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Tanaka T, Kawai K, Ellis CR, Srivastava M, Kawakami R, Konishi T, Shiraki T, Sekimoto T, Virmani R, Finn AV. Challenges and advances in device-related thrombus in left atrial appendage occlusion. Future Cardiol 2024:1-16. [PMID: 38948932 DOI: 10.1080/14796678.2024.2363063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO.
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Affiliation(s)
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD 20878, USA
| | | | - Mukta Srivastava
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
| | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD 20878, USA
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
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2
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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3
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Cundari G, Alkadhi H, Eberhard M. The role of CT in arrhythmia management-treatment planning and post-procedural imaging surveillance. Br J Radiol 2023; 96:20230028. [PMID: 37191058 PMCID: PMC10607403 DOI: 10.1259/bjr.20230028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 03/21/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023] Open
Abstract
Several interventional treatment options exist in patients with atrial and ventricular arrhythmia. Cardiac CT is routinely performed prior to occlusion of the left atrial appendage, pulmonary vein isolation, and cardiac device implantation. Besides the evaluation of coronary artery disease, cardiac CT provides isotropic, high-resolution CT images of the cardiac anatomy with the possibility of multiplanar reformations and three-dimensional reconstructions which are helpful to guide interventional treatment. In addition, cardiac CT is increasingly used to rapidly evaluate periprocedural complications and for the routine post-procedural imaging surveillance in patients after interventions. This review article will discuss current applications of pre- and post-interventional CT imaging in patients with arrhythmia.
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Affiliation(s)
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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4
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Branzoli S, Guarracini F, Marini M, D’Onghia G, Catanzariti D, Merola E, Annicchiarico L, Casagranda G, Stegagno C, Fantinel M, La Meir M. Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective. J Clin Med 2022; 11:6492. [PMID: 36362719 PMCID: PMC9656641 DOI: 10.3390/jcm11216492] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. METHODS Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. RESULTS Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. CONCLUSION Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.
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Affiliation(s)
- Stefano Branzoli
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
- Cardiac Surgery Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Massimiliano Marini
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
- Heart Rhythm Management Centre, UZ Brussel, 1050 Brussel, Belgium
| | - Giovanni D’Onghia
- Department of Cardiology, Santa Chiara Hospital, 38122 Trento, Italy
| | | | - Elettra Merola
- Gastroenterology Unit, Santa Chiara Hospital, 38122 Trento, Italy
| | | | | | - Chiara Stegagno
- Neurology Rehabilitation Unit, Eremo Hospital, 38122 Trento, Italy
| | - Mauro Fantinel
- Cardiology Unit, Santa Maria Hospital, 32032 Feltre, Italy
| | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, 1050 Brussels, Belgium
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5
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Clinical and echocardiographic risk factors for device-related thrombus after left atrial appendage closure: an analysis from the multicenter EUROC-DRT registry. Clin Res Cardiol 2022; 111:1276-1285. [PMID: 35849156 DOI: 10.1007/s00392-022-02065-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry. METHODS We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics. RESULTS Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 ± 18.5 vs. 42.4 ± 18.0 cm/s, p = 0.02). Occluders implanted in DRT patients were larger (25.5 ± 3.8 vs. 24.6 ± 3.5 mm, p = 0.03) and implanted deeper in the LAA (mean depth: 7.6 ± 4.7 vs. 5.7 ± 4.7 mm, p < 0.01). Coverage of the appendage ostium was achieved less often in DRT patients (69.5% vs. 81.5%, p < 0.01), while DRT patients were less frequently on oral anticoagulation (7.1% vs. 16.7%, p < 0.01). Multivariate analysis identified age, prior stroke/TIA and SEC as independent risk factors for DRT. After PSM, implantation depth was found to be predictive. Rates of stroke/TIA were higher in DRT patients (13.5% vs. 3.8%, Hazard Ratio: 4.21 [95%-confidence interval: 1.88-9.49], p < 0.01). CONCLUSIONS DRT after LAAC is associated with adverse outcome and appears to be of multifactorial origin, depending on patient characteristics, anticoagulation regimen and device position.
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Sedaghat A, Vij V, Al-Kassou B, Gloekler S, Galea R, Fürholz M, Meier B, Valgimigli M, O'Hara G, Arzamendi D, Agudelo V, Asmarats L, Freixa X, Flores-Umanzor E, De Backer O, Søndergaard L, Nombela-Franco L, McInerney A, Korsholm K, Nielsen-Kudsk JE, Afzal S, Zeus T, Operhalski F, Schmidt B, Montalescot G, Guedeney P, Iriart X, Miton N, Saw J, Gilhofer T, Fauchier L, Veliqi E, Meincke F, Petri N, Nordbeck P, Rycerz S, Ognerubov D, Merkulov E, Cruz-González I, Gonzalez-Ferreiro R, Bhatt DL, Laricchia A, Mangieri A, Omran H, Schrickel JW, Rodes-Cabau J, Nickenig G. Device-Related Thrombus After Left Atrial Appendage Closure: Data on Thrombus Characteristics, Treatment Strategies, and Clinical Outcomes From the EUROC-DRT-Registry. Circ Cardiovasc Interv 2021; 14:e010195. [PMID: 34003661 DOI: 10.1161/circinterventions.120.010195] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
| | - Vivian Vij
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
| | - Baravan Al-Kassou
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
| | - Steffen Gloekler
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Roberto Galea
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Monika Fürholz
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Bernhard Meier
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.)
| | - Marco Valgimigli
- University Hospital Bern, Switzerland (S.G., R.G., M.F., B.M., M.V.).,Cardiocentro Ticino, Lugano, Switzerland (M.V.)
| | - Gilles O'Hara
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.)
| | - Dabit Arzamendi
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | - Victor Agudelo
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | - Lluis Asmarats
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.).,Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A., L.A.)
| | | | | | - Ole De Backer
- Rigshospitalet Copenhagen University Hospital, Denmark (O.D.B., L.S.)
| | - Lars Søndergaard
- Rigshospitalet Copenhagen University Hospital, Denmark (O.D.B., L.S.)
| | | | - Angela McInerney
- Hospital Clinico San Carlos Madrid, Spain (L.N.-F., A. McInerney)
| | | | | | - Shazia Afzal
- University Hospital Düsseldorf, Germany (S.A., T.Z.)
| | - Tobias Zeus
- University Hospital Düsseldorf, Germany (S.A., T.Z.)
| | - Felix Operhalski
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany (F.O., B.S.)
| | - Boris Schmidt
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany (F.O., B.S.)
| | - Gilles Montalescot
- Surbonne University Pitié-Salpêtrière Hospital (AP-HP) Paris, France (G.M., P.G.)
| | - Paul Guedeney
- Surbonne University Pitié-Salpêtrière Hospital (AP-HP) Paris, France (G.M., P.G.)
| | | | - Noelie Miton
- University Hospital Bordeaux, France (X.I., N.M.)
| | | | | | | | - Egzon Veliqi
- St. Georg Hospital Hamburg, Germany (E.V., F.M.)
| | | | - Nils Petri
- University Hospital Würzburg, Germany (N.P., P.N.)
| | | | - Szymon Rycerz
- Schwarzwald-Baar Klinikum, Villingen-Schwenningen, Germany (S.R.)
| | - Dmitrii Ognerubov
- Russian Cardiology Research and Production Complex, Moscow (D.O., E.M.)
| | - Evgeny Merkulov
- Russian Cardiology Research and Production Complex, Moscow (D.O., E.M.)
| | | | | | - Deepak L Bhatt
- Heart and Vascular Center, Brigham and Women's Hospital Harvard Medical School, Boston (D.L.B.)
| | | | | | | | | | - Josep Rodes-Cabau
- Quebec Heart & Lung Institute, Laval University, Canada (G.O., L.A., J.R.-C.)
| | - Georg Nickenig
- University Hospital Bonn, Germany (A.S., V.V., B.A.-K., J.W.S., G.N.)
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7
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Glikson M, Wolff R, Hindricks G, Mandrola J, Camm AJ, Lip GYH, Fauchier L, Betts TR, Lewalter T, Saw J, Tzikas A, Sternik L, Nietlispach F, Berti S, Sievert H, Bertog S, Meier B. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion - an update. EUROINTERVENTION 2020; 15:1133-1180. [PMID: 31474583 DOI: 10.4244/eijy19m08_01] [Citation(s) in RCA: 162] [Impact Index Per Article: 40.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michael Glikson
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
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8
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Abstract
Excluding the left atrial appendage in patients with nonvalvular atrial fibrillation is a mechanical way to decrease stroke risk. During endothelialization, the closure device is exposed to circulating blood, which might activate the coagulation cascade. In excessive proportions, possibly resulting in the development of device-related thrombus, requiring a bridging period with optimal antithrombotic treatment. Initial protocol treatment is less suitable for patients with contraindications to anticoagulation. Less intensive antithrombotic regimens investigated suggest safety and efficacy, however further research is required. A tailored treatment, considering bleeding and thromboembolic risk based on patient/procedural characteristics in every patient, is probably the best approach.
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Affiliation(s)
- Moniek Maarse
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands.
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435CM Nieuwegein, The Netherlands; Department of Cardiology, Amsterdam UMC, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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9
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Glikson M, Wolff R, Hindricks G, Mandrola J, Camm AJ, Lip GYH, Fauchier L, Betts TR, Lewalter T, Saw J, Tzikas A, Sternik L, Nietlispach F, Berti S, Sievert H, Bertog S, Meier B, Lenarczyk R, Nielsen-Kudsk JE, Tilz R, Kalarus Z, Boveda S, Deneke T, Heinzel FR, Landmesser U, Hildick-Smith D. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update. Europace 2019; 22:184. [DOI: 10.1093/europace/euz258] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Michael Glikson
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Rafael Wolff
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gerhard Hindricks
- Heartcenter Leipzig at Leipzig University and Leipzig Heart Institute, Department of Electrophysiology, Leipzig, Germany
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Tim R Betts
- Oxford University Hospitals NHS Foundation Trust, Oxford Biomedical Research Centre, Department of Cardiology, Oxford, United Kingdom
| | - Thorsten Lewalter
- Dept. of Cardiology and Intensive Care, Hospital for Internal Medicine Munich South, Munich, Germany
- Dept. of Cardiology, University of Bonn, Bonn, Germany
| | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Apostolos Tzikas
- Structural & Congenital Heart Disease, AHEPA University Hospital & Interbalkan European Medical Center, Thessaloniki, Greece
| | - Leonid Sternik
- Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Fabian Nietlispach
- Cardiovascular Center Zurich, Hirslanden Klinik im Park, Zurich, Switzerland
| | - Sergio Berti
- Heart Hospital-Fondazione C.N.R. Reg. Toscana G. Monasterio, Cardiology Department, Massa, Italy
| | - Horst Sievert
- CardioVascular Center CVC, Cardiology and Angiology, Frankfurt, Germany
- Anglia Ruskin University, Chelmsford, United Kingdom
- University of California San Francisco, San Francisco, CA, USA
- Yunnan Hospital Fuwai, Kunming, China
| | - Stefan Bertog
- CardioVascular Center CVC, Cardiology and Angiology, Frankfurt, Germany
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital Bern, Bern, Switzerland
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10
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Incidence, Prevention, and Management of Periprocedural Complications of Left Atrial Appendage Occlusion. Interv Cardiol Clin 2019. [PMID: 29526292 DOI: 10.1016/j.iccl.2017.12.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Major procedural complications related to left atrial appendage occlusion (LAAO) are relatively infrequent but may be associated with major morbidity and mortality. LAAO operators should be knowledgeable about these potential complications. Prompt recognition and treatment are necessary to avoid rapid deterioration and dire consequences. With stringent guidelines on operator training, competency requirements, and procedural-technical refinements, LAAO can be performed safely with low complication rates. This article focuses on commonly used devices, as well as prevention, treatment, and management of complications of LAOO.
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11
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Limpo B, López-Mínguez JR, Millán-Núñez MV, Fuentes-Cañamero ME, González-Fernández R, Nogales-Asensio JM. Trombosis tardía asociada a dispositivo de cierre percutáneo de orejuela. ¿Es poco frecuente o está infradiagnosticada? Rev Esp Cardiol (Engl Ed) 2018. [DOI: 10.1016/j.recesp.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: 11/28/2022]
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12
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Santangeli P, Epstein AE. Exploring the dark side of left atrial appendage closure devices. J Cardiovasc Electrophysiol 2018; 29:14-16. [DOI: 10.1111/jce.13358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 09/29/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Pasquale Santangeli
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
| | - Andrew E. Epstein
- Electrophysiology Section, Cardiovascular Division; Hospital of the University of Pennsylvania; Philadelphia PA USA
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13
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Limpo B, López-Mínguez JR, Millán-Núñez MV, Fuentes-Cañamero ME, González-Fernández R, Nogales-Asensio JM. Late Thrombosis Associated With Left Atrial Appendage Closure Devices. Is It Rare or Is It Underdiagnosed? ACTA ACUST UNITED AC 2017; 71:767-769. [PMID: 28844829 DOI: 10.1016/j.rec.2017.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/07/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Bruno Limpo
- Servicio de Cardiología, Hospital Universitario Infanta Cristina, Badajoz, Spain
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