Safety of percutaneous left atrial appendage closure with the amplatzer cardiac plug in patients with atrial fibrillation and contraindications to anticoagulation

Meta-analysis of postoperative antithrombotic therapy after left atrial appendage occlusion

Objective

This meta-analysis explored the safety and effectiveness of different anticoagulant regimens after left atrial appendage occlusion (LAAO).

Methods

Databases, such as PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane Library, were searched to identify eligible studies according to the inclusion criteria. The incidences of events, including device-related thrombus (DRT) formation, stroke, systemic thromboembolism, bleeding, cardiovascular mortality, and all-cause mortality, were analyzed using R version 3.2.3.

Results

The screening retrieved 32 studies, including 36 study groups and 4,474 patients. The incidence of outcomes after LAAO was calculated via meta-analysis. In the subgroup analysis, the rates of DRT formation, cardiovascular mortality, and all-cause mortality were significantly different among different antithrombotic methods. Single antiplatelet therapy was associated with the highest rate of adverse events, followed by dual antiplatelet therapy (DAPT). Vitamin K antagonists (VKAs) and new oral anticoagulants (NOACs) carried lower rates of adverse events.

Conclusions

Anticoagulant therapy had better safety and efficacy than antiplatelet therapy. Thus, for patients with nonabsolute anticoagulant contraindications, anticoagulant therapy rather than DAPT should be actively selected. NOACs displayed potential for further development, and these treatments might represent alternatives to VKAs in the future.

Left Atrial Appendage Occlusion in the Management of Stroke in Patients With Atrial Fibrillation

Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.

Device-associated thrombus formation after left atrial appendage occlusion: A systematic review of events reported with the Watchman, the Amplatzer Cardiac Plug and the Amulet

OBJECTIVES

This study aimed to provide a systematic review of device-associated thrombosis (DAT) after left atrial appendage occlusion (LAAO) with the Watchman, Amplatzer Cardiac Plug, and Amulet devices.

BACKGROUND

DAT is known as a complication of LAAO but data about its clinical impact is scarce.

METHODS

A systematic review of studies evaluating the incidence, treatment and clinical implications of DAT from January 2008 to September 2015 was conducted.

RESULTS

A total of 30 studies describing DAT events were included in the analysis. The overall incidence of DAT was 3.9% (82 DAT for 2118 implanted devices). The median time from procedure to diagnosis of DAT was 1.5 months (IQR: 0-2.9). Most cases were diagnosed with transesophageal echocardiogram (TEE). The treatment consisted of low molecular weight heparin (LMWH) in 45.5% of cases, and oral anticoagulation (OAC) or other treatment modalities in 54.5%. Complete thrombus resolution was achieved in 95.0% of cases (100% with LMWH and 89.5% with OAC). Treatment duration varied greatly with a median treatment duration of 45 days (IQR: 14-135). Clinical events related to DAT consisted of neurologic events namely two transient ischemic attacks (2.4%) and four ischemic strokes (4.9%).

CONCLUSIONS

DAT is an infrequent complication of percutaneous LAAO. It occurs mainly early after the procedure and is associated with a low rate of neurological complications. In the majority of cases, diagnosis is made during follow-up imaging with TEE. Anticoagulation treatment seems to be safe and highly effective. Further studies are needed to evaluate the optimal management of DAT. © 2017 Wiley Periodicals, Inc.

A meta-analysis for efficacy and safety evaluation of transcatheter left atrial appendage occlusion in patients with nonvalvular atrial fibrillation

OBJECTIVES

This meta-analysis was conducted to evaluate the efficacy and safety of transcatheter left atrial appendage (LAA) occlusion in patients with nonvalvular atrial fibrillation.

METHODS

The randomized controlled trials (RCT) or observational studies with any transcatheter LAA occlusion devices were searched in PubMed, Embase, and Cochrane library from inception to November 2015. The incidence rates from individual studies were combined to evaluate the procedural efficacy and safety, including all-cause death, cardiac/neurological death, stroke, transient ischemic attack (TIA), thrombosis, hemorrhagic complications, and pericardial effusion/tamponade.

RESULTS

Thirty-eight studies involving 3585 patients and 6 different occlusion devices were eligible for our inclusion criteria. The procedural failure rate for LAA closure was 0.02 (95% CI: 0.02-0.03). The all-cause mortality was 0.03 (95% CI: 0.02-0.03) and cardiac/neurological mortality was 0 (95% CI: 0.00-0.01). The stroke/TIA rate was estimated only 0.01 (95% CI: 0.01-0.01). The incidence of thrombus on devices was 0.01 (95% CI: 0.01-0.02). The major hemorrhagic complication rate was estimated 0.01 (95% CI: 0.00-0.01). Pericardial effusion/tamponade was estimated 0.02 (95% CI: 0.02-0.03). No heterogeneity was observed for above pooled estimates (I = 0). In devices subgroups analysis, the all-cause mortality and cardiac/neurological mortality of PLAATO group were the highest (P = 0.01 and P < 0.01 respectively), whereas the incidence of thrombus on devices in the ACP group was the highest (P < 0.01). In follow-up period subgroups analysis, there were significant differences in all-cause death, stroke/TIA, major hemorrhage, and pericardial effusion/tamponade events between the shorter and longer follow-up period subgroups (P < 0.05). However, the differences among the subgroups were numerically small.

CONCLUSIONS

the pooled data demonstrated that transcatheter LAA occlusion was effective and safe in the patients with nonvalvular atrial fibrillation who were not suitable for lifelong antithrombotic therapy.

Efficacy and Safety of Percutaneous Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation: A Meta-analysis of Contemporary Studies

BACKGROUND

Percutaneous left atrial appendage (LAA) occlusion has emerged as an important treatment for patients with nonvalvular atrial fibrillation (NVAF) who are at high stroke risk and have contraindications for anticoagulation. However, literature about the efficacy and safety of LAA occlusion is minimal to date. We performed a meta-analysis to assess the rates of stroke events and adverse events for patients treated with occlusion devices.

METHODS

We conducted a comprehensive search on PubMed, Web of Science, OVID, SCOPUS databases and the Cochrane Central Register of Controlled Trials databases from inception to December 31, 2014 for studies of percutaneous LAA occlusion for patients with NVAF. Studies were included in the meta-analysis if at least 10 patients were studied with six months or more of follow-up period and reported at least one outcome of interest.

RESULTS

A total of 2779 patients in 25 studies were included in the meta-analysis. Two were randomised control trials (RCTs), others were cohort studies. The adjusted incidence rate of stroke was 1.2/100 person-years (PY) (95% confidence interval [CI], 0.9-1.6/100 PY). The ischaemic and haemorrhagic stroke rates were 1.1/100 PY (95% CI, 0.8-1.4/100 PY) and 0.2/100 PY (95% CI, 0.1-0.3/100 PY), respectively. The combined efficacy outcomes (stroke or transient ischaemic attacks [TIAs], systemic embolism, or cardiovascular death) was 2.7/100 PY (95% CI, 1.9- 3.4/100 PY). Major bleeding and pericardial effusions were the most commonly observed adverse events at a rate of 2.6% (95% CI, 1.5%-3.6%) and 2.5% (95% CI, 1.8%-3.2%), respectively.

CONCLUSIONS

Percutaneous LAA occlusion is a reasonably efficacious and safe therapeutic option in patients with NVAF who are at high risk for stroke and contraindicated for long-term anticoagulation.

--LAA Occluder View for post-implantation Evaluation (LOVE)--standardized imaging proposal evaluating implanted left atrial appendage occlusion devices by cardiac computed tomography

Background

A standardized imaging proposal evaluating implanted left atrial appendage (LAA) occlusion devices by cardiac computed tomography angiography (cCTA) has never been investigated.

Methods

cCTA datasets were acquired on a 3^rd generation dual-source CT system and reconstructed with a slice thickness of 0.5 mm. An interdisciplinary evaluation was performed by two interventional cardiologists and one radiologist on a 3D multi-planar workstation. A standardized multi-planar reconstruction algorithm was developed in order to assess relevant clinical aspects of implanted LAA occlusion devices being outlined within a pictorial essay.

Results

The following clinical aspects of implanted LAA occlusion devices were evaluated within the most appropriate cCTA multi-planar reconstruction: (1) topography to neighboring structures, (2) peri-device leaks, (3) coverage of LAA lobes, (4) indirect signs of neo-endothelialization. These are illustrated within concise CT imaging examples emphasizing the potential value of the proposed cCTA imaging algorithm: Starting from anatomical cCTA planes and stepwise angulation planes perpendicular to the base of the LAA devices generates an optimal LAA Occluder View for post-implantation Evaluation (LOVE). Aligned true axial, sagittal and coronal LOVE planes offer a standardized and detailed evaluation of LAA occlusion devices after percutaneous implantation.

Conclusions

This pictorial essay presents a standardized imaging proposal by cCTA using multi-planar reconstructions that enables systematical follow-up and comparison of patients after LAA occlusion device implantation.

Electronic supplementary material

The online version of this article (doi:10.1186/s12880-016-0127-y) contains supplementary material, which is available to authorized users.

Percutaneous left atrial appendage closure-An alternative strategy for anticoagulation in atrial fibrillation and hereditary hemorrhagic telangiectasia?

Many patients with hereditary hemorrhagic telangiectasia (HHT) are unable to sustain oral anticoagulation (OAC) because of severe epistaxis, gastrointestinal (GI) bleeding and the risk of life-threatening bleeding from cerebral arteriovenous malformations (CAVMs) or pulmonary arteriovenous malformations (PAVMs). In patients with atrial fibrillation (AF), most thromboembolic complications arise from the left atrial appendage (LAA) and percutaneous transcatheter LAA closure proved to be non-inferior to OAC at mid-term follow-up. We report our experience with LAA closure in HHT with a follow-up of 12 months. Percutaneous LAA closure was performed in five patients with both HHT and high thromboembolic risk AF (CHA2DS2-VASc score ≥2) without peri-procedural complications. At 3 months no thromboembolic event occurred. After 12 months one patient had a transient ischemic attack while another patient had recurrence of stroke, this latter patient had a significant stenosis of the carotid artery and an incomplete closure of the LAA without any signs of thrombus on echocardiogram. Both patients had a non-treatable pulmonary right-to-left shunt (RLS). Percutaneous closure of the LAA may provide an alternative strategy to long-term OAC therapy in HHT patients with AF induced high stroke risk and intolerance for OAC.

An overview of left atrial appendage occlusion devices

Atrial fibrillation (AF) places patients at increased risk of thromboembolic events that can be devastating. The left atrial appendage (LAA) has been identified as the source of thrombus formation in nonvalvular AF. Traditionally, systemic anticoagulation has been used to reduce the risk of stroke and systemic embolism. However, anticoagulation is not well tolerated in all patients and is underutilized. As a potential alternative to anticoagulation, novel therapies have been developed to remove the LAA. Three main techniques are being utilized to accomplish LAA exclusion: percutaneous intracardiac, percutaneous epicardial, and surgical approaches. Emerging evidence suggests that LAA exclusion may be an effective means of reducing the risk of stroke in patients with nonvalvular AF.

Transcatheter Aortic Valve Replacement and Left Atrial Appendage Occlusion - A Stitch in Time?

Many patients have now been able to receive transcatheter aortic valve replacement (TAVR) therapy for severe aortic stenosis. These patients have atrial fibrillation and are placed on warfarin for stroke prophylaxis. The opportunity for treatment with left atrial appendage occlusion (LAAO) in place of warfarin for this population exists, especially for those with increased bleeding risk. This paper discusses the prevalence and aetiology of stroke in patients presenting for TAVR (with a focus on the risk from chronic and acute atrial fibrillation) and also the benefit of LAAO closure in this population.