Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug

Interventional occlusion of left atrial appendage in patients with atrial fibrillation. Gender-related outcomes in the German LAARGE Registry

INTRODUCTION

Gender-based differences in atrial fibrillation have been identified, but limited data exist for patients undergoing left atrial appendage occluder (LAAO) implantation. This study reports gender-related periprocedural and 1-year outcomes of the prospective, multicenter German left atrial appendage occlusion registry (LAARGE).

METHODS

LAARGE enrolled 641 patients who were scheduled for LAAO implantation from July 2014 to January 2016 in 38 hospitals in Germany. The data collected included demographics, clinical characteristics, details of implantation, and outcome. Efficacy and safety at 1-year follow-up were assessed by the occurrence of thrombembolic and bleeding events, as well as mortality.

RESULTS

Of 638 patients undergoing LAAO implantation 38.9% were female and 61.1% male. Females were older (76.4 ± 8.2 [females] vs. 75.6 ± 7.7 [males], p = .042) and had a higher stroke risk (CHA₂ DS₂ -VASc score: 4.9 ± 1.5 vs. 4.3 ± 1.5, p < .001). In contrast, males suffered more often from coronary artery (33.1% vs. 53.8%, p < .001) and vascular disease (18.5% vs. 31.0%, p < .001). Technical success was high and similar for both genders (98.4% vs. 97.2%, p = .33). Severe periprocedural complications (6.9% vs. 3.1%, p = .032) occurred more often in females. At 1-year follow-up the rates of all-cause stroke (0.5% vs. 1.3%, p = .65) and severe bleeding (0.0% and 1.0%, p = .29) were low and comparable between the genders. Also, one-year all-cause mortality (9.2% vs. 13.1%, p = .14) did not differ significantly.

CONCLUSION

LAARGE documented in this elderly patient population undergoing LAAO implantation a higher rate of severe periprocedural complications in females. At 1-year follow-up similar efficacy and safety outcomes were observed for both genders.

Clinical Impact of Preprocedural CT-Based 3D Computational Simulation of Left Atrial Appendage Occlusion with Amulet

Aims

Standard of care (SoC) device size selection with transoesophageal echocardiography (TOE) and computed tomography (CT) in LAAO can be challenging due to a certain degree of variability at both patient and device levels. The aim of this study was to prospectively evaluate the clinical impact of 3D computational modelling software in the decision-making of left atrial appendage occlusion (LAAO) with Amplatzer Amulet.

Methods and Results

SoC preprocedural assessments as well as CT-based 3D computational simulations (FEops) were performed in 15 consecutive patients scheduled for LAAO with Amulet. Preprocedural device size selection and degree of confidence were determined after SoC and after FEops-based assessments and compared to the implanted device. FEops-based preprocedural assessment correctly selected the implanted device size in 11 out of 15 patients (73.3%), compared to 7 patients (46.7%) for SoC-based assessment. In 4 patients (26.7%), FEops induced a change in device size initially selected by SoC. In the 7 patients (46.7%) in which FEops confirmed the SoC device size selection, the degree of confidence of the size selection increased from 6.4 ± 1.4 for SoC to 8.1 ± 0.7 for FEops. One patient (6.7%) could not be implanted for anatomical reason, as correctly identified by FEops.

Conclusions

Preprocedural 3D computational simulation by FEops impacts Amulet size selection in LAAO compared to TOE and CT-based SoC assessment. Operators could consider FEops computational simulation in their preprocedural device size selection.

Clinical Performance of a Powered Surgical Stapler for Left Atrial Appendage Resection in a Video-Assisted Thoracoscopic Ablation for Patients with Nonvalvular Atrial Fibrillation

Left atrial appendage (LAA) has been found to be associated with the occurrence of thromboembolism in patients with nonvalvular atrial fibrillation (NVAF). Stapling exclusion of LAA during surgical ablation could be an alternative to oral anticoagulation for NVAF patients. However, its safety and efficacy have rarely been examined. Thus, in this study, we aimed to evaluate the safety and efficacy of a powered surgical stapler for LAA resection during ablation for patients with NVAF.Adult patients with NVAF undergoing stapler surgery were included in this study. LAAs of patients were cut off using a powered surgical stapler. Intraoperative transesophageal echocardiogram (TEE) was applied before and after the operation. Each patient received anticoagulant therapy for 2 months after surgery and was regularly followed up by appointment or via telephone call. Patients would undergo physical examinations, echocardiography, and 24-hour dynamic electrocardiogram in a local or in our hospital to determine whether there was a recurrence of atrial fibrillation (AF) or thromboembolism caused by AF.In total, 124 patients were included in this study (male: 88 (71.0%); mean age: 62.3 years). Blood loss was less than 100 mL in all patients with no operative complications or hospital deaths. Moreover, 119 (96.0%) follow-up data were collected, with a mean period of 27.4 months. All patients discontinued oral anticoagulants 2 months after their operation. As per our findings, AF recurred in 23 patients (18.5%), with an average of 9.1 months after surgery. No patients were diagnosed with thromboembolism related to AF.Stapling exclusion of LAA during surgical ablation could safely and completely resect the LAA. The effect of thrombus prevention was deemed satisfactory.

Strategies for Recovering an Embolized Percutaneous Device

PURPOSE OF REVIEW

Device embolization is a rare but potentially life-threatening complication of transcatheter structural heart interventions and may require prompt intervention. The present work aims to provide an overview of strategies for device retrievals in order to better guide the evaluation and management of device embolization.

RECENT FINDINGS

Although the evolution of transcatheter device therapies has had a tremendous impact on the management in structural heart disease, availability of various retrieval devices, knowledge in how to use them, and multidisciplinary collaboration are key for successful device retrieval. Understanding the reasons for embolization, strategies to avoid embolization, and the techniques for retrieval of devices used in structural heart disease should be appreciated by the treating physician.

Comorbidity burden in patients undergoing left atrial appendage closure

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.

Sex Differences in Outcomes Following Left Atrial Appendage Closure

OBJECTIVE

To evaluate the effects of female sex on in-hospital outcomes and to provide estimates for sex-specific prediction models of adverse outcomes following left atrial appendage closure (LAAC).

PATIENTS AND METHODS

Cohort-based observational study querying the National Inpatient Sample database between October 1, 2015, and December 31, 2017. Demographics, baseline characteristics, and comorbidities were assessed with the Charlson Comorbidity Index (CCI), Elixhauser Comorbidity Index score (ECS), and CHA₂DS₂-VASc score. The primary outcome was in-hospital major adverse events (MAEs) defined as the composite of bleeding, vascular, cardiac complications, post-procedural stroke, and acute kidney injury. The associations of the CCI, ECS, and CHA₂DS₂-VASc score with in-hospital MAE were examined using logistic regression models for women and men, respectively.

RESULTS

A total of 3294 hospitalizations were identified, of which 1313 (40%) involved women and 1981 (60%) involved men. Women were older (76.3±7.7 vs 75.2±8.4 years, P<.001), had a higher CHA₂DS₂-VASc score (4.9±1.4 vs 3.9±1.4, P<.001) but showed lower CCI and ECS compared with men (2.1±1.9 vs 2.3±1.9, P=.01; and 9.3±5.9 vs 9.9±5.7, P=.002, respectively). The primary composite outcome occurred in 4.6% of patients and was higher in women compared with men (women 5.6% vs men 4.0%, P=.04), and this was mainly driven by the occurrence of cardiac complications (2.4% vs 1.2%, P=.01). In women, older age, higher median income, and higher CCI (adjusted odds ratio [aOR], 1.32; 95% confidence interval [CI], 1.21 to 1.44; P<.001), ECS (aOR, 1.04; 95% CI, 1.02 to 1.07; P=.002), and CHA₂DS₂-VASc score (aOR, 1.24; 95% CI, 1.10 to 1.39; P<.001) were associated with increased risk of in-hospital MAE. In men, non-White race/ethnicity, lower median income, and higher ECS (aOR, 1.06; 95% CI, 1.04 to 1.09; P<.001) were associated with increased risk of in-hospital MAE.

CONCLUSION

Women had higher rates of in-hospital adverse events following LAAC than men did. Women with older age and higher median income, CCI, ECS, and CHA₂DS₂-VASc scores were associated with in-hospital adverse events, whereas men with non-White race/ethnicity, lower median income, and higher ECS were more likely to experience adverse events. Further research is warranted to identify sex-specific, racial/ethnic, and socioeconomic pathways during the patient selection process to minimize complications in patients undergoing LAAC.

Recent developments in next-generation occlusion devices

Transcatheter closure has been widely accepted as a highly effective way to treat abnormal blood flows and/or embolization of thrombus in the heart. It allows the closure of four types of congenital heart defects (CHDs) and stroke-associated left atrial appendage (LAA). The four types of CHDs include atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), and ventricular septal defect (VSD). Advancements in the materials and configurations of occlusion devices have spurred the transition from open-heart surgery with high complexity and morbidity, or lifelong medication with a high risk of bleeding, to minimally invasive deployment. A variety of occlusion devices have been developed over the past few decades, particularly novel ones represented by biodegradable and 3D-printed occlusion devices, which are considered as next-generation alternatives to conventional Nitinol-based occlusion devices due to biodegradability, customization, and improved biocompatibility. The aim here is to comprehensively review the next-generation occlusion devices in terms of materials, configurations, manufacturing methods, deployment strategies, and (if available) experimental results or clinical data. The current challenges and the direction of future work are also proposed. STATEMENT OF SIGNIFICANCE: Implantation of occlusion devices has become a widely accepted and highly effective treatment for occluding abnormal blood/thrombus flow within the heart. Due to the serious complications such as erosion and displacement of conventional Nitinol-based occluders, next-generation occluders with reduced risk of complications and improved biocompatibility has emerged. Here, we comprehensively review the next-generation occluders developed for atrial septal defect (ASD), patent foramen ovale (PFO), patent ductus arteriosus (PDA), ventricular septal defect (VSD), and left atrial appendage (LAA), with special emphasis on biodegradable occluders. Besides, intelligent materials (e.g., automatically deployable shape memory polymers) and rapid customized manufacturing methods (3D/4D printing) for the fabrication of occluders are also introduced. Lastly, the directions of future work are highlighted.

What Does the Future Hold?: Ideal Device, Newer Devices, and More

Please verify if "pigtail guided" should be "pigtail catheter-guided": Recent design changes for left atrial appendage (LAA) closure devices have led to significant improvement by facilitating the procedural workflow (no need for pigtail guided LAA intubation), moving the workspace from distal LAA to the landing zone (closed distal end design), and improving device stability (different anchor design). The availability of different device types (plug vs disc-lobe design) offers an option to tailor a device type to a patient's anatomy; thereby, sealing results have improved substantially. The issue of device-related thrombus has not been resolved and deserves future research, with the goal of eliminating postprocedural antithrombotic medication without increasing risk for stroke.

Initial and long-term antithrombotic therapy after left atrial appendage closure with the WATCHMAN

AIMS

Evidence regarding post-procedural antithrombotic regimen other than used in randomized trials assessing percutaneous left atrial appendage (LAA) closure is limited. The present work aimed to compare different antithrombotic strategies applied in the real-world EWOLUTION study.

METHODS AND RESULTS

A total of 998 patients with successful WATCHMAN implantation were available for the present analysis. The composite ischaemic endpoint of stroke, transitory ischaemic attack, systemic embolism and device thrombus, and the bleeding endpoint defined as at least major bleeding were assessed during an initial period (from implant until first medication change) and long-term period (from first change up to 2 years). The antithrombotic medication chosen in the initial phase was dual antiplatelet therapy (DAPT) in 60%, oral anticoagulation (OAC) in 27%, single antiplatelet therapy (SAPT) in 7%, and no medication in 6%. In the second long-term phase, SAPT was used in 65%, DAPT in 23%, no therapy in 8%, and OAC in 4%. No significant differences were found between the groups regarding the ischaemic endpoint both in the initial period (Kaplan-Meier estimated rate 2.9% for DAPT vs. 4.3% for OAC vs. 3.9% for SAPT or no therapy) and in the second period (4.2% for SAPT vs. 1.8% for DAPT vs. 3.5% for no therapy). With respect to bleeding events, the only difference was found in the initial phase with a higher incidence in patients under SAPT or no therapy.

CONCLUSIONS

Tailored antithrombotic treatment using even very reduced strategies such as SAPT or no therapy showed no significant differences regarding ischaemic complications after LAA closure.

Incidence, predictors, and clinical impact of bleeding recurrence in patients with prior gastrointestinal bleeding undergoing LAAC

BACKGROUND

Gastrointestinal bleeding (GIB) is associated with a high recurrence rate and a prior GIB episode is common in real-world left atrial appendage closure (LAAC) recipients. The present study sought to evaluate the clinical characteristics and outcomes of patients with prior GIB undergoing LAAC, and to determine the factors associated with and clinical impact of GIB recurrence.

METHODS

Multicenter study including 277 consecutive patients who underwent percutaneous LAAC and had prior GIB. All-cause death, all bleeding, GIB recurrence, and clinical ischemic stroke were recorded.

RESULTS

After a median follow-up of 17 (interquartile range: 6-37) months post-LAAC, the rates of death, bleeding, GIB recurrence, and ischemic stroke were 14.0 per 100 person-year (PY), 29.3 per 100 PY, 17.7 per 100 PY, and 1.1 per 100 PY, respectively. GIB recurrence occurred within 3 months post-LAAC in 55.8% of patients. A previous lower GIB (vs. upper or unclassified) (HR: 1.76; 95% CI: 1.09-2.82; p = .020) and eGFR < 45 mL/min (HR: 1.70; 95% CI:1.04-2.67; p = .033) determined an increased risk of GIB recurrence. By multivariable analysis, eGFR < 45 mL/min (HR: 2.72; 95% CI: 1.70-4.34; p < .001), GIB recurrence following LAAC (HR: 2.15; 95% CI: 1.33-3.46; p = .002), diabetes mellitus (HR: 1.77; 95% CI: 1.10-2.84; p = .018), and age (HR: 1.06; 95% CI: 1.03-1.10; p < .001) were associated with an increased mortality.

CONCLUSIONS

Patients with prior GIB undergoing LAAC exhibited a relatively low rate of GIB recurrence, and prior lower GIB and moderate-to-severe chronic kidney disease determined an increased risk. GIB recurrence was associated with an increased mortality.

The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030

Cardiovascular disease is the leading cause of death in women. Decades of grassroots campaigns have helped to raise awareness about the impact of cardiovascular disease in women, and positive changes affecting women and their health have gained momentum. Despite these efforts, there has been stagnation in the overall reduction of cardiovascular disease burden for women in the past decade. Cardiovascular disease in women remains understudied, under-recognised, underdiagnosed, and undertreated. This Commission summarises existing evidence and identifies knowledge gaps in research, prevention, treatment, and access to care for women. Recommendations from an international team of experts and leaders in the field have been generated with a clear focus to reduce the global burden of cardiovascular disease in women by 2030. This Commission represents the first effort of its kind to connect stakeholders, to ignite global awareness of sex-related and gender-related disparities in cardiovascular disease, and to provide a springboard for future research.

Left atrial appendage occlusion in the UK: prospective registry and data linkage to Hospital Episode Statistics

AIMS

Non-valvular atrial fibrillation (AF) greatly increases the risk of ischaemic stroke. For people with contraindications to oral anticoagulation, left atrial appendage occlusion (LAAO) provides a non-pharmacological management alternative. The aim of this study was to measure the procedural safety and longer-term effectiveness of LAAO for AF in a UK setting.

METHODS AND RESULTS

This was a prospective, single-armed registry of patients with AF for whom anticoagulation was unsuitable. Registry data were collected between October 2014 and April 2018 and linked to routine data sources for Follow-up.Data from 583 LAAO procedures were entered into the registry, of which 537 (from 525 patients) were eligible for inclusion (median CHA2DS2-VASc score 4). A closure device was successfully implanted in 93.4% of cases, with a procedural success rate (device implanted without major complication) of 88.9%. Five patients (1.0%) died in hospital. During follow-up (median 729 (Q1: Q3, 523:913) days) 45 patients experienced neurological events; 33 of which were ischaemic. The ischaemic neurological event rate was 3.3 [1.6 to 5.0]% at 1 year (n = 387) and 7.0 [4.3 to 9.6]% at 2-years (n = 196). There were significant improvements in overall patient health (via Visual Analogue Scale) measured at 6 weeks and 6 months, but no significant improvements observed in patient utility over time.

CONCLUSION

The findings of our study suggest that LAAO is not without procedural risk, but that this risk may be justified in high-risk patients with AF who cannot take an anticoagulant. Moreover the data do not provide support for more widespread use of LAAO as the complication rate was relatively high and would be would be difficult to justify in many patients with AF who tolerate anticoagulation.

Intracardiac echocardiography for guidance of transcatheter left atrial appendage occlusion: An expert consensus document

Transcatheter left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in selected patients with atrial fibrillation. Intraprocedural imaging is a crucial for a successful intervention, with transesophageal echocardiography (TEE) as the current gold standard. Since some important limitations may affect TEE use, intracardiac echocardiography (ICE) is increasingly used as an alternative to TEE for guiding LAAO. The lack of a standardized imaging protocol has slowed the adoption of ICE into clinical practice. On the basis of current research and expert consensus, this paper provides a protocol for ICE support of left atrial appendage occlusion.

Amplatzer left atrial appendage closure: Single versus combined procedures

OBJECTIVES

This study compares procedural and late clinical outcomes of left atrial appendage closure (LAAC) with Amplatzer devices as a single versus a combined procedure with other structural or coronary interventions.

BACKGROUND

Multiple cardiac conditions are frequent among elderly patients and invite simultaneous treatment to ensure a favorable patient outcomes.

METHODS

559 consecutive patients (73.3 ± 11.1 years) underwent LAAC with Amplatzer devices at two centres (Bern and Zurich university hospitals, Switzerland) either as a single procedure or combined with other interventions. The primary safety endpoint was a composite of major peri-procedural complications and major bleeding at follow-up, the primary efficacy endpoint included stroke, systemic embolism, and cardiovascular/unexplained death. All event rates are reported per 100 patient-years.

RESULTS

In 263 single and 296 combined procedures with percutaneous coronary interventions (47.6%), closure of an atrial septal defect (8.4%) or a patent foramen ovale (36.5%), transcatheter aortic valve implantation (10.1%), mitral clipping (4.1%), atrial fibrillation ablation (8.8%), or another procedure (3.0%) were analyzed. Device success (96.6% [single] vs. 99.0% [combined], p = .08) did not differ between the groups. After a mean follow-up of 2.6 ± 1.5 vs. 2.5 ± 1.5 years and a total of 1,422 patient-years, the primary efficacy (40/677, 5.9% [single] vs. 37/745, 5.0% [combined]; HR, 1.2, 95% CI, 0.8-1.9, p = .44), as well as the primary safety endpoint (25/677, 3.7% vs 28/745, 3.8%; HR, 1.0, 95% CI, 0.6-1.8, p = .89) were comparable.

CONCLUSIONS

LAAC with Amplatzer devices combined with structural, coronary, and electrophysiological procedures offers procedural feasibility and safety, as well as long-term efficacy.

Left atrial appendage occlusion in chicken-wing anatomies: Imaging assessment, procedural, and clinical outcomes of the "sandwich technique"

OBJECTIVES

To describe imaging assessment, procedural and follow-up outcome of patients undergoing left atrial appendage (LAA) occlusion (LAAO) using a "sandwich" technique.

BACKGROUND

The presence of a LAA with chicken wing morphology constitutes a challenge that sometimes requires specific occlusion strategies like the "sandwich" technique. However, procedural and follow-up data focusing on this implanting strategy is scarce.

METHODS

This multicenter study collected individual data from eight centers between 2012 and 2019. Consecutive patients with chicken-wing LAAs defined as an early (<20 mm from the ostium) and severe bend (>90°) who underwent LAAO with Amplatzer devices and using the "sandwich" technique were included in the analysis.

RESULTS

Overall, 190 subjects were enrolled in the study. Procedures were done with the Amulet device (85%) and the Amplatzer Cardiac Plug (15%). Successful implantation was achieved in 99.5% with ≤1 partial recapture in 80% of cases. Single (46.2%) and dual antiplatelet therapy (39.4%) were the most used antithrombotic therapies after LAAO. In-hospital major adverse events rate was 1.5% with no deaths. One patient (0.5%) had cardiac tamponade requiring percutaneous drainage. With a mean follow-up of 19.6 ± 14.8 months, the mortality and stroke rates were 7.7%/year and 2.5%/year, respectively. Follow-up transesophageal echocardiography (TEE) at 2-3 months showed device-related thrombosis in 2.8% and peri-device leak ≥3 mm in 1.2% of patients.

CONCLUSIONS

In a large series of patients with chicken wing LAA anatomies undergoing LAAO, the use of the "sandwich" technique was feasible and safe. Preprocedural imaging was a key-factor to determine specific measurements.

Impact of individual stroke risk on outcome after Amplatzer left atrial appendage closure in patients with atrial fibrillation

OBJECTIVES

To investigate periprocedural and long-term outcome of left atrial appendage closure (LAAC) using Amplatzer occluders with respect to individual pre-procedural stroke risk.

BACKGROUND

LAAC is a proven strategy for prevention from stroke and bleeding in patients with nonvalvular atrial fibrillation not amenable to oral anticoagulation. Whether individual pre-procedural stroke risk may affect procedural and long-term clinical outcome after LAAC is unclear.

METHODS

Multicenter study of consecutive patients who underwent Amplatzer-LAAC. Using pre-procedural CHADS₂ score, outcomes were compared between a low (0-2 points) and a high stroke risk group (3-6 points).

RESULTS

Five hundred consecutive patients (73.9 ± 10.1 years) who underwent Amplatzer-LAAC. Two hundred and forty eight had preprocedural CHADS₂ score ≤ 2 points (low-risk group) and the remaining 252 patients had 3-6 points (high-risk group). Periprocedural complication rates (6.0% vs. 5.6%, p = .85), procedural success (LAAC without major periprocedural or device-related complications or major para-device leaks: 89.4% vs. 87.9%, p = .74), and 30-day-mortality (2.4% vs. 2.6%, p = .77) were comparable. After 1,346 patient-years (PY), the long-term composite efficacy endpoint (stroke, systemic embolism, cardiovascular, and unexplained death) was reached in 23/653 (3.5/100 PY) versus 52/693 (7.5/100 PY); HR = 2.13; 95%-CI, 1.28-3.65, p = .002) with stroke rates 67% and 68% lower than anticipated by preprocedural CHADS₂ score. Combined safety endpoint (major periprocedural complications and major, life-threatening or fatal bleedings) occurred in 22/653 (3.4/100 PY) versus 28/693 (4.0/100 PY); HR = 1.20; 95%-CI, 0.66-2.20, p = .52).

CONCLUSIONS

Compared with patients at low risk of stroke, LAAC with Amplatzer devices is associated with similar safety and efficacy in high-risk patients in our study.

Delayed pericardial effusion after left atrial appendage closure with the LAmbre device: Importance of a fully open umbrella

INTRODUCTION

We aimed to investigate whether a modified implantation method facilitating a fully open umbrella can reduce the pericardial effusion/pericardial tamponade (PE/PT) rate after left atrial appendage closure (LAAC) with the LAmbre device compared with the conventional method (CM) in patients with non-valvular atrial fibrillation (NVAF).

METHODS AND RESULTS

Patients with NVAF who received either isolated LAAC or combined catheter ablation and LAAC using the LAmbre device at the First Affiliated Hospital of Wenzhou Medical University from January 2018 to December 2019 were enrolled. CM was used for device implantation in the initial 59 patients, while a modified method (MM) was used in the remaining 165 patients. Successful implantation was achieved in 98.3% of patients in the CM group and 98.8% in the MM group. A higher rate of a fully open umbrella (98.8% vs. 69%, p < .001), less requirement for recapture (46% vs. 62.1%, p = .036), and a lower incidence of delayed PE/PT (1.2% vs. 8.6%, p = .005) were found in the MM group compared with the CM group. All of the five delayed PT events occurred in patients with combined treatment. An umbrella that was not fully open was the only factor associated with delayed PE/PT events in a multivariable Cox model.

CONCLUSIONS

LAAC with the LAmbre device using an MM significantly increases the rate of a fully open umbrella and decreases the requirement for recapture and the incidence of delayed PE/PT. This method is more effective in patients with combined treatment.

Left atrial appendage closure for stroke prevention in atrial fibrillation: Final report from the French left atrial appendage closure registry

OBJECTIVES

The French left atrial appendage (LAA) closure registry (FLAAC) aimed to assess the safety and efficacy of LAA closure in daily practice.

BACKGROUND

LAA closure has emerged as an alternative for preventing thromboembolic events (TE) in patients with non-valvular atrial fibrillation (NVAF). Clinical data in this field remains limited and few investigator-initiated, real-world registries have been reported.

METHODS

This nationwide, prospective study was performed in 36 French centers. The primary endpoint was the TE rate after successful LAA closure.

RESULTS

The FLAAC registry included 816 patients with a mean age of 75.5 ± 0.3 years, mean follow-up of 16.0 ± 0.3 months, high TE (CHA₂ DS₂ -VASc score: 4.6 ± 0.1) and bleeding risks (HAS-BLED score: 3.2 ± 0.05) and common contraindications to long-term anticoagulation (95.7%). Procedure or device-related serious adverse events occurred in 49 (6.0%) patients. The annual rate of ischemic stroke/systemic embolism was 3.3% (2.4-4.6). This suggests a relative 57% reduction compared to the risk of stroke in historical NVAF populations without antithrombotic therapy. By multivariate analysis, history of TE was the only factor associated with stroke/systemic embolism during follow-up (HR, 3.3 [1.58-6.89], p = 0.001). The annual mortality rate was 10.2% (8.4-12.3). Most of the deaths were due to comorbidities or underlying cardiovascular diseases and unrelated to the device or to TE.

CONCLUSIONS

Our study suggests that LAA closure can be an option in patients with NVAF. Long-term follow-up mortality was high, mostly due to comorbidities and underlying cardiovascular diseases, highlighting the importance of multidisciplinary management after LAA closure.

REGISTRATION

NCT02252861.

Left atrial appendage occlusion with the Amplatzer™ Amulet™ device: full results of the prospective global observational study

AIMS

To evaluate the safety and efficacy of left atrial appendage occlusion (LAAO) with the Amplatzer™ Amulet™ occluder.

METHODS AND RESULTS

Patients with atrial fibrillation eligible for LAAO were recruited to a prospective global study. Implant procedures were undertaken with echocardiographic guidance. Transoesophageal echocardiography (TOE) was undertaken 1-3 months post-LAAO. Implant and follow-up TOEs were evaluated by a CoreLab. The primary endpoint was a composite of ischaemic stroke and cardiovascular death at 2 years. Serious adverse events were adjudicated by an independent clinical events committee. A total of 1088 patients were enrolled, aged 75.2 ± 8.5 years; 64.5% were male. CHA2DS2-VASc and HAS-BLED scores were 4.2 ± 1.6 and 3.3 ± 1.1, respectively. A total of 71.7% had prior major bleeding, and 82.8% had contraindications to oral anticoagulants. Implant success was 99.1%. Major adverse events (≤7 days post-procedure) occurred in 4.0%, including death (0.3%), stroke (0.4%), major vascular (1.3%), and device embolization (0.2%). A total of 80.2% of patients were discharged on antiplatelet therapy alone. Peridevice flow was <3 mm in 98.4% at follow-up TOE. Device-related thrombus (DRT) was seen in 1.6% of cases. Cardiovascular death or ischaemic stroke occurred in 8.7% of patients at 2 years. The ischaemic stroke rate was 2.2%/year-a 67% reduction compared to the CHA2DS2-VASc predicted rate. Major bleeding (Bleeding Academic Research Consortium type ≥ 3) occurred at rates of 10.1%/year (year 1) and 4.0%/year (year 2).

CONCLUSION

Following LAAO with the Amplatzer Amulet device, the ischaemic stroke rate was reduced by 67% compared to the predicted risk. Closure was complete in 98.4% of cases and DRT seen in only 1.6%.

Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding

Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.

Left atrial appendage perforation during appendage angiography treated by percutaneous left atrial appendage closure: a case report

Background

Pericardial effusion is a common complication of percutaneous left atrial appendage (LAA) closure. Acute management is the cornerstone of pericardial effusion treatment and interrupting the intervention is often required.

Case summary

A 65-year-old man presented an acute 10 mm pericardial effusion following pigtail contrast appendage injection. A rapid Watchman Flex 24 mm (Boston Scientific) deployment permitted bleeding interruption. A needle pericardiocentesis was achieved in order to prevent any haemodynamical instability.

Discussion

This case report describes an atypical cause of pericardial effusion and a technique for bleeding control with LAA closure device deployment.

Percutaneous left atrial appendage occlusion: A review of current devices, clinical evidence, patient selection, and post procedural antithrombotic management

Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.

Non-vitamin K antagonist oral anticoagulation versus left atrial appendage occlusion for primary and secondary stroke prevention after cardioembolic stroke

INTRODUCTION

This study aimed to evaluate the performance of non-vitamin K antagonist oral anticoagulation (NOAC) in patients with previous stroke and non-valvular atrial fibrillation (AF) compared with left atrial appendage occlusion (LAAO) in primary and secondary stroke prevention settings.

METHODS

This was a prospective, single-center, non-randomized cohort study of 302 consecutive patients with non-valvular AF and at high risk for stroke. Two treatment strategies were compared: LAAO (n=91) and long-term treatment with NOAC (n=149). The primary outcome was the composite endpoint of death, stroke and major bleeding. Propensity score and cause-of-death analyses were performed to compare outcomes.

RESULTS

In a mean follow-up of 13 months, there were 30 deaths (LAAO 8.8% vs. NOAC 14.8%), five strokes (LAAO 1.1% vs. NOAC 2.7%) and six major bleeds (LAAO 1.1% vs. NOAC 3.4%). There was a non-significant trend for a lower incidence of the primary endpoint in the LAAO group (11.0% vs. 20.9%; HR 0.42, 95% CI 0.17-1.05, p=0.064). Considering only secondary prevention LAAO patients (34.1% of the LAAO group), there was also a non-significant lower incidence of the primary endpoint (LAAO 6.5% vs. 20.9%; HR 0.30, 95% CI 0.07-1.39, p=0.12). While about a fifth of LAAO patients stopped antiplatelet treatment six months after device implantation due to recurrent minor bleeding, no adverse cardiovascular event or major bleeding occurred in this subset of patients.

CONCLUSION

In this registry-based study, LAAO was a reasonable alternative to NOAC for the prevention of a composite endpoint of all-cause mortality, stroke and major bleeding in patients at high risk for stroke.

A comprehensive comparison of various patient-specific CFD models of the left atrium for atrial fibrillation patients

BACKGROUND

Recently, advances in medical imaging, segmentation techniques, and high-performance computing have supported the use of patient-specific computational fluid dynamics (CFD) simulations. At present, CFD-compatible atrium geometries can be easily reconstructed from atrium images, providing important insight into the atrial fibrillation (AF) phenomenon, and assistance during therapy selection and surgical procedures. However, the hypothesis assumed for such CFD models should be adequately validated.

AIM

This work aims to perform an extensive study of the different hypotheses that are commonly assumed when performing atrial simulations for AF patients, as well as to evaluate and compare the range of indices that are usually applied to assess thrombus formation within the left atrium appendage (LAA).

METHODS

The atrial geometries of two AF patients have been segmented. The resulting geometries have been registered and interpolated to construct a dynamic mesh, which has been employed to compare the rigid and flexible models. Two families of hemodynamic indices have been calculated and compared: wall shear-based and blood age distribution-based.

RESULTS

The findings of this study illustrate the importance of validating the rigid atrium hypothesis when utilizing an AF CFD model. In particular, the absence of the A-wave contraction does not avoid a certain degree of passive atrial contraction, making the rigid model a poor approximation in some cases. Moreover, a new thrombosis predicting index has been proposed, i.e., M4, which has been shown to predict stasis more effectively than other indicators.

Design and Rationale of the Swiss-Apero Randomized Clinical Trial: Comparison of Amplatzer Amulet vs Watchman Device in Patients Undergoing Left Atrial Appendage Closure

Residual or newly acquired leaks are routinely appraised after left atrial appendage closure (LAAC). The Watchman and the Amulet are the two most frequently used devices for LAAC but no randomized study has so far assessed their comparative leak rates after intervention. The "Comparison of Amplatzer Amulet vs Watchman devices in patients undergoing left atrial appendage closure" (Swiss-Apero, clinicaltrial.gov NCT03399851) is an academic-sponsored multicenter, randomized clinical trial comparing Amulet versus Watchman/FLX devices among patients undergoing a clinically indicated LAAC. The study is designed to assess the superiority of Amulet vs. Watchman/FLX in terms of leaks detected by cardiac computed tomography angiography (CCTA) at 45 days (primary endpoint) and 13 months (secondary endpoint) after intervention by an imaging Core Laboratory. The Swiss-Apero study is the first randomized clinical trial comparing Amulet and Watchman/FLX with respect to the prevalence of post-procedural leak as assessed with CCTA.

Non-vitamin K antagonist oral anticoagulation versus left atrial appendage occlusion for primary and secondary stroke prevention after cardioembolic stroke

INTRODUCTION

This study aimed to evaluate the performance of non-vitamin K antagonist oral anticoagulation (NOAC) in patients with previous stroke and non-valvular atrial fibrillation (AF) compared with left atrial appendage occlusion (LAAO) in primary and secondary stroke prevention settings.

METHODS

This was a prospective, single-center, non-randomized cohort study of 302 consecutive patients with non-valvular AF and at high risk for stroke. Two treatment strategies were compared: LAAO (n=91) and long-term treatment with NOAC (n=149). The primary outcome was the composite endpoint of death, stroke and major bleeding. Propensity score and cause-of-death analyses were performed to compare outcomes.

RESULTS

In a mean follow-up of 13 months, there were 30 deaths (LAAO 8.8% vs. NOAC 14.8%), five strokes (LAAO 1.1% vs. NOAC 2.7%) and six major bleeds (LAAO 1.1% vs. NOAC 3.4%). There was a non-significant trend for a lower incidence of the primary endpoint in the LAAO group (11.0% vs. 20.9%; HR 0.42, 95% CI 0.17-1.05, p=0.064). Considering only secondary prevention LAAO patients (34.1% of the LAAO group), there was also a non-significant lower incidence of the primary endpoint (LAAO 6.5% vs. 20.9%; HR 0.30, 95% CI 0.07-1.39, p=0.12). While about a fifth of LAAO patients stopped antiplatelet treatment six months after device implantation due to recurrent minor bleeding, no adverse cardiovascular event or major bleeding occurred in this subset of patients.

CONCLUSION

In this registry-based study, LAAO was a reasonable alternative to NOAC for the prevention of a composite endpoint of all-cause mortality, stroke and major bleeding in patients at high risk for stroke.

Leaks after Left Atrial Appendage Closure: Ignored or Neglected?

Left atrial appendage (LAA) closure has recently been approved as an alternative management for stroke prevention in patients with chronic atrial fibrillation who have difficulties with long-term oral anticoagulation. The various shapes and sizes of LAA and orientation of the atrial ostium may contribute to the incomplete LAA closure from circular design devices and orientation of the non-steerable delivery catheter. Incomplete closure of LAA leads to a high-velocity blood flow through the peri-device gap, resulting in peri-device leak (PDL). Residual leaks are frequently diagnosed after LAA closure procedures, regardless of closure methods. There is a controversy in the clinical significance of the leaks, particularly about its association with thromboembolic events. PDL <5 mm was not associated with any increase of risk for thromboembolism. Current literatures with small study population have not been sufficient to clarify the role of the leaks after LAA closure. Nevertheless, management of severe leaks has been a challenging concern for cardiologists. Leaks after epicardial LAA closures are at the neck of the incompletely closed LAA and have shown to increase the risk of thromboembolism. Percutaneous closure of the leaks after LAA closure has been attempted with good safety and success, but long-term safety and efficacy remains unclear. Further large long-term studies which aim to assess the role of leaks or PDLs in predicting thromboembolic events and management strategies are warranted.

Safety of reduced or absent antithrombotic therapy after left atrial appendage closure in patients affected by hereditary haemorrhagic telangiectasia and atrial fibrillation

BACKGROUND

Left atrial appendage (LAA) closure represents a novel therapeutic chance for patients with contraindications to long-term anticoagulation therapy, such as those affected by Hereditary Hemorrhagic Telangiectasia (HHT) and atrial fibrillation (AF). Nevertheless, current experts' indications suggest the post-procedural administration of antithrombotic therapies to minimize the residual thromboembolic risk due to AF and to the need for device endothelialization. The aim of our study was to investigate the safety and effectiveness of LAA closure in preventing arterial thromboembolism in a very high-bleeding risk group, such as HHT patients, who are at risk not to tolerate even the mild post-procedural antithrombotic therapy usually recommended.

METHODS

Eight HHT-affected patients with non-valvular AF, high-bleeding risk and/or known intolerance to antiplatelet and anticoagulant therapy were treated with interventional LAA occlusion with the Amplatzer™ Cardiac Plug™ and Amplatzer™ Amulet™ devices. Device implantation was successful in all patients.

RESULTS

Post-procedural antiplatelet/anticoagulation therapy was attempted in seven patients: adherence to therapy exceeded six months only for one, while four patients suspended all antithrombotic medications within 30 days from the procedure due to an increase in bleeding frequency and/or severity and the other two discontinued treatment within six months; a single patient was not prescribed any antithrombotic therapy. At a medium follow-up of 22.4±14.3 months no thromboembolic episodes attributable to AF or device related thrombosis were reported. Two deaths were recorded 1231 and 783 days after the procedure which were classified as unrelated to any cerebral or cardiovascular accident.

CONCLUSIONS

Our study suggests that the percutaneous LAA closure in HHT patients with AF could be safe and effective in preventing arterial systemic thromboembolism, also in the presence of reduced or absent post-interventional antithrombotic treatment. LAA occluder implantation can represent a valid and potentially life-saving alternative to lifelong anticoagulant therapy in HHT, as in other very high-bleeding risk patients.

Short-term non-vitamin K antagonist oral anticoagulants vs. warfarin in preventing device-related thrombosis after left atrial appendage closure

Up to now we have had few evidences on the Non-vitamin K Antagonist Oral Anticoagulants (NOACs)' efficacy and safety in preventing device-related thrombosis (DRT) after percutaneous left atrial appendage closure (LAAC). After LAAC implantation, short-term anticoagulation (NOACs or warfarin) was prescribed. Baseline clinical characteristics, procedural parameters and postoperative follow up data were collected and compared between the two groups. From May 2014 to June 2018, 361 consecutive patients underwent LAAC implantation in our center. 170 patients received warfarin for 45 days at least after LAAC implantation, who were compared with 170 age-matched patients on NOACs. The basic clinical characteristics, as well as procedural parameters were comparable between the two groups, while the NOACs group had higher average CHA2DS2-VASc score (3.3  ±  1.6 vs. 2.9  ±  1.5, P = 0.022*). At 45 days follow up, 289 (86.5%) patients received transoesophageal echocardiography (TEE), and the overall incidence of DRT was 2.4%. The DRT rate was not significantly different between the NOACs and warfarin groups (2.7% vs. 2.1%, P > 0.05), while the NOACs group showed lower all bleeding rate (1.2% vs. 9.0%, P < 0.01). The rates of ischemic stroke as well as major bleeding were comparable between the two groups. Except for 7 DRTs and 1 major peri-device leakage (> 5 mm), anticoagulation was terminated in all other patients. During the follow-up thereafter (mean 868 days), the rates of all-cause death, ischemic stroke and bleeding were comparable between the two groups. Short-term NOACs after LAAC appear to be as effective as warfarin in preventing DRT, with lower bleeding rate.

Pulmonary ridge coverage and device-related thrombosis after left atrial appendage occlusion

AIMS

The aim of this study was to evaluate the impact of pulmonary ridge (PR) coverage on both clinical and imaging follow-up outcomes in patients undergoing left atrial appendage occlusion (LAAO).

METHODS AND RESULTS

The study included consecutive patients with non-valvular atrial fibrillation who underwent LAAO with disc and lobe devices. Patients were classified into two groups according to the PR coverage. A total of 147 patients were included. Among these, the PR was covered in 109 (74%) and uncovered in 38 (26%). Successful implantation was achieved in 98.6%. No differences in procedural outcomes were observed between the groups. The rate of procedural major adverse events was 3% (only major bleedings and/or vascular access complications). No device embolisation, cardiac tamponade or in-hospital mortality was observed. After a mean follow-up of 1.77±2.2 years, the annualised ischaemic stroke and major bleeding rate was 1.3%/year and 6.5%/year, respectively, without differences between groups. At follow-up, patients with a covered PR presented a lower incidence of device-related thrombosis (DRT) (1%) than those with an uncovered PR (27%); p<0.001. In multivariable analysis, the presence of PR coverage emerged as an independent predictor of DRT.

CONCLUSIONS

Pulmonary ridge coverage was associated with a lower incidence of DRT after LAAO. Procedural and follow-up clinical outcomes did not differ between covered PR and uncovered PR patients.

Modification of the left atrial appendage and its role in stroke risk reduction with non-valvular atrial fibrillation

Atrial fibrillation is one of the most common cardiovascular disorders encountered by clinicians in clinical practice. Patients with atrial fibrillation are at risk of cerebrovascular and systemic embolic events, which may be attenuated by commencement of anticoagulation therapy. Even so, due to extremely high bleeding risk certain patients may not be suitable for long-term anticoagulation therapy. The left atrial appendage is a common site for thrombus formation in patients with atrial fibrillation. Left atrial appendage exclusion, either surgical or percutaneous, has been performed to ostensibly reduce the risk of cerebrovascular events and potentially minimise or omit anticoagulation therapy in select patients. This review summarises the role of the left atrial appendage in cerebrovascular events, current evidence with modification of the left atrial appendage and future trials that may change practice with these procedures.

Percutaneous left atrial appendage occlusion

PURPOSE OF REVIEW

To review recent evidence evaluating the long-term safety and efficacy outcomes of left atrial appendage occlusion (LAAO), current guideline recommendations for LAAO use, performance of LAAO in comparison with direct oral anticoagulants (DOAC) and recently approved LAAO device.

RECENT FINDINGS

The last 18 months have been marked with increasing evidence of the utility of LAAO in patients who are not candidates for long-term oral anticoagulation (OAC). Long-term data from two continued access registries to PROTECT-AF and PREVAIL support LAAO as a safe and effective long-term anticoagulation therapy. This new evidence led to class IIb recommendation for LAAO in nonvalvular atrial fibrillation (NVAF) patients not eligible for long-term OAC. PRAGUE-17 randomized controlled trial showed LAAO is noninferior to DOAC lending support to use of this modality in current era. PINNACLE FLX trial showed improved implant success and adequate closure rate which led to the device's Food and Drug Administration approval.

SUMMARY

In conclusion, percutaneous LAAO appears to be a promising option for NVAF patients who are not candidates for long-term OAC in the current era. Further evidence guiding optimal patient selection and periprocedural antithrombotic regimen will help identify the patients who would benefit the most from this procedure.

Percutaneous Left Atrial Appendage Occlusion Yields Favorable Neurological Outcomes in Patients with Non-Valvular Atrial Fibrillation

BACKGROUND AND OBJECTIVES

Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy.

METHODS

Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment. Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke.

RESULTS

mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively. Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01).

CONCLUSIONS

Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Long-Term Safety and Efficacy of Percutaneous Left Atrial Appendage Closure with the LAmbre Device

Background

Left atrial appendage closure (LAAC) using the LAmbre device has been associated with prevention of stroke in patients with nonvalvular atrial fibrillation (AF). Here, we interrogated the long-term safety and efficacy of using the LAmbre device in percutaneous LAAC.

Methods

We analyzed 56 records of patients with nonvalvular AF undergoing LAAC procedures with the LAmbre device. We collected and analyzed the data to define the safety and efficacy of the LAmbre device implantation.

Result

The LAAC was successfully occluded in the 56 patients. Our data showed no serious residual leak or pericardial effusion occurred during the perioperative period. At a mean follow-up of 37.8 ± 23.5 months, there were 7.1%, 3.6%, and 3.6% rates of death, stroke, and device-related thrombus, respectively. There were no cases of severe residual leak or systemic embolism.

Conclusion

Taken together, we demonstrate that execution of LAAC with the LAmbre device has high procedural success and prevents AF-related stroke. However, further large-scale trials might be required to confirm our findings.

Incidence, risk factors, and clinical impact of peridevice leak following left atrial appendage closure with the LAmbre device-Data from a prospective multicenter clinical study

BACKGROUND

In the present study, we sought to explore the incidence, risk factors, and clinical impact of peridevice leaks (PDLs), following LAmbre-assisted left atrial appendage closure (LAAC).

METHODS

We performed transesophageal echocardiography (TEE) on patients participating in the LAmbre multicenter study, at Day 1 postimplantation, then at 3 and 12 months to assess PDL, device-related thrombus, left atrial appendage (LAA) thrombus, and left atrial thrombus. Clinical events were recorded during follow-up.

RESULT

A total of 152 patients with atrial fibrillation successfully completed LAAC. At 3 months follow-up, 123 patients underwent TEE, with 21 (17%) of them presenting PDL. Among the 121 patients who underwent TEE at 12 months follow-up, 19 (15.7%) presented PDL. Patients with PDL exhibited larger LAA orifice diameters and larger device sizes compared to those in the no leak group. In addition, we found no significant differences in thromboembolic events between patients in the PDL and no leak groups.

CONCLUSION

LAmbre-assisted LAA closure resulted in a relatively low PDL occurrence, and its rate decreased over time. In addition, PDL was more prominent in patients with larger LAA orifice diameter and larger device size. However, the condition was not associated with an increased risk for thromboembolic events.

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

BACKGROUND

Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH.

METHODS

This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed.

RESULTS

The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%.

CONCLUSIONS

Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations

Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.

Impact of the CHA2DS2-VASc score on late clinical outcomes in patients undergoing left atrial appendage occlusion

BACKGROUND

Left atrial appendage occlusion (LAAO) is an accepted strategy for cardioembolic events prevention in patients with non-valvular atrial fibrillation (AF) unsuitable for anticoagulation. However, uncertainties persist regarding the benefit of LAAO in highly-comorbid patients. The aim of this study was to assess the impact of the CHA₂DS₂-VASc score beyond thromboembolic risk in predicting clinical outcomes in patients undergoing LAAO.

METHODS

160 patients who underwent LAAO were included and categorized into two groups according to their stroke risk (89 with CHA₂DS₂-VASc >4 vs. 71 with lower risk). The coprimary endpoints were death and stroke at follow-up. Thromboembolic and bleeding events were compared to those predicted from CHA₂DS₂-VASc and HAS-BLED scores.

RESULTS

Over a median follow-up of 679 days, CHA₂DS₂-VASc >4 was associated with increased all-cause mortality compared with patients with lower thromboembolic risk (HR: 3.23; 95% CI: 1.28-8.19; p < 0.001). However, the rates of stroke after LAAO were not significantly different between risk groups. The observed annual rates of stroke and major bleeding were lower than predicted.

CONCLUSIONS

Despite increased long-term mortality in patients with CHA₂DS₂-VASc >4, LAAO remains beneficial in reducing stroke and bleeding events in high-risk AF patients unsuitable for anticoagulation.

Comparative Safety and Efficacy of Left Atrial Appendage Occlusion with the Watchman Device and Amplatzer Cardiac Plug: Results of the Russian National Registry

PURPOSE

This multicenter, prospective registry evaluated the comparative safety and efficacy of left atrial appendage occlusion (LAAO) using the Watchman device (WD) and the Amplatzer Cardiac Plug (ACP) in patients with nonvalvular atrial fibrillation (NVAF) in real-world clinical practice in Russia.

METHODS

The study included data from 200 consecutive NVAF patients (66.8 ± 7.8 years, 44.5% female, median CHA2DS2VASc 4, median HAS-BLED 3) who had undergone LAAO implantation using WD (n = 108) or ACP (n = 92) from September 2015 to December 2017 in 5 medical centers in Russia. The primary safety endpoint was the procedure-related major adverse events, and the primary efficacy endpoint was the composite of thromboembolic events, device thrombosis, hemorrhagic events, and unexplained death during the 12-month follow-up.

RESULTS

Successful LAAO was performed in all 92 (100%) patients with ACP and 105 (97.2%) with WD (p = 0.053). At 12 months, primary safety endpoint occurred in 6.5% of patients in the ACP group with no events in the WD group (6.5% vs. 0%, p = 0.008). During the 12-month follow-up, the primary efficacy endpoint has occurred in 8.3% of patients in the WD group (n = 9) and 1.1% of patients in the ACP group (n = 1) (p = 0.016).

CONCLUSIONS

In this multicenter prospective registry, LAA closure with the WD was associated with significantly higher thromboembolic events rate in NVAF patients. Patients, receiving the ACP, had more procedure-related major adverse events. However, further multicenter studies are necessary to evaluate these findings.

Safety and Efficacy of Single Versus Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion

The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.

[Success rate of one-stop procedure for atrial fibrillation ablation and its impact on cardiac function: a propensity-matched study]

OBJECTIVE

To investigate the effect of the combination of atrial fibrillation (AF) ablation and left atrial appendage closure (LAAC) on cardiac function and the success rate of AF ablation.

METHODS

We retrospectively analyzed the data of 56 patients with AF undergoing a one-stop procedure for AF ablation and LAAC in our hospital between May, 2015 and May, 2019. Propensity score matching (PSM) at the ratio of 1:1 was used to select 56 control patients undergoing AF ablation at high risk of stroke, for matching with the hybrid procedure group. The perioperative complications, thromboembolic events, recurrence of atrial arrhythmia and cardiac function were compared between the groups.

RESULTS

The two groups of patients were comparable for age, gender, BMI, duration and type of AF, concomitant diseases, CHA2DS2-VASc and HAS-BLED scores (P > 0.05). The incidence of complications did not differ significantly between the hybrid procedure group and AF ablation group (17.9% vs 12.5%, P=0.430). Compared with the control patients with AF ablation alone, the patients undergoing the hybrid procedure had a lowered incidence of thromboembolic events, but the difference was not statistically significant (1.8%vs 3.6%, P=1.000). The hybrid procedure did not improve the success rate of AF ablation (OR: 1.338, 95%CI: 0.451-3.973, P= 0.600) but significantly improved the cardiac function parameters including NT-pro BNP (945.3±1401.6 pg/mL vs 1520.7±2089.1 pg/mL, P=0.010), LVEF[(60.8±7.0)% vs (58.6±7.8)%, P=0.044], and left atrial diameter (43.9±7.5 mm vs 45.6±6.3 mm, P=0.076); but the improvement of cardiac function was more obvious in the control patients undergoing AF ablation alone (P < 0.039).

CONCLUSIONS

The combination of AF ablation and LAAC is safe but does not improve the success rate of AF ablation. The one-stop procedure can improve cardiac function of the patients, but AF ablation alone can achieve better improvement of cardiac function.

Plugs for left atrial appendage occlusion: an overview of available devices

INTRODUCTION

Approximately one-third of all ischemic strokes and the ensuing health and economic burden can be attributed to the presence of atrial fibrillation (AF). The global prevalence of AF continues to rise, thus making it by far the most common diagnosed cardiac arrhythmia. Percutaneous left atrial appendage (LAA) occlusion or obliteration has been developed to protect from the occurrence of stroke in patients with nonvalvular AF.

AREAS COVERED

We address the characteristics and techniques for implantation as well as some clinical registries and randomized trials of the various catheter-based devices for the occlusion of the LAA that are either currently available or in the clinical evaluation stage.

EXPERT OPINION

Over less than 2 decades, LAA occlusion progressed from being a concept applied in a few specialized centers to a globally recognized procedure implemented in numerous hospitals as part of daily interventional practice. The respective devices are to date safer and easier to deploy than initially. Periprocedural and postprocedural complications will continue to decrease as already evident from prospective randomized trials and registries. Although current indications focus on patients with nonvalvular AF and contraindications for oral anticoagulation, it is all but certain that the future will bring a widening in the spectrum of indications, applicability, and usage of these devices.