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Abstract
Resection of the left atrial appendage (LAA) to prevent recurrent arterial emboli in patients with atrial fibrillation was first suggested more than 60 years ago. Longer-term follow-up from randomized studies of the safety and efficacy of transcatheter LAA occlusion has recently been completed; data from large, observational cohorts are being reported. These recent data provide further insights into procedural safety with current techniques and the ability of LAA closure to reduce thromboembolic stroke compared with warfarin anticoagulation. This review summarizes the latest data regarding transcatheter LAA occlusion, focusing on larger prospective studies and further analyses of seminal clinical trials.
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Korsholm K, Jensen JM, Nielsen-Kudsk JE. Cardiac Computed Tomography for Left Atrial Appendage Occlusion: Acquisition, Analysis, Advantages, and Limitations. Interv Cardiol Clin 2018. [PMID: 29526291 DOI: 10.1016/j.iccl.2017.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Transcatheter left atrial appendage occlusion is increasingly used for stroke prevention in atrial fibrillation. The technique has proven effective and safe in randomized trials and multiple observational studies. The procedure is challenging due to the complex anatomy of the left atrial appendage; accurate cardiac imaging is essential for procedural guidance. Transesophageal echocardiography is the gold standard, but cardiac computed tomography (CT) has gained increasing interest within recent years. Cardiac CT offers high-resolution imaging allowing for preprocedural anatomic evaluation and device sizing, but may also be useful for exclusion of left atrial appendage thrombus, and follow-up assessment of residual peri-device leaks.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N DK-8200, Denmark.
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Mazzone P, D’Angelo G, Regazzoli D, Molon G, Senatore G, Saccà S, Canali G, Amellone C, Turri R, Bella PD. Percutaneous Left Atrial Appendage Closure with WATCHMAN™ device: peri-procedural and mid-term outcomes from the TRAPS Registry. J Interv Card Electrophysiol 2018. [DOI: 10.1007/s10840-018-0351-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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304
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Teiger E, Thambo JB, Defaye P, Hermida JS, Abbey S, Klug D, Juliard JM, Pasquie JL, Rioufol G, Lepillier A, Elbaz M, Horvilleur J, Brenot P, Pierre B, Le Corvoisier P, Amabile N, Andronache M, Anselme F, Armero S, Aubry P, Audureau E, Babuty D, Bakouboula B, Bars C, Baruteau AE, Bille J, Bonnet JL, Brigadeau F, Brochet E, Bun SS, Cailla G, Cesari O, Champagnac D, Chevalier P, Combes N, Comet B, Commeau P, Dearo JC, Dompnier A, Farah B, Garot P, Gras D, Giraudeau C, Granier M, Guerin P, Iriart X, Jalal Z, Jesel-Morel L, Jeu A, Kamtchueng P, Lellouche N, Meneveau N, Nighoghossian N, Otmani A, Pelliere R, Pillière R, Pons M, Popovic B, Pujadas P, Rossi R, Roux A, Saludas Y, Spaulding C, Statiev V, Ternacle J, Traulle S, Winum PF. Percutaneous Left Atrial Appendage Closure Is a Reasonable Option for Patients With Atrial Fibrillation at High Risk for Cerebrovascular Events. Circ Cardiovasc Interv 2018. [DOI: 10.1161/circinterventions.117.005841] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background—
Percutaneous left atrial appendage (LAA) closure is an emerging option for patients with atrial fibrillation at high risk for cerebrovascular events. The multicenter FLAAC registry (French Nationwide Observational LAA Closure Registry) was established to assess LAA closure outcomes in everyday practice.
Methods and Results—
Four hundred thirty-six patients referred from April 2013 to September 2015 to 33 French interventional cardiology centers for percutaneous LAA closure were included prospectively in the FLAAC registry. Mean age was 75.4±0.4 years. The stroke risk was high (mean CHA
2
DS
2
–VASc score, 4.5±0.1) and most patients had experienced clinically significant bleeding (HAS-BLED score, 3.1±0.05). The device used was Amplatzer LAA occluder in 58% and the Watchman device in 42% of the patients. The procedural success rate was 98.4%. Median postprocedure follow-up was 12.0 (11.8–12.0) months and a single patient was lost to follow-up. During the periprocedural and subsequent follow-up period, procedure-related severe adverse events occurred in 21 (4.9%) and 10 (2.3%) patients, respectively. One-year cumulative incidences of ischemic stroke and cerebral hemorrhage were 2.9% (1.6–5.0) and 1.5% (0.7–3.2), respectively. Overall, 1-year mortality was 9.3% (6.9–12.5) with 7 of the 39 deaths related or possibly related to the device or procedure.
Conclusions—
This nationwide prospective registry shows that, in the French population, LAA closure is mainly used in patients with high comorbidity rates and a poor prognosis. LAA closure in such patients seems reasonable to decrease the stroke rate. The overall health status of these patients should be taken into account during the preprocedural evaluation process.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02252861.
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Affiliation(s)
- Emmanuel Teiger
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Jean-Benoit Thambo
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Pascal Defaye
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Jean-Sylvain Hermida
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Sélim Abbey
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Didier Klug
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Jean-Michel Juliard
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Jean-Luc Pasquie
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Gilles Rioufol
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Antoine Lepillier
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Meyer Elbaz
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Jerome Horvilleur
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Philippe Brenot
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Bertrand Pierre
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
| | - Philippe Le Corvoisier
- From the Interventional Cardiology Unit (E.T.) and Inserm, CIC 1430, U955 team 3 (P.L.C.), Henri Mondor Hospital, Creteil, France; Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France (J.-B.T.); Department of Rhythmology, University Hospital of Grenoble-Alpes, France (P.D.); Department of Cardiac Arrhythmia, Picardie University Hospital, Amiens, France (J.-S.H.); Interventional Cardiology Unit, Hopital Prive du Confluent, Nantes, France (S.A.)
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305
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Pérez de Prado A, Serrador A, Jiménez-Quevedo P, Benito González T, Fernández Vázquez F, Pan M. Selección de lo mejor del año 2017 en cierre percutáneo de la orejuela izquierda: completando la evidencia científica. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2017.10.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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306
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Affiliation(s)
- Bernhard Meier
- From the Cardiovascular Department, University Hospital of Bern, Switzerland
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307
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Percutaneous left atrial appendage occlusion in the prevention of stroke in atrial fibrillation: a systematic review. Heart Fail Rev 2018; 23:191-208. [DOI: 10.1007/s10741-018-9681-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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308
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Kamtchueng P. [Percutaneous closure of the left atrial appendage: Eliminate the thromboembolic risk of atrial fibrillation?]. JOURNAL DE MÉDECINE VASCULAIRE 2018; 43:1-3. [PMID: 29425535 DOI: 10.1016/j.jdmv.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 11/23/2017] [Indexed: 11/17/2022]
Affiliation(s)
- P Kamtchueng
- Service de cardiologie interventionnelle, groupe hospitalier Paris Saint-Joseph, 185, rue Raymond-Losserand, 75014 Paris, France.
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309
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Fastner C, Behnes M, Sartorius B, Wenke A, Lang S, Yücel G, Sattler K, Rusnak J, Saleh A, Barth C, Mashayekhi K, Hoffmann U, Borggrefe M, Akin I. Interventional Left Atrial Appendage Closure Affects the Metabolism of Acylcarnitines. Int J Mol Sci 2018; 19:ijms19020500. [PMID: 29414920 PMCID: PMC5855722 DOI: 10.3390/ijms19020500] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 12/21/2022] Open
Abstract
Background: Left atrial appendage closure (LAAC) represents the interventional alternative to oral anticoagulation for stroke prevention in atrial fibrillation (AF). The metabolism of acylcarnitines was shown to affect cardiovascular diseases. This study evaluates the influence of successful LAAC on the metabolism of acylcarnitines. Methods: Patients undergoing successful LAAC were enrolled prospectively. Peripheral blood samples for metabolomics measurements were collected immediately before (i.e., index) and six months after LAAC (i.e., mid-term). A targeted metabolomics analysis based on electrospray ionization–liquid chromatography–mass spectrometry (ESI–LC–MS/MS) and MS/MS measurements was performed. Results: 44 patients with non-valvular AF (median CHA2DS2-VASc score 4, median HAS-BLED score 4) and successful LAAC were included. Significant changes in acylcarnitine levels were found in the total cohort, which were mainly attributed to patients with impaired left ventricular and renal function, elevated amino-terminal pro-brain natriuretic peptide (NT-proBNP) and diabetes mellitus. Adjusted multivariable regression models revealed significant changes of five metabolites over mid-term follow-up: C2, C14:1, C16, and C18:1 decreased significantly (each p < 0.05); short-chain C5 acylcarnitine plasma levels increased significantly (p < 0.05). Conclusion: This study demonstrates that successful LAAC affects the metabolism of acylcarnitines at mid-term follow-up. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02985463.
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Affiliation(s)
- Christian Fastner
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Annika Wenke
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Siegfried Lang
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Gökhan Yücel
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Katherine Sattler
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Jonas Rusnak
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Ahmad Saleh
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Christian Barth
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, 79189 Bad Krozingen, Germany.
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, 68167 Mannheim, Germany.
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310
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Pérez de Prado A, Serrador A, Jiménez-Quevedo P, Benito González T, Fernández Vázquez F, Pan M. Selection of the Best of 2017 in Left Atrial Appendage Occlusion: Filling the Gap in Knowledge. ACTA ACUST UNITED AC 2018; 71:225-227. [PMID: 29352720 DOI: 10.1016/j.rec.2017.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 10/11/2017] [Indexed: 11/17/2022]
Affiliation(s)
| | - Ana Serrador
- Servicio de Cardiología, Hospital Clínico Universitario, CIBERCV, Valladolid, Spain
| | - Pilar Jiménez-Quevedo
- Servicio de Cardiología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | | | | | - Manuel Pan
- Servicio de Cardiología, Hospital Universitario Reina Sofía, Universidad de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), Córdoba, Spain
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311
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Safety and Efficacy of Transcatheter Left Atrial Appendage Closure for Stroke Prevention in Patients with Atrial Fibrillation. Prog Cardiovasc Dis 2018; 60:542-549. [PMID: 29339165 DOI: 10.1016/j.pcad.2018.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/10/2018] [Indexed: 12/13/2022]
Abstract
Atrial Fibrillation (AF) is associated with a substantial risk of thromboembolic stroke. Although long-term treatment with warfarin or the non-vitamin K oral anticoagulants can reduce this risk, such therapy is underutilized, and safe and consistent long-term treatment can be challenging. Transcatheter left atrial appendage (LAA) closure is an emerging alternative to long-term oral anticoagulation. Long-term follow-up of randomized clinical trials demonstrate that Watchman LAA closure provides significant reductions in hemorrhagic stroke, cardiovascular death, and all-cause mortality compared with continued warfarin therapy. Major bleeding is also reduced compared with continued warfarin therapy once the post-implant pharmacologic regimen is completed. This review summarizes the current dataset for the safety and efficacy of transcatheter LAA closure, and highlights the gaps in evidence and future directions for clinical research.
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312
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Hernández JM, Urso S, Tena MÁ, Sadaba R, Portela F. Cierre percutáneo de la orejuela izquierda: revisión sistemática de los resultados de seguridad y eficacia. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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313
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McBride DA, Markman TM, Liang JJ, Santangeli P. Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF. US CARDIOLOGY REVIEW 2018. [DOI: 10.15420/usc.2018.6.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.
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314
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Gurol ME. Nonpharmacological Management of Atrial Fibrillation in Patients at High Intracranial Hemorrhage Risk. Stroke 2018; 49:247-254. [PMID: 29203684 PMCID: PMC5847291 DOI: 10.1161/strokeaha.117.017081] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 12/17/2022]
Affiliation(s)
- M Edip Gurol
- From the Department of Neurology, Massachusetts General Hospital, Boston.
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315
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Altamirano R. ALTERNATIVAS TERAPÉUTICAS EN FIBRILACIÓN AURICULAR. REVISTA MÉDICA CLÍNICA LAS CONDES 2018. [DOI: 10.1016/j.rmclc.2018.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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316
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Huded C, Krishnaswamy A, Kapadia S. Percutaneous Left Atrial Appendage Closure: is there a Role in Valvular Atrial Fibrillation. J Atr Fibrillation 2017; 9:1524. [PMID: 29250272 DOI: 10.4022/jafib.1524] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 01/04/2017] [Accepted: 01/30/2017] [Indexed: 12/23/2022]
Abstract
Atrial fibrillation, a chronic and highly morbid cardiovascular condition which affects over 33 million people worldwide, can be broadly categorized as valvular vs non-valvular in etiology. However, definitions of valvular atrial fibrillation have varied widely in the literature, and there is no clear consensus definition to date. Historically, patients with atrial fibrillation in the setting of rheumatic mitral valve disease have constituted a particularly high risk group for cardioembolic stroke, and for this reason many contemporary trials of pharmaceutical and device therapies for atrial fibrillation have systematically excluded patients with valvular heart disease. Therefore, vitamin K antagonism remains the favored approach to mitigate stroke risk in valvular atrial fibrillation, and the optimal strategy to treat atrial fibrillation patients with valvular heart disease who cannot tolerate oral anticoagulation therapy is unknown. Recent trials have demonstrated an important role for percutaneous left atrial appendage occlusion devices in patients with non-valvular atrial fibrillation, but the role of these devices in patients with valvular atrial fibrillation is uncertain. Given the worldwide burden of valvular atrial fibrillation, future trials intended to clarify the role of percutaneous left atrial appendage closure devices in valvular atrial fibrillation should provide important insight for the care of millions of patients.
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Affiliation(s)
- Chetan Huded
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
| | - Amar Krishnaswamy
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation (Cleveland, OH)
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317
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Nishimura M, Sab S, Reeves RR, Hsu JC. Percutaneous left atrial appendage occlusion in atrial fibrillation patients with a contraindication to oral anticoagulation: a focused review. Europace 2017; 20:1412-1419. [DOI: 10.1093/europace/eux313] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022] Open
Affiliation(s)
- Marin Nishimura
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Shiv Sab
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Ryan R Reeves
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, 9452 Medical Center Dr 3rd Fl, Rm 3E-417, San Diego, La Jolla, CA, USA
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318
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Gloekler S, Hajredini B, Rycerz S, Jäckle S, Jung W. [Left atrial appendage clusure in nonvalvular atrial fibrillation : Clinical evidence 2017]. Herzschrittmacherther Elektrophysiol 2017; 28:366-380. [PMID: 29143099 DOI: 10.1007/s00399-017-0536-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 10/05/2017] [Indexed: 06/07/2023]
Abstract
Nonvalvular atrial fibrillation (AF) is the most common arrhythmia with a prevalence of 1-2% and affects approximately 15-20% of all octogenarians. Patients are at increased risk of thromboembolic stroke, with an overall risk of 5% per year. Thrombi form almost exclusively in the left atrial appendage (LAA), a blind sac-like heterogeneous structure trabeculated by pectinate muscles. In the past five decades, life-long oral anticoagulation (OAC) with vitamin K antagonists (VKA) has been the state-of-the art treatment to prevent stroke and systemic embolism from thrombi in AF. In the last decade, nonvitamin K dependent oral anticoagulants (NOAC) have been shown to be superior to VKA. Given the safety issues of indefinite OAC with either VKA or NOAC, it is plausible to consider left atrial appendage closure (LAAC) as an alternative strategy to prevent death, stroke or other systemic embolization, and bleeding. In recent years, LAAC has been compared to VKA in prospective randomized trials, yielding superior results regarding efficacy and noninferiority regarding safety in the mid-term. This review provides an update on the current state of LAAC in the field of prevention of death, stroke, and bleedings in patients suffering from nonvalvular AF. We elucidate the evidence and limitations of anticoagulation as the classical treatment paradigm, and review devices and techniques for LAAC. Most importantly, the current clinical evidence on efficacy and safety is outlined.
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Affiliation(s)
- Steffen Gloekler
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland.
| | - Bajram Hajredini
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Simon Rycerz
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Sebastian Jäckle
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
| | - Werner Jung
- Klinik für Innere Medizin III, Kardiologie, Schwarzwald-Baar-Klinikum, 78052, Villingen-Schwenningen, Deutschland
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319
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Gloekler S, Saw J, Koskinas KC, Kleinecke C, Jung W, Nietlispach F, Meier B. Left atrial appendage closure for prevention of death, stroke, and bleeding in patients with nonvalvular atrial fibrillation. Int J Cardiol 2017; 249:234-246. [DOI: 10.1016/j.ijcard.2017.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 08/11/2017] [Accepted: 08/17/2017] [Indexed: 01/06/2023]
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320
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Bergmann MW, Israel CW. [Oral anticoagulation and platelet inhibition after atrial appendage occlusion]. Herzschrittmacherther Elektrophysiol 2017; 28:388-394. [PMID: 29181735 DOI: 10.1007/s00399-017-0537-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 02/03/2023]
Abstract
In Europe left atrial appendage occluders (LAAO) are most frequently used in patients with contraindications for oral anticoagulation (OAC); therefore, the classical therapeutic OAC scheme from the PROTECT-AF trial (vitamin K antagonist plus acetylsalicylic acid) is usually changed to dual anti-platelet therapy (DAPT) after implantation of a Watchman® or Amulet® LAAO (St. Jude Medical/Abbott, Eschborn, Germany). For many years, patients with an LAAO received DAPT for 1-6 months. The current standard comprises DAPT for 3 months, followed by permanent acetylsalicylic acid monotherapy if the transesophageal echocardiogram excludes a thrombus at the site of the LAAO. In patients with high risk of bleeding, anti-platelet therapy can be stopped at 3 months after an individual risk-benefit calculation. There are no randomized studies on the risk of bleeding and stroke/embolism in patients with an LAA occluder under DAPT versus OAC. Experience from the EWOLUTION registry shows that NOACs may be used as an alternative with low bleeding and thrombus risks. In patients with a suboptimal implantation result, thrombus on the LAAO or specific risk factors, variations of the standard scheme have to be applied and if necessary lifelong DAPT or NOAC therapy has to be used. Thrombi on the LAAO occur in approximately 4-6% of patients and are associated with a very low short-term stroke risk.
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Affiliation(s)
- Martin W Bergmann
- Interventionelle Kardiologie, Cardiologicum Hamburg Standort Wandsbek, Schlossgarten 3, 22041, Hamburg, Deutschland.
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321
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Costa MJMD, Ferreira E, Quintella EF, Amorim B, Fuchs A, Zajdenverg R, Sabino H, Albuquerque DCD. Left Atrial Appendage Closure with Amplatzer Cardiac Plug in Nonvalvular Atrial Fibrillation: Safety and Long-Term Outcome. Arq Bras Cardiol 2017; 109:541-549. [PMID: 29160390 PMCID: PMC5783435 DOI: 10.5935/abc.20170167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 07/05/2017] [Indexed: 11/25/2022] Open
Abstract
Background Atrial fibrillation (AF) is a cardiac arrhythmia with high risk for
thromboembolic events, specially stroke. Objective To assess the safety of left atrial appendage closure (LAAC) with the
Amplatzer Cardiac Plug for the prevention of thromboembolic events in
patients with nonvalvular AF. Methods This study included 15 patients with nonvalvular AF referred for LAAC, 6
older than 75 years (mean age, 69.4 ± 9.3 years; 60% of the male
sex). Results The mean CHADS2 score was 3.4 ± 0.1, and mean
CHA2DS2VASc , 4.8 ± 1.8, evidencing a high
risk for thromboembolic events. All patients had a HAS-BLED score > 3
(mean, 4.5 ± 1.2) with a high risk for major bleeding within 1 year.
The device was successfully implanted in all patients, with correct
positioning in the first attempt in most of them (n = 11; 73.3%). Conclusion There was no periprocedural complication, such as device migration,
pericardial tamponade, vascular complications and major bleeding. All
patients had an uneventful in-hospital course, being discharged in 2 days.
The echocardiographic assessments at 6 and 12 months showed neither device
migration, nor thrombus formation, nor peridevice leak. On clinical
assessment at 12 months, no patient had thromboembolic events or bleeding
related to the device or risk factors. In this small series, LAAC with
Amplatzer Cardiac Plug proved to be safe, with high procedural success rate
and favorable outcome at the 12-month follow-up.
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Affiliation(s)
| | - Esmeralci Ferreira
- Universidade do Estado do Rio de Janeiro (UERJ); - Rio de Janeiro, RJ - Brazil
| | | | - Bernardo Amorim
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC); - Rio de Janeiro, RJ - Brazil
| | - Alexandre Fuchs
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC); - Rio de Janeiro, RJ - Brazil
| | - Ricardo Zajdenverg
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC); - Rio de Janeiro, RJ - Brazil
| | - Hugo Sabino
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC); - Rio de Janeiro, RJ - Brazil
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322
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Masoud A, Bartoletti S, Fairbairn T, Khurana A, Velavan P, Morrison WL, Khalatbari A, Aggarwal S, Sharma N, Kirchhof P, Gupta D. Outcome of left atrial appendage occlusion in high-risk patients. Heart 2017; 104:594-599. [PMID: 29122931 DOI: 10.1136/heartjnl-2017-312383] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/26/2017] [Accepted: 10/27/2017] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE Percutaneous left atrial appendage (LAA) occlusion can be an interventional alternative to oral anticoagulation for stroke prevention in patients with atrial fibrillation. METHODS We delivered LAA occlusion therapy using a standardised approach to patient referral, multidisciplinary team assessment, implant criteria, imaging and follow-up. We analysed patient characteristics, efficacy and safety of the implant procedure, and 12-month outcomes. RESULTS Of 143 referrals from October 2014 to December 2016, 83 patients (age 76±8years, 32.5% female, mean CHAD2S2-VASc score 4 ±1) were offered LAA occlusion. Eighty (95.3%) had previous major bleeding (intracranial in 59%). LAA occluder implantation with an Amulet device was successful in 82 (98.8%), with periprocedural major adverse events occurring in 5 (6.0%) patients (2 device embolisations including 1 death, 2 major bleeds). Cardiac imaging in 75 (94%) patients 2months following implant showed device-related thrombus in 1 case (1.3%) and minor (<5mm) device leaks in 13 (17.1%). Over a median 12-month follow-up, 3 (3.8%) ischaemic strokes, 2 (2.5%) haemorrhagic strokes and 5 (6.3%) major extracranial bleeds occurred. All-cause mortality was 10%, with most deaths (7, 87.5%) due to non-cardiovascular causes. CONCLUSIONS LAA occlusion may be a reasonable option for stroke prevention inhigh-risk patients with atrial fibrillation ineligible for anticoagulation. However, procedural complication rates are not insignificant, and patients remain at risk of serious adverse events and death even after successful implant.
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Affiliation(s)
- Ahmed Masoud
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK.,Department of Cardiology, Benha University, Benha, Egypt
| | - Stefano Bartoletti
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Timothy Fairbairn
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Ayush Khurana
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Periaswamy Velavan
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | | | - Afshin Khalatbari
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Suneil Aggarwal
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
| | - Nikhill Sharma
- Department for Stroke, Gerontology and General Internal Medicine, Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital NHS Trust, Liverpool, UK
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323
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Skurk C, Hartung JJ, Landmesser U. [Recent and upcoming randomized trials for left atrial appendage occlusion : Need for a definite assessment of the situation]. Herzschrittmacherther Elektrophysiol 2017; 28:395-402. [PMID: 29101545 DOI: 10.1007/s00399-017-0534-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Accepted: 10/05/2017] [Indexed: 01/20/2023]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia affecting more than 1.6 million patients in Germany. Based on demographic developments, an the number is expected to increase. Embolic strokes in AF patients are particularly severe, and individualized new oral anticoagulant (NOAC) therapy reduces the incidence of stroke in these patients by approximately 70%. Besides vitamin K antagonists, the NOACs rivaroxaban, dabigatran, apixaban, and edoxaban have been introduced into clinical practice; however, major bleeding still occurs at a rate of 2-3% per year. Moreover, randomized studies and real-life registries suggest that >20% of patients with AF and an indication for anticoagulation cannot tolerate chronic oral anticoagulant therapy. Therefore, an alternative method for stroke prevention in AF patients has been developed, i. e., catheter-based exclusion of the left atrial appendage (LAA), a location that is prone for thrombus formation in these patients. The randomized trials of catheter-based LAA occlusion have compared this interventional therapy with vitamin K antagonists. In the future, however, LAA exclusion needs to be compared with NOAC therapy. Moreover, percutaneous LAA exclusion in clinical practice is mostly offered to patients ineligible for long-term oral anticoagulation or with high bleeding risk. However, no controlled, randomized trial data exist for this patient population. These data are needed for appropriate clinical judgment and optimal clinical management. Ongoing studies and scientific questions that are important to define the future for catheter-based LAA closure are discussed in this review.
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Affiliation(s)
- Carsten Skurk
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - Johannes Jakob Hartung
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - Ulf Landmesser
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland. .,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland. .,Berlin Institute of Health (BIH), Berlin, Deutschland.
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324
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Intracardiac Echocardiography From the Left Atrium for Procedural Guidance of Transcatheter Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2017; 10:2198-2206. [DOI: 10.1016/j.jcin.2017.06.057] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 06/27/2017] [Accepted: 06/29/2017] [Indexed: 11/24/2022]
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325
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Guedeney P, Hammoudi N, Duthoit G, Yan Y, Silvain J, Pousset F, Isnard R, Redheuil A, Kerneis M, Collet JP, Montalescot G. Intravenous enoxaparin anticoagulation in percutaneous left atrial cardiac procedures. EUROINTERVENTION 2017; 13:1226-1233. [DOI: 10.4244/eij-d-17-00518] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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326
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Sievert H, Bertog S. Left Atrial Appendage Closure. JACC Cardiovasc Interv 2017; 10:2195-2197. [DOI: 10.1016/j.jcin.2017.07.028] [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: 07/17/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
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327
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Affiliation(s)
- Lluis Asmarats
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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328
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Hell M, Achenbach S, Yoo I, Franke J, Blachutzik F, Roether J, Graf V, Raaz-Schrauder D, Marwan M, Schlundt C. 3D printing for sizing left atrial appendage closure device: head-to-head comparison with computed tomography and transoesophageal echocardiography. EUROINTERVENTION 2017; 13:1234-1241. [DOI: 10.4244/eij-d-17-00359] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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329
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Guérios ÊE, Chamié F, Montenegro M, Saad EB, Brito FSD, Caramori PA, Simões LC, Oliveira FRAD, Giuliano LC, Tavares CMDF. First results of the Brazilian Registry of Percutaneous Left Atrial Appendage Closure. Arq Bras Cardiol 2017; 109:440-447. [PMID: 29069203 PMCID: PMC5729780 DOI: 10.5935/abc.20170150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/29/2017] [Indexed: 12/14/2022] Open
Abstract
Background Left atrial appendage closure (LAAC) is an effective alternative to oral
anticoagulation (OA) for the prevention of stroke in patients with
non-valvular atrial fibrillation (NVAF). Objective To present the immediate results and late outcomes of patients submitted to
LAAC and included in the Brazilian Registry of Percutaneous Left Atrial
Appendage Closure. Methods 91 patients with NVAF, high stroke risk (CHA2DS2VASc
score = 4.5 ± 1.5) and restrictions to OAC (HAS-BLED score = 3.6
± 1.0) underwent 92 LAAC procedures using either the Amplatzer
cardiac plug or the Watchman device in 11 centers in Brazil, between late
2010 and mid 2016. Results Ninety-six devices were used (1.04 device/procedure, including an additional
non-dedicated device), with a procedural success rate of 97.8%. Associated
procedures were performed in 8.7% of the patients. Complete LAAC was
obtained in 93.3% of the successful cases. In cases of incomplete closure,
no residual leak was larger than 2.5 mm. One patient needed simultaneous
implantation of 2 devices. There were 7 periprocedural major (5 pericardial
effusions requiring pericardiocentesis, 1 non-dedicated device embolization
and 1 coronary air embolism without sequelae) and 4 minor complications.
After 128.6 patient-years of follow-up there were 3 deaths unrelated to the
procedure, 2 major bleedings (one of them in a patient with an unsuccessful
LAAC), thrombus formation over the device in 2 cases (both resolved after
resuming OAC for 3 months) and 2 strokes (2.2%). Conclusions In this multicenter, real world registry, that included patients with NVAF
and high thromboembolic and bleeding risks, LAAC effectively prevented
stroke and bleeding when compared to the expected rates based on
CHA2DS2VASc and HASBLED scores for this
population. Complications rate of the procedure was acceptable considering
the beginning of the learning curve of most of the involved operators.
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Affiliation(s)
| | - Francisco Chamié
- Hospital dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
| | - Márcio Montenegro
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | | | | | - Paulo Avancini Caramori
- Centro de Pesquisa Cardiovasculares do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS - Brasil
| | - Luiz Carlos Simões
- Instituto Nacional de Cardiologia (INC - MS), Rio de Janeiro, RJ - Brasil
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330
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Akodad M, Garot P. [Left atrial appendage closure and embolic events]. Ann Cardiol Angeiol (Paris) 2017; 66:441-446. [PMID: 29106834 DOI: 10.1016/j.ancard.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Atrial fibrillation (AF) is frequent and responsible for embolic events. Currently, the gold standard to prevent such embolic events is anticoagulant therapy with vitamin K antagonist (VKA) or direct oral anticoagulant in nonvalvular AF. Recently, left atrial appendage closure was proposed as an alternative to anticoagulant inpatient with high embolic risk and contraindication to anticoagulant therapy. Data from randomized trials were consistent with a non-inferiority of left atrial appendage closure in comparison to VKA in terms of stroke and cardiovascular death. However, despite improvements in procedure results and complications reduction, this invasive strategy has to be performed with optimal security as this strategy is a preventive treatment in high-risk patients. These improvements may allow an extension of indications of left atrial appendage closure to lower profile risk patients as an alternative to anticoagulant. Indeed, anticoagulant is a risky therapy with hemorrhagic events and observance is a real issue in an asymptomatic population. Finally, there is a lack of data in recent literature comparing left atrial appendage closure to direct oral anticoagulant, widely used in daily practice, as well as cost-effectiveness of this procedure in comparison to anticoagulant.
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Affiliation(s)
- M Akodad
- Service Angio, institut cardiovasculaire Paris-Sud (ICPS), hôpital Jacques Cartier, Ramsay-Generale de santé, Massy, France
| | - P Garot
- Service Angio, institut cardiovasculaire Paris-Sud (ICPS), hôpital Jacques Cartier, Ramsay-Generale de santé, Massy, France.
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331
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Left atrial appendage occluder implantation for stroke prevention in elderly patients with atrial fibrillation: acute and long-term results. JOURNAL OF GERIATRIC CARDIOLOGY : JGC 2017; 14:590-592. [PMID: 29056959 PMCID: PMC5641648 DOI: 10.11909/j.issn.1671-5411.2017.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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332
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Ueberham L, Dagres N, Potpara TS, Bollmann A, Hindricks G. Pharmacological and Non-pharmacological Treatments for Stroke Prevention in Patients with Atrial Fibrillation. Adv Ther 2017; 34:2274-2294. [PMID: 28956288 PMCID: PMC5656712 DOI: 10.1007/s12325-017-0616-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Indexed: 02/06/2023]
Abstract
Atrial fibrillation (AF) is associated with significant risk of stroke and other thromboembolic events, which can be effectively prevented using oral anticoagulation (OAC) with either vitamin K antagonists (VKAs) or non-VKA oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, or edoxaban. Until recently, VKAs were the only available means for OAC treatment. NOACs had similar efficacy and were safer than or as safe as warfarin with respect to reduced rates of hemorrhagic stroke or other intracranial bleeding in the respective pivotal randomized clinical trials (RCTs) of stroke prevention in non-valvular AF patients. Increasing “real-world” evidence on NOACs broadly confirms the results of the RCTs. However, individual patient characteristics including renal function, age, or prior bleeding should be taken into account when choosing the OAC with best risk–benefit profile. In patients ineligible for OACs, surgical or interventional stroke prevention strategies should be considered. In patients undergoing cardiac surgery for other reasons, the left atrial appendage excision, ligation, or amputation may be the best option. Importantly, residual stumps or insufficient ligation may result in even higher stroke risk than without intervention. Percutaneous left atrial appendage occlusion, although requiring minimally invasive access, failed to demonstrate reduced ischemic stroke events compared to warfarin. In this review article, we summarize current treatment options and discuss the strengths and major limitations of the therapies for stroke risk reduction in patients with AF.
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Affiliation(s)
- Laura Ueberham
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany.
| | - Nikolaos Dagres
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Tatjana S Potpara
- Cardiology Clinic, Clinical Center of Serbia, School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Andreas Bollmann
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, HELIOS Heart Center Leipzig, Leipzig, Germany
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333
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Hildick-Smith D, Diener HC, Schmidt B, Paul V, Settergren M, Teiger E, Camm J, Tondo C, Landmesser U. Rationale and design of a global registry to evaluate real-world clinical outcomes in patients with atrial fibrillation and high risk of stroke treated with left atrial appendage occlusion using the AMPLATZER amulet device-Perspective of available/ongoing. Catheter Cardiovasc Interv 2017; 91:540-547. [DOI: 10.1002/ccd.27252] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 06/15/2017] [Accepted: 07/22/2017] [Indexed: 11/07/2022]
Affiliation(s)
- David Hildick-Smith
- Sussex Cardiac Centre; Brighton and Sussex University Hospitals; Brighton United Kingdom
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien; Agaplesion Markus-Krankenhaus; Frankfurt Germany
| | - Vincent Paul
- Department of Cardiology; Royal Perth Hospital; Perth Australia
| | - Magnus Settergren
- Department of Cardiology; Karolinska University Hospital and Karolinska Institutet; Stockholm Sweden
| | | | - John Camm
- St George's University of London and Imperial College; London United Kingdom
| | - Claudio Tondo
- Cardiac Arrhythmia Research Centre, Department of Cardiovascular Sciences; University of Milan, Centro Cardiologico Monzino, IRCCS; Italy
| | - Ulf Landmesser
- Department of Cardiology; Charite Universitätsmedizin Berlin (CBF); Berlin Institute of Health (BIH); Berlin Germany
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334
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Nietlispach F, Moarof I, Taramasso M, Maisano F, Meier B. Left atrial appendage occlusion. EUROINTERVENTION 2017; 13:AA78-AA84. [DOI: 10.4244/eij-d-17-00412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Managing the Left Atrial Appendage in Atrial Fibrillation: Current State of the Art. Ann Thorac Surg 2017; 104:2111-2119. [PMID: 28826990 DOI: 10.1016/j.athoracsur.2017.05.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 03/19/2017] [Accepted: 05/05/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND Patients with atrial fibrillation are at increased risk for thromboembolic stroke originating predominantly in the left atrial appendage. To reduce the risk, the standard of care is anticoagulation. In addition, several devices for exclusion of the left atrial appendage have been developed. METHODS PubMed was searched for articles relevant to left atrial appendage management. The resulting articles were reviewed as were relevant articles in their bibliographies. Relevant journals were manually searched for sources. RESULTS Devices are being used for left atrial appendage exclusion by percutaneous and surgical approaches. Their indications, limitations, and outcomes are reviewed. CONCLUSIONS Excision and exclusion of the left atrial appendage is safe and as effective as medical management of atrial fibrillation for stroke prevention. The choice of treatment should be made based on patients' anatomy, history, and preference informed by an appropriate left atrial appendage management team.
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336
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Left Atrial Appendage Closure: Is the Strategy Enough to Lower Long-Term Stroke Risk? CURRENT CARDIOVASCULAR RISK REPORTS 2017. [DOI: 10.1007/s12170-017-0555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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337
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de J Ramos Ramirez M, Young B, Harjai K, Mascarenhas V, Vijayaraman P. Left atrial appendage occlusion: 2016 in review. J Interv Cardiol 2017; 30:448-456. [PMID: 28799239 DOI: 10.1111/joic.12410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Revised: 07/09/2017] [Accepted: 07/10/2017] [Indexed: 01/14/2023] Open
Abstract
A significant body of data has emerged in the area of Percutaneous Left Atrial Appendage Occlusion (LAAO). In this article, we present an overview of the most notable publications along with a review of the most important publications on LAAO in 2016. We also present important historical data such as landmark clinical studies, review of most utilized occlusion devices, and important clinical studies that are underway.
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Affiliation(s)
| | - Bonnie Young
- Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania
| | - Kishore Harjai
- Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania
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338
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Caliskan E, Cox JL, Holmes DR, Meier B, Lakkireddy DR, Falk V, Salzberg SP, Emmert MY. Interventional and surgical occlusion of the left atrial appendage. Nat Rev Cardiol 2017; 14:727-743. [DOI: 10.1038/nrcardio.2017.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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339
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Lempereur M, Aminian A, Freixa X, Gafoor S, Shakir S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Cruz-Gonzalez I, Kanagaratnam P, Nietlispach F, Ibrahim R, Sievert H, Schillinger W, Park JW, Gloekler S, Tzikas A. Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Previous Major Gastrointestinal Bleeding (from the Amplatzer Cardiac Plug Multicenter Registry). Am J Cardiol 2017; 120:414-420. [PMID: 28595859 DOI: 10.1016/j.amjcard.2017.04.046] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/25/2017] [Accepted: 04/25/2017] [Indexed: 12/19/2022]
Abstract
History of major gastrointestinal (GI) bleeding may represent a frequent clinical indication for left atrial appendage occlusion (LAAO) in patients with non-valvular atrial fibrillation (AF). This study aims to investigate the procedural safety and long-term outcome of patients with previous major GI bleeding (MGIB) who underwent LAAO. Data from the Amplatzer Cardiac Plug multicenter registry on 1,047 patients were analyzed. Patients with previous MGIB as indication for LAAO were compared with patients without previous MGIB. A total of 151 patients (14.4%) with previous MGIB were identified. Periprocedural major bleeding events were more frequent in patients with previous MGIB (4.0% vs 0.8%, p = 0.001). With an average follow-up of 1.3 years, the observed annual rate of stroke/transient ischemic attack and major bleeding for patients with previous MGIB were 2.1% (61.4% relative reduction according to the Congestive Heart failure, Hypertension, Age ≥75 (doubled), Diabetes, Stroke (doubled), Vascular disease, Age 65-74, and Sex (female) [CHA2DS2-VASc] score) and 4.6% (20.1% relative reduction according to the expected rate based on the Hypertension, Abnormal renal/liver function (1 point each), Stroke, Bleeding history or predisposition, Labile INR, Elderly (>65 years), Drugs/alcohol concomitantly (1 point each) [HAS-BLED] score), respectively. In conclusion, in patients with non-valvular atrial fibrillation and previous MGIB, LAAO was associated with a low annual rate of stroke/transient ischemic attack. Periprocedural major bleeding events were more frequent in this specific population although the annual major bleeding rate showed a 20.1% relative risk reduction according to the HAS-BLED score.
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340
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Regoli F, Araco M, Moccetti T, Caputo ML, Conte G, Auricchio A, Moccetti M. Potential Clinical Utility and Feasibility of Combined Left Atrial Appendage Closure and Positioning of Miniaturized Pacemaker Through a Single Right Femoral Vein Access. Am J Cardiol 2017; 120:236-242. [PMID: 28558866 DOI: 10.1016/j.amjcard.2017.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 11/28/2022]
Abstract
This study assessed the clinical utility and feasibility of concomitant of combined left atrial appendage (LAA) closure and positioning of miniaturized pacemaker (Micra TPS). All consecutive patients who underwent VVI-PM implant from November 2015 to October 2016 were considered. VVI-PM implant was conducted either using transvenous approach or by positioning Micra TPS. In selected patients with concomitant contraindication to OAC, Micra TPS was combined with LAA occlusion ("combined approach"), performed in general anesthesia and guided by multimodality imaging; procedural and follow-up data of these specific patients were registered. Sixty patients were treated with VVI-PM implant. Six patients (10.0%) presented OAC contraindication, of which 4 (6.7%) were eligible for the "combined procedure"; 2 of 4 of these patients presented chronic hemodialysis-dependent renal failure. The combined approach was successful in all 4 patients without intra- or periprocedural complications. No adverse events linked to the combined approach occurred during mid-term follow-up (7.5, interquartile range 5.0 to 7.9 months). In conclusion, VVI-PM indication and concomitant contraindication to OAC is not uncommon; in selected patients, combined LAA closure and positioning of Micra TPS may be a feasible therapeutic option.
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Affiliation(s)
- François Regoli
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland.
| | - Marco Araco
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Tiziano Moccetti
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Maria Luce Caputo
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Giulio Conte
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Angelo Auricchio
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
| | - Marco Moccetti
- Cardiology Department, Fondazione Cardiocentro Ticino, Lugano, Switzerland
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341
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Fernández A, Rodríguez A, Sénior JM, Aldana V, Borja H. Seguridad y eficacia a corto plazo del cierre de orejuela izquierda con dispositivo WATCHMAN ® en fibrilación auricular no valvular en pacientes con alto riesgo de sangrado. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2016.10.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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342
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Dave AS, Valderrábano M. Approaches to Left Atrial Appendage Closure: Device Design, Performance, and Limitations. Methodist Debakey Cardiovasc J 2017; 13:106-113. [PMID: 29743994 DOI: 10.14797/mdcj-13-3-106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Up to 6.1 million people in the United States have atrial fibrillation (AF), which is associated with an increased risk of stroke. Oral anticoagulants are the mainstay of stroke prevention in AF. For decades, warfarin was the only available drug, fraught with compliance limitations, a narrow therapeutic window, and a high risk of hemorrhage. Pharmacologic developments have produced new anticoagulants that have improved the rates of stroke related to AF; however, they still confer a high risk of bleeding, making them unsuitable for some patients. Studies have shown that roughly 90% of strokes in patients with AF occur in the left atrial appendage (LAA). This understanding has prompted the development and testing of novel percutaneous strategies for LAA closure as an alternative to anticoagulation therapy. The following review examines the relative merits and shortcomings of these strategies and explores future prospects in the prevention of AF-related stroke.
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Affiliation(s)
- Amish S Dave
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Miguel Valderrábano
- METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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343
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Holmes DR, Reddy VY, Buchbinder M, Stein K, Elletson M, Bergmann MW, Schmidt B, Saw J. The Assessment of the Watchman Device in Patients Unsuitable for Oral Anticoagulation (ASAP-TOO) trial. Am Heart J 2017. [PMID: 28625383 DOI: 10.1016/j.ahj.2017.03.007] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Oral anticoagulants (OACs) reduce stroke risks with nonvalvular atrial fibrillation (AF); however, they are underused because of absolute or relative contraindications due to real or perceived risk of bleeding. Although left atrial appendage closure is increasingly performed in OAC-ineligible patients, this has not been studied in a randomized controlled trial. STUDY OBJECTIVES The ASAP-TOO study is designed to establish the safety and effectiveness of the Watchman left atrial appendage closure device in patients with nonvalvular AF who are deemed ineligible for OAC. The primary effectiveness end point is the time to first occurrence of ischemic stroke or systemic embolism. The primary safety end point includes all-cause death, ischemic stroke, systemic embolism, or device- or procedural-related event requiring open cardiac surgery or major endovascular intervention. STUDY DESIGN This is a multinational, multicenter prospective randomized trial. Patients meeting the inclusion criteria with CHA2DS2-VASc score≥2 and who are deemed by 2 study physicians to be unsuitable for OAC will be randomized in a 2:1 allocation ratio to Watchman versus control. Control patients will be prescribed single antiplatelet therapy or no therapy at the discretion of the study physician. Up to 888 randomized subjects will be enrolled from up to 100 global investigational sites. Both device group and control patients will have follow-up visits at 3, 6, and 12months and then every 6months through 60months. SUMMARY This trial will assess the safety and efficacy of Watchman in this challenging population of high-stroke risk AF patients.
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344
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Fastner C, Behnes M, Ansari U, El-Battrawy I, Borggrefe M. Interventional Left Atrial Appendage Closure: Focus on Practical Implications. Interv Cardiol 2017. [DOI: 10.5772/67773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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345
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El-Chami M, Kowal RC, Soejima K, Ritter P, Duray GZ, Neuzil P, Mont L, Kypta A, Sagi V, Hudnall JH, Stromberg K, Reynolds D. Impact of operator experience and training strategy on procedural outcomes with leadless pacing: Insights from the Micra Transcatheter Pacing Study. Pacing Clin Electrophysiol 2017; 40:834-842. [PMID: 28439940 DOI: 10.1111/pace.13094] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/17/2017] [Accepted: 04/12/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Leadless pacemaker systems have been designed to avoid the need for a pocket and transvenous lead. However, delivery of this therapy requires a new catheter-based procedure. This study evaluates the role of operator experience and different training strategies on procedural outcomes. METHODS A total of 726 patients underwent implant attempt with the Micra transcatheter pacing system (TPS; Medtronic, Minneapolis, MN, USA) by 94 operators trained in a teaching laboratory using a simulator, cadaver, and large animal models (lab training) or locally at the hospital with simulator/demo model and proctorship (hospital training). Procedure success, procedure duration, fluoroscopy time, and safety outcomes were compared between training methods and experience (implant case number). RESULTS The Micra TPS procedure was successful in 99.2% of attempts and did not differ between the 55 operators trained in the lab setting and the 39 operators trained locally at the hospital (P = 0.189). Implant case number was also not a determinant of procedural success (P = 0.456). Each operator performed between one and 55 procedures. Procedure time and fluoroscopy duration decreased by 2.0% (P = 0.002) and 3.2% (P < 0.001) compared to the previous case. Major complication rate and pericardial effusion rate were not associated with case number (P = 0.755 and P = 0.620, respectively). There were no differences in the safety outcomes by training method. CONCLUSIONS Among a large group of operators, implantation success was high regardless of experience. While procedure duration and fluoroscopy times decreased with implant number, complications were low and not associated with case number. Procedure and safety outcomes were similar between distinct training methodologies.
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Affiliation(s)
- Mikhael El-Chami
- Division of Cardiology, Section of Electrophysiology, Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Kyoko Soejima
- Department of Cardiology, Kyorin University Hospital, Tokyo, Japan
| | - Philippe Ritter
- Department of Cardiac Pacing and Electrophysiology, CHU/Université de Bordeaux, Pessac, France and L'Institut de Rythmologie et de Modélisation Cardiaque LIRYC, CHU/Université de Bordeaux/INSERM U1045, Pessac, France
| | - Gabor Z Duray
- Clinical Electrophysiology Department of Cardiology, Medical Centre, Hungarian Defence Forces, Budapest, Hungary
| | | | - Lluis Mont
- Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Alexander Kypta
- Department of Cardiology, Linz General Hospital, Johannes Kepler University School of Medicine, Linz, Austria
| | - Venkata Sagi
- Baptist Heart Specialists, Jacksonville, Florida
| | | | | | - Dwight Reynolds
- Cardiovascular Section, University of Oklahoma Health Sciences Center, OU Medical Center, Oklahoma City, Oklahoma
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Sunagawa G, Karimov JH, Breitbach M, Robinson NA, Fukamachi K. Impact of a refined advanced design for left atrial appendage exclusion. Eur J Cardiothorac Surg 2017. [DOI: 10.1093/ejcts/ezx188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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347
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Schlaganfallprophylaxe bei Vorhofflimmern. Herz 2017; 42:373-379. [DOI: 10.1007/s00059-017-4568-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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348
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Boersma LV, Ince H, Kische S, Pokushalov E, Schmitz T, Schmidt B, Gori T, Meincke F, Protopopov AV, Betts T, Foley D, Sievert H, Mazzone P, De Potter T, Vireca E, Stein K, Bergmann MW. Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm 2017; 14:1302-1308. [PMID: 28577840 DOI: 10.1016/j.hrthm.2017.05.038] [Citation(s) in RCA: 313] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Left atrial appendage (LAA) occlusion with WATCHMAN has emerged as viable alternative to vitamin K antagonists in randomized controlled trials. OBJECTIVE EWOLUTION was designed to provide data in routine practice from a prospective multicenter registry. METHODS A total of 1025 patients scheduled for a WATCHMAN implant were prospectively and sequentially enrolled at 47 centers. Indication for LAA closure was based on European Society of Cardiology guidelines. Follow-up and transesophageal echocardiography (TEE) were performed per local practice. RESULTS The baseline CHA2DS2-VASc score was 4.5 ± 1.6; the mean age was 73.4 ± 9 years; previous transient ischemic attack/ischemic stroke was present in 312 (30.5%), 155 (15.1%) had previous hemorrhagic stroke, and 320 (31.3%) had a history of major bleeding; and 750 (73%) were deemed unsuitable for oral anticoagulation therapy. WATCHMAN implant succeeded in 1005 (98.5%) of patients, without leaks >5 mm in 1002 (99.7%) with at least 1 TEE follow-up in 875 patients (87%). Antiplatelet therapy was used in 784 (83%), while vitamin K antagonists were used in only 75 (8%). At 1 year, mortality was 98 (9.8%), reflecting the advanced age and comorbidities in this population. Device thrombus was observed in 28 patients at routine TEE (3.7%) and was not correlated with the drug regimen (P = .14). Ischemic stroke rate was 1.1% (relative risk 84% vs estimated historical data); the major bleeding rate was 2.6% and was predominantly (2.3%) nonprocedure/device related. CONCLUSION LAA closure with the WATCHMAN device has a high implant and sealing success. This method of stroke risk reduction appears to be safe and effective with an ischemic stroke rate as low as 1.1%, even though 73% of patients had a contraindication to and were not using oral anticoagulation.
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Affiliation(s)
- Lucas V Boersma
- St. Antonius Ziekenhuis Nieuwegein/AMC, Amsterdam, The Netherlands.
| | | | | | - Evgeny Pokushalov
- State Research Institute of Circulation Pathology, Novosibirsk, Russia
| | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt/Main, Germany
| | - Tommaso Gori
- Universitätsmedizin Mainz und DZHK Standort Rhein-Main, Mainz, Germany
| | - Felix Meincke
- Asklepios Klinik St Georg, Cardiology, Hamburg, Germany
| | | | - Timothy Betts
- Oxford University Hospitals NHS Trust, Oxford, United Kingdom
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349
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Cruz-González I, Freixa X, Fernández-Díaz JA, Moreno-Samos JC, Martín-Yuste V, Goicolea J. Left Atrial Appendage Occlusion With the LAmbre Device: Initial Experience. ACTA ACUST UNITED AC 2017; 71:755-756. [PMID: 28522304 DOI: 10.1016/j.rec.2017.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 02/27/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Ignacio Cruz-González
- Servicio de Cardiología, Hospital Universitario de Salamanca, IBSAL, Salamanca, Spain.
| | - Xavier Freixa
- Servicio de Cardiología, Hospital Clínic, Barcelona, Spain
| | | | | | | | - Javier Goicolea
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
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350
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Lempereur M, Aminian A, Dulgheru R, De Potter T, Oury C, Lancellotti P. Role of Imaging in Left Atrial Appendage Occlusion. INTERNATIONAL JOURNAL OF CARDIOVASCULAR PRACTICE 2017. [DOI: 10.21859/ijcp-020203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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