151
|
Price MJ, Friedman DJ, Du C, Wang Y, Lin Z, Curtis JP, Freeman JV. Comparative Safety of Transcatheter LAAO With the First-Generation Watchman and Next-Generation Watchman FLX Devices. JACC Cardiovasc Interv 2022; 15:2115-2123. [DOI: 10.1016/j.jcin.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
|
152
|
Abstract
PURPOSE OF REVIEW Atrial fibrillation is associated with a significant increase in stroke and systemic embolism. This review explores the areas of stroke prevention. RECENT FINDINGS In the last decade, NOAC has overtaken warfarin as the anticoagulant of choice for stroke prevention in AF. For patients unable to take anticoagulation, LAA closure has proven to be a valid option. The use of digital devices has led to widespread consumer-directed AF screening. It remains to be determined if all device detect AF pose the same amount of risk as recent studies have shown that short and infrequent episodes of AF may not benefit from anticoagulation. Stroke prevention is paramount in the management of AF. In this review we describe the risk factors contributing to stroke, recent advances in antithrombotic therapies, and the increasing role of digital health in guiding AF detection and stroke prevention.
Collapse
Affiliation(s)
- Xu Gao
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rod Passman
- Northwestern Center for Arrhythmia Research, Northwestern University Feinberg School of Medicine, 676 North St. Claire, Suite 600, Chicago, IL, 60657, USA.
| |
Collapse
|
153
|
De Backer O, Søndergaard L. Striving for Perfection in Transcatheter LAA Closure. JACC Cardiovasc Interv 2022; 15:2124-2126. [DOI: 10.1016/j.jcin.2022.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022]
|
154
|
Killu AM, Alkhouli MA. Performing transcatheter left atrial appendage closure: Techniques and challenges. Heart Rhythm 2022; 19:1899-1906. [PMID: 35944890 DOI: 10.1016/j.hrthm.2022.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
| | - Mohamad A Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
155
|
Peridevice Leak After Transcatheter Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2022; 15:2127-2138. [DOI: 10.1016/j.jcin.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
|
156
|
Kümler T, Strange JE, Andersen NH. Percutaneous left atrial appendage occlusion discrepancy between randomised trials and clinical practice. Open Heart 2022; 9:openhrt-2022-002079. [PMID: 36270714 PMCID: PMC9594568 DOI: 10.1136/openhrt-2022-002079] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 11/05/2022] Open
Abstract
In patients with atrial fibrillation and previous episodes of bleeding on oral anticoagulant treatment, left atrial appendage occlusion (LAAO) has emerged as an alternative way to decrease the risk of stroke. The use of the procedure has been on the rise, and the news coverage has been dominated by an uncritical acceptance of the benefit of this procedure, which probably have contributed to the increasing number of procedures. This commentary is a presentation and critical appraisal of the available evidence on the efficacy and safety of left atrial appendage closure as stroke prophylaxis. We illustrate that LAAO is supported by limited randomised data risk of serious complications, which we do not believe supports the current widespread use.
Collapse
|
157
|
Alkhouli M, Russo AM, Thaler D, Windecker S, Anderson JA, Gage R, Lakkireddy D. Sex Differences in Safety and Effectiveness of Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2022; 15:2143-2155. [DOI: 10.1016/j.jcin.2022.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/06/2022]
|
158
|
Pivato CA, Liccardo G, Sanz‐Sanchez J, Pelloni E, Pujdak K, Xuareb RG, Cruz‐Gonzalez I, Pisano F, Scotti A, Tarantini G, Cook S, Regazzoli D, Reimers B, Condorelli G, Bragato RM, Stefanini GG, Pagnotta P. Left atrial appendage closure with the II generation Ultraseal device: An international registry. The LIGATE study. Catheter Cardiovasc Interv 2022; 100:620-627. [PMID: 35842775 PMCID: PMC9796275 DOI: 10.1002/ccd.30336] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/31/2022] [Accepted: 07/02/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To assess feasibility and safety of second-generation left atrial appendage closure (LAAC) Ultraseal device in patients with nonvalvular atrial fibrillation (NVAF). BACKGROUND LAAC with first-generation Ultraseal device (Cardia, Eagan, Minnesota) has been shown to be a feasible therapeutic option in patients with NVAF. However, there is a paucity of data regarding the novel second-generation Ultraseal device. METHODS All patients with NVAF undergoing second-generation Ultraseal device implantation between February 2018 and September 2020 were included in a multicenter international registry. Periprocedural and post-discharge events were collected through 6-month follow-up. Co-primary efficacy endpoints were device success and technical success while primary safety endpoint was in-hospital major adverse event (MAE) occurrence. RESULTS A total of 52 patients were included: mean age 75 ± 8, 30.8% women, mean HAS-BLED 3 ± 1. The device was successfully implanted in all patients. Technical success was achieved in 50 patients (96.1%). In-hospital MAEs occurred in three patients (5.8%). The incidence of 6-month all-cause death and major bleeding was 11.6% and 2.1%, respectively. No strokes, transient ischemic attacks, systemic embolisms, or device embolization were reported after discharge. CONCLUSIONS Second-generation Ultraseal device implantation was associated with high success rates and a low incidence of peri-procedural complications. Larger studies with longer follow-up are warranted to further evaluate the safety and the efficacy of this device, especially at long-term follow-up.
Collapse
Affiliation(s)
- Carlo A. Pivato
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele‐MilanItaly,Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Gaetano Liccardo
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele‐MilanItaly,Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Jorge Sanz‐Sanchez
- Cardiology DepartmentHospital Universitari i Politècnic La FeValenciaSpain,Centro de Investigación Biomedica en Red (CIBERCV)MadridSpain
| | | | | | | | | | | | - Andrea Scotti
- Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, del PoliclinicoUniversitario di PadovaPadovaItaly
| | - Giuseppe Tarantini
- Dipartimento di Scienze Cardiologiche, Toraciche e Vascolari, del PoliclinicoUniversitario di PadovaPadovaItaly
| | | | | | - Bernhard Reimers
- Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Gianluigi Condorelli
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele‐MilanItaly,Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | | | - Giulio G. Stefanini
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele‐MilanItaly,Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| | - Paolo Pagnotta
- Cardio CenterIRCCS Humanitas Research HospitalRozzano‐MilanItaly
| |
Collapse
|
159
|
Abdelfattah OM, Sayed A, Munir M, Almotawally S, Wilson K, Gad MM, Abushouk AI, Elsayed M, Wazni OM, Saliba WI, Elgendy IY, Jneid H, Kapadia S. Meta-Analysis Comparing Left Atrial Appendage Occlusion, Direct Oral Anticoagulants, and Warfarin for Nonvalvular Atrial Fibrillation. Am J Cardiol 2022. [DOI: 10.1016/j.amjcard.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
|
160
|
Korsholm K, Valentin JB, Damgaard D, Diener HC, Camm AJ, Landmesser U, Hildick-Smith D, Johnsen SP, Nielsen-Kudsk JE. Clinical outcomes of left atrial appendage occlusion versus direct oral anticoagulation in patients with atrial fibrillation and prior ischemic stroke: A propensity-score matched study. Int J Cardiol 2022; 363:56-63. [PMID: 35780932 DOI: 10.1016/j.ijcard.2022.06.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/05/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND This propensity-score matched study investigated clinical outcomes associated with left atrial appendage occlusion (LAAO) versus direct oral anticoagulation (DOAC) in patients with AF and prior ischemic stroke. METHODS AF patients enrolled in the Amulet Observational Study with a history of ischemic stroke and successful LAAO (n = 299) were compared with a propensity-score matched cohort of incident AF patients with prior ischemic stroke and treated by DOAC (n = 301). The control cohort was identified through the Danish National Patient Registries. Propensity score matching was based on covariates of the CHA2DS2-VASc and HAS-BLED scores, with a 1:2 ratio and using Greedy 5:1 digit matching with replacement. The analysis included 2-years follow-up, with a primary composite outcome of ischemic stroke, major bleeding (BARC ≥ 3) or all-cause mortality. RESULTS Mean (SD) CHA2DS2-VASc scores were 5.26 (1.42) and 5.40 (1.31) and HAS-BLED scores were 3.95 (0.91) and 4.03 (0.96), for the LAAO and DOAC group, respectively. Total number of primary composite outcome events were 61 (12.4 events/100 patient-years) and 117 (26.9 events/100 patient-years) in the LAAO and DOAC group, respectively. Risk of the primary composite outcome was significantly lower in the LAAO group, hazard rate ratio [HR] 0.48 (95% CI: 0.35-0.65). Ischemic stroke risk was comparable, HR 0.71 (95% CI: 0.34-1.45), while risk of major bleeding, HR 0.41 (95% CI: 0.25-0.67), and all-cause mortality, HR 0.48 (95% CI: 0.32-0.71), were significantly lower with LAAO. Cardiovascular mortality did not differ statistically between the LAAO and DOAC group, HR 0.75 (95% CI: 0.39-1.42). Results were consistent across sensitivity analyses. CONCLUSION This study indicated significantly lower risk of the composite outcome of stroke, major bleeding and all-cause mortality with LAAO therapy compared to DOAC, in patients with AF and prior stroke. The stroke prevention effectiveness appeared similar, with a significantly lower risk of major bleeding events with LAAO. The suggested clinical benefit of LAAO over DOAC require confirmation in the ongoing randomized OCCLUSION-AF trial.
Collapse
Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jan Brink Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Hans-Christoph Diener
- Institute of Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University of Duisburg-Essen, Essen, Germany
| | - Alan John Camm
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St. Georges University of London, London, United Kingdom
| | - Ulf Landmesser
- Department of Cardiology, Charité - Universitätsmedizin, Berlin, Germany
| | - David Hildick-Smith
- Department of Cardiology, Sussex Cardiac Centre, Brighton and Sussex University Hospital, Brighton, UK
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | |
Collapse
|
161
|
Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:2268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
Collapse
Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| |
Collapse
|
162
|
Rozen G, Margolis G, Marai I, Roguin A, Rahamim E, Planer D, Heist EK, Amir O, Tahiroglu I, Ruskin J, Mansour M, Elbaz-Greener G. Left atrial appendage exclusion in atrial fibrillation. Front Cardiovasc Med 2022; 9:949732. [PMID: 36176999 PMCID: PMC9513198 DOI: 10.3389/fcvm.2022.949732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Although oral anticoagulants (OACs) are first-line therapy for stroke prevention in patients with atrial fibrillation (AF), some patients cannot be treated with OACs due to absolute or relative contraindications. Left atrial appendage (LAA) exclusion techniques have been developed over the years as a therapeutic alternative for stroke prevention. In this paper, we review the evolution of surgical techniques, employed as an adjunct to cardiac surgery or as a stand-alone procedure, as well as the recently introduced and widely utilized percutaneous LAA occlusion techniques. Until recently, data on surgical LAAO were limited and based on non-randomized studies. We focus on recently published randomized data which strongly support an add-on surgical LAAO in eligible patients during cardiac surgery and could potentially change current practice guidelines. In recent years, the trans-catheter techniques for LAA occlusion have emerged as another, less invasive alternative for patients who cannot tolerate oral anticoagulation. We review the growing body of evidence from prospective studies and registries, focusing on the two systems which are in widespread clinical use nowadays: the Watchman and Amulet type devices. These data show favorable results for both Watchman and Amulet devices, setting them as an important tool in our arsenal for stroke reduction in AF patients, especially in those who have contraindications for OACs. A better understanding of the different therapeutic alternatives, their specific benefits, and downfalls in different patient populations can guide us in tailoring the optimal therapeutic approach for stroke reduction in our AF patients.
Collapse
Affiliation(s)
- Guy Rozen
- Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Guy Rozen
| | - Gilad Margolis
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ibrahim Marai
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Ariel Roguin
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Eldad Rahamim
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Edwin Kevin Heist
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilgar Tahiroglu
- Department of Cardiology, Baku Health Center University, Baku, Azerbaijan
| | - Jeremy Ruskin
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Moussa Mansour
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
163
|
Bai Y, Tang X, Xu X, Zhao X, Xu Y, Chen W, Zhu X, Wang Q, Han Z, Wang C, He L, Zhang Y, Pan X, Wang C, Chen L, Cen X, Qu B, Zhu N, Zhang S, Huang X, Qin Y. A newly designed disk-lobe occluder with isogenous barbs for left atrial appendage closure: Initial multicenter experience. Front Cardiovasc Med 2022; 9:974994. [PMID: 36119731 PMCID: PMC9478548 DOI: 10.3389/fcvm.2022.974994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022] Open
Abstract
Background Although the implant success rate of left atrial appendage closure (LAAC) has increased and complications have decreased over time, there are still anatomically and technically complicated cases where novel LAA occluders may simplify the procedure and thus might potentially improve the clinical outcome. Objectives This study aimed to assess the safety and efficacy of the newly designed device with isogenous barbs in LAAC. Methods Eight centers in China participated in this prospective study from July 2016 to April 2018. Peri- and post-procedural safety and efficacy were evaluated through scheduled follow-ups and transesophageal echocardiography (TEE). Results A total of 175 patients with a mean age of 68.4 ± 9.2 years old, a mean CHA2DS2-VASc score of 4.7 ± 1.8, and a mean HAS-BLED score of 3.2 ± 1.3, were included. The device was successfully implanted in 173 patients (98.9%). The device size ranged from 18 to 34 mm. Clinically relevant pericardial effusion (PEF) in the perioperative period, occurred in 3 patients (1.7%). TEE follow-up was available in 167 (96.5%) patients at 12-month. During follow-up, 9 patients suffered serious adverse event: 4 death (2.3%), 1 ischemic stroke (0.6%), and 2 gastro-intestinal bleeding (1.2%) and 2 device-related thrombus (DRT) (1.2%). Estimated annual thromboembolism rate reduced by 90% and estimated annual major bleeding rate reduced by 81% after LAAC with the newly designed device. Conclusion The newly designed device with isogenous barbs for LAAC could be performed effectively with a low incidence of adverse events and a high incidence of anatomic closure.
Collapse
Affiliation(s)
- Yuan Bai
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Xuechao Tang
- Department of Cardiology, The 960th Hospital of People’s Liberation Army, Tai’an, China
| | - Xudong Xu
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Xianxian Zhao
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Wei Chen
- Department of Cardiology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xianyang Zhu
- Department of Congenital Heart Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Qiguang Wang
- Department of Congenital Heart Disease, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhihua Han
- Department of Cardiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Changqian Wang
- Department of Cardiology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lu He
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yushun Zhang
- Department of Structural Heart Disease, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Xin Pan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Cheng Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lianglong Chen
- Department of Cardiology, Fujian Medical University Affiliated Union Hospital, Fuzhou, China
| | - Xuejiang Cen
- Department of Cardiology, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Baiming Qu
- Department of Cardiology, Zhejiang Provincial People’s Hospital, Hangzhou, China
| | - Ni Zhu
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Sha Zhang
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Xinmiao Huang
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
| | - Yongwen Qin
- Department of Cardiology, Shanghai Changhai Hospital, Navy Military Medical University, Shanghai, China
- *Correspondence: Yongwen Qin,
| |
Collapse
|
164
|
Left Atrial Appendage Closure: When Does a Procedure Become Futile? JACC Clin Electrophysiol 2022; 8:1103-1105. [PMID: 36137714 DOI: 10.1016/j.jacep.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 11/23/2022]
|
165
|
Mendez K, Kennedy DG, Wang DD, O’Neill B, Roche ET. Left Atrial Appendage Occlusion: Current Stroke Prevention Strategies and a Shift Toward Data-Driven, Patient-Specific Approaches. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100405. [PMID: 39131471 PMCID: PMC11308563 DOI: 10.1016/j.jscai.2022.100405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 08/13/2024]
Abstract
The left atrial appendage (LAA) is a complex structure with unknown physiologic function protruding from the main body of the left atrium. In patients with atrial fibrillation, the left atrium does not contract effectively. Insufficient atrial and LAA contractility predisposes the LAA morphology to hemostasis and thrombus formation, leading to an increased risk of cardioembolic events. Oral anticoagulation therapies are the mainstay of stroke prevention options for patients; however, not all patients are candidates for long-term oral anticoagulation. Percutaneous occlusion devices are an attractive alternative to long-term anticoagulation therapy, although they are not without limitations, such as peri-implant leakage and device-related thrombosis. Although efforts have been made to reduce these risks, significant interpatient heterogeneity inevitably yields some degree of device-anatomy mismatch that is difficult to resolve using current devices and can ultimately lead to insufficient occlusion and poor patient outcomes. In this state-of-the-art review, we evaluated the anatomy of the LAA as well as the current pathophysiologic understanding and stroke prevention strategies used in the management of the risk of stroke associated with atrial fibrillation. We highlighted recent advances in computed tomography imaging, preprocedural planning, computational modeling, and novel additive manufacturing techniques, which represent the tools needed for a paradigm shift toward patient-centric LAA occlusion. Together, we envisage that these techniques will facilitate a pipeline from the imaging of patient anatomy to patient-specific computational and bench-top models that enable customized, data-driven approaches for LAA occlusion that are engineered specifically to meet each patient's unique needs.
Collapse
Affiliation(s)
- Keegan Mendez
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Darragh G. Kennedy
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Biomedical Engineering, Columbia University, New York, New York
| | | | | | - Ellen T. Roche
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
| |
Collapse
|
166
|
Chiang CE, Chao TF, Choi EK, Lim TW, Krittayaphong R, Li M, Chen M, Guo Y, Okumura K, Lip GY. Stroke Prevention in Atrial Fibrillation: A Scientific Statement of JACC: Asia (Part 2). JACC. ASIA 2022; 2:519-537. [PMID: 36624790 PMCID: PMC9823285 DOI: 10.1016/j.jacasi.2022.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/29/2022] [Accepted: 06/22/2022] [Indexed: 01/12/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and is associated with substantial increases in the risk for stroke and systemic thromboembolism. With the successful introduction of the first non-vitamin K antagonistdirect oral anticoagulant agent (NOAC) in 2009, the role of vitamin K antagonists has been replaced in most clinical settings except in a few conditions for which NOACs are contraindicated. Data for the use of NOACs in different clinical scenarios have been accumulating in the past decade, and a more sophisticated strategy for patients with AF is now warranted. JACC: Asia recently appointed a working group to summarize the most updated information regarding stroke prevention in AF. The aim of this statement is to provide possible treatment options in daily practice. Local availability, cost, and patient comorbidities should also be considered. Final decisions may still need to be individualized and based on clinicians' discretion. This is part 2 of the statement.
Collapse
Affiliation(s)
- Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan,Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Address for correspondence: Dr Chern-En Chiang, General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei 112, Taiwan. @en_chern
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan,Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Toon Wei Lim
- National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Rungroj Krittayaphong
- Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mingfang Li
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Minglong Chen
- Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yutao Guo
- Department of Pulmonary Vessel and Thrombotic Disease, Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Gregory Y.H. Lip
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea,Division of Cardiology, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand,Division of Cardiology, First Affiliated Hospital of Nanjing Medical University, Nanjing, China,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, United Kingdom,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| |
Collapse
|
167
|
Zhu MZ, Song H, Song GM, Bai X. Safety and efficacy of the Amplatzer amulet and watchman2.5 for left atrial appendage occlusion: a Systematic review and meta-analysis. Pacing Clin Electrophysiol 2022; 45:1237-1247. [PMID: 35933600 DOI: 10.1111/pace.14576] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulation (OAC) to decrease the risk of stroke in patients with nonvalvular atrial fibrillation (NVAF); however, certain complications remain a concern. Amplatzer Amulet and Watchman are the two most popular used devices for preventing stroke in patients with NVAF. We assessed the safety and efficacy of LAAO using the Amplatzer Amulet and Watchman. METHODS A meta-analysis was conducted to compare the safety and efficacy outcomes associated with the use of the Amplatzer Amulet and Watchman 2.5. The Newcastle-Ottawa Scale has been utilized to assess the quality of study. RESULTS The meta-analysis includes seven studies involving 2,926 patients (1,418 patients with an amulet and 1,508 with a Watchman 2.5). Generally, adverse event rates for both systems were minimal. No significant differences between the two devices were found in safety (pericardial effusion, device embolization, and cardiac tamponade) or efficacy outcomes (death, TIA, stroke, major/minor bleeding, device leak, and thromboembolic events). CONCLUSIONS The data suggest LAAO is a safe procedure, regardless of which device was used. LAAO devices generally have low complication rates. Outcomes were comparable between the two groups with no significant differences in their safety or efficacy. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Ming-Zhen Zhu
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Hao Song
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Guang-Min Song
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| | - Xiao Bai
- Department of Cardiovascular Surgery, Qilu Hospital of Shandong University, 107 West Wen Hua Road, Jinan, 250012, China
| |
Collapse
|
168
|
Ciobotaru V, Tadros VX, Martin CA, Hascoet S. Complex transcatheter left atrial appendage closure using a tailored trans-jugular approach simulated by 3D printing: a case report. Eur Heart J Case Rep 2022; 6:ytac304. [PMID: 35965604 PMCID: PMC9366637 DOI: 10.1093/ehjcr/ytac304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/09/2022] [Accepted: 07/20/2022] [Indexed: 11/15/2022]
Abstract
Background Transcatheter left atrial appendage (LAA) closure (LAAc) is less feasible in patients with unusual LAA anatomy. Case summary A 65-year-old woman with persistent atrial fibrillation was referred for LAAc. Transesophageal echocardiography (TEE) revealed spontaneous contrast in the LAA without formation of a thrombus; the LAA shape was tortuous and difficult to assess. A first LAAc procedure was unsuccessful given the unsuitable sheath position. Therefore, a soft three-dimensional (3D) model printing was performed by laser sintering and revealed excessive sheath kinking with an inferior approach, but successful deployment would be feasible using a superior approach. Successful trans-jugular implantation of a Watchman FLX 31 device in stable position without residual leakage was achieved during the subsequent procedure. At 3-month follow-up, and after cessation of oral anticoagulation, the patient’s symptoms improved. Imaging demonstrated complete LAA occlusion and correct placement of the device along the LAA superior axis. Discussion This is the first-reported clinical case of a complex transcatheter LAAc through a trans-jugular approach. Simulating the patient’s anatomy with a laser sintering 3D-printed model showed why the transfemoral approach failed, validated the trans-jugular procedure, enabled selection of the simple curve access sheath that had the most direct trajectory towards the LAA, confirmed that transseptal puncture was possible, allowed determination of the angle of puncture, enabled selection of the most appropriate LAA device and had a very low cost compared with planning software or other printing methods.
Collapse
Affiliation(s)
- Vlad Ciobotaru
- Structural and Valvular Unit, Hôpital Privé les Franciscaines , 3 rue Jean Bouin, 30000 Nîmes , France
- Inserm UMR 999, Hôpital Marie Lannelongue, Faculté de Médecine, Université Paris Saclay , 92296 Chatenay-Malabry , France
| | - Victor-Xavier Tadros
- Structural and Valvular Unit, Hôpital Privé les Franciscaines , 3 rue Jean Bouin, 30000 Nîmes , France
| | - Claire A Martin
- Division of Cardiac Electrophysiology, Royal Papworth Hospital NHS Foundation Trust , Cambridge CB2 0AY , UK
| | - Sebastien Hascoet
- Inserm UMR 999, Hôpital Marie Lannelongue, Faculté de Médecine, Université Paris Saclay , 92296 Chatenay-Malabry , France
- Hôpital Marie Lannelongue, Groupe Hospitalier Paris Saint Joseph , 92350 Le Plessis-Robinson , France
| |
Collapse
|
169
|
Impact of Peridevice Leak on 5-Year Outcomes After Left Atrial Appendage Closure. J Am Coll Cardiol 2022; 80:469-483. [PMID: 35902169 DOI: 10.1016/j.jacc.2022.04.062] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/16/2022] [Accepted: 04/20/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND In the U.S. Food and Drug Administration (FDA) clinical trials of left atrial appendage (LAA) closure, a postimplantation peridevice leak (PDL) of ≤5 mm (PDL≤5) was accepted as sufficient LAA "closure." However, the clinical consequences of these PDLs on subsequent thromboembolism are poorly characterized. OBJECTIVES We sought to assess the impact of PDL≤5 on clinical outcomes after implantation of the Watchman device. METHODS Using combined data from the FDA studies PROTECT-AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation), PREVAIL (Evaluation of the Watchman Left Atrial Appendage Closure Device in Patients With Atrial Fibrillation vs Long Term Warfarin Therapy), and CAP2 (Continued Access to PREVAIL), we assessed patients with successful device implantation for PDL by means of protocol-mandated transesophageal echocardiograms (TEEs) at 45 days and 1 year. Five-year outcomes were assessed as a function of the absence or presence of PDL≤5. RESULTS The cohort included 1,054 patients: mean age 74 ± 8.3 years, 65% male, and CHA2DS2-VASc 4.1 ± 1.4. TEE imaging at 45 days revealed 634 patients (60.2%) without and 404 (38.3%) with PDL≤5, and 1-year TEE revealed 704 patients (71.6%) without and 272 (27.7%) with PDL≤5. The presence of PDL≤5 at 1 year, but not at 45 days, was associated with an increased 5-year risk of ischemic stroke or systemic embolism (adjusted HR: 1.94; 95% CI: 1.15-3.29; P = 0.014), largely driven by an increase in nondisabling stroke (HR: 1.97; 95% CI: 1.03-3.78; P = 0.04), while disabling or fatal stroke rates were similar (HR: 0.69; 95% CI: 0.19-2.46; P = 0.56). PDL≤5 was not associated with an increased risk of cardiovascular or unexplained death (HR: 1.20; P = 0.45) or all-cause death (HR: 0.87; P = 0.42). CONCLUSIONS PDL≤5 at 1 year after percutaneous LAA closure with the Watchman device are associated with increased thromboembolism, driven by increased nondisabling stroke, but similar mortality. (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation [PROTECT-AF; NCT00129545]; Evaluation of the Watchman Left Atrial Appendage Closure Device in Patients With Atrial Fibrillation vs Long Term Warfarin Therapy [PREVAIL; NCT01182441]; Continued Access to PREVAIL [CAP2; NCT01760291]).
Collapse
|
170
|
Schmidt B, Chun KRJ. Peridevice Leaks: The Plot Hole of Left Atrial Appendage Closure for Stroke Prophylaxis. J Am Coll Cardiol 2022; 80:484-485. [PMID: 35902170 DOI: 10.1016/j.jacc.2022.04.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 10/16/2022]
Affiliation(s)
- Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Academic Teaching Hospital of Goethe University, Frankfurt, Germany.
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Academic Teaching Hospital of Goethe University, Frankfurt, Germany. https://twitter.com/jongichun
| |
Collapse
|
171
|
Munir MB, Hsu JC. Left atrial appendage occlusion should be offered only to select atrial fibrillation patients. Heart Rhythm O2 2022; 3:448-454. [PMID: 36097461 PMCID: PMC9463703 DOI: 10.1016/j.hroo.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 07/05/2022] [Accepted: 07/06/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California Davis, Sacramento, California
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| | - Jonathan C. Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, California
| |
Collapse
|
172
|
Holmes DR, Simard TJ, Killu AM, Alkhouli MA. Left Atrial Appendage Occlusion, A Misnomer?: Where Do We Go From Here? Mayo Clin Proc 2022; 97:1525-1533. [PMID: 35933138 DOI: 10.1016/j.mayocp.2022.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/16/2022] [Accepted: 03/30/2022] [Indexed: 10/16/2022]
Abstract
The importance of the left atrial appendage (LAA) as the source of thromboembolism including stroke in patients with nonvalvular atrial fibrillation is well documented, with more than 90% of ischemic strokes related to a LAA thrombus. Although oral anticoagulation has been the standard of care, approximately 50% to 60% of patients either have contraindications to oral anticoagulation or do not continue the medication beyond the first year. This led to the development of local site-specific therapy to occlude the LAA by either surgical or transcatheter means. Despite marked advancements, incomplete LAA closure with surgical and transcatheter approaches remains frequent. The etiology of incomplete LAA closure and its clinical implications remain unclear. Multiple strategies are in development including changes in deployment techniques, a new device design, and alternative approaches to leak closure.
Collapse
Affiliation(s)
- David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Trevor J Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
173
|
Huijboom M, Maarse M, Aarnink E, van Dijk V, Swaans M, van der Heijden J, IJsselmuiden S, Folkeringa R, Blaauw Y, Elvan A, Stevenhagen J, Vlachojannis G, van der Voort P, Westra S, Chaldoupi M, Khan M, de Groot J, van der Kley F, van Mieghem N, van Dijk E, Dijkgraaf M, Tijssen J, Boersma L. COMPARE LAAO: Rationale and design of the randomized controlled trial "COMPARing Effectiveness and safety of Left Atrial Appendage Occlusion to standard of care for atrial fibrillation patients at high stroke risk and ineligible to use oral anticoagulation therapy". Am Heart J 2022; 250:45-56. [PMID: 35537503 DOI: 10.1016/j.ahj.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). In patients with a long-term or permanent contraindication for OAC randomized controlled trial (RCT) data is lacking. STUDY OBJECTIVES To assess the efficacy and safety of LAAO in AF patients who are ineligible to use OAC. The co-primary efficacy endpoint is (1) time to first occurrence of stroke (ischemic, hemorrhagic, or undetermined) and (2) time to first occurrence of the composite of stroke, transient ischemic attack (TIA), and systemic embolism (SE). The primary safety endpoint is the 30-day rate of peri-procedural complications. STUDY DESIGN This is a multicenter, investigator-initiated, open-label, blinded endpoint (PROBE), superiority-driven RCT. Patients with AF, a CHA₂DS₂-VASc score ≥2 for men and ≥3 for women and a long-term or permanent contraindication for OAC will be randomized in a 2:1 fashion to the device- or control arm. Patients in the device arm will undergo percutaneous LAAO and will receive post-procedural dual antiplatelet therapy (DAPT) per protocol, while those in the control arm will continue their current treatment consisting of no antithrombotic therapy or (D)APT as deemed appropriate by the primary responsible physician. In this endpoint-driven trial design, assuming a 50% lower stroke risk of LAAO compared to conservative treatment, 609 patients will be followed for a minimum of 1 and a maximum of 5 years. Cost-effectiveness and budget impact analyses will be performed to allow decision-making on reimbursement of LAAO for the target population in the Netherlands. SUMMARY The COMPARE LAAO trial will investigate the clinical superiority in preventing thromboembolic events and cost-effectiveness of LAAO in AF patients with a high thromboembolic risk and a contraindication for OAC use. NCT TRIAL NUMBER NCT04676880.
Collapse
Affiliation(s)
- Marina Huijboom
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands.
| | - Moniek Maarse
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Errol Aarnink
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Vincent van Dijk
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Martin Swaans
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Richard Folkeringa
- Medical Center Leeuwarden, Cardiology Department, Leeuwarden, The Netherlands
| | - Yuri Blaauw
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Arif Elvan
- Cardiology Department, Isala Hospital, Zwolle, The Netherlands
| | - Jeroen Stevenhagen
- Medical Spectrum Twente, Department of Cardiology, Enschede, The Netherlands
| | - George Vlachojannis
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Sjoerd Westra
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marisevi Chaldoupi
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Muchtiar Khan
- Cardiology Department, OLVG, Amsterdam, The Netherlands
| | - Joris de Groot
- Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| | - Frank van der Kley
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nicolas van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewoud van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel Dijkgraaf
- Location AMC, Department of Epidemiology and Data Science, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jan Tijssen
- Clinical Epidemiology & Biostatistics, Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lucas Boersma
- Cardiology Department, St. Antonius Hospital, Nieuwegein, The Netherlands; Amsterdam University Medical Center, location AMC, Cardiology Department, Amsterdam, The Netherlands
| |
Collapse
|
174
|
Huijboom MF, Boersma LV. Left atrial appendage occlusion is underutilized. Heart Rhythm O2 2022; 3:444-447. [PMID: 36097456 PMCID: PMC9463706 DOI: 10.1016/j.hroo.2022.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
175
|
Lakkireddy D, Thaler D, Ellis CR, Swarup V, Sondergaard L, Carroll J, Gold MR, Hermiller J, Diener HC, Schmidt B, MacDonald L, Mansour M, Maini B, Anderson JA, Gage R, Windecker S. Outcomes of the roll-in cohort of the Amulet IDE trial of left atrial appendage occlusion. Heart Rhythm O2 2022; 3:493-500. [DOI: 10.1016/j.hroo.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022] Open
|
176
|
Simard TJ, Hibbert B, Alkhouli MA, Abraham NS, Holmes DR. Device-related thrombus following left atrial appendage occlusion. EUROINTERVENTION 2022; 18:224-232. [PMID: 35440430 DOI: 10.4244/eij-d-21-01010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Thrombus formation on intracardiac devices remains a subject of importance, with rates in the 2-5% range. Device-related thrombus (DRT) following left atrial appendage occlusion is an area of particular concern considering its association with embolic events. DRT continues to present numerous questions, including the optimal definition, incidence, risk factors, monitoring, therapy, and clinical outcomes - all subjects of ongoing assessment. Herein, we discuss these considerations, building upon the relevant historical context and pathophysiologic insights while discussing the future considerations in this rapidly evolving field.
Collapse
Affiliation(s)
- Trevor J Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Hibbert
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Neena S Abraham
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
177
|
Munir MB, Khan MZ, Darden D, Asad ZUA, Choubdar PA, Din MTU, Osman M, Singh GD, Srivatsa UN, Balla S, Reeves R, Hsu JC. Association of advanced age with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the National Inpatient Sample of 36,065 procedures. J Interv Card Electrophysiol 2022; 65:219-226. [PMID: 35731328 PMCID: PMC9550678 DOI: 10.1007/s10840-022-01266-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 06/02/2022] [Indexed: 11/25/2022]
Abstract
Background Age-stratified analyses of atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) are limited. The purpose of current study was to compare in-hospital outcomes in elderly AF patients (age > 80 years) to a relatively younger cohort (age £ 80 years) after LAAO. Methods Data were extracted from National Inpatient Sample for calendar years 2015–2018. LAAO device implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO. Results A total of 36,065 LAAO recipients were included in the final analysis, of which 34.6% (n=12,475) were performed on elderly AF patients. Elderly AF patients had a higher prevalence of major complications (6.7% vs. 5.7%, p < 0.01) and mortality (0.4% vs. 0.1%, p < 0.01) after LAAO device implantation in the crude analysis. After multivariate adjustment of potential confounders, age > 80 years was associated with increased risk of inpatient mortality (adjusted odds ratio [aOR] 4.439, 95% confidence interval [CI] 2.391–8.239) but not major complications (aOR 1.084, 95% CI 0.971–1.211), prolonged length of stay (aOR 0.943, 95% CI 0.88–1.101), or increased hospitalization costs (aOR 0.909, 95% CI 0.865–0.955). Conclusion Over 1 in 3 LAAO device implantations occurred in elderly AF patients. After adjusting for potential confounding variables, advanced age was associated with inpatient mortality, but not with other LAAO procedural–related outcomes including major complications, prolonged length of stay, or increased hospitalization costs.
Collapse
Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, San Diego, CA, USA
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Douglas Darden
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, San Diego, CA, USA
| | - Zain Ul Abideen Asad
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Parnia Abolhassan Choubdar
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, San Diego, CA, USA
| | | | - Mohammed Osman
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Gagan D Singh
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Uma N Srivatsa
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Sudarshan Balla
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Ryan Reeves
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, San Diego, CA, USA
| | - Jonathan C Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, San Diego, CA, USA.
- University of California San Diego, 9452 Medical Center Dr., MC7411, La Jolla, San Diego, CA, 92037, USA.
| |
Collapse
|
178
|
Kretzler L, Mues C, Wunderlich C, Langbein A, Spitzer SG, Gerk U, Schellong S, Ketteler T, Neuser H, Schwefer M, Strasser R, Ibrahim K, Schoen S, Christoph M. Short term outcome after left atrial appendage occlusion with the AMPLATZER Amulet and WATCHMAN device: results from the ORIGINAL registry (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure). BMC Cardiovasc Disord 2022; 22:271. [PMID: 35710343 PMCID: PMC9205092 DOI: 10.1186/s12872-022-02708-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 05/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Various randomized multicenter studies have shown that percutaneous left atrial appendage closure (LAAC) is not inferior in stroke prevention compared to vitamin K antagonists (VKA) and can be performed safely and effectively. Aims The prospective multicenter ORIGINAL registry in the Free State of Saxony (saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure) investigated the efficiency and safety of LAAC with Watchman or Amulet device in a real word setting. A special focus was put on the influence of LAAC frequency on periprocedural efficiency and safety. Methods and results The total of 482 consecutive patients (Abbott Amulet N = 93 and Boston Scientific Watchman N = 389) were included in the periinterventional analyses. After 6 weeks, 353 patients completed the first follow-up including transoesophageal echocardiography (TEE) (73.2%). Successful LAAC could be performed in more than 94%. The complication rate does not significantly differ between device types (p = 0.92) according to Fischer test and comprised 2.2% in the Amulet and 2.3% in the Watchman group. The kind of device and the frequency of LAAC per study center had no influence on the success and complication rates. Device related thrombus could be revealed more frequently in the Watchman group (4.5%) than in the Amulet group (1.4%) but this difference is still not significant in Fisher test (p = 0.14). Same conclusion can be made about residual leakage 1.1% versus 0% [not significant in Fisher test (p = 0.26)]. Dual antiplatelet therapy followed the intervention in 64% and 22% of patients were discharged under a combination of an anticoagulant (VKA/DOAC/Heparin) and one antiplatelet agent. Conclusions The ORIGINAL registry supports the thesis from large, randomized trials that LAAC can be performed with a very high procedural success rate in the everyday clinical routine irrespective of the used LAA device (Watchman or Amulet). The postprocedural antithrombotic strategy differs widely among the participating centers. Trial registration Name of the registry: "saxOnian RegIstry analyzinG and followINg left atrial Appendage cLosure", Trial registration number: DRKS00023803; Date of registration: 15/12/2020 'Retrospectively registered'; URL of trial registry record: https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00023803.
Collapse
Affiliation(s)
- Lucie Kretzler
- Clinical Study Center (CSC), Berlin Institute of Health (BIH), Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. .,Dresden University of Technology, Dresden, Germany.
| | - Christoph Mues
- Dresden University of Technology, Dresden, Germany.,St.-Johannes-Hospital Dortmund, Dortmund, Germany
| | - Carsten Wunderlich
- Dresden University of Technology, Dresden, Germany.,Technische Universität Dresden, Pirna Hospital, Pirna, Germany
| | - Anke Langbein
- Dresden University of Technology, Dresden, Germany.,Praxisklinik Herz und Gefäße Dresden, Dresden, Germany
| | - S G Spitzer
- Dresden University of Technology, Dresden, Germany.,Praxisklinik Herz und Gefäße Dresden, Dresden, Germany
| | - Ulrich Gerk
- Dresden University of Technology, Dresden, Germany.,Städtisches Klinikum Dresden, Dresden, Germany
| | - Sebastian Schellong
- Dresden University of Technology, Dresden, Germany.,Städtisches Klinikum Dresden, Dresden, Germany
| | - Thomas Ketteler
- Dresden University of Technology, Dresden, Germany.,HELIOS Klinikum Aue, Aue, Germany
| | - Hans Neuser
- Dresden University of Technology, Dresden, Germany.,HELIOS Klinikum Plauen, Plauen, Germany
| | - Marcus Schwefer
- Dresden University of Technology, Dresden, Germany.,Elblandklinikum Riesa, Riesa, Germany
| | - Ruth Strasser
- Dresden University of Technology, Dresden, Germany.,Klinikum Hochrhein, Waldshut-Tiengen, Germany
| | - Karim Ibrahim
- Technische Universität Dresden, Campus Chemnitz , Klinikum Chemnitz, Flemmingstrasse 2, 09116, Chemnitz, Germany
| | - Steffen Schoen
- Dresden University of Technology, Dresden, Germany.,Technische Universität Dresden, Pirna Hospital, Pirna, Germany
| | - Marian Christoph
- Technische Universität Dresden, Campus Chemnitz , Klinikum Chemnitz, Flemmingstrasse 2, 09116, Chemnitz, Germany
| |
Collapse
|
179
|
Peri-Device Leak After Left Atrial Appendage Occlusion: Minding the Gap. JACC Clin Electrophysiol 2022; 8:779-781. [PMID: 35738854 DOI: 10.1016/j.jacep.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 04/05/2022] [Indexed: 11/22/2022]
|
180
|
DeCampos D, Teixeira R, Saleiro C, Oliveira-Santos M, Paiva L, Costa M, Botelho A, Gonçalves L. 3D printing for left atrial appendage closure: A meta-analysis and systematic review. Int J Cardiol 2022; 356:38-43. [PMID: 35358638 DOI: 10.1016/j.ijcard.2022.03.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/15/2022] [Accepted: 03/18/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Three-dimensional printing (3D) has emerged as an alternative to imaging to guide left atrial appendage closure (LAAC) device sizing. AIMS We assessed the usefulness of 3D printing compared to a standard imaging-only approach for LAAC. METHODS We identified studies comparing an imaging-only with a 3D printing approach in LAAC. A fixed-effects meta-analysis was performed targeting a co-primary endpoint of disagreement in device sizing and leaks. RESULTS Eight studies that assigned 283 participants to an imaging-only approach and 3D printing approach (145 patients) were included. 3D printing significantly reduced the risk of the co-primary endpoint (risk raio (RR) = 0.19; 95% confidence interval (CI) 0.09-0.37), with consistency across the studies (I2 = 0%). Individually, both device size disagreements [RR 0.13 (95% CI 0.06-0.29), P < 0.001] and leaks [RR 0.24 (95% CI 0.09-0.64) P = 0.004] were reduced under a 3D printing modeling strategy. CONCLUSION Compared with an imaging-only strategy, 3D printing is associated with reduction in device size disagreements and leaks.
Collapse
Affiliation(s)
- Diana DeCampos
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal.
| | - Rogério Teixeira
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, Diana de Campos, 3000-370 Coimbra. Portugal
| | - Carolina Saleiro
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal
| | - Manuel Oliveira-Santos
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal
| | - Luis Paiva
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal
| | - Marco Costa
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal
| | - Ana Botelho
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal
| | - Lino Gonçalves
- Centro Hospitalar e Universitário de Coimbra - Hospital Geral, Quinta dos Vales, São Martinho do Bispo 108, 3041-801 Coimbra, Portugal; Faculdade de Medicina da Universidade de Coimbra, R. Larga 2, Diana de Campos, 3000-370 Coimbra. Portugal
| |
Collapse
|
181
|
Munir MB, Khan MZ, Darden D, Asad ZUA, Osman M, Singh GD, Srivatsa UN, Han FT, Reeves R, Hsu JC. Association of heart failure with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the national inpatient sample of 62 980 procedures. Europace 2022; 24:1451-1459. [PMID: 35613020 DOI: 10.1093/europace/euac043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/07/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS To determine outcomes in atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) with concomitant heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS Data were extracted from National Inpatient Sample for calendar years 2015-2019. LAAO device implantations were identified on the basis of ICD-10-CM code of 02L73DK. The outcomes assessed in our study included complications, in-patient mortality, and resource utilization. A total of 62 980 LAAO device implantations were studied. HFpEF (14.4%, n = 9040) and HFrEF (11.2%, n = 7100) were associated with a higher prevalence of major complications and in-patient mortality in crude analysis. In the multivariate model adjusted for potential confounders, HFpEF and HFrEF were not associated with major complications [adjusted odds ratio (aOR) 1.04, 95% confidence interval (CI) 0.93-1.16 and aOR 1.07, 95% CI 0.95-1.21] or in-patient mortality (aOR 1.48, 95% CI 0.85-2.55 and aOR 1.26, 95% CI 0.67-2.38). HFpEF and HFrEF were associated with prolonged length of stay (LOS) > 1 day (aOR 1.41, 95% CI 1.31-1.53 and aOR 1.66, 95% CI 1.53-1.80) and increased hospitalization costs > median cost 24 752$ (aOR 1.26, 95% CI 1.19-1.34 and aOR 1.21, 95% CI 1.13-1.29). CONCLUSION The prevalence of HF in AF patients undergoing percutaneous LAAO was approximately 26%. HF was not independently associated with major complications and in-patient mortality but was associated with prolonged LOS and higher hospitalization costs.
Collapse
Affiliation(s)
- Muhammad Bilal Munir
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - Muhammad Zia Khan
- Division of Cardiovascular Medicine, West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Douglas Darden
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - Zain Ul Abideen Asad
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma, OK, USA
| | - Mohammed Osman
- Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR, USA
| | - Gagan D Singh
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Uma N Srivatsa
- Division of Cardiovascular Medicine, University of California Davis, Sacramento, CA, USA
| | - Frederick T Han
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - Ryan Reeves
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| | - Jonathan C Hsu
- Section of Electrophysiology, Division of Cardiology, University of California San Diego, La Jolla, CA, USA
| |
Collapse
|
182
|
Chen Y, Zhang Y, Qu L, Chen C, Su X, Chen Y. Sex Differences in Efficacy and Safety After Left Atrial Appendage Closure: A 4.3-Year Follow-Up Analysis. Front Cardiovasc Med 2022; 9:814958. [PMID: 35665257 PMCID: PMC9157540 DOI: 10.3389/fcvm.2022.814958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Women are related to higher stroke risk and poorer outcome after stroke attack in patients with non-valvular atrial fibrillation (NVAF). The sex differences in efficacy and safety after left atrial appendage closure (LAAC) have remained elusive. This retrospective study aimed to investigate the safety, feasibility, and clinical outcomes of LAAC between women and men. Methods From 2014 to 2018, 395 patients who underwent LAAC in our center were enrolled in this retrospective study. Baseline clinical characteristics, procedural parameters, and postoperative follow-up data were collected and compared between women and men. Results The study included 154 women and 241 men. Compared with men, women were older (68.1 ± 7.9 vs. 64.6 ± 8.8, p < 0.01**), with higher CHA2DS2-VASc score (4.0 ± 1.7 vs. 3.0 ± 1.6, p < 0.01**). During the mean follow-up duration of 1,566 days (4.3 years), there were 39 major adverse cardiovascular events (MACE, including 19 cardiovascular or unexplained deaths, 15 ischemic strokes, and 5 major bleedings) recorded in 34 patients. The overall rate of ischemic stroke was 0.9 per 100 patient-years, and the overall rate of MACE was 2.1 per 100 patient-years. The cardiovascular or unexplained death and major bleeding were comparable between women and men. Compared with men, women had lower rates of ischemic stroke, fatal or disabling ischemic stroke, MACE, and fatal or disabling MACE, but none of them reached statistical differences (HR: 0.361, p = 0.099, HR: 0.429, p = 0.276, HR: 0.600, p = 0.170, and HR: 0.621, p = 0.254, respectively). In the adjusted analyses with multivariate Cox regression models, women had a lower fatal or disabling ischemic stroke rate compared with men (HR: 0.100, p = 0.041). Conclusion Left atrial appendage closure was feasible and safe for patients of both genders. The ischemic stroke, cardiovascular or unexplained death, and major bleeding were comparable between women and men. However, women were the independent protective factors against fatal or disabling ischemic stroke after LAAC implantation.
Collapse
|
183
|
Holmes DR. Antithrombotic Therapy After Left Atrial Appendage Occlusion: Cornucopia and Gertrude Stein. J Am Coll Cardiol 2022; 79:1799-1801. [PMID: 35512859 DOI: 10.1016/j.jacc.2022.03.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
|
184
|
Freeman JV, Higgins AY, Wang Y, Du C, Friedman DJ, Daimee UA, Minges KE, Pereira L, Goldsweig AM, Price MJ, Reddy VY, Gibson D, Doshi SK, Varosy PD, Masoudi FA, Curtis JP. Antithrombotic Therapy After Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation. J Am Coll Cardiol 2022; 79:1785-1798. [PMID: 35512858 PMCID: PMC9097170 DOI: 10.1016/j.jacc.2022.02.047] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/21/2022] [Accepted: 02/15/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Pivotal trials of percutaneous left atrial appendage occlusion (LAAO) used specific postprocedure treatment protocols. OBJECTIVES This study sought to evaluate patterns of postprocedure care after LAAO with the Watchman device in clinical practice and compare the risk of adverse events for different discharge antithrombotic strategies. METHODS We evaluated patients in the LAAO Registry of the National Cardiovascular Data Registry who underwent LAAO with the Watchman device between 2016 and 2018. We assessed adherence to the full postprocedure trial protocol including standardized follow-up, imaging, and antithrombotic agents and then evaluated the most commonly used antithrombotic strategies and compared the rates and risk of adverse events at 45 days and 6 months by means of multivariable COX frailty regression. RESULTS Among 31,994 patients undergoing successful LAAO, only 12.2% received the full postprocedure treatment protocol studied in pivotal trials; the most common protocol deviations were with discharge antithrombotic medications. The most common discharge medication strategies were warfarin and aspirin (36.9%), direct oral anticoagulant (DOAC) and aspirin (20.8%), warfarin only (13.5%), DOAC only (12.3%), and dual antiplatelet therapy (5.0%). In multivariable Cox frailty regression, the adjusted risk of any adverse event through the 45-day follow-up visit were significantly lower for discharge on warfarin alone (HR: 0.692; 95% CI: 0.569-0.841) and DOAC alone (HR: 0.731; 95% CI: 0.574-0.930) compared with warfarin and aspirin. Warfarin alone retained lower risk at the 6-month follow-up. CONCLUSIONS In contemporary U.S. practice, practitioners rarely used the full U.S. Food and Drug Administration-approved postprocedure treatment protocols studied in pivotal trials of the Watchman device. Discharge after implantation on warfarin or DOAC without concomitant aspirin was associated with lower risk of adverse outcomes.
Collapse
Affiliation(s)
- James V Freeman
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA.
| | | | - Yongfei Wang
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Daniel J Friedman
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Usama A Daimee
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Karl E Minges
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Lucy Pereira
- Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Douglas Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Shephal K Doshi
- Division of Cardiology, St John's Health Center, Pacific Heart Institute, Santa Monica, California, USA
| | - Paul D Varosy
- Division of Cardiology, University of Colorado School of Medicine, Aurora, Colorado, USA; Veterans Affairs Eastern Colorado Health Care System, Aurora, Colorado, USA
| | | | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut, USA
| |
Collapse
|
185
|
Tang SA, Doshi SK. Left Atrial Appendage Occlusion: Practice Makes Perfect? JACC Cardiovasc Interv 2022; 15:962-964. [PMID: 35512919 DOI: 10.1016/j.jcin.2022.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Stephen A Tang
- Division of Cardiac Electrophysiology, Pacific Heart Institute, Santa Monica, California, USA
| | - Shephal K Doshi
- Division of Cardiac Electrophysiology, Pacific Heart Institute, Santa Monica, California, USA.
| |
Collapse
|
186
|
Kiankhooy A, Liem B, Dunnington GH, Pierce C, Eisenberg SJ, Burk S, Kaiser DW, Lyons T, Huber D. Left Atrial Appendage Ligation Using the AtriClip Device: Single-Center Study of Device Safety and Efficacy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:209-216. [PMID: 35532959 DOI: 10.1177/15569845221091998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Left atrial appendage (LAA) occlusion at the time of cardiac surgery in patients with atrial fibrillation has been shown to reduce the incidence of postoperative embolic stroke. However, the optimal method for LAA occlusion is not universally accepted. We sought to examine the safety and effectiveness of LAA occlusion with the AtriClip epicardial occlusion device. METHODS Cardiac surgical patients with atrial fibrillation who underwent LAA AtriClip placement were evaluated prospectively. Clip placement and clinical outcomes were examined after 1 year of follow-up with transesophageal echocardiography (TEE). The presence of a 10 mm or greater residual pouch, presence of flow into the LAA, or device-related thrombus (DRT) were considered failures. RESULTS Ninety-seven patients were analyzed. The mean CHA2DS2-VASc score was 2.4 ± 1.4. The postoperative follow-up period ranged from 366 to 1,693 days (mean 685 days or 1.87 years). Seventy-four AtriClips were placed with video-assisted thoracic surgery, whereas 23 were placed via sternotomy or thoracotomy. Successful closure was found in 96% (93 of 97) of patients at follow-up. Failure occurred in 4 patients. No clip migration or DRT was seen on 3-dimensional imaging. Of all 97 patients, 76 (78%) were on presurgical oral anticoagulation, whereas 5 (5.1%) were on postprocedure oral anticoagulation. There were no postoperative thromboembolic events at the time of the study TEE. CONCLUSIONS The AtriClip epicardial surgical occlusion device can provide an excellent rate of successful closure of the LAA during surgical ablation procedures without DRT.
Collapse
Affiliation(s)
- Armin Kiankhooy
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| | - Bing Liem
- Electrophysiology, Department of Cardiology, 19980University of California San Francisco and San Francisco VA Health Care, CA, USA
| | | | - Carolyn Pierce
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| | - Susan J Eisenberg
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| | - Shelby Burk
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| | - Daniel W Kaiser
- Electrophysiology, Department of Cardiology, St Thomas Heart, Nashville, TN, USA
| | - Timothy Lyons
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| | - Daniel Huber
- Cardiothoracic Surgery, Department of Surgery, Adventist Health-St Helena Hospital, CA, USA
| |
Collapse
|
187
|
Aarnink EW, Huijboom MF, Bor WL, Maarse M, Zheng KL, ten Cate H, Ten Berg JM, Boersma LV. Hemostatic biomarkers and antithrombotic strategy in percutaneous left atrial interventions: State-of-the-art review. Thromb Res 2022; 215:41-51. [DOI: 10.1016/j.thromres.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/29/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022]
|
188
|
Tan BEX, Rao M, Baibhav B, Chuprun D, Shah A, Bhatt DL, Depta JP. Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin Following WATCHMAN in High-Risk Patients. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100042. [PMID: 39131954 PMCID: PMC11307383 DOI: 10.1016/j.jscai.2022.100042] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/11/2022] [Accepted: 03/07/2022] [Indexed: 08/13/2024]
Abstract
Background In the pivotal WATCHMAN trials, warfarin was used exclusively for postprocedural anticoagulation following left atrial appendage closure. We sought to investigate the safety and efficacy of direct oral anticoagulants (DOACs) in high-risk patients with atrial fibrillation who underwent left atrial appendage closure with WATCHMAN. Methods This was a retrospective study of 318 patients who underwent the WATCHMAN procedure in a tertiary referral center (June 2016-September 2020). We compared the outcomes of patients who were discharged on DOACs versus warfarin after the WATCHMAN procedure. The primary outcome was the composite of any bleeding, thromboembolism, or cardiovascular death through 7 days and 45 days after the procedure. Results The final analysis included 301 patients, of whom 82.4% (248/301) were discharged on DOACs and 17.6% (53/301) were discharged on warfarin. The mean CHA2DS2-VASc and HAS-BLED scores were 4.9 ± 1.6 and 2.9 ± 0.9, respectively. The primary composite outcome was similar between the DOAC and warfarin groups through 7 days (3.2% vs 5.6%; adjusted odds ratio [OR], 0.65; 95% confidence interval [CI], 0.13-3.17; P = .59) and 45 days after procedure (10.1% vs 11.3%; adjusted OR, 1.18; 95% CI, 0.41-3.45; P = .76). Major bleeding (5.2% vs 9.5%; P = .34) and all-cause readmission (12.5% vs 16.9%; P = .85) at 45 days were comparable between the DOAC and warfarin groups. The overall incidence of device-related thrombus and significant peri-device flow at 45 days were low (<0.5%). Conclusions In high-risk patients with atrial fibrillation, the primary composite outcome of any bleeding, thromboembolism, or cardiovascular death through 7 days and 45 days following WATCHMAN implantation was similar in patients receiving DOACs versus warfarin.
Collapse
Affiliation(s)
- Bryan E-Xin Tan
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Mohan Rao
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, New York
| | - Bipul Baibhav
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, New York
| | - Dmitry Chuprun
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, New York
| | - Abrar Shah
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, New York
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Jeremiah P. Depta
- Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, New York
| |
Collapse
|
189
|
Price MJ, Valderrábano M, Zimmerman S, Friedman DJ, Kar S, Curtis JP, Masoudi FA, Freeman JV. Periprocedural Pericardial Effusion Complicating Transcatheter Left Atrial Appendage Occlusion: A Report From the NCDR LAAO Registry. Circ Cardiovasc Interv 2022; 15:e011718. [PMID: 35369701 PMCID: PMC9132377 DOI: 10.1161/circinterventions.121.011718] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/01/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pericardial effusion (PE) is a potential complication of transcatheter left atrial appendage occlusion. The objective of this study was to investigate the incidence, associated characteristics, and outcomes of PE following left atrial appendage occlusion. METHODS Patients in the NCDR LAAO Registry who underwent a Watchman procedure between January 1, 2016 and December 31, 2019 were included. The primary outcome was in-hospital PE requiring intervention (percutaneous drainage or surgery). Odds ratios (ORs) were calculated for adverse event rates associated with PE. RESULTS The study population consisted of 65 355 patients. The mean patient age was 76.2±8.1 years, and the mean CHA2DS2-VASc score was 4.6±1.5. PE occurred in 881 patients (1.35%). Clinical variables independently associated with PE included older age, female sex, left ventricular function, paroxysmal atrial fibrillation, prior bleeding, lower serum albumin, and preprocedural dual antiplatelet therapy; procedural variables included number of delivery sheaths used, sinus rhythm during the procedure, and moderate sedation rather than general anesthesia. PE was associated with increased risk of in-hospital stroke (OR, 6.58 [95% CI, 3.32-13.06]; P<0.0001), death (OR, 56.88 [95% CI, 39.79-81.32]; P<0.0001), and the composite of death, stroke, or systemic embolism (OR, 28.64 [95% CI, 21.24-38.61]; P<0.0001). PE during the index hospitalization was associated with increased risk of death (OR, 3.52 [95% CI, 2.23-5.54]; P<0.0001) and the composite of death, stroke, or systemic embolism (OR, 3.42 [95% CI, 2.31-5.07]; P<0.0001) between discharge and 45-day follow-up. CONCLUSIONS In-hospital PE during transcatheter left atrial appendage occlusion is infrequent but associated with a substantially higher risk of adverse events, including in-hospital and early postdischarge mortality. Strategies to minimize PE are critical to improve the risk-benefit ratio for this therapy.
Collapse
Affiliation(s)
- Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
| | - Miguel Valderrábano
- Division of Cardiac Electrophysiology, Houston Methodist Hospital, Houston, TX
| | - Sarah Zimmerman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | | | - Saibal Kar
- Los Robles Regional Medical Center, Thousand Oaks, CA
| | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | | | - James V. Freeman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
190
|
Natale A, Kar S, Holmes D. Letter by Natale et al Regarding Article, "Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial". Circulation 2022; 145:e847-e848. [PMID: 35467955 DOI: 10.1161/circulationaha.121.057567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrea Natale
- Texas Cardiac Arrythmia Institute, Austin, TX (A.N.)
| | - Saibal Kar
- Los Robles Regional Medical Center, Thousand Oaks, CA (S.K.)
| | | |
Collapse
|
191
|
Lakkireddy D, Thaler D, Windecker S. Response by Lakireddy et al to Letters Regarding Article, "Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial". Circulation 2022; 145:e850-e851. [PMID: 35467954 DOI: 10.1161/circulationaha.122.059423] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, KS (D.L.)
| | | | | |
Collapse
|
192
|
Dhruva SS, Redberg RF. Letter by Dhruva and Redberg Regarding Article, "Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial". Circulation 2022; 145:e845-e846. [PMID: 35467950 DOI: 10.1161/circulationaha.121.057472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Sanket S Dhruva
- Philip R. Lee Institute for Health Policy Studies (S.S.D., R.F.R.)
- University of California, San Francisco. Section of Cardiology, Department of Medicine, San Francisco Veterans Affairs Medical Center, CA (S.S.D.)
| | - Rita F Redberg
- Philip R. Lee Institute for Health Policy Studies (S.S.D., R.F.R.)
- Department of Medicine, Division of Cardiology (R.F.R.), University of California, San Francisco School of Medicine, San Francisco
| |
Collapse
|
193
|
Price MJ, Gibson DN, Kar S. Letter by Price et al Regarding the Article, "Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial". Circulation 2022; 145:e849. [PMID: 35467951 DOI: 10.1161/circulationaha.121.058485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P., D.NG.)
| | - Doug N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, CA (M.J.P., D.NG.)
| | - Saibal Kar
- Los Robles Regional Medical Center, Thousand Oaks, CA (S.K.)
| |
Collapse
|
194
|
Qiao J, Zhang B, Wang J, Pan L, Cheng T, Wang Y, Xiong E. Comparison between Amplatzer and Watchman left atrial appendage closure devices for stroke prevention in atrial fibrillation:a systematic review and meta-analysis. Cardiology 2022; 147:290-297. [PMID: 35468598 DOI: 10.1159/000524626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 04/09/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The Amplatzer and Watchman left atrial appendage closure (LAAC) devices are the two most frequently used devices for left atrial appendage closure devices worldwide. This meta-analysis aims to compare the safety and efficacy of the two devices. METHODS We searched the PubMed, EMBASE and the Cochrane Library for studies up to 6 February 2022 that compared the safety and efficacy of the Amplatzer and Watchman devices. RESULTS Fifteen studies including 2,150 patients in randomized controlled trials (RCTs) and 2,526 patients in observational studies were included in the meta-analysis. Amplatzer device was associated with higher rates of major procedure-related complications (odds ratio [OR]: 1.99, 95% confidence interval [CI]: 1.45-2.74, P <0.0001) and device embolization (OR: 1.99, 95% CI: 1.09-3.64, P =0.03). However, Amplatzer device had lower rates of total peridevice leak (PDL) (OR:0.48, 95% CI: 0.27-0.83, P =0.009), significant PDL (OR:0.27, 95% CI: 0.12-0.57, P =0.0007) and device-related thrombus (DRT) (OR:0.67, 95% CI: 0.48-0.95, P =0.02). No statistical differences were observed between the two devices in other safety and efficacy endpoints, such as pericardial effusion, cardiac tamponade, air embolism, vascular complications, ischemic stroke/ transient ischemic attack (TIA), hemorrhagic stroke, all-cause death, cardiovascular death and bleeding. CONCLUSIONS Amplatzer LAAC device was associated with higher rates of major procedure-related complications, especially in device embolization. Watchman LAAC device was associated with higher rates of PDL and DRT. There were no significant differences between two devices in ischemic stroke/TIA, hemorrhagic stroke, all-cause death, cardiovascular death and bleeding.
Collapse
Affiliation(s)
- Jianzhong Qiao
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Bin Zhang
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Jie Wang
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Lingxin Pan
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Tieniu Cheng
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Yuan Wang
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| | - Enlai Xiong
- Department of Cardiology, Tongling People's Hospital, Tongling, China
| |
Collapse
|
195
|
Management of atrial fibrillation: two decades of progress - a scientific statement from the European Cardiac Arrhythmia Society. J Interv Card Electrophysiol 2022; 65:287-326. [PMID: 35419669 DOI: 10.1007/s10840-022-01195-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/21/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades. RESULTS Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction. CONCLUSIONS Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.
Collapse
|
196
|
Tzikas A. "Rocking the Boat" in Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2022; 15:751-752. [PMID: 35393109 DOI: 10.1016/j.jcin.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 02/27/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Apostolos Tzikas
- AHEPA University Hospital & European Interbalkan Medical Center, Thessaloniki, Greece.
| |
Collapse
|
197
|
Price MJ, Slotwiner D, Du C, Freeman JV, Turi Z, Rammohan C, Kusumoto FM, Kavinsky C, Akar J, Varosy PD, Koutras C, Curtis JP, Masoudi FA. Clinical Outcomes at 1 Year Following Transcatheter Left Atrial Appendage Occlusion in the United States. JACC Cardiovasc Interv 2022; 15:741-750. [PMID: 35393108 DOI: 10.1016/j.jcin.2022.02.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to report 1-year clinical outcomes following commercial transcatheter left atrial appendage occlusion (LAAO) in the United States. BACKGROUND The National Cardiovascular Data Registry LAAO Registry was initiated to meet a condition of Medicare coverage and allow the assessment of clinical outcomes. The 1-year rates of thromboembolic events after transcatheter LAAO in such a large cohort of "real-world" patients have not been previously reported. METHODS Patients entered into the National Cardiovascular Data Registry LAAO Registry for a Watchman procedure between January 1, 2016, and December 31, 2018, were included. The primary endpoint was ischemic stroke. Key secondary endpoints included the rate of ischemic stroke or systemic embolism, mortality, and major bleeding. Major bleeding was defined as any bleeding requiring hospitalization, and/or causing a decrease in hemoglobin level > 2g/dL, and/or requiring blood transfusion that was not hemorrhagic stroke. The Kaplan-Meier method was used for 1-year estimates of cumulative event rates. RESULTS The study population consisted of 36,681 patients. The mean age was 76.0 ± 8.1 years, the mean CHA2DS2-VASc score was 4.8 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.1. Prior stroke was present in 25.5%, clinically relevant bleeding in 69.5%, and intracranial bleeding in 11.9%. Median follow-up was 374 days (IQR: 212-425 days). The Kaplan-Meier-estimated 1-year rate of ischemic stroke was 1.53% (95% CI: 1.39%-1.69%), the rate of ischemic stroke or systemic embolism was 2.19% (95% CI: 2.01%-2.38%), and the rate of mortality was 8.52% (95% CI: 8.19%-8.87%). The 1-year estimated rate of major bleeding was 6.93% (95% CI: 6.65%-7.21%). Most bleeding events occurred between discharge and 45 days following the procedure. CONCLUSIONS This study characterizes important outcomes in a national cohort of patients undergoing transcatheter LAAO in the United States. Clinicians and patients can integrate these data in shared decision making when considering this therapy.
Collapse
Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA.
| | - David Slotwiner
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zoltan Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Chidambaram Rammohan
- Division of Cardiovascular Medicine, Palo Alto Medical Foundation, El Camino Hospital, Mountain View, California
| | - Fred M Kusumoto
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
| | - Clifford Kavinsky
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Akar
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paul D Varosy
- VA Eastern Colorado Health Care System and University of Colorado, Aurora, Colorado, USA
| | - Christina Koutras
- American College of Cardiology Foundation, Washington, District of Columbia, USA
| | - Jeptha P Curtis
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | | |
Collapse
|
198
|
Daniels MJ, Parry-Jones A. The Future of LAAC-In 5, 10, and 20 Years. Interv Cardiol Clin 2022; 11:219-231. [PMID: 35361466 DOI: 10.1016/j.iccl.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation. Finally, we consider how to make the procedure safer and more effective.
Collapse
Affiliation(s)
- Matthew J Daniels
- Manchester Heart Centre, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, UK; Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, UK; Division of Cell Matrix Biology and Regenerative Medicine, University of Manchester, Manchester, UK.
| | - Adrian Parry-Jones
- Division of Cardiovascular Sciences, Manchester Academic Health Sciences Centre, University of Manchester, UK; Geoffrey Jefferson Brain Research Centre, Manchester Academic Health Science Centre, Northern Care Alliance & University of Manchester, Manchester UK; Manchester Centre for Clinical Neurosciences, Northern Care Alliance NHS Group, Stott Lane, Salford M6 8HD, UK
| |
Collapse
|
199
|
Sievert K, Asmarats L, Arzamendi D. Left Atrial Appendage Occlusion Strengths and Weaknesses of the Lobe-Only Occluder Concept in Theory and in Practice. Interv Cardiol Clin 2022; 11:195-203. [PMID: 35361464 DOI: 10.1016/j.iccl.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design. This review highlights the potential features and benefits of the single-lobe devices.
Collapse
Affiliation(s)
- Kolja Sievert
- CardioVascular Center Frankfurt (CVC), St. Catherine Hospital, Seckbacher Landstraße 65, 60389 Frankfurt am Main, Germany
| | - Lluis Asmarats
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Dabit Arzamendi
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).
| |
Collapse
|
200
|
Wong I, Tzikas A, Søndergaard L, De Backer O. The Strengths and Weaknesses of the LAA Covering Disc Occluders-Conceptually and in Practice. Interv Cardiol Clin 2022; 11:185-194. [PMID: 35361463 DOI: 10.1016/j.iccl.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Endocardial left atrial appendage (LAA) occluders with a covering disc encompass a wide range of devices that share the common feature of a distal anchoring "body" and proximal covering "disc" design. This unique design feature has potential advantages in certain complex LAA anatomies and challenging clinical scenarios. The current review article summarizes the different features of established and novel devices, preprocedural imaging updates, intraprocedural technical considerations, and postprocedural follow-up issues specific to this category of LAA occluders.
Collapse
Affiliation(s)
- Ivan Wong
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Apostolos Tzikas
- European Interbalkan Medical Centre & AHEPA University Hospital, Asklipiou 10, Thessaloniki 57001, Greece
| | - Lars Søndergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark.
| |
Collapse
|