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Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
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52
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Sharma SP, Park P, Lakkireddy D. Left Atrial Appendages Occlusion: Current Status and Prospective. Korean Circ J 2018; 48:692-704. [PMID: 30073807 PMCID: PMC6072669 DOI: 10.4070/kcj.2018.0231] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
Stroke continues to be a major cause of morbidity and mortality in atrial fibrillation (AF) patients. Oral anticoagulation (OAC) provides protection against stroke and peripheral embolization in AF but significant proportion of patients could not be started on anticoagulation because of bleeding complications. Left atrial appendage harbors clot in about 90% of nonvalvular AF. The advent of left atrial appendage occlusion (LAAO) techniques has provided these patients with alternative to OAC for stroke prophylaxis. Multiple LAAO devices are currently available with Watchman and Amulet being the most commonly used in clinical practice. Randomized studies are available for Watchman device only. Data on Amplatzer Cardiac Plug, Amulet and Lariat devices are limited by the paucity of randomized data. Long-term data on different LAAO techniques are showing promising results. Device related thrombosis continues to be a serious complication associated with LAAO. Future studies should look into comparative effectiveness between different LAAO techniques, optimal patient selection, risk of complications, and anticoagulant treatment after LAAO. This article aims to provide current available evidence on efficacy and safety of different LAAO devices and future prospective.
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Affiliation(s)
| | - Peter Park
- Kansas City Heart Rhythm Institute, Overland Park, KS, USA
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53
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Turagam MK, Velagapudi P, Kar S, Holmes D, Reddy VY, Refaat MM, Di Biase L, Al-Ahmed A, Chung MK, Lewalter T, Edgerton J, Cox J, Fisher J, Natale A, Lakkireddy DR. Cardiovascular Therapies Targeting Left Atrial Appendage. J Am Coll Cardiol 2018; 72:448-463. [PMID: 29954658 PMCID: PMC8420938 DOI: 10.1016/j.jacc.2018.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Saibal Kar
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - David Holmes
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiology/Cardiac Electrophysiology and Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Luigi Di Biase
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Amin Al-Ahmed
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James Edgerton
- Department of Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Fisher
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya R Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park Regional Medical Center, Kansas City, Kansas.
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54
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Musat D, Mittal S. LARIAT Trial Updates. J Atr Fibrillation 2018; 11:1806. [PMID: 30455830 DOI: 10.4022/jafib.1806] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/19/2018] [Accepted: 05/14/2018] [Indexed: 11/10/2022]
Abstract
The thrombus formed within the LAA is responsible for the vast (about 90%) majority of strokes. Anticoagulation, although effective therapy for stroke prevention is not feasible in a significant minority of patients due to various reasons. Two percutaenous LAA exclusion techniques have been developed in an effort to decrease risk for stroke: endocardial closure/plugging of the LAA (Watchman, Amplatzer devices) and epicardial LAA ligation (LARIAT). The aim of this study is to review the trial data to date for the LARIAT device. The LARIAT suture has been used in more than 4500 patients with high success of LAA complete closure (92-100%), mostly in the patients unable to take anticoagulation and in a small minority as antiarrhythmic option. The LARIAT technique has evolved with a change in pericardial access method that resulted in dramatic improvement of safety. LAA closure performance with LARIAT system seems to be similar to Watchman device, with small leaks during follow-up in 6-24% of the cases, which do not to correlate with thrombo-embolic events. LAA has been proven to play an important triggering role in patients with persistent atrial fibrillation. Small studies had shown that LAA ligation with LARIAT could terminate persistent atrial fibrillation and possible improve ablation success. Ongoing aMAZE randomized trial is studying if LAA ligaiton using LARIAT suture leads to improved atrial fibrillation ablation success. Available data suggests that LAA closure using LARIAT epicardial suture is a good alternative for stroke risk reduction in patients who are unable to be on anticoagulation therapy. LARIAT system might improve success of AF ablation for patients with persistent and long persistent AF, pending the results of the ongoing aMAZE trial.
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Affiliation(s)
- Dan Musat
- Valley Health System of NY and NJ, Paramus, NJ
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55
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Fink T, Schlüter M, Tilz RR, Heeger CH, Lemes C, Maurer T, Reissmann B, Rottner L, Santoro F, Mathew S, Rillig A, Ouyang F, Kuck KH, Metzner A. Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience. Clin Res Cardiol 2018; 107:1139-1147. [DOI: 10.1007/s00392-018-1288-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
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56
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Rogers PA, Bernard ML, Madias C, Thihalolipavan S, Mark Estes N, Morin DP. Current Evidence-Based Understanding of the Epidemiology, Prevention, and Treatment of Atrial Fibrillation. Curr Probl Cardiol 2018; 43:241-283. [DOI: 10.1016/j.cpcardiol.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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57
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Piccini JP, Sievert H, Patel MR. Left atrial appendage occlusion: rationale, evidence, devices, and patient selection. Eur Heart J 2018; 38:869-876. [PMID: 27628431 DOI: 10.1093/eurheartj/ehw330] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 07/11/2016] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is a worldwide epidemic associated with significant morbidity and mortality, often due to disabling or fatal thromboembolic stroke. Oral anticoagulation is highly effective at preventing ischaemic stroke and improving all-cause survival in patients with non-valvular AF. Despite the efficacy of oral anticoagulation, many patients are not treated due to either absolute or perceived contraindications to therapy, including bleeding. Left atrial appendage (LAA) closure has emerged as a mechanical alternative to pharmacologic stroke prevention. Initial and mid-term clinical trial data suggest that LAA closure is safe, with less intracranial bleeding, and a net clinical benefit that appears to be non-inferior to oral anticoagulation. However, concern remains over the possible increased risk of ischaemic stroke in long-term follow-up. Careful patient selection for LAA closure is paramount. Patients with prior intracranial bleeding or recurrent serious bleeding who are not eligible for long-term oral anticoagulation are typical candidates for LAA closure; however, other populations may benefit as well, such as patients with end-stage renal disease. Clinical investigation and randomized trials are needed to clarify the best methods of LAA occlusion, optimal pharmacologic strategies in the short-term after LAA closure, and to identify patient populations who will derive the most benefit from LAA occlusion. In this article, we review the rationale for LAA closure, the currently available devices and their evidence base, patient selection, challenges in management, and future directions for LAA closure science.
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Affiliation(s)
- Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Horst Sievert
- CardioVascular Center Frankfurt, Sankt Katharinen Hospital, Frankfurt, Germany
| | - Manesh R Patel
- Duke Center for Atrial Fibrillation, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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58
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Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF), the most common sustained arrhythmia, is a major cause of stroke and systemic embolism, and is increasing in prevalence. Device closure of the left atrial appendage (LAA) represents a non-pharmacologic approach to stroke prevention in AF patients. This review presents the rationale for LAA closure (LAAC), describes current transcatheter approaches to LAAC, and summarizes the current evidence for LAAC for stroke prevention, highlighting the main randomized trials and the most recent data available. RECENT FINDINGS Meta-analysis of randomized clinical trials demonstrates similar rates of all-cause stroke with transcatheter LAAC compared with vitamin K antagonist therapy and significantly less bleeding with LAAC after cessation of mandated post-procedure pharmacology. Recent prospective observational studies, including those evaluating outcomes after commercial approval in the USA, show significantly improved procedure safety compared with earlier experiences. LAAC appears to be an attractive alternative strategy for stroke prevention in AF patients, particularly in those who can take short-term oral anticoagulation (OAC), but are not optimal candidates for long-term OAC. Recent data suggests the procedure can be safely performed in patients with contraindications to OAC. Further, robust studies are needed to evaluate safety and efficacy in OAC-contraindicated patients, to compare outcomes with non-vitamin K antagonist OACs, and to explore the relative safety and efficacy of different LAAC devices.
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Affiliation(s)
- Ricardo Kosturakis
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA, 92037, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA, 92037, USA.
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59
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Chava R, Turagam MK, Lakkireddy D(DJ. Left Atrial Appendage Occlusion: What Are the Options and Where is the Evidence? J Innov Card Rhythm Manag 2018; 9:3095-3106. [PMID: 32494488 PMCID: PMC7252870 DOI: 10.19102/icrm.2018.090402] [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: 06/14/2017] [Accepted: 08/23/2017] [Indexed: 11/13/2022] Open
Abstract
Left atrial appendage occlusion (LAAO) has emerged as an effective site-directed therapy in patients with nonvalvular atrial fibrillation (AF) for stroke prevention, who are ineligible for long-term oral anticoagulation. The objective of this study was to assess the safety, efficacy, and availability of LAAO devices by reviewing the literature and to review the development and effectiveness of LAAO by the transcatheter approach with plugging devices such as WATCHMAN™ (Boston Scientific, Natick, MA, USA); AMPLATZER™ Cardiac Plug and AMPLATZER™ Amulet™ (Abbott Laboratories, Chicago, IL, USA); and the LARIAT® Suture Delivery Device (SentreHEART, Redwood City, CA, USA), which features an entirely unique hybrid (endocardial and epicardial) approach in closing the left atrial appendage (LAA). The conducted literature review ultimately revealed a substantial body of literature supporting the safety and efficacy of various LAAO strategies, including endocardial, epicardial, and hybrid approaches, in AF patients who are not eligible for long-term oral anticoagulant use. Specifically, the most attractive population suitable for LAA closure appears to be patients at high risk for ischemic stroke with a longer life expectancy but a moderate-to-high bleeding risk with long-term oral anticoagulation. The benefit of LAA closure in reducing the incidence of stroke in patients with nonvalvular AF has been evolving gradually, and we are confident that this new field of percutaneous LAA closure will continue to emerge as a game-changer in the treatment of AF.
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Affiliation(s)
- Raghuram Chava
- Department of Internal Medicine, MedStar Harbor Hospital, Baltimore, MD, USA
| | - Mohit K. Turagam
- Section of Electrophysiology, Mount Sinai Hospital, New York, NY, USA
| | - Dhanunjaya (DJ) Lakkireddy
- Department of Internal Medicine, MedStar Harbor Hospital, Baltimore, MD, USA
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital and Medical Center, Kansas City, KS, USA
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60
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Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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61
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The Role of the Left Atrial Appendage in Stroke and Arrhythmia Provocation. CURRENT CARDIOVASCULAR RISK REPORTS 2018. [DOI: 10.1007/s12170-018-0576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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62
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Abstract
Resection of the left atrial appendage (LAA) to prevent recurrent arterial emboli in patients with atrial fibrillation was first suggested more than 60 years ago. Longer-term follow-up from randomized studies of the safety and efficacy of transcatheter LAA occlusion has recently been completed; data from large, observational cohorts are being reported. These recent data provide further insights into procedural safety with current techniques and the ability of LAA closure to reduce thromboembolic stroke compared with warfarin anticoagulation. This review summarizes the latest data regarding transcatheter LAA occlusion, focusing on larger prospective studies and further analyses of seminal clinical trials.
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63
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Yerasi C, Lazkani M, Kolluru P, Miryala V, Kim J, Moole H, Sawant AC, Morris M, Pershad A. An updated systematic review and meta-analysis of early outcomes after left atrial appendage occlusion. J Interv Cardiol 2018; 31:197-206. [DOI: 10.1111/joic.12502] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 01/24/2018] [Indexed: 12/31/2022] Open
Affiliation(s)
- Charan Yerasi
- St. Joseph's Hospital and Medical Center; Phoenix Arizona
| | - Mohamad Lazkani
- University of Arizona; Banner University Medical Center; Phoenix Arizona
| | - Prathik Kolluru
- MedStar Georgetown University/MedStar Washington Hospital Center; Washington District of Columbia
| | | | - Jae Kim
- MedStar Georgetown University/MedStar Washington Hospital Center; Washington District of Columbia
| | - Harsha Moole
- University of Illinois College of Medicine; Peoria Illinois
| | | | - Michael Morris
- University of Arizona; Banner University Medical Center; Phoenix Arizona
| | - Ashish Pershad
- University of Arizona; Banner University Medical Center; Phoenix Arizona
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64
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Percutaneous left atrial appendage occlusion in the prevention of stroke in atrial fibrillation: a systematic review. Heart Fail Rev 2018; 23:191-208. [DOI: 10.1007/s10741-018-9681-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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65
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Hernández JM, Urso S, Tena MÁ, Sadaba R, Portela F. Cierre percutáneo de la orejuela izquierda: revisión sistemática de los resultados de seguridad y eficacia. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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66
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McBride DA, Markman TM, Liang JJ, Santangeli P. Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2018.6.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.
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67
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Gurol ME. Nonpharmacological Management of Atrial Fibrillation in Patients at High Intracranial Hemorrhage Risk. Stroke 2018; 49:247-254. [PMID: 29203684 PMCID: PMC5847291 DOI: 10.1161/strokeaha.117.017081] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 12/17/2022]
Affiliation(s)
- M Edip Gurol
- From the Department of Neurology, Massachusetts General Hospital, Boston.
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68
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Cosedis Nielsen J, Curtis AB, Davies DW, Day JD, d’Avila A, (Natasja) de Groot NMS, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace 2018; 20:e1-e160. [PMID: 29016840 PMCID: PMC5834122 DOI: 10.1093/europace/eux274] [Citation(s) in RCA: 708] [Impact Index Per Article: 118.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hugh Calkins
- From the Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George's University of London, London, United Kingdom
| | | | | | | | | | | | - D Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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69
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Huded C, Krishnaswamy A, Kapadia S. Percutaneous Left Atrial Appendage Closure: is there a Role in Valvular Atrial Fibrillation. J Atr Fibrillation 2017; 9:1524. [PMID: 29250272 DOI: 10.4022/jafib.1524] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 12/23/2022]
Abstract
Atrial fibrillation, a chronic and highly morbid cardiovascular condition which affects over 33 million people worldwide, can be broadly categorized as valvular vs non-valvular in etiology. However, definitions of valvular atrial fibrillation have varied widely in the literature, and there is no clear consensus definition to date. Historically, patients with atrial fibrillation in the setting of rheumatic mitral valve disease have constituted a particularly high risk group for cardioembolic stroke, and for this reason many contemporary trials of pharmaceutical and device therapies for atrial fibrillation have systematically excluded patients with valvular heart disease. Therefore, vitamin K antagonism remains the favored approach to mitigate stroke risk in valvular atrial fibrillation, and the optimal strategy to treat atrial fibrillation patients with valvular heart disease who cannot tolerate oral anticoagulation therapy is unknown. Recent trials have demonstrated an important role for percutaneous left atrial appendage occlusion devices in patients with non-valvular atrial fibrillation, but the role of these devices in patients with valvular atrial fibrillation is uncertain. Given the worldwide burden of valvular atrial fibrillation, future trials intended to clarify the role of percutaneous left atrial appendage closure devices in valvular atrial fibrillation should provide important insight for the care of millions of patients.
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Affiliation(s)
- Chetan Huded
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
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70
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Nishimura M, Sab S, Reeves RR, Hsu JC. Percutaneous left atrial appendage occlusion in atrial fibrillation patients with a contraindication to oral anticoagulation: a focused review. Europace 2017; 20:1412-1419. [DOI: 10.1093/europace/eux313] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marin Nishimura
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Shiv Sab
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Ryan R Reeves
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
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71
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Gloekler S, Hajredini B, Rycerz S, Jäckle S, Jung W. [Left atrial appendage clusure in nonvalvular atrial fibrillation : Clinical evidence 2017]. Herzschrittmacherther Elektrophysiol 2017; 28:366-380. [PMID: 29143099 DOI: 10.1007/s00399-017-0536-9] [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] [Received: 08/30/2017] [Accepted: 10/05/2017] [Indexed: 06/07/2023]
Abstract
Nonvalvular atrial fibrillation (AF) is the most common arrhythmia with a prevalence of 1-2% and affects approximately 15-20% of all octogenarians. Patients are at increased risk of thromboembolic stroke, with an overall risk of 5% per year. Thrombi form almost exclusively in the left atrial appendage (LAA), a blind sac-like heterogeneous structure trabeculated by pectinate muscles. In the past five decades, life-long oral anticoagulation (OAC) with vitamin K antagonists (VKA) has been the state-of-the art treatment to prevent stroke and systemic embolism from thrombi in AF. In the last decade, nonvitamin K dependent oral anticoagulants (NOAC) have been shown to be superior to VKA. Given the safety issues of indefinite OAC with either VKA or NOAC, it is plausible to consider left atrial appendage closure (LAAC) as an alternative strategy to prevent death, stroke or other systemic embolization, and bleeding. In recent years, LAAC has been compared to VKA in prospective randomized trials, yielding superior results regarding efficacy and noninferiority regarding safety in the mid-term. This review provides an update on the current state of LAAC in the field of prevention of death, stroke, and bleedings in patients suffering from nonvalvular AF. We elucidate the evidence and limitations of anticoagulation as the classical treatment paradigm, and review devices and techniques for LAAC. Most importantly, the current clinical evidence on efficacy and safety is outlined.
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Affiliation(s)
- Steffen Gloekler
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland.
| | - Bajram Hajredini
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Simon Rycerz
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Sebastian Jäckle
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Werner Jung
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
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72
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Gloekler S, Saw J, Koskinas KC, Kleinecke C, Jung W, Nietlispach F, Meier B. Left atrial appendage closure for prevention of death, stroke, and bleeding in patients with nonvalvular atrial fibrillation. Int J Cardiol 2017; 249:234-246. [DOI: 10.1016/j.ijcard.2017.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023]
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73
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Turagam M, Atkins D, Earnest M, Lee R, Nath J, Ferrell R, Bartus K, Badhwar N, Rasekh A, Cheng J, Di Biase L, Natale A, Wilber D, Lakkireddy D. Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry. J Cardiovasc Electrophysiol 2017; 28:1433-1442. [DOI: 10.1111/jce.13343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mohit Turagam
- Division of Cardiovascular Medicine; University of Missouri Hospital and Clinics; Columbia MO USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Randall Lee
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Jayant Nath
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Ryan Ferrell
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | | | - Nitish Badhwar
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Abdi Rasekh
- Baylor St. Luke's Medical Center; Houston TX USA
| | - Jie Cheng
- Texas Heart Institute; Houston TX USA
| | - Luigi Di Biase
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - Andrea Natale
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
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74
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Jazayeri MA, Vuddanda V, Turagam MK, Parikh V, Lavu M, Atkins D, Earnest M, Di Biase L, Natale A, Wilber D, Reddy YM, Lakkireddy DR. Safety profiles of percutaneous left atrial appendage closure devices: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016. J Cardiovasc Electrophysiol 2017; 29:5-13. [DOI: 10.1111/jce.13362] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/29/2017] [Accepted: 10/02/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Mohammad-Ali Jazayeri
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Venkat Vuddanda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Mohit K. Turagam
- Division of Cardiovascular Disease; University of Missouri Hospital & Clinics; Columbia MO USA
| | - Valay Parikh
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Madhav Lavu
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Luigi Di Biase
- Electrophysiology Section; Albert Einstein College of Medicine at Montefiore Medical Center; Bronx NY USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL
| | - Yeruva Madhu Reddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Dhanunjaya R. Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
- Mid-America Cardiology, Bloch Heart Rhythm Center; University of Kansas Hospital & Medical Center; Kansas City KS USA
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75
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Affiliation(s)
- Lluis Asmarats
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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Yarlagadda B, Parikh V, Dar T, Lakkireddy D. Leaks after left atrial appendage ligation with Lariat device: Incidence, pathophysiology, clinical implications and methods of closure- A case based discussion. J Atr Fibrillation 2017; 10:1725. [PMID: 29250246 DOI: 10.4022/jafib.1725] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 10/19/2017] [Accepted: 10/22/2017] [Indexed: 12/31/2022]
Abstract
Catheter based left atrial appendage (LAA) closure techniques are emerging as a promising alternative for stroke prevention in patients who cannot tolerate oral anticoagulation. Lariat procedure involves percutaneous catheter based epicardial ligation of the LAA with a suture via an endo-epicardial hybrid approach. It offers the advantage of not leaving behind a focus for thrombus formation or embolization. Similar to surgical ligation of the left atrial appendage, Lariat ligation is limited by leaks in a small percentage of patients. The incidence of leaks is variable and can be seen in the immediate post procedure period or during follow up. The electrical and mechanical implications of leaks are still under debate. In this review, we discuss the incidence, pathophysiology, clinical implications and methods of closure of leaks after Lariat. In the end, we present a case of a Lariat leak closed with an Amplatzer septal occluder.
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Affiliation(s)
- Bharath Yarlagadda
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Valay Parikh
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Tawseef Dar
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute, University of Kansas Hospital & Medical Center, Kansas City, KS
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Abstract
Incomplete left atrial appendage closure (LAAC) occurs in ∼30-40 % of cases following both surgical and percutaneous closure methods. Incomplete surgical LAAC may further be classified as incompletely surgically ligated LAA (ISLL) or LAA stump. ISLL is associated with a significantly increased risk of thrombus formation/thromboembolism. Moreover, this risk is highest in the absence of oral anticoagulation (OAC) and inversely correlates with the size of the ISLL neck. Not only routine screening for ISLL seems critical, but also long-term OAC should strongly be considered in this high-risk cohort. Alternatively, complete endocardial occlusion using a surrogate method may represent a reasonable option, particularly in those intolerant to long-term OAC therapy. Although thrombus formation/thromboembolic events have also been described in patients with incomplete LAAC following percutaneous occlusion, an association between the two remains less clear. However, given the rise and growing interest in percutaneous LAAC methods, additional research in this area is clearly warranted.
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Affiliation(s)
- Arash Aryana
- Mercy Medical Group and Dignity Health Heart and Vascular Institute, Sacramento, CA, USA.
| | - André d'Avila
- Instituto de Pesquisa em Arritmia Cardiaca, Hospital Cardiologico, Florianopolis, Santa Catarina, Brazil
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78
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Ueberham L, Dagres N, Potpara TS, Bollmann A, Hindricks G. Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation. Adv Ther 2017; 34:2274-2294. [PMID: 28956288 PMCID: PMC5656712 DOI: 10.1007/s12325-017-0616-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.
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Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany.
| | - Nikolaos Dagres
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Bollmann
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
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79
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Calkins H, Hindricks G, Cappato R, Kim YH, Saad EB, Aguinaga L, Akar JG, Badhwar V, Brugada J, Camm J, Chen PS, Chen SA, Chung MK, Nielsen JC, Curtis AB, Davies DW, Day JD, d’Avila A, de Groot N(N, Di Biase L, Duytschaever M, Edgerton JR, Ellenbogen KA, Ellinor PT, Ernst S, Fenelon G, Gerstenfeld EP, Haines DE, Haissaguerre M, Helm RH, Hylek E, Jackman WM, Jalife J, Kalman JM, Kautzner J, Kottkamp H, Kuck KH, Kumagai K, Lee R, Lewalter T, Lindsay BD, Macle L, Mansour M, Marchlinski FE, Michaud GF, Nakagawa H, Natale A, Nattel S, Okumura K, Packer D, Pokushalov E, Reynolds MR, Sanders P, Scanavacca M, Schilling R, Tondo C, Tsao HM, Verma A, Wilber DJ, Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm 2017; 14:e275-e444. [PMID: 28506916 PMCID: PMC6019327 DOI: 10.1016/j.hrthm.2017.05.012] [Citation(s) in RCA: 1370] [Impact Index Per Article: 195.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Riccardo Cappato
- Humanitas Research Hospital, Arrhythmias and Electrophysiology Research Center, Milan, Italy (Dr. Cappato is now with the Department of Biomedical Sciences, Humanitas University, Milan, Italy, and IRCCS, Humanitas Clinical and Research Center, Milan, Italy)
| | | | - Eduardo B. Saad
- Hospital Pro-Cardiaco and Hospital Samaritano, Botafogo, Rio de Janeiro, Brazil
| | | | | | - Vinay Badhwar
- West Virginia University School of Medicine, Morgantown, WV
| | - Josep Brugada
- Cardiovascular Institute, Hospital Clínic, University of Barcelona, Catalonia, Spain
| | - John Camm
- St. George’s University of London, London, United Kingdom
| | | | | | | | | | | | - D. Wyn Davies
- Imperial College Healthcare NHS Trust, London, United Kingdom
| | - John D. Day
- Intermountain Medical Center Heart Institute, Salt Lake City, UT
| | | | | | - Luigi Di Biase
- Albert Einstein College of Medicine, Montefiore-Einstein Center for Heart & Vascular Care, Bronx, NY
| | | | | | | | | | - Sabine Ernst
- Royal Brompton and Harefield NHS Foundation Trust, National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Guilherme Fenelon
- Albert Einstein Jewish Hospital, Federal University of São Paulo, São Paulo, Brazil
| | | | | | | | | | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Warren M. Jackman
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Jose Jalife
- University of Michigan, Ann Arbor, MI, the National Center for Cardiovascular Research Carlos III (CNIC) and CIBERCV, Madrid, Spain
| | - Jonathan M. Kalman
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Australia
| | - Josef Kautzner
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Hans Kottkamp
- Hirslanden Hospital, Department of Electrophysiology, Zurich, Switzerland
| | | | | | - Richard Lee
- Saint Louis University Medical School, St. Louis, MO
| | - Thorsten Lewalter
- Department of Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | | | - Laurent Macle
- Montreal Heart Institute, Department of Medicine, Université de Montréal, Montréal, Canada
| | | | - Francis E. Marchlinski
- Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | - Hiroshi Nakagawa
- Heart Rhythm Institute, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX
| | - Stanley Nattel
- Montreal Heart Institute and Université de Montréal, Montreal, Canada, McGill University, Montreal, Canada, and University Duisburg-Essen, Essen, Germany
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | | | | | - Claudio Tondo
- Cardiac Arrhythmia Research Center, Centro Cardiologico Monzino, IRCCS, Department of Cardiovascular Sciences, University of Milan, Milan, Italy
| | | | - Atul Verma
- Southlake Regional Health Centre, University of Toronto, Toronto, Canada
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81
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WITHDRAWN: 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. J Arrhythm 2017. [DOI: 10.1016/j.joa.2017.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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82
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Managing the Left Atrial Appendage in Atrial Fibrillation: Current State of the Art. Ann Thorac Surg 2017; 104:2111-2119. [PMID: 28826990 DOI: 10.1016/j.athoracsur.2017.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/19/2017] [Accepted: 05/05/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with atrial fibrillation are at increased risk for thromboembolic stroke originating predominantly in the left atrial appendage. To reduce the risk, the standard of care is anticoagulation. In addition, several devices for exclusion of the left atrial appendage have been developed. METHODS PubMed was searched for articles relevant to left atrial appendage management. The resulting articles were reviewed as were relevant articles in their bibliographies. Relevant journals were manually searched for sources. RESULTS Devices are being used for left atrial appendage exclusion by percutaneous and surgical approaches. Their indications, limitations, and outcomes are reviewed. CONCLUSIONS Excision and exclusion of the left atrial appendage is safe and as effective as medical management of atrial fibrillation for stroke prevention. The choice of treatment should be made based on patients' anatomy, history, and preference informed by an appropriate left atrial appendage management team.
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83
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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84
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Bajwa RJ, Kovell L, Resar JR, Arbab-Zadeh A, Mandal K, Calkins H, Berger RD. Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. Clin Cardiol 2017; 40:825-831. [PMID: 28750152 DOI: 10.1002/clc.22764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 06/21/2017] [Accepted: 06/26/2017] [Indexed: 01/23/2023] Open
Abstract
Atrial fibrillation (AF) is a commonly sustained atrial arrhythmia with associated morbidity and mortality. AF is associated with increased risk of thromboembolism and stroke, requiring use of anticoagulation. Anticoagulation decreases the risk of stroke but is associated with a higher risk of bleeding, necessitating discontinuation in some patients. The left atrial appendage is the likely source of thrombus in the majority of patients with AF. This has led to the development of left atrial appendage occlusion as a means to reduce stroke risk in patients who have a contraindication to long-term anticoagulation. Multiple implantable devices have surfaced in the last few years, with some promising prospects. The main purpose of this review is to highlight the indications and use of these devices for left atrial appendage occlusion.
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Affiliation(s)
- Rizma Jalees Bajwa
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lara Kovell
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jon R Resar
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Armin Arbab-Zadeh
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaushik Mandal
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ronald D Berger
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
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85
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Dave AS, Valderrábano M. Approaches to Left Atrial Appendage Closure: Device Design, Performance, and Limitations. Methodist Debakey Cardiovasc J 2017; 13:106-113. [PMID: 29743994 DOI: 10.14797/mdcj-13-3-106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Up to 6.1 million people in the United States have atrial fibrillation (AF), which is associated with an increased risk of stroke. Oral anticoagulants are the mainstay of stroke prevention in AF. For decades, warfarin was the only available drug, fraught with compliance limitations, a narrow therapeutic window, and a high risk of hemorrhage. Pharmacologic developments have produced new anticoagulants that have improved the rates of stroke related to AF; however, they still confer a high risk of bleeding, making them unsuitable for some patients. Studies have shown that roughly 90% of strokes in patients with AF occur in the left atrial appendage (LAA). This understanding has prompted the development and testing of novel percutaneous strategies for LAA closure as an alternative to anticoagulation therapy. The following review examines the relative merits and shortcomings of these strategies and explores future prospects in the prevention of AF-related stroke.
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Affiliation(s)
- Amish S Dave
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Miguel Valderrábano
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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86
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Abstract
The relationship of stroke and atrial fibrillation seems to become more complex as we gain more knowledge of the issue. Recent studies have questioned the temporal relationship between the two, which also questions causation. Left atrial appendage closure is an attractive, but unproven technology when compared with the 50-year experience with warfarin. In a patient who is on warfarin and having no issues with bleeding, medication intolerance, or lack of efficacy, it is difficult to justify stopping the drug and placing a closure device as sole therapy to prevent a stroke.
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Affiliation(s)
- Michael C Giudici
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA.
| | - Prashant D Bhave
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242, USA
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87
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Schlaganfallprophylaxe bei Vorhofflimmern. Herz 2017; 42:373-379. [DOI: 10.1007/s00059-017-4568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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88
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Phillips KP, Paul V. Dealing With the Left Atrial Appendage for Stroke Prevention: Devices and Decision-Making. Heart Lung Circ 2017; 26:918-925. [PMID: 28652029 DOI: 10.1016/j.hlc.2017.05.113] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Accepted: 05/02/2017] [Indexed: 11/25/2022]
Abstract
Left atrial appendage (LAA) device occlusion represents a major evolution in stroke prevention for atrial fibrillation (AF). Left atrial appendage device occlusion is now a proven strategy which provides long-term thromboembolic stroke prevention for patients with non-rheumatic AF. Evidence supports its benefit as an alternative to long-term anticoagulation while mitigating long-term bleeding risks and improving cardiovascular mortality. The therapy offers expanded options to physicians and patients negotiating stroke prevention (both primary and secondary prevention), but a good understanding of the risks and benefits is required for decision-making. This review aims to summarise the evolution of LAA device occlusion therapy, current knowledge in the field and a snapshot of current status of the therapy in clinical practice in Australia and around the world.
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Affiliation(s)
- Karen P Phillips
- HeartCare Partners, GenesisCare, Greenslopes Private Hospital, Greenslopes, Brisbane, Qld, Australia.
| | - Vince Paul
- Fiona Stanley Hospital, Perth, WA, Australia
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Casu G, Gulizia MM, Molon G, Mazzone P, Audo A, Casolo G, Di Lorenzo E, Portoghese M, Pristipino C, Ricci RP, Themistoclakis S, Padeletti L, Tondo C, Berti S, Oreglia JA, Gerosa G, Zanobini M, Ussia GP, Musumeci G, Romeo F, Di Bartolomeo R. ANMCO/AIAC/SICI-GISE/SIC/SICCH Consensus Document: percutaneous occlusion of the left atrial appendage in non-valvular atrial fibrillation patients: indications, patient selection, staff skills, organisation, and training. Eur Heart J Suppl 2017; 19:D333-D353. [PMID: 28751849 PMCID: PMC5520759 DOI: 10.1093/eurheartj/sux008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia and its prevalence is increasing due to the progressive aging of the population. About 20% of strokes are attributable to AF and AF patients are at five-fold increased risk of stroke. The mainstay of treatment of AF is the prevention of thromboembolic complications with oral anticoagulation therapy. Drug treatment for many years has been based on the use of vitamin K antagonists, but recently newer and safer molecules have been introduced (dabigatran etexilate, rivaroxaban, apixaban, and edoxaban). Despite these advances, many patients still do not receive adequate anticoagulation therapy because of contraindications (relative and absolute) to this treatment. Over the last decade, percutaneous closure of left atrial appendage, main site of thrombus formation during AF, proved effective in reducing thromboembolic complications, thus offering a valid medical treatment especially in patients at increased bleeding risk. The aim of this consensus document is to review the main aspects of left atrial appendage occlusion (selection and multidisciplinary assessment of patients, currently available methods and devices, requirements for centres and operators, associated therapies and follow-up modalities) having as a ground the significant evolution of techniques and the available relevant clinical data.
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Affiliation(s)
- Gavino Casu
- CCU-Cardiology Department, Ospedale San Francesco Nuoro, Via Mannironi, 1 Nuoro, Italy
- Corresponding author. Tel: +393356623601, Fax: +390784240376,
| | - Michele Massimo Gulizia
- Cardiology Department, Ospedale Garibaldi-Nesima, Azienda di Rilievo Nazionale e Alta Specializzazione “Garibaldi, Catania”, Italy
| | - Giulio Molon
- Cardiology Unit Ospedale Sacro Cuore, Negrar (Verona), Italy
| | - Patrizio Mazzone
- Arrhythmology and Electrophysiology Unit, Ospedale San Raffaele, Milan, Italy
| | - Andrea Audo
- Cardiac Surgery Unit, Ospedale Civile SS. Antonio e Biagio, Alessandria, Italy
| | - Giancarlo Casolo
- Cardiology Department, Nuovo Ospedale Versilia, Lido di Camaiore (Lucca), Italy
| | | | | | | | - Renato Pietro Ricci
- CCU-Cardiology Department Presidio Ospedaliero San Filippo Neri, Rome, Italy
| | - Sakis Themistoclakis
- Electrophysiology and Electrostimulation Department, Ospedale dell’Angelo, Venice Mestre, Italy
| | - Luigi Padeletti
- Experimental and Clinical Medicine Department, Università degli Studi, Florence, Italy
| | - Claudio Tondo
- Arrhythmology Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Sergio Berti
- Diagnostic and Interventional Cardiology Department, Fondazione Toscana “G. Monasterio”, Ospedale del Cuore, Massa, Italy
| | | | - Gino Gerosa
- Cardiac Surgery Unit—Centro V. Gallucci, Azienda Ospedaliera di Padova, Padua, Italy
| | - Marco Zanobini
- Cardiac Surgery Unit, Centro Cardiologico Monzino, Milan, Italy
| | - Gian Paolo Ussia
- Systems Medicine Department, Università degli Studi di Roma “Tor Vergata”, Rome, Italy
| | | | - Francesco Romeo
- Cardiology and Interventional Cardiology, Policlinico “Tor Vergata”, Rome, Italy
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Abstract
More than 2.3 million adults in the United States have atrial fibrillation (AF), which exposes them to a 5-fold increased risk of stroke. The left atrial appendage (LAA) appears to be the source of thrombus formation in the vast majority of these patients. Anticoagulation significantly reduces the risk of stroke, but often we encounter patients who have absolute or relative contraindication to anticoagulation. Percutaneous LAA exclusion offers an alternative to anticoagulation to decrease the risk of stroke. Three device systems are currently available in the United States. The WATCHMAN® device is the most studied and approved by Food and Drug Administration (FDA) to be used in patients with AF unsuitable for anticoagulation who are at a high risk of stroke. The Amulet® device is currently being used as part of the AMPLATZER® Amulet® LAA Occluder trial, which is a non-inferiority randomized trial comparing the Amulet® to the WATCHMAN® device. The third device in use is the LARIAT®, which is an FDA approved snare and pre-tied stich system. It is used to approximate soft tissue which in this case is the LAA. It is a hybrid system and requires both epicardial and endocardial access. The main obstacle to percutaneous LAA closure is procedural related complications, which can be minimized with optimum operator experience.
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Affiliation(s)
- Arijit Chanda
- John Ochsner Heart & Vascular Center, Cardiac Catheterization Laboratory, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121
| | - John P Reilly
- John Ochsner Heart & Vascular Center, Cardiac Catheterization Laboratory, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121.
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91
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Aryana A, Bhaskar R. Incomplete surgical ligation of the left atrial appendage-time for a new look at an old problem. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:141. [PMID: 28462221 DOI: 10.21037/atm.2017.02.17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Arash Aryana
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
| | - Rohit Bhaskar
- Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California, USA
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92
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Sharma M, Khalighi K. Non-Pharmacologic Approach to Prevent Embolization in Patients with Atrial Fibrillation in Whom Anticoagulation is Contraindicated. Clin Pract 2017; 7:898. [PMID: 28243428 PMCID: PMC5264548 DOI: 10.4081/cp.2017.898] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/09/2016] [Accepted: 12/28/2016] [Indexed: 12/26/2022] Open
Abstract
Ischemic stroke is the most common complication of atrial fibrillation (AF). Anticoagulation therapy reduces the risk of systemic embolization in almost all patients with AF irrespective of the type of AF (paroxysmal, persistent or permanent). But, all patients are not suitable candidates for systemic anticoagulation mainly due to the risk of bleeding. Left atrial appendage closure (LAAC) devices have been found to be very effective non-pharmacologic alternative therapy for such patients. There are various types of LAAC devices but United States Food and Drug Administration (US-FDA) have approved only Watchman device. Initially, bigger medical centers in the US had started the insertion of Watchman device but with improving procedural techniques and exciting outcomes, even the community-based hospitals have started to embrace this therapy. We have presented the first three cases of Watchman device placement performed in our hospital and discussed about the indications for placement of LAAC devices. We have also reviewed their efficacy individually.
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Affiliation(s)
- Munish Sharma
- Department of Internal Medicine, Easton Hospital , Easton, PA
| | - Koroush Khalighi
- Department of Cardiology, Easton Hospital and Clinical Medicine, Drexel University College of Medicine , Easton, PA, USA
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94
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Tzikas A, Holmes DR, Gafoor S, Ruiz CE, Blomström-Lundqvist C, Diener HC, Cappato R, Kar S, Lee RJ, Byrne RA, Ibrahim R, Lakkireddy D, Soliman OI, Nabauer M, Schneider S, Brachmann J, Saver JL, Tiemann K, Sievert H, Camm AJ, Lewalter T. Percutaneous left atrial appendage occlusion: the Munich consensus document on definitions, endpoints, and data collection requirements for clinical studies. Europace 2017; 19:4-15. [PMID: 27540038 PMCID: PMC5841559 DOI: 10.1093/europace/euw141] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
The increasing interest in left atrial appendage occlusion (LAAO) for ischaemic stroke prevention in atrial fibrillation (AF) fuels the need for more clinical data on the safety and effectiveness of this therapy. Besides an assessment of the effectiveness of the therapy in specific patients groups, comparisons with pharmacological stroke prophylaxis, surgical approaches, and other device-based therapies are warranted. This paper documents the consensus reached among clinical experts in relevant disciplines from Europe and North America, European cardiology professional societies, and representatives from the medical device industry regarding definitions for parameters and endpoints to be assessed in clinical studies. Adherence to these definitions is proposed in order to achieve a consistent approach across clinical studies on LAAO among the involved stakeholders and various clinical disciplines and thereby facilitate continued evaluation of therapeutic strategies available.
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Affiliation(s)
- Apostolos Tzikas
- Department of Cardiology, AHEPA University Hospital, Asklipiou 10, 57001 Thessaloniki, Greece
| | | | | | - Carlos E Ruiz
- Hackensack UMC Heart and Vascular Hospital and The Joseph M. Sanzari Children's Hospital, Hackensack, NJ, USA
| | | | - Hans-Christoph Diener
- Department of Neurology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Riccardo Cappato
- Arrhythmia and Electrophysiology Research Center, IRCCS Humanitas Research Hospital, Milan, Italy
- Arrhythmia and Electrophysiology II Center, Humanitas Gavazzeni Clinics, Bergamo, Italy
| | - Saibal Kar
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Randal J Lee
- Cardiovascular Research Institute and Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Robert A Byrne
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
| | - Reda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Dhanunjaya Lakkireddy
- Bloch Heart Rhythm Center @ University of Kansas Hospital, KU Cardiovascular Research Institute, Kansas City, KS, USA
| | - Osama I Soliman
- Cardialysis and Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, The Netherlands
| | - Michael Nabauer
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität, Munich, Germany
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung (Foundation IHF), Ludwigshafen, Germany
| | | | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine at the University of California, Los Angeles, CA, USA
| | - Klaus Tiemann
- Department of Nuclear Medicine, Technical University of Munich,Munich, Germany
| | | | - A John Camm
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London, London, UK
| | - Thorsten Lewalter
- Department of Medicine-Cardiology and Intensive Care, Peter Osypka Heart Center, Clinic Munich-Thalkirchen, Am Isarkanal 36, 81379 Munich, Germany
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95
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Abstract
Whereas the left atrial appendage plays a rather minor role under physiological circumstances, it gains an importance in patients with atrial fibrillation. Compelling evidence has revealed that the left atrial appendage is implicated as the source of thrombus in the vast majority of strokes in atrial fibrillation. Oral anticoagulation remains the standard of care for stroke prevention in atrial fibrillation; nevertheless, this treatment has several limitations and is often contraindicated, particularly in the elderly population in whom the risk of stroke is high. Therefore, occluding the left atrial appendage is a logical approach to prevent thrombus formation and subsequent cardioembolic events in these patients. We present a review of clinical outcomes of patients with atrial fibrillation undergoing left atrial appendage closure and the challenges faced in this field.
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96
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Kreidieh B, Mañero MR, Cortez SHI, Schurmann P, Valderrábano M. The Cost Effectiveness of LAA Exclusion. J Atr Fibrillation 2016; 8:1374. [PMID: 27909482 DOI: 10.4022/jafib.1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 02/09/2016] [Accepted: 02/22/2016] [Indexed: 11/10/2022]
Abstract
Left atrial appendage (LAA) exclusion strategies are increasingly utilized for stroke prevention in lieu of oral anticoagulants. Reductions in bleeding risk and long-term compliance issues bundled with comparable stroke prevention benefits have made these interventions increasingly attractive. Unfortunately, healthcare funding remains limited. Comparative cost economic analyses are therefore critical in optimizing resource allocation. In this review we seek to discourse the cost economics analysis of LAA exclusion over available therapeutic alternatives (warfarin and the new oral anticoagulants (NOACs)). .
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Affiliation(s)
- Bahij Kreidieh
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Moisés Rodríguez Mañero
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Sergio H Ibarra Cortez
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Paul Schurmann
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
| | - Miguel Valderrábano
- Methodist DeBakey Heart and Vascular Center and Methodist Hospital Research Institute, The Methodist Hospital, Houston, Texas
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97
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Morin DP, Bernard ML, Madias C, Rogers PA, Thihalolipavan S, Estes NAM. The State of the Art: Atrial Fibrillation Epidemiology, Prevention, and Treatment. Mayo Clin Proc 2016; 91:1778-1810. [PMID: 27825618 DOI: 10.1016/j.mayocp.2016.08.022] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 08/04/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022]
Abstract
As the most common sustained arrhythmia in adults, atrial fibrillation (AF) is an established and growing epidemic. To provide optimal patient care, it is important for clinicians to be aware of AF's epidemiological trends, methods of risk reduction, and the various available treatment modalities. Our understanding of AF's pathophysiology has advanced, and with this new understanding has come advancements in prevention strategies as well as pharmacological and nonpharmacological treatment options. Following PubMed and MEDLINE searches for AF risk factors, epidemiology, and therapies, we reviewed relevant articles (and bibliographies of those articles) published from 2000 to 2016. This "state-of-the-art" review provides a comprehensive update on the understanding of AF in the world today, contemporary therapeutic options, and directions of ongoing and future study.
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Affiliation(s)
- Daniel P Morin
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA; Ochsner Clinical School, The University of Queensland School of Medicine, New Orleans, LA.
| | | | - Christopher Madias
- Electrophysiology, Arrhythmia and Pacemaker Program, Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Paul A Rogers
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA
| | | | - N A Mark Estes
- Cardiac Arrhythmia Center, Tufts Medical Center, Boston, MA
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98
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Prakash R, Saw J. Imaging for percutaneous left atrial appendage closure. Catheter Cardiovasc Interv 2016; 92:437-450. [DOI: 10.1002/ccd.26828] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 10/08/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Roshan Prakash
- Division of Cardiology; Vancouver General Hospital; Vancouver BC V5Z1M9 Canada
| | - Jacqueline Saw
- Division of Cardiology; Vancouver General Hospital; Vancouver BC V5Z1M9 Canada
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99
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4703] [Impact Index Per Article: 587.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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100
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