per Article: 276.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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6
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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7
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Gurol ME, Wright CB, Janis S, Smith EE, Gokcal E, Reddy VY, Merino JG, Hsu JC. Stroke Prevention in Atrial Fibrillation: Our Current Failures and Required Research. Stroke 2024; 55:214-225. [PMID: 38134262 PMCID: PMC11167726 DOI: 10.1161/strokeaha.123.040447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Nonvalvular atrial fibrillation is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. These medications also require strict compliance for efficacy, and they have nontrivial failure rates in higher-risk patients. Left atrial appendage closure is a nonpharmacological method to prevent ischemic strokes in atrial fibrillation without the need for lifelong anticoagulant use, but this procedure has the potential for complications and residual embolic events. This workshop of the Roundtable of Academia and Industry for Stroke Prevention discussed future research needed to further decrease the ischemic and hemorrhagic risks among patients with atrial fibrillation. A direct thrombin inhibitor, factor Xa inhibitors, and left atrial appendage closure are FDA-approved approaches whereas factor XIa inhibitors are currently being studied in phase 3 randomized controlled trials for stroke prevention. The benefits, risks, and shortcomings of these treatments and future research required in different high-risk patient populations are reviewed in this consensus statement.
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Affiliation(s)
- M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Clinton B Wright
- Division of Clinical Research, NINDS, Bethesda, MD (C.B.W., S.J.)
| | | | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.)
| | - Elif Gokcal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Vivek Y Reddy
- Helmsley Trust Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York (V.Y.R.)
| | - José G Merino
- Department of Neurology, Georgetown University Medical Center (J.G.M.)
| | - Jonathan C Hsu
- Department of Cardiology, University of California, San Diego, La Jolla (J.C.H.)
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8
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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9
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Ding X, Xiang K, Qian C, Hou X, Wu F. Intracardiac echocardiography is a promising strategy for guiding closure of the left atrial appendage. Health Sci Rep 2023; 6:e1762. [PMID: 38116174 PMCID: PMC10728371 DOI: 10.1002/hsr2.1762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background and Aims Percutaneous transcatheter left atrial appendage (LAA) closure (LAAC) is an effective approach for preventing ischemic stroke in nonvalvular atrial fibrillation patients. Intracardiac echocardiography (ICE), a new imaging modality, is a promising strategy for guiding LAAC. This review highlights the various strategies for ICE-guided-LAAC as an option for clinical policy. Methods A comprehensive literature search was conducted of PubMed, ScienceDirect, Ovid Web of Science, SpringerLink, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to ICE and its application in the guidance of LAAC. Results Various methods are used to evaluate the spatial structure and dimensions of the LAA. The main techniques for guiding LAAC are transesophageal echocardiography (TEE), cardiac computed tomography (CTA), and ICE. Among these techniques, the advantages of ICE typically include (1) multiangle and real-time assessment of intracardiac structure, (2) a reduction in procedural fluoroscopy, (3) reduced operation time and improved workflow in the catheterization laboratory, and (4) the avoidance of general anesthesia and the early detection of complications. Conclusion ICE is a promising strategy for the guidance of LAAC. Among the most advanced and recent technological innovations in cardiovascular imaging in general and volume imaging in particular, ICE offers greater efficacy and safety.
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Affiliation(s)
- Xueyan Ding
- Department of CardiologySir Run Run Shaw Hospital Zhejiang University School of MedicineHangzhouZhejiangP.R. China
| | - Kefa Xiang
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Congli Qian
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Xu Hou
- Bengbu Medical CollegeBengbuAnhuiP.R. China
| | - Feng Wu
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
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10
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Al-Sabbagh MQ, Thirunavukkarasu S, Eswaradass P. Advances in Cardiac Workup for Transient Ischemic Attack: Improving Diagnostic Yield and Reducing Recurrent Stroke Risk. Cardiol Rev 2023:00045415-990000000-00155. [PMID: 37750739 DOI: 10.1097/crd.0000000000000607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2023]
Abstract
Transient ischemic attack (TIA) is a warning sign for an impending stroke, with a 10-20% chance of a stroke occurring within 90 days of the initial event. Current clinical practice for cardiac workup in TIA includes cardiac enzymes, with 12-lead electrocardiogram, transthoracic echocardiography, and 24-hour Holter monitoring. However, the diagnostic yield of these investigations is variable, and there is a need for better diagnostic approaches to increase the detection of cardiac abnormalities in a cost-effective way. This review article examines the latest research on emerging diagnostic tools and strategies and discusses the potential benefits and challenges of using these advanced diagnostic approaches in clinical practice. Novel biomarkers, imaging techniques, and prolonged rhythm monitoring devices have shown great promise in enhancing the diagnostic yield of cardiac workup in TIA patients. Echocardiography, Transcranial Doppler ultrasound, cardiac MRI, and cardiac CT are among the promising diagnostic tools being studied. We conclude the article with a suggested diagnostic algorithm for cardiac workup in TIA. Further research is necessary to enhance their usefulness and to outline future directions for research and clinical practice in this field.
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Affiliation(s)
- Mohammed Q Al-Sabbagh
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
| | | | - Prasanna Eswaradass
- From the Department of Neurology, University of Kansas Medical Center, Kansas City, KS
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11
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Agasthi P, Pujari SH. Peri- and Post-procedural Anticoagulation with Left Atrial Appendage Occlusion Devices. Heart Int 2023; 17:54-59. [PMID: 37456348 PMCID: PMC10339453 DOI: 10.17925/hi.2023.17.1.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
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12
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Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
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Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
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13
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Saraf K, Morris GM. Left Atrial Appendage Closure: What the Evidence Does and Does Not Reveal-A View from the Outside. Card Electrophysiol Clin 2023; 15:169-181. [PMID: 37076229 DOI: 10.1016/j.ccep.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
This review summarizes the evidence for left atrial appendage closure (LAAC) as an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation. LAAC reduces hemorrhagic stroke and mortality versus warfarin, but is inferior for ischemic stroke reduction based on randomized data. Whilst a feasible treatment in OAC-ineligible patients, questions remain over procedural safety, and the improvement in complications observed in nonrandomized registries is uncorroborated by contemporary randomized trials. Management of device-related thrombus and peridevice leak remain unclear, and robust randomized data versus direct OACs are required before recommendations can be made for widespread adoption in OAC-eligible populations.
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Affiliation(s)
- Karan Saraf
- Division of Cardiovascular Sciences, The University of Manchester, Oxford Road, Manchester M139PL, UK; Manchester Heart Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M139WL, UK
| | - Gwilym M Morris
- Division of Cardiovascular Sciences, The University of Manchester, Oxford Road, Manchester M139PL, UK; Manchester Heart Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M139WL, UK.
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14
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Ranasinghe T, Gurol ME. Are Ischemic Strokes the Same? The Special Case Argument of Atrial Fibrillation. Card Electrophysiol Clin 2023; 15:111-117. [PMID: 37076223 DOI: 10.1016/j.ccep.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
A comprehensive evaluation is necessary to identify the etiologic factors in order to select optimal stroke-prevention measures. Atrial fibrillation is one of the most important stroke causes. Although anticoagulant therapy is the treatment of choice for patients with nonvalvular atrial fibrillation, it should not be considered uniformly to treat all patients given the high mortality associated with anticoagulant-related hemorrhages. The authors propose a risk-stratified individualized approach for stroke prevention in patients with nonvalvular atrial fibrillation by considering nonpharmacologic approaches for patients at high hemorrhage risk or otherwise unsuitable for lifelong anticoagulation.
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Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA.
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15
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Adedara VO, Sharma V, Nawaz H, Reyes-Rivera J, Afzal-Tohid S, Pareshbhai PT, Boyapati SP, Sharafshah A. Transesophageal Echocardiogram Before Cardioversion in Atrial Fibrillation Patients. Cureus 2023; 15:e39702. [PMID: 37398783 PMCID: PMC10309076 DOI: 10.7759/cureus.39702] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/30/2023] [Indexed: 07/04/2023] Open
Abstract
Transesophageal echocardiography (TEE) offers an invaluable, non-invasive avenue for diagnosing and managing various cardiac conditions, including atrial fibrillation (AF). As the most common cardiac arrhythmia, AF affects millions and can lead to severe complications. Cardioversion, a procedure to restore the heart's normal rhythm, is frequently conducted on AF patients resistant to medication. Due to inconclusive data, TEE's utility prior to cardioversion in AF patients remains ambiguous. Understanding TEE's potential benefits and limitations in this population could significantly influence clinical practice. This review aims to scrutinize the current literature on the use of TEE before cardioversion in AF patients. The principal objective is to understand TEE's potential benefits and limitations comprehensively. The study seeks to offer a clear understanding and practical recommendations for clinical practice, thereby improving the management of AF patients before cardioversion using TEE. A literature search of databases was conducted using the keywords "Atrial Fibrillation," "Cardioversion" and "Transesophageal echocardiography," resulting in 640 articles. These were narrowed to 103 following title and abstract reviews. After applying exclusion and inclusion criteria with a quality assessment, 20 papers were included: seven retrospective studies, 12 prospective observational studies, and one randomized controlled trial (RCT). Stroke risk associated with direct-current cardioversion (DCC) potentially results from post-cardioversion atrial stunning. Thromboembolic events occur post cardioversion, with or without prior atrial thrombus or cardioversion complications. Generally, cardiac thrombus localizes in the left atrial appendage (LAA), a clear contraindication to cardioversion. Atrial sludge without LAA thrombus in TEE is a relative contraindication. TEE before electrical cardioversion (ECV) in anticoagulated AF individuals is uncommon. In AF patients planned for cardioversion, contrast enhancement facilitates thrombus exclusion in TEE images, reducing embolic events. Left atrial thrombus (LAT) frequently occurs in AF patients, necessitating TEE examination. Despite the increased use of pre-cardioversion TEE, thromboembolic events persist. Notably, patients with post-DCC thromboembolic events had no LA thrombus or LAA sludge. The use of TEE-guided DCC has grown due to its ability to detect atrial thrombi pre-cardioversion, aiding risk stratification. Thrombus in the left atrium also signals an elevated risk of future thromboembolic events in AF patients. While atrial stunning post cardioversion detected by TEE is a significant risk factor for future thromboembolic events, further evidence is required. Therapeutic anticoagulation is essential during and post cardioversion, even if no atrial thrombus is detected. Current data recommends cardioversion guided by TEE, particularly in outpatient settings.
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Affiliation(s)
- Victor O Adedara
- Medicine, St. George's University School of Medicine, St. George's, GRD
| | - Vagisha Sharma
- Medicine, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, IND
| | - Hassan Nawaz
- Medicine, Nishtar Medical University and Hospital, Multan, PAK
| | | | | | | | - Sri P Boyapati
- Medicine, Siddartha Medical College, Dr. YSR University of Health Sciences, Vijayawada, IND
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16
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Shabtaie SA, Tan NY, Ward RC, Lewis BR, Yang EH, Holmes DR, Herrmann J. Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Cancer. JACC CardioOncol 2023; 5:203-212. [PMID: 37144110 PMCID: PMC10152198 DOI: 10.1016/j.jaccao.2022.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 03/09/2023] Open
Abstract
Background The prevention of stroke in patients with atrial fibrillation (AF) and cancer is challenging because patients are at increased bleeding and thrombotic risk. Objectives The authors sought to assess left atrial appendage occlusion (LAAO) as a safe and effective strategy for reducing stroke at no increased bleeding risk in cancer patients with AF. Methods We reviewed patients with nonvalvular AF who underwent LAAO at Mayo Clinic sites from 2017 to 2020 and identified those who had undergone prior or current treatment for cancer. We compared the incidence of stroke, bleeding, device complications, and death with a control group who underwent LAAO without malignancy. Results Fifty-five patients were included; 44 (80.0%) were male, and the mean age was 79.0 ± 6.1 years. The median CHA2Ds2-VASc score was 5 (Q1-Q3: 4-6), with 47 (85.5%) having a prior bleeding event. Over the first year, ischemic stroke occurred in 1 (1.4%) patient, bleeding complications in 5 (10.7%) patients, and death in 3 (6.5%) patients. Compared with controls who underwent LAAO without cancer, there was no significant difference in ischemic stroke (HR: 0.44; 95% CI: 0.10-1.97; P = 0.28), bleeding complication (HR: 0.71; 95% CI: 0.28-1.86; P = 0.19), or death (HR: 1.39; 95% CI: 0.73-2.64; P = 0.32). Conclusions Within our cohort, LAAO in cancer patients was achieved with good procedural success and offered a reduction in stroke at no increased bleeding risk similar to noncancer patients.
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Affiliation(s)
- Samuel A. Shabtaie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Y. Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C. Ward
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R. Lewis
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric H. Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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17
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Mochen M, Branzoli S, D'Onghia G, Pertile R, Casagranda G, Spagnolli F, Rozzanigo U, Guarracini F, Marini M, Graffigna A, Bonmassari R, Menni K, Mansueto G, Cademartiri F, Centonze M. The role of cardiac imaging before and after left atrial appendage standalone thoracoscopic exclusion. J Cardiovasc Med (Hagerstown) 2023; 24:191-199. [PMID: 36753726 DOI: 10.2459/jcm.0000000000001446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
AIMS To assess the characteristics of left atrial appendage (LAA) stump and left atrial (LA) volume after standalone totally thoracoscopic LAA exclusion in 40 patients with nonvalvular atrial fibrillation (NVAF) and contraindications to oral anticoagulation (OAC), using cardiac computed tomography (CCT) and transoesophageal echocardiography (TOE). METHODS Using CCT and TOE, we evaluated correct AtriClip Pro II positioning, the presence and characteristics of the LAA stump and the postprocedural LA volume, at 3 months' follow-up. Stump depth was measured with both CCT and TOE using a new method, based on left circumflex artery (LCX) course. RESULTS After placement of AtriClip, all 40 patients discontinued OAC, and no stroke occurred. LAA exclusion was achieved in 40/40 patients at 3 months' follow-up. LAA stump (depth <10 mm in 12/18 stump, 67%) was observed in 18 patients. The overall (LA + LAA) volume and isolated LA volume were statistically different when comparing cases with and without LAA stump (P < 0.02). LAA ostium dimensions (perimeter and area) and LAA volume correlate with stump depth (P < 0.02). There was a high correlation between CCT and TOE in stump identification and depth measurement (P < 0.02). Compared with the baseline, CCT LA volume increased (P < 0.01) at 3 months' follow-up. CONCLUSION Preprocedural and postprocedural CCT and TOE are useful and comparable in patients undergoing standalone totally thoracoscopic exclusion of LAA, because these imaging methods can identify anatomical LAA and LA characteristics predisposing for a postprocedural residual stump.
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Affiliation(s)
| | | | | | - Riccardo Pertile
- Department of Clinical and Evaluative Epidemiology, APSS of Trento
| | | | | | | | | | | | | | | | - Katiuscia Menni
- Department of Radiology, San Pellegrino Hospital, Castiglione delle Stiviere
| | - Giancarlo Mansueto
- Department of Radiology, G.B. Rossi Hospital Borgo Roma-University of Verona, Verona
| | | | - Maurizio Centonze
- Department of Radiology, San Pellegrino Hospital, Castiglione delle Stiviere
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18
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Zhu X, Li W, Chu H, Zhong L, Wang C, Li J, Liang P, Wang L, Shi L. Catheter ablation in combined procedures is associated with residual leaks. Front Cardiovasc Med 2023; 9:1091049. [PMID: 36818912 PMCID: PMC9928718 DOI: 10.3389/fcvm.2022.1091049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/28/2022] [Indexed: 02/05/2023] Open
Abstract
Objectives To compare patients with atrial fibrillation (AF) undergoing left atrial appendage closure (LAAC) with catheter ablation (CA) and those without CA. Background The CA of AF may cause ridge edema, which may affect the safety of LAAC. Methods Patients with AF (N = 98) who underwent LAAC (combined CA + LAAC procedure group; N = 51) or alone (LAAC group; N = 47) received pre-procedural, intra-procedural, and 6 week post-procedural transesophageal echocardiography (TEE). The depth and ostial diameter of LAA, device compression, residual leak, and ridge thickness were evaluated in the patients who had undergone combined and alone procedures, as well as images of LAA and primary clinical characteristics. Results A residual leak was identified in 27 patients at 6 weeks after implantation by TEE (19 in the combined procedures group and eight in the alone group; p = 0.04). The combined procedure group had a significantly higher rate of a new residual leak than the alone group (25.5 vs. 8.5%; p = 0.03). Meanwhile, compared with at the time of implant, a smaller amount of device compression ratio was significant after 6 weeks (22.44 ± 3.90 vs. 19.59 ± 5.39; p = 0.03). There was no significant difference between both groups in all-cause mortality, cardiovascular mortality, and TIA/stroke/system embolism. Conclusion The combined procedures of CA and LAAC for AF are feasible and safe; however, during the follow-up period, we found that the resolution of ridge edema caused by CA might cause an increased residual leak and a smaller device compression ratio.
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Affiliation(s)
- Xuefeng Zhu
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Wenjing Li
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Hongxia Chu
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lin Zhong
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Chunxiao Wang
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Jianping Li
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Pingping Liang
- Department of Cardiology, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lihong Wang
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Lei Shi
- Doppler Ultrasonic Department, Yantai Yuhuangding Hospital, Yantai, Shandong, China
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19
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Chen C, Chen Y, Qu L, Su X, Chen Y. 3-Year outcomes after left atrial appendage closure in patients with nonvalvular atrial fibrillation: cardiomyopathy related with increased death and stroke rate. BMC Cardiovasc Disord 2023; 23:27. [PMID: 36650429 PMCID: PMC9844026 DOI: 10.1186/s12872-023-03054-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Left atrial appendage closure (LAAC) is a novel treatment for stroke prevention in high-risk patients with non-valvular atrial fibrillation (NVAF). However, the long-term outcomes after LAAC in Chinese NVAF patients are still lacking. METHODS This was a single-center, bidirectional, nonrandomized registered study. Patients who underwent LAAC implantation from May 2014 to April 2021 in a large Chinese center were enrolled. The primary endpoint was combined all-cause death and stroke. RESULTS From May 2014 to April 2021, a total of 673 NVAF patients were enrolled. The overall successful implantation rate was 97.62% (657 of 673). The rate of perioperative adverse events was 1.19% (8 of 673), including 3 cardiac tamponades, 2 ischemic strokes, one device-related thrombus (DRT) and 2 device dislocations. 604 (92.24%) patients completed the follow-up, the median follow-up period was 36.9 months (IQR 24.8-56.5 months). 16 stroke events occurred in 15 patients (one patient suffered from both hemorrhagic and ischemic strokes). 13 patients (2.15%) had ischemic stroke, and the fatal rate was 0.33% (2 of 604). 3 patients (0.15%) suffered from hemorrhagic stroke, and the fatal rate was 0.17% (1 of 604). The overall stroke rate was 0.74% per-year. The combined death and stroke rate was 1.93% per-year. In the multivariate Cox regression analysis, age ≥ 75 (hazard ratio 2.264, 95% CI 1.074-4.772, P = 0.032) and ventricular cardiomyopathy (hazard ratio 2.738, 95% CI 1.060-7.071, P = 0.037) were independent predictors of combined mortality and stroke. CONCLUSION The overall successful implantation rate of LAAC was 97.62% and the rate of perioperative adverse events was 1.19% in this study, and the stroke rate was 0.74% per year during the long-term follow-up. Age ≥ 75 years and ventricular cardiomyopathy were independent predictors of the primary endpoint. Trial registration This study was retrospectively registered.
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Affiliation(s)
- Chunyu Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China ,grid.413247.70000 0004 1808 0969Department of Cardiology, The Second Affiliated Hospital of Wuhan University, Zhongnan Hospital, Wuhan, 430060 China
| | - Yuyi Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Lulu Qu
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Xi Su
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Yanhong Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
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20
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Chung WH, Ajijola OA. Editorial commentary: Atrial fibrillation and stroke: The journey continues. Trends Cardiovasc Med 2023; 33:30-31. [PMID: 34979177 DOI: 10.1016/j.tcm.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 12/28/2021] [Indexed: 02/01/2023]
Affiliation(s)
- Wei-Hsin Chung
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United Stated
| | - Olujimi A Ajijola
- UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, CA, United Stated
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21
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Takaya Y, Nakayama R, Yokohama F, Toh N, Nakagawa K, Miyamoto M, Ito H. Left atrial appendage morphology with the progression of atrial fibrillation. PLoS One 2022; 17:e0278172. [PMID: 36449497 PMCID: PMC9710751 DOI: 10.1371/journal.pone.0278172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 11/10/2022] [Indexed: 12/02/2022] Open
Abstract
Left atrial appendage (LAA) size is crucial for determining the indication of transcatheter LAA closure. The aim of this study was to evaluate the differences in LAA morphology according to the types of atrial fibrillation (AF). A total of 299 patients (mean age: 67 ± 13 years) who underwent transesophageal echocardiography (TEE) were included. Patients were classified into non-AF (n = 64), paroxysmal AF (n = 86), persistent AF (n = 87), or long-standing persistent AF (n = 62). LAA morphology, including LAA ostial diameter and depth, was assessed using TEE. Patients with long-standing persistent AF had larger LAA ostial diameter and depth and lower LAA flow velocity. The maximum LAA ostial diameter was 19 ± 4 mm in patients with non-AF, 21 ± 4 mm in patients with paroxysmal AF, 23 ± 5 mm in patients with persistent AF, and 26 ± 5 mm in patients with long-standing persistent AF. LAA ostial diameter was increased by 2 or 3 mm with the progression of AF. LAA ostial diameter was correlated with LA volume index (R = 0.37, P < 0.01) and the duration of continuous AF (R = 0.30, P < 0.01), but not with age or the period from the onset of AF. In conclusion, LAA size was increased with the progression of AF.
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Affiliation(s)
- Yoichi Takaya
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
- * E-mail:
| | - Rie Nakayama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Fumi Yokohama
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Norihisa Toh
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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22
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Ueno H, Imamura T, Tanaka S, Fukuda N, Kinugawa K. Left atrial appendage closure for stroke prevention in nonvalvular atrial fibrillation: A current overview. J Cardiol 2022; 81:420-428. [PMID: 36400415 DOI: 10.1016/j.jjcc.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and its prevalence increases with age. AF causes palpitations, heart failure, and cardiogenic embolism. Of them, the most critical and fatal complication is a cardio-embolic event. Oral anticoagulation plays a central role in reducing stroke risk in AF patients. Recently, when oral anticoagulation is considered in patients with non-valvular AF who are eligible for direct oral coagulations, they are preferred to vitamin K antagonist based on accumulating evidence. Although many patients can tolerate oral anticoagulation, there is a subset of patients who cannot tolerate long-term oral anticoagulation. Such a subset has a higher bleeding risk as indicated by the HAS-BLED score under oral anticoagulation. This subset of patients requires effective and safe non-pharmacological alternative therapies for stroke prevention. One of the promising non-pharmacological therapies is left atrial appendage closure. Three randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using WATCHMAN family to oral anticoagulation (Boston Scientific, Marlborough, MA, USA). WATCHMAN FLX, which was innovated following WATCHMAN 2.5, was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved issues remain, including device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage. Left atrial appendage closure for patients with non-valvular AF may be an alternative therapy to avoid cardiac embolism for high bleeding risk patients with contraindications to long-term oral anticoagulation therapy.
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Affiliation(s)
- Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Shuhei Tanaka
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Nobuyuki Fukuda
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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23
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Ge J, Chen T, Ma C, Maduray K, Zhong J. Can intracardiac echocardiography completely replace transesophageal echocardiography to guide left atrial appendage closure?-The comparisons of intracardiac echocardiography with transesophageal echocardiography. J Card Surg 2022; 37:2766-2775. [PMID: 35726669 DOI: 10.1111/jocs.16695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/27/2022]
Abstract
Left atrial appendage closure (LAAC) is an effective means of preventing ischemic stroke in patients with nonvalvular atrial fibrillation. Transesophageal echocardiography (TEE) is the primary imaging technique to guide LAAC. Its shortcomings, namely the use of general anesthesia and tracheal intubation, inevitably increase procedural risks. Intracardiac echocardiography (ICE), a novel imaging modality for guiding LAAC, has proven more advantageous over TEE due to use of local anesthesia, shortened procedural time, and reduced radiation exposure. This review highlights the differences between ICE and TEE guided LAAC, aiming to provide a reference for clinical decision-making.
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Affiliation(s)
- Junye Ge
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tongshuai Chen
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhen Ma
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kellina Maduray
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jingquan Zhong
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
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Ding X, Li M, Chen H, Yang G, Zhang F, Ju W, Gu K, Li J, Chen M. Low-Voltage Area at the Anterior Wall of the Left Atrium Is Associated With Thromboembolism in Atrial Fibrillation Patients With a Low CHA2DS2-VA Score. Front Cardiovasc Med 2022; 9:869862. [PMID: 35770214 PMCID: PMC9234162 DOI: 10.3389/fcvm.2022.869862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/09/2022] [Indexed: 11/21/2022] Open
Abstract
Background Non-valvular atrial fibrillation (NVAF) in patients at low risk of thromboembolism (TE) does not mean “no risk.” We sought to assess the risk factors associated with TE in clinically low-risk AF patients with a non-gender CHA2DS2-VASc score (CHA2DS2-VA score) of 0 or 1. Methods In this single-center cross-sectional study, NVAF patients with a CHA2D-VA score of 0 or 1 who underwent index high-density bipolar voltage mapping of the left atrium (LA) and AF ablation were consecutively enrolled from 2017 to 2020. The population was divided into patients with and without TE history before voltage mapping. AF patients with CHA2DS2-VA score of 0 to 1 before TE (TE group) were analyzed and compared with clinically low-risk AF patients without TE history (non-TE group). The association among LA low voltage area (LVA), other clinical factors and TE history was analyzed with logistic regression. Results In the TE group, LVA was more prevalent [15/25 (60%) vs. 105/359 (29.2%), p = 0.003] and more preferentially located at the anterior wall [8/15 (53%) vs. 24/105 (23%), p = 0.025]. Among patients with LVA, the activation time from the sinus node to the left atrial appendage was significantly longer in the TE group (77.09 ± 21.09 vs. 57.59 ± 15.19 ms, p < 0.001). Multivariate analysis demonstrated that LVA at the anterior wall of the LA [OR: 4.17 (95% CI: 1.51 to 11.51); p = 0.006] and being female [OR: 3.40 (95% CI: 1.36 to 8.51); p = 0.009] were associated with TE history. Conclusions LVA at the anterior wall of the LA is associated with TE history in NVAF patients with a low CHA2DS2-VA score.
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Affiliation(s)
- Xiangwei Ding
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Cardiology, Taizhou People's Hospital, Taizhou, China
| | - Mingfang Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hongwu Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Gang Yang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Fengxiang Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weizhu Ju
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Kai Gu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jianqing Li
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
- Jianqing Li
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- *Correspondence: Minglong Chen
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Experience of Combined Procedure during Percutaneous LAA Closure. J Clin Med 2022; 11:jcm11123280. [PMID: 35743351 PMCID: PMC9224581 DOI: 10.3390/jcm11123280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 02/01/2023] Open
Abstract
Introduction: Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulants (OAC) in patients with non-valvular atrial fibrillation (AF) and contraindication to long-term OAC. Combined strategy with percutaneous LAAC at the same time of other cardiac structural or electrophysiological procedures has emerged as an alternative to a staged strategy. Aim: To describe our experience with combined LAAC procedures using Watchman™ devices. Methods: All patients with combined LAAC procedures using Watchman™ (WN) devices performed from 2016 to 2021 were included. The primary safety endpoint was a composite of periprocedural complications and adverse events during the follow-up. The primary efficacy endpoint included strokes, systemic embolisms, major bleeding and cardiovascular death. Results: From 2016, among 160 patients who underwent LAAC using WN devices, 19 underwent a combined strategy: 7 transcatheter edge-to-edge mitral valve repair (TEMVR) (37%), 6 typical atrial flutter ablation (31%), 2 leadless pacemaker (LP) implantation (10%) and 4 AF ablation (22%). The WN device was successfully implanted in 98% and 100% of cases for single and combined LAAC procedures, respectively (p = 0.63). Median follow-up was 13 months (IQR 25/75 3/24). Device-related complications occurred in 6 out of 141 patients (4%) who underwent single LAAC and in no (0/19) patient in the combined LAAC procedure (p = ns). The procedural-related complications did not differ significantly between groups (5% vs. 10%, respectively, in the single and combined group, p = 0.1). Conclusion: Combined procedure using the Watchman™ devices and one other structural or electrophysiological procedure appears safe and effective. Larger series are needed to confirm these results.
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Sebag FA, Garot P, Galea R, de Backer O, Lepillier A, De Meesteer A, Hildick-Smith D, Armero S, Moubarak G, Ducrocq G, Eschalier R, Aminian A, Sauguet A, Lellouche N, Mahmoudi K, Räber L, Amabile N. Left atrial appendage closure for thrombus trapping: the international, multicentre TRAPEUR registry. EUROINTERVENTION 2022; 18:50-57. [PMID: 34794937 PMCID: PMC9903160 DOI: 10.4244/eij-d-21-00713] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although the presence of a thrombus contraindicates left atrial appendage closure procedure (LAAC), a previous study reported the feasibility of the thrombus trapping procedure (TTP) technique to overcome this limitation. AIMS This study aimed to analyse the short-term outcomes in a series of patients who underwent LAAC using the TTP (TTP-LAAC). METHODS This retrospective series included patients who underwent TTP-LAAC between January 2018 and May 2020 in 13 European centres. Device choice, pre-interventional work-up and post-discharge antithrombotic therapy regimens were left to the discretion of the operators. The primary endpoint was the 30-day occurrence of stroke, systemic embolism or cardiovascular death. RESULTS During the study period, a total of 1,918 patients underwent LAAC. A thrombus was identified in 71 cases but completely disappeared in 24 patients before procedure. TTP-LAAC was finally performed in 53 cases (3%). Thrombi were identified ahead of the actual day of implantation in 47 patients (87%) and were mostly limited in size (50 cases with extension <50% of the LAA surface). The Amplatzer Amulet and WATCHMAN FLX occluders were implanted in 44 and 9 patients, respectively. A single deployment approach was applied in 70% and a cerebral embolic protection system was used in 9% of the patients. The overall success rate was 100%. Small pericardial effusion without tamponade was observed in 6% of the cases. Patients were discharged with 72% under antiplatelet therapy and 10% under short-term oral anticoagulation. The primary endpoint occurred in one patient. CONCLUSIONS TTP-LAAC might be used in a minority of LAAC procedures but appears to be feasible and safe in the short-term, in select cases.
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Affiliation(s)
- Frederic A. Sebag
- Service de Cardiologie, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014 Paris, France
| | - Philippe Garot
- Hôpital Privé Jacques Cartier, Institut Cardiovasculaire Paris Sud (ICPS), Ramsay Santé, Massy, France
| | - Roberto Galea
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Ole de Backer
- Department of Cardiology, Rigshospital, Copenhagen, Denmark
| | - Antoine Lepillier
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | | | - David Hildick-Smith
- Cardiology Department, Royal Sussex Cardiac Centre, Brighton, United Kingdom
| | | | | | - Gregory Ducrocq
- Department of Cardiology, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Romain Eschalier
- Department of Cardiology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Adel Aminian
- Department of Cardiology, C.H.U. de Charleroi, Charleroi, Belgium
| | | | | | - Khalil Mahmoudi
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
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Freeman JV, Higgins AY, Wang Y, Du C, Friedman DJ, Daimee UA, Minges KE, Pereira L, Goldsweig AM, Price MJ, Reddy VY, Gibson D, Doshi SK, Varosy PD, Masoudi FA, Curtis JP. Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation. J Am Coll Cardiol 2022; 79:1785-1798. [PMID: 35512858 PMCID: PMC9097170 DOI: 10.1016/j.jacc.2022.02.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pivotal trials of percutaneous left atrial appendage occlusion (LAAO) used specific postprocedure treatment protocols. OBJECTIVES This study sought to evaluate patterns of postprocedure care after LAAO with the Watchman device in clinical practice and compare the risk of adverse events for different discharge antithrombotic strategies. METHODS We evaluated patients in the LAAO Registry of the National Cardiovascular Data Registry who underwent LAAO with the Watchman device between 2016 and 2018. We assessed adherence to the full postprocedure trial protocol including standardized follow-up, imaging, and antithrombotic agents and then evaluated the most commonly used antithrombotic strategies and compared the rates and risk of adverse events at 45 days and 6 months by means of multivariable COX frailty regression. RESULTS Among 31,994 patients undergoing successful LAAO, only 12.2% received the full postprocedure treatment protocol studied in pivotal trials; the most common protocol deviations were with discharge antithrombotic medications. The most common discharge medication strategies were warfarin and aspirin (36.9%), direct oral anticoagulant (DOAC) and aspirin (20.8%), warfarin only (13.5%), DOAC only (12.3%), and dual antiplatelet therapy (5.0%). In multivariable Cox frailty regression, the adjusted risk of any adverse event through the 45-day follow-up visit were significantly lower for discharge on warfarin alone (HR: 0.692; 95% CI: 0.569-0.841) and DOAC alone (HR: 0.731; 95% CI: 0.574-0.930) compared with warfarin and aspirin. Warfarin alone retained lower risk at the 6-month follow-up. CONCLUSIONS In contemporary U.S. practice, practitioners rarely used the full U.S. Food and Drug Administration-approved postprocedure treatment protocols studied in pivotal trials of the Watchman device. Discharge after implantation on warfarin or DOAC without concomitant aspirin was associated with lower risk of adverse outcomes.
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Affiliation(s)
- James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA.
| | | | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Usama A Daimee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karl E Minges
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Lucy Pereira
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Shephal K Doshi
- Division of Cardiology, St John's Health Center, Pacific Heart Institute, Santa Monica, California, USA
| | - Paul D Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA; Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | | | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
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Saraf K, Morris GM. Left Atrial Appendage Closure: What the Evidence Does and Does Not Reveal-A View from the Outside. Interv Cardiol Clin 2022; 11:171-183. [PMID: 35361462 DOI: 10.1016/j.iccl.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
This review summarizes the evidence for left atrial appendage closure (LAAC) as an alternative to oral anticoagulation (OAC) for stroke prevention in atrial fibrillation. LAAC reduces hemorrhagic stroke and mortality versus warfarin, but is inferior for ischemic stroke reduction based on randomized data. Whilst a feasible treatment in OAC-ineligible patients, questions remain over procedural safety, and the improvement in complications observed in nonrandomized registries is uncorroborated by contemporary randomized trials. Management of device-related thrombus and peridevice leak remain unclear, and robust randomized data versus direct OACs are required before recommendations can be made for widespread adoption in OAC-eligible populations.
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Affiliation(s)
- Karan Saraf
- Division of Cardiovascular Sciences, The University of Manchester, Oxford Road, Manchester M139PL, UK; Manchester Heart Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M139WL, UK
| | - Gwilym M Morris
- Division of Cardiovascular Sciences, The University of Manchester, Oxford Road, Manchester M139PL, UK; Manchester Heart Centre, Manchester University NHS Foundation Trust, Oxford Road, Manchester M139WL, UK.
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Galloo X, Carmeliet T, Prihadi EA, Lochy S, Scott B, Verheye S, Schoors D, Vermeersch P. Left atrial appendage occlusion in recurrent ischaemic stroke, a multicentre experience. Acta Clin Belg 2022; 77:255-260. [PMID: 32951514 DOI: 10.1080/17843286.2020.1821494] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Oral anticoagulation therapy (OAC) remains the gold standard for ischaemic stroke prevention in patients with non-valvular atrial fibrillation (NVAF) and elevated stroke risk. Percutaneous left atrial appendage occlusion (LAAO) has emerged as a potential alternative for stroke prevention in patients who cannot tolerate OAC. Although no randomized data is available, recurrent stroke in NVAF-patients, while on adequate OAC, is regarded as a treatment failure and therefore is considered as a potential indication for LAAO, based upon expert opinion. METHODS/OBJECTIVES A multicentre retrospective cohort study evaluating efficacy, safety and mortality of LAAO in NVAF-patients presenting with recurrent ischaemic stroke, after excluding other plausible causes. RESULTS Fifteen LAAO have been performed in NVAF-patients with recurrent stroke despite ongoing OAC, after exclusion of other plausible causes. Mean age was 78.1 ± 5.8 years, mean CHA2DS2-VASc-score = 6 ± 1.2 and mean HAS-BLED-score = 5 ± 1.2. Successful implantation was achieved in all patients (73% Amplatzer device and 27% Watchman device), without any access-related complications and only one procedure/device-related complication (device embolization) was reported. In all but four patients, OAC was continued at long term after LAAO. No haemorrhagic strokes and only two ischaemic strokes were observed. During follow-up three patients died, all due to non-atrial fibrillation or non-device-related causes. CONCLUSIONS In NVAF-patients at high risk for stroke presenting with recurrent stroke despite adequate OAC, LAAO may be considered an adjunctive, but not alternative treatment to OAC with high feasibility and safety. Abbreviations: AF: atrial fibrillation; ESC: European Society of Cardiology; INR: international normalized ratio; LAA: left atrial appendage; LAAO: left atrial appendage occlusion; NOAC: non-vitamin K oral anticoagulants; NVAF: non-valvular atrial fibrillation; OAC: oral anticoagulation; RS: recurrent (ischaemic) stroke; SD: standard deviation; TIA: transient ischaemic attack; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography; VKA: vitamin K antagonists.
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Affiliation(s)
- X. Galloo
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - T. Carmeliet
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - EA. Prihadi
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
| | - S. Lochy
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - B. Scott
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
| | - S. Verheye
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - D. Schoors
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - P. Vermeersch
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
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Ranasinghe T, Gurol ME. Are Ischemic Strokes the Same? The Special Case Argument of Atrial Fibrillation. Interv Cardiol Clin 2022; 11:113-119. [PMID: 35361456 DOI: 10.1016/j.iccl.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
A comprehensive evaluation is necessary to identify the etiologic factors in order to select optimal stroke-prevention measures. Atrial fibrillation is one of the most important stroke causes. Although anticoagulant therapy is the treatment of choice for patients with nonvalvular atrial fibrillation, it should not be considered uniformly to treat all patients given the high mortality associated with anticoagulant-related hemorrhages. The authors propose a risk-stratified individualized approach for stroke prevention in patients with nonvalvular atrial fibrillation by considering nonpharmacologic approaches for patients at high hemorrhage risk or otherwise unsuitable for lifelong anticoagulation.
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Affiliation(s)
- Tamra Ranasinghe
- Department of Neurology, Wake Forest School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157, USA
| | - Mahmut Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 300, Boston, MA 02114, USA.
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31
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Kreimer F, Mügge A, Gotzmann M. How should I treat patients with subclinical atrial fibrillation and atrial high-rate episodes? Current evidence and clinical importance. Clin Res Cardiol 2022; 111:994-1009. [PMID: 35292844 PMCID: PMC9424173 DOI: 10.1007/s00392-022-02000-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/01/2022] [Indexed: 11/28/2022]
Abstract
Long-term and continuous ECG monitoring using cardiac implantable electronic devices and insertable cardiac monitors has improved the capability of detecting subclinical atrial fibrillation (AF) and atrial high-rate episodes. Previous studies demonstrated a high prevalence (more than 20%) in patients with cardiac implantable electronic devices or insertable cardiac monitors. Subclinical AF and atrial high-rate episodes are often suspected as the cause of prior or potential future ischemic stroke. However, the clinical significance is still uncertain, and the evidence is limited. This review aims to present and discuss the current evidence on the clinical impact of subclinical AF and atrial high-rate episodes. It focuses particularly on the association between the duration of the episodes and major clinical outcomes like thromboembolic events. As subclinical AF and atrial high-rate episodes are presumed to be associated with ischemic strokes, detection will be particularly important in patients with cryptogenic stroke and in high-risk patients for thromboembolism. In this context, it is also interesting whether there is a temporal relationship between the detection of subclinical AF and atrial high-rate episodes and the occurrence of thromboembolic events. In addition, the review will examine the question whether there is a need for a therapy with oral anticoagulation.
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Affiliation(s)
- Fabienne Kreimer
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Mügge
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Michael Gotzmann
- University Hospital St Josef-Hospital Bochum, Cardiology and Rhythmology, Ruhr University Bochum, Gudrunstraße 56, 44791, Bochum, Germany.
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Pour-Ghaz I, Heckle MR, Maturana M, Seitz MP, Zare P, Khouzam RN, Kabra R. Percutaneous Left Atrial Appendage Closure: Review of Anatomy, Imaging, and Outcomes. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2022. [DOI: 10.1007/s11936-022-00958-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Slostad B, Lee K, Trybula M, Konda S, Macrinici V, Frazin L, Kansal M. A quantitative gain-independent assessment of the left atrial appendage as a method of thromboembolic risk stratification. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:153-158. [PMID: 34967953 DOI: 10.1002/jcu.23123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Visual assessment of the left atrial appendage (LAA) by echocardiography for the presence of thrombus is inherently qualitative. However, whether quantitative assessments can provide increased value over qualitative assessment has not been thoroughly examined. METHODS One hundred and thirty-eight patients (mean age 59 ± 13 years, 70% male) undergoing transesophageal echocardiography prior to pulmonary vein isolation or electrical cardioversion were retrospectively studied. LAA were examined by two expert readers and identified as thrombus, sludge, spontaneous echocardiograph contrast, or normal. LAA were then separately examined to calculate a gain-independent ratio between the average pixel density of the LAA cavity and that of the LAA wall (C/W ratio). RESULTS C/W ratio was significantly related with qualitative LAA analysis (p < 0.0001) and with thromboembolic events (OR 1.60, 95% CI 1.095-2.347, p = 0.02). The C/W ratio (AUC 0.73, 95% CI 0.60-0.86) was a reliable predictor for future thromboembolic events when compared to expert reader LAA assessment (Expert Reader 1 AUC = 0.72, 95% CI 0.53-0.90; Expert Reader 2 AUC = 0.69). CONCLUSIONS The C/W ratio may be a complementary method to adjudicate thromboembolic risk in patients with AF that is readily quantifiable at time of TEE.
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Affiliation(s)
- Brody Slostad
- Department of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Kevin Lee
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Michael Trybula
- Department of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Sreenivas Konda
- Department of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Victor Macrinici
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Leon Frazin
- Department of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Cardiology, Jesse Brown VA Medical Center, Chicago, Illinois, USA
| | - Mayank Kansal
- Department of Cardiology, University of Illinois at Chicago, Chicago, Illinois, USA
- Department of Cardiology, Jesse Brown VA Medical Center, Chicago, Illinois, USA
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Suwa Y, Miyasaka Y, Taniguchi N, Harada S, Nakai E, Shiojima I. Atrial fibrillation and stroke: importance of left atrium as assessed by echocardiography. J Echocardiogr 2022; 20:69-76. [DOI: 10.1007/s12574-021-00561-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/04/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
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Ben H, Changsheng M, Shulin W. 2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:535-555. [PMID: 35032332 PMCID: PMC9314806 DOI: 10.1111/pace.14448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).
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Affiliation(s)
- He Ben
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ma Changsheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wu Shulin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Sakhnini A, Carasso S, Znait ZA, Amjad S, Grossman L, Marai I. Does Duration of Symptoms Reliably Predict Detection of Left Atrial Thrombus in Newly Diagnosed Atrial Fibrillation. J Atr Fibrillation 2021; 14:20200481. [PMID: 34950371 DOI: 10.4022/jafib.20200481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 03/19/2021] [Accepted: 05/20/2021] [Indexed: 11/10/2022]
Abstract
Background Large prospective trials attribute minimal thromboembolic risk for cardioversion of atrial fibrillation (AF) when duration of symptoms is shorter than 48 hours. Our goal is to compare the prevalence of left atrial appendage (LAA) thrombus as demonstrated by a Trans esophageal echocardiography (TEE) exam between patients presenting with less or more than 48 hours of AF symptoms. Methods Observational cohort study including consecutive patients hospitalized with primary diagnosis of new onset AF, not previously treated with oral anticoagulation. All patients underwent TEE to exclude LAA thrombus, regardless of symptoms duration. Patients were divided into two groups based on AF duration: 1) early presenters: up to 48 hours, 2) later presenters: longer than 48 hours. Results The study included 122 patients mean age 65.8 years). The "early presenters" were younger, with less co-morbidities. LAA thrombus was detected in 13(21%) of 62 early presenters, compared to 20 (33%) of 60 patients of the second group (P=0.12). Significant predictors of LAA thrombus in the whole cohort by univariate analysis were ≥65 years of age (1.051, P=0.017), acute heart failure (2.394, P=0.038), and history of coronary artery/ peripheral vascular disease (2.7, P= 0.019). Notably neither duration of symptoms nor CHA2DS2-VASc score significantly predicted LAA thrombus. Inmultivariate analysis, only age ≥65 was found to be a significant predictor of LAA thrombus. Conclusions LAA thrombus in patients presenting within 48 hours of AF symptoms onset is not uncommon. Duration of symptoms is not reliable for excluding LAA thrombus.
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Affiliation(s)
- Ali Sakhnini
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shemy Carasso
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Zyad Abu Znait
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Shalabi Amjad
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Lisa Grossman
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
| | - Ibrahim Marai
- Cardiovascular Department, Baruch Padeh Medical Center, Poriya, Lower Galilee, Israel.,The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Zefat, Israel
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Abusnina W, Latif A, Al-Abdouh A, Mostafa MR, Radaideh Q, Alshebani Y, Aboeata A, Ben-Dor I, Michos ED, Dahal K. Sex differences in the clinical outcomes after left atrial appendage closure: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 41:29-34. [PMID: 34952822 DOI: 10.1016/j.carrev.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/12/2021] [Accepted: 12/13/2021] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Left atrial appendage occlusion (LAAO) has emerged as a reasonable alternative to oral anticoagulation in a selective group of patients with atrial fibrillation (AF). While women are known have higher risk of AF-related stroke, the impact of sex differences on the clinical outcomes of LAAO has not been well studied. OBJECTIVE We sought to perform a meta-analysis evaluating sex differences on the outcomes of patients undergoing LAAO. METHODS We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov databases (from inception to October 2021) for studies evaluating the impact of sex difference on LAAO procedural outcomes. We used a random-effect model to calculate risk ratio (RR) with 95% confidence intervals (CI). In-hospital all-cause mortality and ischemic stroke were the primary endpoints. In-hospital pericardial effusion/cardiac tamponade, major bleeding, technical success, device related thrombus and hospital length of stay were secondary outcomes. RESULTS A total of 5 studies with 54,754 patients were included, of which 22,461 (41%) were females. Female sex was associated with higher rates of in-hospital all-cause mortality (RR 2.18; 95% CI 1.46-3.26; P = 0.0001) and in-hospital ischemic stroke (RR 1.67; 95% CI 1.06-2.61; P = 0.03) when compared with males. Females had higher rates of in-hospital major bleeding (RR 1.93; 95% CI 1.40-2.67; P < 0.0001) and hospital length of stay >1 day (RR 1.38; 95% CI 1.33-1.45; P < 0.00001). There was no differences between females and males in terms of technical success and device related thrombus (RR 1.00; 95% CI 1.00-1.00; P = 1.00) and (RR 0.94, 95% CI 0.31-2.82; P = 0.91), respectively. CONCLUSION In conclusion, women are more likely to experience worse periprocedural outcomes with longer hospital stay after LAA closure. Further efforts are needed to increase the participation of women in clinical studies and to assess these differences to properly address the discrepancy in outcomes between men and women.
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Affiliation(s)
- Waiel Abusnina
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Azka Latif
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | | | | | - Qais Radaideh
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Yazeid Alshebani
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Ahmad Aboeata
- Department of Cardiology, Creighton University School of Medicine, NE, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Khagendra Dahal
- Department of Cardiology, Creighton University School of Medicine, NE, USA.
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Minimally invasive thoracoscopic left atrial appendage occlusion compared with transcatheter left atrial appendage closure for stroke prevention in recurrent nonvalvular atrial fibrillation patients after radiofrequency ablation: a prospective cohort study. J Geriatr Cardiol 2021; 18:877-885. [PMID: 34908925 PMCID: PMC8648546 DOI: 10.11909/j.issn.1671-5411.2021.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Tanscatheter left atrial appendage (LAA) closure and minimally invasive thoracoscopic LAA occlusion are local interventions of LAA for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). However, the safety and efficacy of these methods have not been compared. This prospective cohort study aimed to assess the safety and efficacy of those two treatment approaches for stroke prevention in NVAF patients. METHODS Two hundred and nine recurrent NVAF patients who received radiofrequency ablation were enrolled. These patients were treated with transcatheter LAA closure or thoracoscopic LAA occlusion. The patients were followed up from the first postoperative day and evaluated for efficacy endpoints (stroke/transient ischemic attack (TIA), systemic embolism (SE), and death) and a safety endpoint (bleeding events). Perioperative complications were recorded. RESULTS After a median follow-up of 1.8 years (383 patient-years), the overall rate of the composite efficacy endpoints was similar between the two groups (3.8 vs. 2.7 events per 100 patient-years; HR = 0.71; 95% CI: 0.225-2.237; P = 0.559). However, regarding primary safety endpoint, there were 1.5 bleeding events per 100 patient-years in the thoracoscopic LAA occlusion group, compared with 6.4 in transcatheter LAA closure group (HR = 0.246; 95% CI: 0.074-0.819; P = 0.022). The incidence of operative complications was 3/138 (2.17%) in thoracoscopic LAA occlusion group and 1/71 (1.41%) in transcatheter LAA closure group. CONCLUSIONS Thoracoscopic LAA occlusion and transcatheter LAA closure have similar efficacy in preventing stroke in NVAF patients. However, the thoracoscopic group had fewer bleeding events than the transcatheter group, but the former group required a longer hospital stay.
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Gilhofer TS, Abdellatif W, Nicolaou S, Jalal S, Powell J, Inohara T, Starovoytov A, Saw J. Cardiac CT angiography after percutaneous left atrial appendage closure: early versus delayed scanning after contrast administration. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:703-709. [PMID: 34792023 DOI: 10.5152/dir.2021.20349] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
PURPOSE Cardiac computed tomography angiography (CCTA) is increasingly used for device surveillance after left atrial appendage closure (LAAC). While CT protocols with delayed scans are useful to diagnose thrombus in the LAA, an optimal protocol for post-procedural CCTA has not been established. Therefore, we assessed the role of delayed versus early scans for device surveillance. METHODS We retrospectively reviewed patients who underwent LAAC at Vancouver General Hospital who had follow-up CCTAs using standard (early) and delayed scans. Scans were performed on Toshiba 320-detector (Aquilion ONE). Image quality was interpreted by 2 independent observers for anatomy, LAA contrast patency, and device-related thrombus (DRT) using VitreaWorkstationTM. A Likert scale of 1-5 was used (1= poor quality, 5= excellent) for assessment. RESULTS We included 27 consecutive LAAC patients (9 Amplatzer, 18 WATCHMAN) with mean age 76.0±7.7 years, mean CHADS2 score 2.8±1.3, CHA2DS2-VASc score 4.4±1.6 and HAS-BLED score 3.4±1.0. Subjective quality assessments by both reviewers favored early scans for assessment of anatomy (reviewer 1: 4.63±0.63 [early] vs. 1.74±0.71 [delayed]; reviewer 2: 4.63±0.63 [early] vs. 1.89±0.64 [delayed]) and DRT (reviewer 1: 4.78±0.42 [early] vs. 3.11±1.16 [delayed]; reviewer 2: 4.70±0.47 [early] vs. 3.04±1.29 [delayed]). Inter-rater variability showed good correlation between reviewers (intraclass correlation 0.61-0.95). Mean LAA/LA attenuation ratios were significantly different between scans, with larger mean percent reduction of contrast opacification from LA to LAA in the early scans (57.0±36.6% reduction for early vs. 29.1±30.8% for delayed; p < 0.001) CONCLUSION: For CT device surveillance post-LAAC early phase imaging provides superior image quality objectively and subjectively compared with delayed scanning.
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Affiliation(s)
- Thomas S Gilhofer
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Waleed Abdellatif
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Savvas Nicolaou
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Sabeena Jalal
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jennifer Powell
- Deparment of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Taku Inohara
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Andrew Starovoytov
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Jacqueline Saw
- Department of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
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Tanaka K, Koga M, Lee KJ, Kim BJ, Mizoguchi T, Park EL, Lee J, Yoshimura S, Cha JK, Lee BC, Koge J, Bae HJ, Toyoda K. Transesophageal Echocardiography in Ischemic Stroke With Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022242. [PMID: 34743551 PMCID: PMC8751927 DOI: 10.1161/jaha.121.022242] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background To clarify differences in clinical significance of intracardiac thrombi in nonvalvular atrial fibrillation‐associated stroke as identified by transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE). Methods and Results Using patient data on nonvalvular atrial fibrillation‐associated ischemic stroke between 2011 and 2014 from 15 South Korean stroke centers (n=4841) and 18 Japanese centers (n=1192), implementation rates of TEE/TTE, and detection rates of intracardiac thrombi at each center were correlated. The primary outcome was recurrent ischemic stroke at 1 year after the onset. A total of 5648 patients (median age, 75 years; 2650 women) were analyzed. Intracardiac thrombi were detected in 75 patients (1.3%) overall. Thrombi were detected in 7.8% of patients with TEE (either TEE alone or TEE+TTE: n=679) and in 0.6% of those with TTE alone (n=3572). Thrombus detection rates varied between 0% and 14.3% among centers. As TEE implementation rates at each center increased from 0% to 56.7%, thrombus detection rates increased linearly (detection rate [%]=0.11×TEE rate [%]+1.09 [linear regression], P<0.01). TTE implementation rates (32.3%–100%) were not associated with thrombus detection rates (P=0.53). Intracardiac thrombi were associated with risk of recurrent ischemic stroke overall (adjusted hazard ratio [aHR] 2.35, 95% CI, 1.07–5.16). Thrombus‐associated ischemic stroke risk was high in patients with TEE (aHR, 3.13; 95% CI, 1.17–8.35), but not in those with TTE alone (aHR, 0.89; 95% CI, 0.12–6.51). Conclusions Our data suggest clinical relevance of TEE for accurate detection and risk stratification of intracardiac thrombi in nonvalvular atrial fibrillation‐associated stroke. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01581502.
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Affiliation(s)
- Kanta Tanaka
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Keon-Joo Lee
- Department of Neurology Cerebrovascular Center Seoul National University Bundang Hospital Seongnam-si South Korea
| | - Beom Joon Kim
- Department of Neurology Cerebrovascular Center Seoul National University Bundang Hospital Seongnam-si South Korea
| | - Tadataka Mizoguchi
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Eun Lyeong Park
- Department of Biostatistics College of Medicine Korea University Seoul South Korea
| | - Juneyoung Lee
- Department of Biostatistics College of Medicine Korea University Seoul South Korea
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Jae-Kwan Cha
- Department of Neurology Dong-A University Hospital Busan Korea
| | - Byung-Chul Lee
- Department of Neurology Hallym University Sacred Heart Hospital Anyang Korea
| | - Junpei Koge
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hee-Joon Bae
- Department of Neurology Cerebrovascular Center Seoul National University Bundang Hospital Seongnam-si South Korea
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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Fang P, Wei Y, Wang J, Wang X, Yang H. Post-angiography Retention of the Contrast Agent in the Left Atrial Appendage Is Associated With Risk of Cardioembolic Stroke in Patients With Atrial Fibrillation: A Retrospective Study. Front Cardiovasc Med 2021; 8:753949. [PMID: 34778408 PMCID: PMC8581209 DOI: 10.3389/fcvm.2021.753949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Atrial fibrillation (AF) represents an important risk factor for cardioembolic stroke, and most atrial thrombi originate from the left atrial appendage (LAA). Although the CHA2DS2-VASc score is widely used to estimate the risk of cardioembolic stroke in AF patients, yet greatly affected by many factors. This study was undertaken to determine the association between contrast agent retention in LAA after LAA angiography and risks of cardioembolic stroke in patients with AF. Methods: This is a retrospective study. The demographic and clinical data of AF patients undergone left atrial appendage occlusion (LAAO) with or without catheter radiofrequency ablation were retrospectively analyzed. The patients were classified into either stroke or non-stroke group by the history with cardioembolic stroke or transient ischemic attack (TIA). Results: Sixty-two consecutive patients undergone LAAO were finally included, in whom 31 AF patients had a history of cardioembolic stroke or TIA (one TIA), and significantly higher CHA2DS2-VASc score (4.2 ± 1.4 vs. 3.3 ± 1.3; P = 0.006) as well as incidence of contrast agent retention in LAA (n = 20 vs. n = 7; P = 0.001) compared to the patients in non-stroke group. In addition, the relative proportion of distinctive morphological types of LAA was significantly different between groups (P < 0.001). Multivariate logistic regression analysis showed that higher CHA2DS2-VASc scores (OR = 1.7, 95% CI: 1.0-3.0, P = 0.046) and LAA contrast agent retention (OR = 5.1, 95% CI: 1.1-23.9, P = 0.002) were associated with increased risks of cardioembolic stroke. The patients with Windsock type LAA (OR = 7.8, 95% CI: 1.1-57.2, P = 0.044) and Cauliflower LAA (OR = 20.2, 95% CI: 3.2-125.5, P = 0.001) were more prone to cardioembolic stroke compared to those with Chicken Wing type LAA. Conclusion: Left atrial appendage contrast agent retention after LAA angiography is associated with the risks of cardioembolic stroke in patients with AF, and cardioembolic stroke is more seen in AF patients with Windsock or Cauliflower type LAA.
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Affiliation(s)
- Ping Fang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Youquan Wei
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Jinfeng Wang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Xianghai Wang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
| | - Hao Yang
- Department of Cardiology, The First Affiliated Hospital (Yijishan Hospital) of Wannan Medical College, Wuhu, China
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Labbé V, Ederhy S, Lapidus N, Joffre J, Razazi K, Laine L, Sy O, Voicu S, Chemouni F, Aissaoui N, Smonig R, Doyen D, Carrat F, Voiriot G, Mekontso-Dessap A, Cohen A, Fartoukh M. Transesophageal echocardiography for cardiovascular risk estimation in patients with sepsis and new-onset atrial fibrillation: a multicenter prospective pilot study. Ann Intensive Care 2021; 11:146. [PMID: 34661761 PMCID: PMC8523595 DOI: 10.1186/s13613-021-00934-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/02/2021] [Indexed: 12/25/2022] Open
Abstract
Background Echocardiographic parameters have been poorly investigated for estimating cardiovascular risk in patients with sepsis and new-onset atrial fibrillation. We aim to assess the prevalence of transesophageal echocardiographic abnormalities and their relationship with cardiovascular events in mechanically ventilated patients with sepsis and new-onset atrial fibrillation. Methods In this prospective multicenter pilot study, left atrial/left atrial appendage (LA/LAA) dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were assessed using an initial transesophageal echocardiographic study, which was repeated after 48–72 h to detect LA/LAA thrombus formation. The study outcome was a composite of cardiovascular events at day 28, including arterial thromboembolic events (ischemic stroke, non-cerebrovascular arterial thromboembolism, LA/LAA thrombus), major bleeding, and all-cause death. Results The study population comprised 94 patients (septic shock 63%; 35% women; median age 69 years). LA/LAA dysfunction, severe aortic atheroma, and left ventricular systolic dysfunction were detected in 17 (19%), 22 (24%), and 27 (29%) patients, respectively. At day 28, the incidence of cardiovascular events was 46% (95% confidence interval [CI]: 35 to 56). Arterial thromboembolic events and major bleeding occurred in 7 (7%) patients (5 ischemic strokes, 1 non-cerebrovascular arterial thromboembolism, 2 left atrial appendage thrombi) and 18 (19%) patients, respectively. At day 28, 27 patients (29%) died. Septic shock (hazard ratio [HR]: 2.36; 95% CI 1.06 to 5.29) and left ventricular systolic dysfunction (HR: 2.06; 95% CI 1.05 to 4.05) were independently associated with cardiovascular events. Conclusions Transesophageal echocardiographic abnormalities are common in mechanically ventilated patients with sepsis and new-onset atrial fibrillation, but only left ventricular systolic dysfunction was associated with cardiovascular events at day 28. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00934-1.
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Affiliation(s)
- Vincent Labbé
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France. .,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.
| | - Stephane Ederhy
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM U 856, Paris, France
| | - Nathanael Lapidus
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France.,Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
| | - Jérémie Joffre
- Service de Médecine Intensive Réanimation, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, Paris, France
| | - Keyvan Razazi
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.,Service de Médecine Intensive Réanimation, Département Médico-Universitaire Médecine, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, AP-HP, Créteil, France
| | - Laurent Laine
- Service de Médecine Intensive Réanimation, Centre Hospitalier de Saint-Denis, Saint Denis, France
| | - Oumar Sy
- Service de Médecine Intensive Réanimation, Groupe Hospitalier Sud Ile-de-France, Centre Hospitalier Melun, Melun, France
| | - Sebastian Voicu
- Service de Réanimation Médicale et Toxicologique, Hôpital Lariboisière, AP-HP, INSERM UMRS-1144, Université de Paris, Paris, France
| | - Frank Chemouni
- Service de Médecine Intensive Réanimation, Gustave Roussy, Villejuif, France
| | - Nadia Aissaoui
- Service de Médecine Intensive Réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Université Paris-Descartes, Paris, France
| | - Roland Smonig
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France
| | - Denis Doyen
- Service de Médecine Intensive Réanimation, Hôpital l'Archet 1, Centre Hospitalier Universitaire de Nice, and UR2CA Unité de Recherche Clinique Côte d'Azur, Université Côte d'Azur, Nice, France
| | - Fabrice Carrat
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique IPLESP, AP-HP, Paris, France.,Sorbonne Université, Public Health Department, Saint Antoine Hospital, AP-HP, Paris, France
| | - Guillaume Voiriot
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
| | - Armand Mekontso-Dessap
- Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France.,Service de Médecine Intensive Réanimation, Département Médico-Universitaire Médecine, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, AP-HP, Créteil, France
| | - Ariel Cohen
- Department of Cardiology, UNICO Cardio-Oncology Program, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM U 856, Paris, France.,UMR-S ICAN 1166, Sorbonne Université, Paris, France
| | - Muriel Fartoukh
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Médecine Intensive Réanimation, Département Médico-Universitaire APPROCHES, Hôpital Tenon, 4 rue de la Chine, 75020, Paris, France.,Université Paris Est, Groupe de Recherche Clinique GR05 CARMAS, Institut Mondor de recherche biomédicale, INSERM, Créteil, France
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Tanaka M, Yasuoka R, Nagano T, Kotake Y, Maruyama M, Yamamoto H, Iwanaga Y, Hirano Y, Nakazawa G, Kurita T. A novel method to demonstrate thrombus formation of the left atrial appendage in patients with persistent atrial fibrillation by cardiac computed tomography. IJC HEART & VASCULATURE 2021; 36:100866. [PMID: 34527805 PMCID: PMC8433278 DOI: 10.1016/j.ijcha.2021.100866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 08/24/2021] [Indexed: 11/28/2022]
Abstract
We created a new algorism to detect a left atrial appendage (LAA) thrombus on CT. We measured HU density at one proximal (ostium) and seven distal sites of LAA. A distal/proximal ratio and a standard deviation of HU density were analyzed by ROC. Combination of the two parameters demonstrated a high accuracy for LAA thrombus.
Background Transesophageal echocardiography (TEE) is currently the gold standard technique for diagnosing left atrial appendage (LAA) thrombi. Cardiac computed tomography (CT) has been expected to become an alternative method to TEE; however, a reliable quantitative evaluation method has not been established. Methods and results We enrolled 177 patients with persistent atrial fibrillation who underwent both cardiac CT and TEE before catheter ablation. The patients were classified into two groups according to the TEE results: the thrombus group (13 patients) and non-thrombus group (164 patients). The Hounsfield unit (HU) density at the proximal LAA (LAAp) and distal LAA (LAAd) was measured on cardiac CT images. The LAAd/LAAp HU ratio and standard deviation of HU density (HU-SD) at the LAAd were evaluated. We created an algorithm by decision tree analysis to predict LAA thrombus formation using the HU ratio and HU-SD. Definite absence of LAA thrombus (Category-I) was diagnosed for 139 patients by combining the first and second branching of the decision tree (Category-Ia: HU ratio of ≥0.26, Category-Ib: HU ratio of <0.26, HD-SD of ≥26.94). Definite presence of LAA thrombus (Category-Ⅱ) was diagnosed for 3 patients using the third branching of the decision tree (Category-Ⅱ: HU ratio of <0.26 and HU-SD of <13.85). Highly possibility of LAA thrombus (Category-III), but not definite, was diagnosed for the remaining 35 patients; therefore, these patients required diagnostic TEE. The diagnostic accuracy of this algorithm was 0.95. Conclusion We have proposed a reliable algorithm to diagnose LAA thrombus formation using the HU ratio and HU-SD.
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Affiliation(s)
- Motohide Tanaka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Ryobun Yasuoka
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Tomoya Nagano
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yasuhito Kotake
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Masahiro Maruyama
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Hiromi Yamamoto
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yoshitaka Iwanaga
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Yutaka Hirano
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Gaku Nakazawa
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
| | - Takashi Kurita
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Kindai University, 377-2 Onohigashi, Osaka-Sayama, Osaka 589-8511, Japan
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Herman D, Osmancik P, Neuzil P, Hala P, Lekesova V, Benesova K, Hozman M, Jarkovsky J, Novackova M, Widimsky P, Reddy VY. The effect of left atrial appendage closure on heart failure biomarkers: A PRAGUE-17 trial subanalysis. J Cardiovasc Electrophysiol 2021; 32:2645-2654. [PMID: 34402135 DOI: 10.1111/jce.15206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/27/2021] [Accepted: 07/30/2021] [Indexed: 12/19/2022]
Abstract
INTRODUCTION The randomized PRAGUE-17 trial demonstrated noninferiority of left atrial appendage closure (LAAC) to non-vitamin K anticoagulants (NOACs) for the prevention of major cardiovascular or cerebrovascular events. However, the left atrial appendage is an important source of natriuretic peptides and plays a role in left atrial reservoir function. Changes of heart failure (HF) biomarkers after LAAC compared to NOAC has not been studied. The aim of the study was to compare the changes in concentrations of HF biomarkers between LAAC and NOAC patients. METHODS Of 402 patients randomized in the PRAGUE-17 trial, biomarkers were analyzed in 144 patients (73 in the NOAC and 71 in the LAAC group). Both groups had similar baseline characteristics. Serum concentration of NT-proBNP, NT-proANP, Galectin-3, and GDF-15 were measured at baseline (before the procedure in the LAAC group), at the 6-month (and at 24-month for NT-proBNP) follow-up timepoint. RESULTS There were no significant differences in baseline, 6 month, and delta (δ = baseline - 6 month) concentrations of NT-proANP between the groups (NOAC: baseline 2.6 [0.5; 4.9], 6-month 3.1 [1.8; 4.8], p = .068; LAAC: baseline 3.3 [1.1; 4.6], 6-month 2.6 [0.9; 5.3], p = .51; p value for δ in concentrations between groups = 0.42). Similarly, there were no significant differences in baseline, 6, 24 months, and delta concentrations of NT-proBNP between the groups (NOAC: baseline 461.0 [113.5; 1342.0], 6 month 440.0 [120.5; 1291.5], 24 month 798 [274; 2236], p = .39; LAAC: baseline 421.0 [100.0; 1320.0], 6 month 601.0 [145.0; 1230.0], 24 month 855 [410; 1367], p = .28; p value for δ in concentrations between groups = 0.73 at 6 months, and 0.58 at 24 months). Finally, no significant differences were present in baseline, 6 month, and δ concentrations of Galectin-3 and GDF-15 between the two groups. CONCLUSION LAAC did not significantly influence the levels of HF biomarkers 6 months after the procedure.
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Affiliation(s)
- Dalibor Herman
- Department of Cardiology, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University Prague, Prague, Czech Republic
| | - Pavel Osmancik
- Department of Cardiology, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University Prague, Prague, Czech Republic
| | - Petr Neuzil
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Pavel Hala
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Veronika Lekesova
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Klara Benesova
- Department of Data Analysis, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Marek Hozman
- Cardiocenter, Karlovy Vary Regional Hospital, Karlovy Vary, Czech Republic
| | - Jiri Jarkovsky
- Department of Data Analysis, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Martina Novackova
- Department of Data Analysis, Institute of Biostatistics and Analyses, Masaryk University, Brno, Czech Republic
| | - Petr Widimsky
- Department of Cardiology, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University Prague, Prague, Czech Republic
| | - Vivek Y Reddy
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic.,Department of Electrophysiology, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Darden D, Duong T, Du C, Munir MB, Han FT, Reeves R, Saw J, Zeitler EP, Al-Khatib SM, Russo AM, Minges KE, Curtis JP, Freeman JV, Hsu JC. Sex Differences in Procedural Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JAMA Cardiol 2021; 6:1275-1284. [PMID: 34379072 DOI: 10.1001/jamacardio.2021.3021] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Importance Left atrial appendage occlusion (LAAO) has emerged as an alternative to anticoagulation for select patients with atrial fibrillation; however, women have been underrepresented in clinical trials of LAAO, and sex-specific subanalyses are limited. Objective To evaluate the sex differences in the baseline characteristics of patients undergoing LAAO implant and in the in-hospital outcomes after LAAO implant. Design, Setting, and Participants A total of 49 357 patients in the National Cardiovascular Data Registry LAAO Registry undergoing LAAO with the Watchman device between January 1, 2016, and June 30, 2019, were included in this study. Exposure Female or male sex. Main Outcomes and Measures The primary outcomes were aborted or canceled procedure, major adverse event, any adverse event, prolonged hospital stay longer than 1 day, and death. Unadjusted and multivariable adjusted logistic regression analyses were performed to assess sex differences in in-hospital adverse events. Results In this cohort study of 49 357 patients (mean [SD] age, 76.1 [8.0] years), 20 388 women (41.3%) and 28 969 (58.7%) men underwent LAAO. Compared with men, women were older and had a higher prevalence of paroxysmal atrial fibrillation, prior stroke, and uncontrolled hypertension but a lower prevalence of congestive heart failure, diabetes, and coronary artery disease. After multivariable adjustment, there were no differences in aborted or canceled procedures between women and men (613 [3.0%] vs 851 [2.9%]; odds ratio [OR] 1.01, 95% CI, 0.90-1.13). Women were more likely than men to experience any adverse event (1284 [6.3%] vs 1144 [3.9%]; P < .001; OR, 1.63; 95% CI, 1.49-1.77; P < .001) or major adverse event (827 [4.1%] vs 567 [2.0%]; P < .001; OR, 2.06; 95% CI, 1.82-2.34; P < .001) owing to pericardial effusion requiring drainage (241 [1.2%] vs 144 [0.5%]) or major bleeding (349 [1.7%] vs 244 [0.8%]). Women were also more likely than men to experience a hospital stay longer than 1 day (3272 [16.0%] vs 3355 [11.6%]; P < .001; adjusted OR, 1.46; 95% CI, 1.38-1.54; P < .001) or death (adjusted OR, 2.01; 95% CI, 1.31-3.09; P = .001), although death was rare and absolute differences were minimal (58 [0.3%] vs 37 [0.1%]; P < .001). Conclusions and Relevance This study suggests that, compared with men, women have a significantly higher risk of in-hospital adverse events after LAAO. Further research aimed at risk reduction, particularly strategies to reduce the risk of pericardial effusion and major bleeding, in women undergoing LAAO is warranted.
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Affiliation(s)
- Douglas Darden
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
| | - Thao Duong
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
| | - Chengan Du
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Muhammad Bilal Munir
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
| | - Frederick T Han
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
| | - Ryan Reeves
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Emily P Zeitler
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Andrea M Russo
- Cardiac Electrophysiology and Arrhythmia Services, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Karl E Minges
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.,Department of Health Administration and Policy, University of New Haven, West Haven, Connecticut
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Jonathan C Hsu
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla
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Yamamoto T, Endo D, Matsushita S, Shimada A, Nakanishi K, Asai T, Amano A. Evidence and Challenges in Left Atrial Appendage Management. Ann Thorac Cardiovasc Surg 2021; 28:1-17. [PMID: 34334504 PMCID: PMC8915931 DOI: 10.5761/atcs.ra.21-00040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This review aimed to discuss the anatomical properties of the left atrial appendage (LAA), its relationship with atrial fibrillation (AF), effectiveness of LAA occlusion (LAAO), techniques, and new devices used to perform this procedure. An electronic search was performed to identify studies, in the English language, on LAA management. Searches were performed on PubMed Central, Scopus, and Medline from the dates of database inception to February 2020. For the assessed papers, data were extracted from the reviewed text, tables, and figures, by two independent authors. Anticoagulant therapy for patients with AF has proven beneficial and is highly recommended, but it is challenging for many patients to maintain optimal treatment. Surgery is the most cost-effective option; surgical methods include simple LAA resection, thoracoscopic surgery, and catheter treatment. Each procedure has its advantages and disadvantages, and many prospective studies have been conducted to evaluate various treatment methods. In managing the LAA, dissection of the LAA, such as changes in its shape and size due to remodeling during AF, changes in autonomic nerve function, and thrombosis, must be understood anatomically and physiologically. We believe that early treatment intervention for the LAA should be considered particularly in cases of recurrent AF. Conclusion: SLET under artificial pneumothorax is feasible and safe in minimally invasive McKeown esophagectomy.
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Affiliation(s)
- Taira Yamamoto
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Daisuke Endo
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | | | - Akie Shimada
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Keisuke Nakanishi
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
| | - Atsushi Amano
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan
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Sanjoy S, Choi YH, Holmes D, Herrman H, Terre J, Alraies C, Ando T, Tzemos N, Mamas M, Bagur R. Comorbidity burden in patients undergoing left atrial appendage closure. Heart 2021; 107:1246-1253. [PMID: 33229360 DOI: 10.1136/heartjnl-2020-317741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/11/2020] [Accepted: 10/16/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To estimate the risk of in-hospital complications after left atrial appendage closure (LAAC) in relationship with comorbidity burden. METHODS Cohort-based observational study using the US National Inpatient Sample database, 1 October 2015 to 31 December 2017. The main outcome of interest was the occurrence of in-hospital major adverse events (MAE) defined as the composite of bleeding complications, acute kidney injury, vascular complications, cardiac complications and postprocedural stroke. Comorbidity burden and thromboembolic risk were assessed by the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Score (ECS) and CHA2DS2-VASc score. MAE were identified using International Classification of Diseases, Tenth Revision, Clinical Modification codes. The associations of comorbidity with in-hospital MAE were evaluated using logistic regression models. RESULTS A total of 3294 hospitalisations were identified, among these, the mean age was 75.7±8.2 years, 60% were male and 86% whites. The mean CHA2DS2-VASc score was 4.3±1.5 and 29.5% of the patients had previous stroke or transient ischaemic attack. The mean CCI and ECS were 2.2±1.9 and 9.7±5.8, respectively. The overall composite rate of in-hospital MAE after LAAC was 4.6%. Females and non-whites had about 1.5 higher odds of in-hospital AEs as well participants with higher CCI (adjusted OR (aOR): 1.19, 95% CI: 1.13 to 1.24, p<0.001), ECS (aOR: 1.06, 95% CI: 1.05 to 1.08, p<0.001) and CHA2DS2-VASc score (aOR: 1.08, 95% CI: 1.02 to 1.15, p=0.01) were significantly associated with in-hospital MAE. CONCLUSION In this large cohort of LAAC patients, the majority of them had significant comorbidity burden. In-hospital MAE occurred in 4.6% and female patients, non-whites and those with higher burden of comorbidities were at higher risk of in-hospital MAE after LAAC.
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Affiliation(s)
- Shubrandu Sanjoy
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Yun-Hee Choi
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - David Holmes
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Howard Herrman
- Division of Cardiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Juan Terre
- Division of Cardiology, Albert Einstein College of Medicine, New York, New York, USA
| | - Chadi Alraies
- Division of Cardiology, Wayne State University, Detroit, Michigan, USA
| | - Tomo Ando
- Division of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Nikolaos Tzemos
- Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University; London Health Sciences Centre, London, Ontario, Canada
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Division of Cardiology, Department of Medicine, Schulich School of Medicine & Dentistry, Western University; London Health Sciences Centre, London, Ontario, Canada
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institute of Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
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Lozier MR, Sanchez AM, Mihos CG. A systematic review on the use of ultrasound enhancing agents with transesophageal echocardiography to assess the left atrial appendage prior to cardioversion. Echocardiography 2021; 38:1414-1421. [PMID: 34212409 DOI: 10.1111/echo.15150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/16/2021] [Accepted: 06/18/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Assessment of the left atrium and atrial appendage (LAA) for thrombus by transesophageal echocardiography (TEE) may be suboptimal due to difficult imaging windows and ultrasound artifacts. The present study analyzed the benefit of using ultrasound enhancing agents (UEAs) with TEE to improve diagnostic accuracy and image quality. METHODS A systematic review of studies published through December 2020 was performed, and included investigations comparing the number of cases deemed indeterminate for visualization of LAA thrombi on TEE pre- versus post-UEAs prior to cardioversion for atrial fibrillation or flutter (AF). Study results were pooled where the number of indeterminate cases by conventional TEE were re-classified as thrombus present, indeterminate, or thrombus excluded following administration of UEAs. RESULTS Three studies with a total of 399 patients were identified. Of these, 83 (26%) participants met the inclusion criteria. The mean age of the study population from the three studies was 66 ± 12 years, 29% were female, and prevalence of congestive heart failure or neurologic events was 22% and 5%, respectively. Use of UEAs with TEE re-classified 66% (55/83) of cases initially deemed to be indeterminate for LAA thrombus on conventional TEE. Thrombus was present in 13% (11/83) and excluded in 53% (44/83) of cases; 34% (28/83) of cases remained indeterminate on TEE post-UEAs. There were no complications reported with the administration of UEAs. CONCLUSION Adjunctive use of UEAs with TEE can facilitate the diagnosis or exclusion of LAA thrombus, and improve the procedural confidence and cost-efficiency of cardioversion for AF.
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Affiliation(s)
- Matthew R Lozier
- Mount Sinai Heart Institute, Columbia University Division of Cardiology, Miami Beach, Florida, USA
| | | | - Christos G Mihos
- Echocardiography Laboratory, Mount Sinai Heart Institute, Columbia University Division of Cardiology, Miami Beach, Florida, USA
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Briosa E Gala A, Pope MTB, Newton JD, Dawkins S, Betts TR. Caged-in: Successful percutaneous closure of left atrial appendage with Watchman-FLX in the presence of proximal thrombus. J Cardiovasc Electrophysiol 2021; 32:1655-1657. [PMID: 33938078 DOI: 10.1111/jce.15068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/26/2022]
Abstract
Percutaneous mechanical closure of the left atrial appendage (LAA) is a valuable stroke prevention strategy in patients with atrial fibrillation and contraindication to oral anticoagulation. LAA thrombus is a common finding in patients with atrial fibrillation and frequently fails to resolve despite therapeutic anticoagulation. In this scenario, LAA occlusion device implant is generally discouraged due to the high risk of thrombus dislodgement and embolization; however, alternative management options are limited. We report the first case of a successful LAA occlusion device (Watchman-FLX) implant in the presence of a proximal thrombus.
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Affiliation(s)
- Andre Briosa E Gala
- Deparment of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Michael T B Pope
- Deparment of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - James D Newton
- Deparment of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sam Dawkins
- Deparment of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Timothy R Betts
- Deparment of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,Radcliffe Department of Medicine, Division of Cardiovascular Medicine, University of Oxford, Oxford, UK
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50
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Lellouche N, Arrouasse R, Ternacle J, Gallet R, Hermida JS, Hamon D, Juliard JM, Pasquie JL, Dhanjal T, Teiger E, Le Corvoisier P. Atrial fibrillation evolution and rhythm control strategy following left appendage closure: new insights from the prospective FLAAC registry. BMC Cardiovasc Disord 2021; 21:227. [PMID: 33941095 PMCID: PMC8091509 DOI: 10.1186/s12872-021-01994-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) closure is an alternative to oral anticoagulation (OAC) for atrial fibrillation (AF) patients with high thromboembolism risk, particularly with contraindications to OAC. The LAA itself could possess proarrhythmogenic properties. As patients undergoing LAA closure could be candidates for cardioversion or ablation, we aimed to evaluate AF disease progression following LAA closure and the outcome of patients undergoing a rhythm control strategy after the procedure. METHODS The prospective multicenter French Nationwide Observational LAA Closure Registry (FLAAC) comprises 33 French interventional cardiology departments. Patients were included if they fulfilled the following criteria: history of non-valvular AF, successful LAA closure and long-term ECG follow-up. RESULTS A total of 331 patients with successful LAA closure were enrolled in the study. Patients mean age was 75.4 ± 0.5 years. The study population was characterized by a high thromboembolic risk (CHA2DS2-VASc score: 4.5 ± 0.1) and frequent comorbidities. The median follow-up was 11.9 months. One hundred and nineteen (36.0%) patients were in sinus rhythm (SR) at baseline. Among SR patients, documented AF was observed in 16 (13.4%) patients whereas 15 (7.1%) patients in AF at baseline restored SR, at the end of follow up. Finally, only 13 patients (4%) underwent procedures to restore SR without complications during the follow-up. CONCLUSIONS The vast majority of patients undergoing LAA closure have the same AF status at baseline and one year after the index procedure. During the follow-up, a very small proportion (4%) of our population underwent procedures to restore SR without complications whatever the post-procedural antithrombotic strategy was.
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Affiliation(s)
- Nicolas Lellouche
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France. .,AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Créteil, France.
| | | | - Julien Ternacle
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Romain Gallet
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | | | - David Hamon
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Jean-Michel Juliard
- Department of Cardiology, Bichat Hospital, APHP, University Paris VII, DHU FIRE, Sorbonne Paris-Cité, INSERM U-1148, Paris, France
| | - Jean-Luc Pasquie
- Montpellier University Hospital, CNRS UMR9214-Inserm U1046-PHYMEDEXP, Montpellier, France
| | - Tarvinder Dhanjal
- Department of Electrophysiology, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Emmanuel Teiger
- Cardiology Unit Henri Mondor University Hospital Paris XII, Creteil, France
| | - Philippe Le Corvoisier
- Inserm, CIC 1430, Henri Mondor University Hospital, Creteil, France.,Inserm, U955 team 3, Henri Mondor University Hospital, Creteil, France
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