Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial

Thirty-day readmission rate of same-day discharge protocol after left atrial appendage occlusion: A propensity score-matched analysis from the National Readmission Database

BACKGROUND

Given the reduction in periprocedural complication rates, same-day discharge (SDD) after percutaneous left atrial appendage closure (LAAC) could be beneficial. To date, little data exist comparing the standard overnight stay (ONS) vs SDD after LAAC.

OBJECTIVE

The purpose of this study was to investigate the safety and efficacy of SDD compared with ONS.

METHODS

A retrospective cohort study of LAAC procedures performed in the United States from 2015 to 2019 was conducted using the US Nationwide Readmission Database. The primary outcome was all-cause 30-day readmission after discharge in patients who underwent LAAC, and a secondary outcome was requiring total health care cost. A 1:1 propensity score matching was conducted for adjustment. Multivariate Cox proportional hazards regression was also performed to estimate the hazard ratio for all-cause readmission within 30 days of LAAC.

RESULTS

Of 48,953 patients (mean age 76.0 ± 7.9 years), 972 patients (1.99%) were discharged on the same day after LAAC (SDD group) and the remaining 47,981 patients stayed at least 1 night (ONS group). A propensity score-matched analysis generated 961 matched pairs in each group. The 30-day readmission rate after discharge was similar between the groups (SDD vs ONS: 8.5% vs 9.8%; P = .31; hazard ratio 1.13; 95% confidence interval 0.78-1.63; P = .53). The total required health care cost was significantly lower in the SDD group ($23,720 [$18,075-$29,416] vs $25,877 [$19,906-$32,748]; P < .01). Gastrointestinal bleeding was the major cause for readmission (SDD vs ONS: 14.7% vs 15.1%; P = .95), but stroke and pericardial effusion were rare.

CONCLUSION

In patients without procedure-related complications, SDD is a safe and cost-effective protocol.

First-in-Human Experience of Using a Universal Steerable Sheath in Implanting Left Atrial Appendage Closure Devices

Left atrial appendage (LAA) closure (LAAC) device implantation may be challenging in cases with difficult LAA anatomy. A deflectable sheath to approach multiple LAA positions may be helpful. We used a deflectable sheath to implant LAAC devices in 20 patients and included 60 cases using the standard sheaths for comparison. The procedures were successful in all patients without peri-procedural complications. After a median follow-up of 1.52 (IQR: 0.76-2.33) years, none of the patients in the deflectable sheath group had peri-device leak ≥3 mm and experienced thromboembolic stroke. In the standard sheath group, after follow-up of 2.03 (IQR: 0.87-3.19) years, 2 had peri-device leak ≥3 mm and 1 experienced thromboembolic stroke. We first proved the idea of using a universal steerable sheath for LAAC device implantation in difficult LAA anatomy, which also allows rapid switching of different LAAC devices.

Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial

INTRODUCTION

Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA₂DS₂-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population.

METHODS AND ANALYSIS

This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200058109.

Comparison of outcomes between novel oral anticoagulants and warfarin monotherapy in patients with left atrial appendage closure: A systematic review and meta-analysis

Background

Pivotal trials of percutaneous left atrial appendage closure (LAAC) used dedicated post-procedure antithrombotic protocols. However, there is no consensus on the selection of new oral anticoagulants (NOAC) and warfarin monotherapy after LAAC. This study aims to compare NOAC with warfarin monotherapy for efficacy and safety in patients undergoing LAAC.

Methods

A database search was conducted using PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov for trials that compared NOAC with warfarin monotherapy after LAAC. The effective outcomes included any major adverse events (all-cause death, stroke, major bleeding) and their individual components. Safety outcomes included all-cause death, major bleeding, total bleeding, DRT, and PDL >5 mm.

Results

We included 10 non-randomized clinical trials with 10,337 patients, of whom 4,960 patients received NOAC, while 5,377 patients received warfarin. There were no statistically significant differences in any major adverse events (LogOR: −0.11, 95% CI: −0.27, 0.04, P = 0.16), stroke (LogOR: 0.00, 95% CI: −0.42, 0.42, P = 1.00), all-cause death (LogOR: −0.23, 95% CI: −0.48, 0.02, P = 0.07), major bleeding (LogOR: −0.22, 95% CI: −0.45, 0.01, P = 0.06). NOAC was associated with a significant reduction in total bleeding (LogOR: −1.01, 95% CI: −1.47, −0.55, P < 0.0001) compared to warfarin. No statistically significant differences were found in DRT (LogOR: −0.19, 95% CI: −0.15, 0.52, P = 0.27) and PDL >5 mm (LogOR: 0.19, 95% CI: −0.33, 0.72, P = 0.47). Meta-regression and subgroup analysis showed that total bleeding (LogOR: −1.56, 95% CI: −2.15, −0.97, P < 0.001) was significantly lower in the NOAC group in the subgroup of <75 y.

Conclusion

After LAAC, NOAC monotherapy was associated with a lower risk of bleeding compared to warfarin monotherapy for 45 days. There was no significant difference between NOAC and warfarin in terms of other results.

Systematic review registration

www.york.ac.uk/inst/crd, identifier: CRD42022361244.

Left atrial thrombus after placement of watchman device

Atrial fibrillation is an irregular rhythm with increased risk of morbidityand mortality. Commonly due to thromboembolism at the left atrialappendage. Guideline therapy for atrial fibrillation is anticoagulation.Alternative treatment includes closure with the Watchman device. Wepresent a case of Watchman device-related thrombus seven monthsafter placement.

Left atrial appendage closure with the II generation Ultraseal device: An international registry. The LIGATE study

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.

Iatrogenic atrial septal defects after transseptal puncture for percutaneous left atrial appendage occlusion and their hemodynamic effects

BACKGROUND

Percutaneous left atrial appendage occlusion (LAAO) requires puncture of the interatrial septum. The immediate hemodynamic effects of iatrogenic atrial septal defects (iASD) after LAAO have not been examined so far. We aimed at evaluating these effects through invasive measurements of pressure and oxygen saturation. Moreover, we assessed the incidence of persistent iASD at three months.

METHODS

Forty-eight patients scheduled for percutaneous LAAO were prospectively included in the study. Pressure and oxygen saturation were measured (1) in the right atrium (RA) before transseptal puncture, (2) in the left atrium (LA) through the transseptal sheath after transseptal puncture, (3) in the LA after removal of introducer sheath, and (4) in the RA after removal of introducer sheath. Transesophageal echocardiography was performed at three months to detect iASD.

RESULTS

Pressure in the RA increased significantly after removing the introducer sheath (P = 0.034), whereas no difference was found in oxygen saturation in the RA (P = 0.623). Pressure measurement in the LA showed no significant difference after removing the introducer sheath (P = 0.718). Oxygen saturation in the LA also showed no significant difference (P = 0.129). Follow-up transesophageal echocardiogram at 3 months revealed a persistent iASD in 4 patients (8.5 %).

CONCLUSIONS

Our study suggests that iASD after percutaneous LAAO does not result in significant shunts directly after the procedure, although a significant increase of mean right atrial pressure can be observed. Persistent iASDs after percutaneous LAAO seem to be relatively rare at three months.

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study

INTRODUCTION

Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA₂DS₂-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile.

METHODS AND ANALYSIS

Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well.

ETHICS AND DISSEMINATION

Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences.

TRIAL REGISTRATION NUMBER

NCT05144958.

Left atrial appendage exclusion in atrial fibrillation

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.

Peri-device leakage not CHA2DS2-VASc is associated with post-left atrial appendage closure cardiovascular event

OBJECTIVE

In patients with non-valvular atrial fibrillation (NVAF), the left atrial appendage occluder (LAAO) is an alternative treatment for stroke prevention. However, thromboembolic event still occur, and the predictors are unknown.

METHODS

The first Asian long-term follow-up study consisted of 308 patients with mean age 71.9±9.5 years, mean CHA₂DS₂-VASc 4.1 ± 1.8 since 2013. Primary outcome was defined as any type of ischemic stroke/transient ischemic attack (TIA), systemic embolization and cardiovascular death.

RESULTS

There was no procedural-related TIA or stroke. After a mean follow-up of 38±16 months, the ischemic stroke/TIA rate was 1.9 and cardiovascular death rate 0.3 per 100 patient-year. The rate of peri-device leak (PDL) was 11.9% and device-related thrombus (DRT) 2.6%. In the multivariable analyses, PDL was the only independent predictor of stroke/TIA (hazard ratio 5.5, p=0.008). CHA₂DS₂-VASc score, prior history of stroke, DRT and post-procedural anti-thrombotic regimen/duration were not associated with outcomes. Implantation of Watchman was associated with PDL (odds ratio 4.35, p=0.001).

CONCLUSIONS

PDL is the only independent predictor of post-LAAO stroke. The risk of stroke for patients with NVAF may be controllable after LAA is occluded, because PDL is preventable and treatable.

Prevention of Cardioembolic Complications in Patients with Atrial Fibrillation: Efficacy and Safety of Left Atrial Appendage Isolation and Oral Anticoagulants

Aim. To study the outcomes frequency and structure in patients with atrial fibrillation (AF) depending on the cardioembolic events preventing method: left atrial appendage (LAA) isolation, direct oral anticoagulants (DOACs) or warfarin.

Material and methods. A prospective observational study included patients with AF and high risk of cardioembolic complications and without contraindications to anticoagulants. Patients who refused long-term oral anticoagulants taking underwent LAA isolation, the rest of the patients received DOACs or warfarin. The observation period was 3 years. Mortality, cardioembolic complications and major bleeding (according to GARFIELD criteria) cumulative incidence was assessed.

Results. We included 245 patients: 46 patients were treated with LAA isolation, 100 with warfarin, and 99 with DOACs. Multivariate regression analysis demonstrated a statistically significant advantage of LAA occluder in terms of combined endpoint achieving frequency compared to warfarin (hazard ratio [HR] 3.10; 95% confidence interval [CI] 1.01-9.54; p=0.049), and to DOACs (HR 3.44, 95% CI 1.15-10.29; p=0.027). A similar result was obtained for all-cause mortality (HR 5.24; 95% CI 1.12-24.55; p=0.036 and HR 5.58; 95% CI 1.22-25.49; p=0.027, respectively). There were no significant differences in bleeding rates between the groups.

Conclusion. This observational study demonstrates the superiority of LAA isolation as a first-line therapy over DOACs and warfarin in patients with AF and high risk of cardioembolic complications. Randomized trials are required to confirm these observations.

Percutaneous Left Atrial Appendage Closure With a Novel LAA Occluder for Stroke Prevention in Atrial Fibrillation

Background

More than 90% of thromboses originate from the left atrial appendage (LAA) in patients with nonvalvular atrial fibrillation (NVAF).

Objectives

This study was designed to investigate the safety and efficacy of LAA closure with the Leftear device (Pulse Scientific) in NVAF patients.

Methods

A prospective, multicenter, registry-based study was conducted in 200 NVAF patients with CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes, previous stroke/transient ischemic attack, vascular disease, female sex) scores ≥2. The primary safety endpoint was defined as any serious adverse events. Efficacy was assessed by a primary composite endpoint of hemorrhagic or ischemic stroke, systemic embolism, and cardiac or unexplained death at 1 year of follow-up.

Results

The device was implanted in 196 patients, with 1-stop LAA closure combined with atrial fibrillation ablation implemented in 133 patients. The immediate success rate was 100%. There were serious adverse events in 9 patients (4.5%; 95% CI: 1.6%-7.4%), which mainly occurred in 1-stop LAA closure. All pericardial tamponades occurred in 6 patients with 1-stop LAA closure. No patient experienced a major bleeding event or acute device-related thrombus. During the 12-month follow-up period, the risk of the primary composite endpoint was 1.6% (95% CI: 0.3%-4.5%), and statistical noninferiority was achieved (the upper bound of 95% CI: 4.5% < the prespecified maximum annual incidence of 8.0%). Ischemic stroke occurred in 1 patient, 3 patients had incomplete LAA sealing, and no delayed device-related thrombus was found.

Conclusions

LAA closure with the novel disc-like occluder shows high procedural success, satisfactory safety, and encouraging efficacy for stroke prevention in patients with NVAF. Compared with 1-stop LAA closure, single LAA closure may be more tolerable. (A multicenter, single-arm clinical trial to evaluate the efficacy and safety of left atrial appendage system for left atrial appendage occlusion in patients with non-valvular atrial fibrillation; ChiCTR1900023035).

The Convergent Ablation and AtriClip Exclusion of the Left Atrial Appendage in Long-Standing Persistent Atrial Fibrillation

We here present a case of a 54-year-old man with longstanding persistent atrial fibrillation refractory to direct current electrical cardioversion who underwent a concurrent convergent ablation and Atriclip exclusion of left atrial appendage. His preoperative echocardiography revealed dilated 5.8 cm left atrium with a normal left ventricular ejection fraction of 50%. Transmural isolation of pulmonary veins was performed through a subxiphoid approach, and 3 left-sided video-assisted thoracoscopic surgery ports were utilised to occlude the base of the left atrium appendage with the Atriclip device. A peri-operative transoesophageal echocardiogram confirmed left atrium appendage base occlusion, and the patient was in sinus rhythm after having a single 200 kJ direct current cardioversion shock. The postoperative period was uneventful, and the patient was discharged with preprocedural anticoagulant after 24 hours of the procedure and advised to come for follow up after 3 months.

Comparison of anticoagulation with left atrial appendage closure after atrial fibrillation ablation: Rationale and design of the OPTION randomized trial

BACKGROUND

For patients with symptomatic atrial fibrillation (AF), physicians typically offer AF ablation for symptom relief; however, patients often anticipate/expect a life free from anticoagulation. This belief puts patients at increased risk of stroke due to the potential for asymptomatic AF postablation if anticoagulation is ceased contrary to clinical guidelines. Although the WATCHMAN device has been FDA-approved to decrease the risk of thromboembolism from the left atrial appendage (LAA) in patients with an appropriate rationale to avoid oral anticoagulation, it has not been well-studied following AF ablation. Additionally, there are limited data comparing the WATCHMAN device to direct oral anticoagulants. The OPTION study will investigate whether LAA closure with the WATCHMAN FLX device is a reasonable alternative to oral anticoagulation following percutaneous catheter ablation for nonvalvular AF.

TRIAL DESIGN

OPTION is a multinational, multicenter, prospective randomized clinical trial. Patients with a CHA₂DS₂-VASc of ≥2 in men or ≥3 in women and who underwent a AF catheter ablation procedure between 90 and 180 days prior to randomization (sequential) or are planning to have catheter ablation within 10 days of randomization (concomitant) will be randomized in a 1:1 allocation of WATCHMAN FLX vs control. Control patients will start or continue market-approved oral anticoagulation for the duration of the trial. A total of 1600 patients were randomized from 130 global investigational sites. Follow-up for both device and control patients will occur at 3, 12, 24, and 36 months. The primary effectiveness noninferiority endpoint is stroke (ischemic or hemorrhagic), all-cause death, or systemic embolism at 36 months. The primary safety superiority endpoint is nonprocedural bleeding through 36 months (International Society on Thrombosis and Haemostasis [ISTH] major bleeding or clinically relevant nonmajor bleeding). The secondary noninferiority endpoint is ISTH major bleeding through 36 months (including procedural bleeding).

CONCLUSIONS

This trial will assess the safety and efficacy of WATCHMAN FLX in a postablation contemporary clinical AF patient population at risk of stroke.

Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis

BACKGROUND

Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation.

OBJECTIVE

To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding.

DESIGN

Decision analysis with a Markov model.

DATA SOURCES

Evidence from the published literature informed model inputs.

TARGET POPULATION

Women and men with nonvalvular AF and without prior stroke.

TIME HORIZON

Lifetime.

PERSPECTIVE

Clinical.

INTERVENTION

LAAO versus warfarin or direct oral anticoagulants (DOACs).

OUTCOME MEASURES

The primary end point was clinical benefit measured in quality-adjusted life-years.

RESULTS OF BASE-CASE ANALYSIS

The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA₂DS₂-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA₂DS₂-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs.

RESULTS OF SENSITIVITY ANALYSIS

Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data.

LIMITATION

Clinical effectiveness data were drawn primarily from studies on the Watchman device.

CONCLUSION

Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO.

PRIMARY FUNDING SOURCE

None.

Stroke risk evaluation for patients with atrial fibrillation: Insights from left atrial appendage

Left atrial appendage (LAA) is believed to be a common site of thrombus formation in patients with atrial fibrillation (AF). However, the commonly-applied stroke risk stratification model (such as. CHA2DS2-VASc score) does not include any structural or hemodynamic features of LAA. Recent studies have suggested that it is important to incorporate LAA geometrical and hemodynamic features to evaluate the risk of thrombus formation in LAA, which may better delineate the AF patients for anticoagulant administration and prevent strokes. This review focuses on the LAA-related factors that may be associated with thrombus formation and cardioembolic events.

Atrial Fibrillation and Cancer Patients: Mechanisms and Management

PURPOSE OF REVIEW

Cancer-related mortality has significantly declined over the past several decades as a result of improved screening, diagnostics, and therapeutics. Although cancer patients and survivors are living longer, there is increased risk of both short-term and long-term cardiovascular complications, including arrhythmia. In this review, we highlight the current evidence detailing the connections between atrial fibrillation and cancer, provide insight into the mechanisms driving this relationship, and share practical considerations for the management of atrial fibrillation in cancer patients and cancer survivors.

RECENT FINDINGS

Atrial fibrillation is an increasingly recognized condition among cancer patients, with epidemiological data showing increased incidence and worse outcomes in patients with cancer. Studies also describe a bidirectional relationship between cancer and atrial fibrillation, attributable in part to shared risk factors but also potentially due to shared biology. Cancer treatment-associated arrhythmia is an active area of investigation, with ongoing research to identify the mechanisms and pathophysiology behind this phenomenon. Furthermore, management of atrial fibrillation in patients with cancer presents unique challenges, particularly in management of anti-coagulation. Cancer patients have increased risk of developing atrial fibrillation due to the shared risk factors and biology of the two conditions. Moreover, various cancer therapeutics are known to be arrhythmogenic; however, mechanisms remain unclear. Further research is needed to better understand the pathophysiology of atrial fibrillation in cancer patient in order to establish prevention and treatment strategies specific to this population.

Short-Term Outcomes Following Left Atrial Appendage Closure in the Very Elderly: A Population-Based Analysis

Background Data on percutaneous left atrial appendage closure (LAAC) outcomes in the very elderly with atrial fibrillation are limited. We aimed to investigate the clinical characteristics and short-term outcomes of patients 80 years or older following percutaneous LAAC in a large nationwide database. Methods and Results Using the Nationwide Readmissions Database, we identified patients who underwent percutaneous LAAC between January 2016 and December 2018. Patients were categorized based on age (≥80 and <80 years old). The primary outcome was in-hospital mortality. Secondary outcomes were in-hospital end points including periprocedural complications, 30-day outcomes, and all-cause 30-day readmissions. A propensity score-matched model (1:1) was used to adjust for baseline characteristics among the study groups. A total of 13 208 patients were included in this study (43% women, median age in years [interquartile range] 79.5 [73-84]) and matched one-to-one (6604 and 6604 patients were ≥80 and <80 years old, respectively). In-hospital mortality was not statistically different between the study groups and occurred in 21 patients ≥80 years old (0.32%) and in 14 patients <80 years old (0.21%); P=0.236. Rates of in-hospital stroke/transient ischemic attack were higher in patients ≥80 years old compared with those <80 years old (1.22% versus 0.77%; P=0.009). In-hospital bleeding requiring transfusion, vascular complications, systemic embolization, and pericardial effusion/tamponade requiring pericardiocentesis or surgical intervention occurred more frequently in patients ≥80 years old. Furthermore, the elderly group was more likely to be readmitted within 30 days compared with those <80 years old (9.91% versus 8.4%; P=0.004); however, rates of 30-day complications were not statistically different between the study groups. Conclusions In a large nationwide database, patients ≥80 years old undergoing percutaneous LAAC were found to have similar in-hospital mortality but an increased risk of periprocedural complications and 30-day readmission compared with younger patients. Our data suggest that LAAC should be considered on a case-by-case basis in the very elderly, taking into consideration the risks and benefits of this intervention. Further studies are needed to assess long-term LAAC outcomes in this high-risk population.

Long-term outcome of combined catheter ablation and left atrial appendage closure in atrial fibrillation patients

BACKGROUND

The combined procedure of catheter ablation and left atrial appendage closure (LAAC) aims to simultaneously control the heart rhythm and reduce the risk of strokes in patients with atrial fibrillation (AF). The study aims to evaluate the procedural safety and long-term outcome of the combined procedure in a large patient cohort.

METHODS

Clinical data of AF patients who underwent the combined procedure was retrospectively analyzed. Procedural and imaging follow-up parameters were compared between the transesophageal echocardiography-guided standard process and fluoroscopy-guided modified process, and between the single-seal WATCHMAN and dual-seal LACBES devices. Long-term outcomes included all-cause mortality, thromboembolic events, major bleeding, and recurrence of atrial tachyarrhythmias.

RESULTS

A total of 1114 patients were included. The rates of procedure-related major complications were comparable between the standard and modified processes (3.7% vs. 2.2%, p = 0.219), except for a higher incidence of respiratory depression in standard process group (0.9% vs 0%, p = 0.037), and between WATCHMAN and LACBES devices (2.4% vs. 3.3%, p = 0.535). The follow-up imaging evaluation revealed a high rate of satisfactory seals (99.7%) and a low rate of device related thrombus (1.9%), which were similar between two process groups and devices. The follow-up of over 1960 patient-years revealed low rates of mortality, thromboembolism, and nonprocedural major bleeding (1.8, 3.2, and 0.9 per 100 patient-years, respectively). Recurrent atrial tachyarrhythmias was observed in 23.9% patients.

CONCLUSIONS

The results supported the safety and long-term efficacy of the combined procedure of catheter ablation and LAAC. Fluoroscopy-guided LAAC device implantation may be considered in experienced centers.

Safety and efficacy of the Amplatzer amulet and watchman2.5 for left atrial appendage occlusion: a Systematic review and meta-analysis

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.

Efficacy and safety of various antithrombotic regimens after left atrial appendage occlusion

Aim. To evaluate the efficacy and safety of various antithrombotic regimens after left atrial appendage occlusion (LAAO) in real clinical practice.

Material and methods. This prospective observational study included 90 patients with nonvalvular atrial fibrillation and a high risk of ischemic stroke/systemic embolism who underwent endovascular LAAO using the Watchman device. The primary endpoint was the cumulative incidence of ischemic stroke/transient ischemic attack/systemic embolism, major and clinically relevant bleeding according to the Global Anticoagulant Registry in the Field-Atrial Fibrillation (GARFIELD) criteria, and all-cause mortality.

Results. Patients were divided into subgroups depending on the antithrombotic therapy carried out after LAAO: 1) direct oral anticoagulants (DOACs) ± antiplatelet agents; 2) warfarin ± antiplatelet agents; 3) dual antiplatelet therapy (aspirin + clopidogrel). Multivariate analysis showed a trend toward a lower incidence of the primary endpoint in the DOAC group compared with both warfarin (hazard ratio, 8,49; 95% confidence interval: 2,0-36,15; p=0,004) and antiplatelet agents (hazard ratio, 4,34; 95% confidence interval: 1,08-17,36; p=0,038). At the same time, there were no significant differences in the prevalence of primary endpoint between the warfarin and antiplatelet groups. There was no relationship between device-related thrombosis and postoperative antithrombotic regimen.

Conclusion. Endovascular LAAO is an effective and safe alternative to anticoagulant therapy. The present real-world evidence study revealed that the administration of DOACs after LAAO is associated with a greater efficacy and safety profile compared to warfarin and dual antiplatelet therapy.

 

Percutaneous left atrial appendage occlusion in a frail, high-risk, octogenarian patient population, after having undergone transcatheter aortic valve implantation

BACKGROUND

Percutaneous left atrial appendage occlusion (LAAO) represents an alternative stroke prevention method in patients with atrial fibrillation and an increased bleeding risk, chronic kidney disease or contraindications to oral anticoagulants. Aim of our study was to evaluate the feasibility and safety of percutaneous LAAO in high-risk, frail patients having undergone transcatheter aortic valve implantation (TAVI).

METHODS

Thirty-one patients having undergone TAVI and scheduled for LAAO were prospectively included in our study.

RESULTS

Implantation was successful in 29 of 31 cases (93.5%).There were no patients that developed a major acute cardiovascular event, stroke, or device dislocation/embolization. There was a single case of major bleeding (3.2%) and 3 cases of acute kidney injury (9.7%). At 3 months, no patients experienced a stroke, one patient had a device-related thrombus (3.4%), one patient showed a significant peri-device leak, and one patient had a persistent iatrogenic atrial septal defect.

CONCLUSIONS

Our study shows that percutaneous LAAO may represent a feasible alternative strategy for stroke prevention, that can be safely performed in high-risk, multimorbid patients with high bleeding risk or contraindications to oral anticoagulation.

Impact of Peridevice Leak on 5-Year Outcomes After Left Atrial Appendage Closure

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]).

Indications for Left Atrial Appendage Occlusion in the United States and Associated In-Hospital Outcomes: Results From the NCDR LAAO Registry

BACKGROUND

The Food and Drug Administration approved left atrial appendage occlusion with the Watchman device for patients who are at increased stroke risk and are suitable for oral anticoagulation but who have an appropriate reason to seek a nondrug alternative. These broad criteria raise the question of their interpretation in clinical practice. There is a lack of studies comprehensively evaluating the indications for Watchman implantation among a large series of patients from contemporary, real-world practice in the United States.

METHODS

We used the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry to identify Watchman procedures performed between 2016 and 2018. We assessed procedural indications for Watchman implantation in the United States and evaluated the association between procedural indications and in-hospital adverse events.

RESULTS

A total of 38 314 procedures were included. The mean patient age was 76.1±8.1 years, and 58.9% were men. The mean CHA2DS2-VASc score was 4.8±1.5, whereas the mean hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol (HAS-BLED) score was 3.0±1.1. Prior stroke or transient ischemic attack was reported in 40.2% and prior bleeding in 70.1%, with gastrointestinal bleeding being most common (41.9%). The most common site-reported procedural indications for Watchman implantation were increased thromboembolic risk (64.8%) and history of major bleed (64.3%), followed by high fall risk (35.5%). Most (71.9%) had ≥2 procedural indications. Patients with high fall risk had increased risk of in-hospital adverse events (adjusted OR, 1.12; P=0.025), but no other differences were found in the risk of in-hospital adverse events by procedural indication.

CONCLUSIONS

Among patients in the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry, the most common procedural indications for Watchman implantation were increased thromboembolic risk, history of major bleed, and high fall risk. A majority of patients had multiple procedural indications. High fall risk conferred a modestly increased risk of in-hospital adverse events.

Occluding morphologically complicated left atrial appendage using the small-umbrella LAmbre device

BACKGROUND

Percutaneous left atrial appendage (LAA) occlusion is effective for stroke prevention in patients with atrial fibrillation. LAA can have a complex anatomy, such as multiple lobes or a large orifice, which may render it unsuitable for occlusion using regular devices. We aimed to investigate the feasibility, safety, and short-term efficacy of the small-umbrella LAmbre device for morphologically complicated LAA.

METHODS

We retrospectively enrolled 129 consecutive patients who underwent LAA occlusion using the LAmbre device; the small-umbrella LAmbre device was used in 30 of these patients. We analyzed patients' characteristics, procedural details, and outcomes.

RESULTS

Twenty-two patients (73.3%) had multilobed (≥ 2) LAA. The umbrella of the occluder was anchored in the branch in 9 patients and in the common trunks of branches in 13 patients. The landing zone and orifice diameters were 19.0 ± 4.39 mm and 27.4 ± 3.95 mm, respectively. The sizes of the umbrella and occluder cover were 22.0 ± 3.42 mm and 34.3 ± 2.75 mm, respectively. At 3-month follow-up transesophageal echocardiography in 24 patients, no peri-device residual flow was reported. Device thrombosis was detected in one patient at 3 months and disappeared after 3 months of anticoagulation. Ischemic stroke occurred in one patient; no other adverse events were reported.

CONCLUSIONS

Occlusion of morphologically complicated LAA using the small-umbrella LAmbre device was feasible, safe, and effective in patients with atrial fibrillation in this study. This occluder provides an alternative for patients who cannot be treated with regular-sized LAA occlusion devices.

Direct Oral Anticoagulant Versus Warfarin After Left Atrial Appendage Closure With WATCHMAN: Updated Systematic Review and Meta-analysis

BACKGROUND

In the pivotal WATCHMAN trials, warfarin was used for post-procedural anticoagulation in the first 45 days after left atrial appendage closure. We aimed to investigate the efficacy and safety of direct oral anticoagulant (DOAC) versus warfarin after WATCHMAN.

METHODS

We performed a literature search of five electronic databases to identify studies comparing DOAC with warfarin after WATCHMAN. We pooled outcomes for the efficacy (thromboembolism, device-related thrombus [DRT], peri-device leak [PDL] >5mm) and safety endpoints (bleeding, mortality). Thromboembolism was defined as ischemic stroke, transient ischemic attack, or systemic embolism.

RESULTS

We included 10 cohort studies with 2,440 patients, of whom 1,397 (57.3%) received DOAC. Concerning peri-procedural outcomes (within 7 days following implantation), DOAC was associated with a reduction in major bleeding (Risk ratio [RR] 0.32; 95% confidence interval [CI] 0.11-0.92) compared with warfarin, without significant differences in all bleeding (RR 0.46; 95% CI 0.15-1.42) and thromboembolism (RR 0.93; 95% CI 0.21-4.16). On first follow-up transesophageal echocardiography, DRT (RR 0.79; 95% CI 0.39-1.60) and PDL>5mm (RR 0.44; 95% CI 0.16-1.20) were comparable among groups. With a mean follow-up of 1.5-12 months, DOAC was associated with reductions in major bleeding (RR 0.52; 95% CI 0.30-0.89) and all bleeding (RR 0.38; 95% CI 0.25-0.58) compared with warfarin. The outcomes of thromboembolism (RR 0.79; 95% CI 0.36-1.73) and all-cause mortality (RR 0.49; 95% CI 0.19-1.28) were not significantly different between the two groups.

CONCLUSION

Following WATCHMAN implantation, DOAC was associated with reductions in major bleeding and all bleeding compared with warfarin at mid-term follow-up. The outcomes of thromboembolism, all-cause mortality, DRT, and PDL >5mm were comparable among groups.

Clinical and echocardiographic risk factors for device-related thrombus after left atrial appendage closure: an analysis from the multicenter EUROC-DRT registry

BACKGROUND

Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry.

METHODS

We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics.

RESULTS

Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 ± 18.5 vs. 42.4 ± 18.0 cm/s, p = 0.02). Occluders implanted in DRT patients were larger (25.5 ± 3.8 vs. 24.6 ± 3.5 mm, p = 0.03) and implanted deeper in the LAA (mean depth: 7.6 ± 4.7 vs. 5.7 ± 4.7 mm, p < 0.01). Coverage of the appendage ostium was achieved less often in DRT patients (69.5% vs. 81.5%, p < 0.01), while DRT patients were less frequently on oral anticoagulation (7.1% vs. 16.7%, p < 0.01). Multivariate analysis identified age, prior stroke/TIA and SEC as independent risk factors for DRT. After PSM, implantation depth was found to be predictive. Rates of stroke/TIA were higher in DRT patients (13.5% vs. 3.8%, Hazard Ratio: 4.21 [95%-confidence interval: 1.88-9.49], p < 0.01).

CONCLUSIONS

DRT after LAAC is associated with adverse outcome and appears to be of multifactorial origin, depending on patient characteristics, anticoagulation regimen and device position.

Percutaneous Left Atrial Appendage Closure in a Patient with Diffuse Alveolar Hemorrhaging Associated with Anticoagulant Therapy and Atrial Fibrillation

Diffuse alveolar hemorrhaging (DAH) due to oral anticoagulation (OAC) is a life-threatening condition that leads to severe respiratory failure. There is a clinical dilemma in that OAC-induced DAH often forces the discontinuation of OAC therapy and the administration of high-dose corticosteroids, which increases the risk of stroke and cardiovascular events. We herein report the first case of OAC-induced DAH and atrial fibrillation (AF) in a patient who completely discontinued OAC therapy and high-dose corticosteroids after experiencing percutaneous left atrial appendage (LAA) occlusion. This case suggests that percutaneous LAA closure may aid in the management of OAC-induced DAH and AF.

Protecting the Brain, From the Heart: Safely Mitigating the Consequences of Thrombosis in Intracerebral Hemorrhage Survivors With Atrial Fibrillation

Optimal antithrombotic management after intracerebral hemorrhage remains one of the central unresolved issues for patients who survive, especially for those patients with atrial fibrillation. Given the observational nature of the studies regarding anticoagulation resumption after intracerebral hemorrhage, there is uncertainty regarding resumption of oral anticoagulation therapy and its timing. There is limited high-quality evidence to guide clinical practice, leading to significant practice variation and uncertainty for patients and providers. Here, we aim to provide the key elements to guide clinicians in their individual decision: whether or not to start or resume anticoagulation in patients with a history of intracerebral hemorrhage.

Risk of device-related thrombosis following short-term oral anticoagulation with low-dose dabigatran versus warfarin after Watchman left atrial appendage occlusion

BACKGROUND

Percutaneous left atrial appendage occlusion (LAAO) provides an alternative for poor candidates for long-term oral anticoagulation (OAC). To prevent device-related thrombosis (DRT), OAC should be continued for the first 45 days to allow complete endothelialization post-LAAO implantation. Whereas, evidence is limited on the feasibility and safety of direct oral anticoagulants (DOACs) used after LAAO.

METHODS

This was a retrospective observational single-center study of AF patients undergoing LAAO with a Watchman device and receiving either low-dose dabigatran (110mg twice daily) or warfarin in the peri- and post-procedural period for 45 days. Transesophageal echocardiography was scheduled to perform at 6 weeks, 6 months, and 12 months after the procedure to assess the stability of the device and to detect DRT. Incidence of thromboembolic and bleeding events were also evaluated during the follow-up period.

RESULTS

There were a total of 84 patients who successfully underwent Watchman implantation, with 38 patients (45.2%) receiving low-dose dabigatran and 46 patients (54.8%) using warfarin post-LAAO. Peri-procedural complications occurred in 10 patients, with 3 patients in the dabigatran group and 7 patients in the warfarin group (7.9% vs. 15.2%, p = 0.30). During the 12-month follow-up, 1 patient experienced major bleeding and 16 patients suffered minor bleeding in the warfarin group, while 5 patients treated with dabigatran had minor bleeding (34.8% vs. 13.2%, p = 0.02). Besides, 6 DRT (15.8%) were detected in dabigatran groups, and the incidence was higher than in the warfarin group (15.8% vs. 2.2%, p = 0.03). No DRT-related ischemic events were found.

CONCLUSIONS

This study suggested that short-term low-dose dabigatran (110 mg twice daily) could significantly decrease the risk of bleeding compared with warfarin at the expense of increased risk of DRT post-LAAO. Therefore, low-dose dabigatran should be used with caution for post-implant anticoagulation of LAAO. Further studies are urgently needed on the feasibility and safety of DOACs post-LAAO.

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

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.

Can intracardiac echocardiography completely replace transesophageal echocardiography to guide left atrial appendage closure?-The comparisons of intracardiac echocardiography with transesophageal echocardiography

Left atrial appendage closure (LAAC) is an effective means of preventing ischemic stroke in patients with nonvalvular atrial fibrillation. Transesophageal echocardiography (TEE) is the primary imaging technique to guide LAAC. Its shortcomings, namely the use of general anesthesia and tracheal intubation, inevitably increase procedural risks. Intracardiac echocardiography (ICE), a novel imaging modality for guiding LAAC, has proven more advantageous over TEE due to use of local anesthesia, shortened procedural time, and reduced radiation exposure. This review highlights the differences between ICE and TEE guided LAAC, aiming to provide a reference for clinical decision-making.

Experience of Combined Procedure during Percutaneous LAA Closure

Introduction: Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulants (OAC) in patients with non-valvular atrial fibrillation (AF) and contraindication to long-term OAC. Combined strategy with percutaneous LAAC at the same time of other cardiac structural or electrophysiological procedures has emerged as an alternative to a staged strategy. Aim: To describe our experience with combined LAAC procedures using Watchman™ devices. Methods: All patients with combined LAAC procedures using Watchman™ (WN) devices performed from 2016 to 2021 were included. The primary safety endpoint was a composite of periprocedural complications and adverse events during the follow-up. The primary efficacy endpoint included strokes, systemic embolisms, major bleeding and cardiovascular death. Results: From 2016, among 160 patients who underwent LAAC using WN devices, 19 underwent a combined strategy: 7 transcatheter edge-to-edge mitral valve repair (TEMVR) (37%), 6 typical atrial flutter ablation (31%), 2 leadless pacemaker (LP) implantation (10%) and 4 AF ablation (22%). The WN device was successfully implanted in 98% and 100% of cases for single and combined LAAC procedures, respectively (p = 0.63). Median follow-up was 13 months (IQR 25/75 3/24). Device-related complications occurred in 6 out of 141 patients (4%) who underwent single LAAC and in no (0/19) patient in the combined LAAC procedure (p = ns). The procedural-related complications did not differ significantly between groups (5% vs. 10%, respectively, in the single and combined group, p = 0.1). Conclusion: Combined procedure using the Watchman™ devices and one other structural or electrophysiological procedure appears safe and effective. Larger series are needed to confirm these results.

Case report. Thrombus formation on left atrial appendage clip: surgical exclusion and anticoagulation do not obviate transesophageal echocardiography prior to cardioversion

Background

The cornerstone treatment for atrial fibrillation (Afib) is based on the prevention of cardioembolism with the use oral anticoagulants, which inherently increase the risk of bleeding. An alternative for these patients corresponds to left atrial appendage (LAA) exclusion/closure techniques such as Atriclip.

Cases summary

Patient 1: Seventy-two-year-old female who presented with decompensated heart failure, non ST elevation myocardial infarct, and paroxysmal Afib. She underwent coronary artery bypass graft, MAZE procedure, mitral valve repair, and Atriclip (40 mm). Recurrence of Afib postoperatively led to a precardioversion transesophageal echocardiogram (TEE) which demonstrated a LAA pouch thrombus. Patient 2: Sixty-seven-year-old male who underwent electively mitral and tricuspid valve repairs, MAZE procedure, and Atriclip (35 mm). He had recurrent atrial flutter/Afib postoperatively. He received apixaban in addition to rate control medications, and he was readmitted for precardioversion TEE which also demonstrated a LAA pouch thrombus.

Discussion

Atriclip is a stapler exclusion device via epicardial approach which has shown excellent exclusion rates in contemporary data. One of the pitfalls of this technique is the possibility of leaving a LAA remnant stump or pouch that is highly thrombogenic. The optimal timing for stopping anticoagulation and the need for precardioversion echocardiography remain uncertain.

Comparison of the Safety of Left Atrial Appendage Occlusion in Patients Aged <75 Versus Those Aged ≥75 Years (from a Nationwide Cohort Sample)

The mean age in clinical trials of percutaneous left atrial appendage occlusion (LAAO) has been <75 years. We aimed to better understand the safety of LAAO in older patients. National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients with atrial fibrillation who underwent LAAO during the years 2016-2018. Patients were grouped by age <75 and ≥75 years. Baseline characteristics; length of stay; cost; hospital mortality; and other adverse events, including hematoma, vascular complications, perforation/tamponade, and stroke/ transient ischemic attack, were compared for the 2 groups. A total of 6,877 patients were identified, of whom 4,160 (60.4%) were aged ≥75 years. Length of stay and hospitalization costs were similar for the 2 groups. There were 10 deaths in patients aged ≥75 years and 1 death in patients aged <75 years (p = 0.059). The incidence of perforation/tamponade was 1.3% in patients aged ≥75 years versus 0.6% for those <75 years (p = 0.008). This difference persisted on multivariate analysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.01 to 3.07). The risk of perforation/tamponade was also higher in female patients (OR 2.74, 95% CI 1.63 to 4.59). There was a trend toward higher combined procedure-related adverse events (OR 1.46, 95% CI 0.99 to 2.15) in patients ≥75 years. There was no difference in the individual components of hematoma, vascular complication, and stroke/transient ischemic attack between both groups. In conclusion, percutaneous LAAO was associated with a higher risk of perforation and tamponade in older patients, particularly women.

Changes in left atrial appendage orifice following percutaneous left atrial appendage closure using three-dimensional echocardiography

Percutaneous left atrial appendage (LAA) occlusion is increasingly performed in patients with atrial fibrillation and long-term contraindications for anticoagulation. Our aim was to evaluate the effects of LAA occlusion with the Watchman device on the geometry of the LAA orifice and assess its impact on the adjacent left upper pulmonary vein (LUPV) hemodynamics. We included 50 patients who underwent percutaneous LAA occlusion with the Watchman device and had acceptable three-dimensional transesophageal echocardiography images of LAA pre- and post-device placement. We measured offline the LAA orifice diameters in the long axis, and the minimum and maximum diameters, circumference, and area in the short axis view. Eccentricity index was calculated as maximum/minimum diameter ratio. The LUPV peak S and D velocities pre- and post-procedure were also measured. Patients were elderly (mean age 76 ± 8 years), 30 (60%) were men. There was a significant increase of all LAA orifice dimensions following LAA occlusion: diameter 1 (pre-device 18.1 ± 3.2 vs. post-device 21.5 ± 3.4 mm, p < 0.001), diameter 2 (20.6 ± 3.9 vs. 22.1 ± 3.6 mm, p < 0.001), minimum diameter (17.6 ± 3.1 vs. 21.3 ± 3.4 mm, p < 0.001), maximum diameter (21.5 ± 3.9 vs. 22.4 ± 3.6 mm, p = 0.022), circumference (63.6 ± 10.7 vs. 69.6 ± 10.5 mm, p < 0.001), and area (3.1 ± 1.1 vs. 3.9 ± 1.2 cm2, p < 0.001). Eccentricity index decreased after procedure (1.23 ± 0.16 vs. 1.06 ± 0.06, p < 0.001). LUPV peak S and D velocities did not show a significant difference (0.29 ± 0.15 vs. 0.30 ± 0.14 cm/s, p = 0.637; and 0.47 ± 0.19 vs. 0.48 ± 0.20 cm/s, p = 0.549; respectively). LAA orifice stretches significantly and it becomes more circular following LAA occlusion without causing a significant impact on the LUPV hemodynamics.