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Chang SN, Tsai CF, Lin TT, Chiu FC, Hsu JC, Chua SK, Cheng HL, Ho LT, Huang PS, Chen JJ, Wu CK, Wang YC, Hwang JJ, Tsai CT. Long-term outcomes of left atrial appendage occlusion in patients with atrial fibrillation and end stage renal disease. J Formos Med Assoc 2024; 123:116-122. [PMID: 37394333 DOI: 10.1016/j.jfma.2023.06.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/04/2023] Open
Abstract
OBJECTIVE In patients with atrial fibrillation (AF) and end-stage renal disease (ESRD), oral anticoagulants are contraindicated, and left atrial appendage occlusion (LAAO) is an alternative treatment. However, the efficacy of thromboembolic prevention using LAAO in these patients has rarely been reported in Asian populations. To our knowledge, this is the first long-term LAAO study in patients with AF undergoing dialysis in Asia. METHODS In this study, 310 patients (179 men) with a mean age of 71.3 ± 9.6 years and mean CHA2DS2-VASc 4.2 ± 1.8 were consecutively enrolled at multiple centers in Taiwan. The outcomes of 29 patients with AF and ESRD undergoing dialysis who underwent LAAO were compared to those without ESRD. The primary composite outcomes were stroke, systemic embolization, or death. RESULTS No difference in mean CHADS-VASc score was noted between patients with versus without ESRD (4.1 ± 1.8 vs. 4.6 ± 1.9, p = 0.453). After a mean follow-up of 38 ± 16 months, the composite endpoint was significantly higher in patients with ESRD (hazard ratio, 5.12 [1.4-18.6]; p = 0.013) than in those without ESRD after LAAO therapy. Mortality was also higher in patients with ESRD (hazard ratio, 6.6 [1.1-39.7]; p = 0.038). The stroke rate was numerically higher in patients with versus without ESRD, but the difference was not statistically significant (hazard ratio, 3.2 [0.6-17.7]; p = 0.183). Additionally, ESRD was associated with device-related thrombosis (odds ratio, 6.15; p = 0.047). CONCLUSION Long-term outcomes of LAAO therapy may be less favorable in patients with AF undergoing dialysis, possibly because of the poor condition of patients with ESRD.
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Affiliation(s)
- Sheng-Nan Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Chin-Feng Tsai
- School of Medicine, Chung Shan Medical University; Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taiwan
| | - Ting-Tse Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital Hsin-Chu Branch, Hsin-Chu City, Taiwan
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Jung-Cheng Hsu
- Division of Cardiology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Su-Kiat Chua
- Division of Cardiology, Department of Internal Medicine, Shin-Kong Memorial Wu Ho-Su Hospital, Taipei City, Taiwan
| | - Hsiao-Liang Cheng
- Department of Anesthesia, National Taiwan University Hospital, Taipei City, Taiwan
| | - Li-Ting Ho
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, Taiwan.
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Ueno H, Imamura T, Tanaka S, Ushijima R, Fukuda N, Kinugawa K. Initial report of percutaneous left atrial appendage closure in hemodialysis patients with atrial fibrillation and high risk of bleeding in Japan. Cardiovasc Interv Ther 2022:10.1007/s12928-022-00904-9. [PMID: 36562979 DOI: 10.1007/s12928-022-00904-9] [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: 06/25/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022]
Abstract
In the countries like Japan where anticoagulation is not recommended in hemodialysis patients, the feasibility of percutaneous left atrial appendage closure (LAAC) in hemodialysis patients with non-valvular atrial fibrillation (NVAF) accompanying high risks of thromboembolic stroke and bleeding remains unknown. Peri-procedural and 45-day clinical outcomes following LAAC using WATCHMAN system, which were performed in our institute between Jun 2020 and April 2022 according to the Japanese Circulation Society guidelines, were retrospectively compared between those with and without hemodialysis. 118 patients (median 79 years, 81 men) consisting of 25 hemodialysis patients and 93 non-hemodialysis patients were included. CHADS score was 3 (2, 4) in the hemodialysis patients and 3 (2, 4) in the non-hemodialysis patients (p = 0.98). HAS-BREAD score was 4 (3, 5) in the hemodialysis patients and 3 (2, 3) in the non-hemodialysis patients (p < 0.001). All procedures were successful, except for a non-hemodialysis patient with a larger left atrial appendage. There were no major complications during index hospitalization and 45-day observational period, except for a hemodialysis patient with suspected bleeding and a non-hemodialysis patient who died due to cardiac amyloidosis. LAAC seems to be feasible in hemodialysis patients with high risks of thromboembolic events and bleedings.
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Affiliation(s)
- Hiroshi Ueno
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan.
| | - Shuhei Tanaka
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Ryuichi Ushijima
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Nobuyuki Fukuda
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
| | - Koichiro Kinugawa
- The Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama, 930-0194, Japan
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Genovesi S, Porcu L, Slaviero G, Casu G, Bertoli S, Sagone A, Buskermolen M, Pieruzzi F, Rovaris G, Montoli A, Oreglia J, Piccaluga E, Molon G, Gaggiotti M, Ettori F, Gaspardone A, Palumbo R, Viazzi F, Breschi M, Gallieni M, Contaldo G, D'Angelo G, Merella P, Galli F, Rebora P, Valsecchi M, Mazzone P. Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis. J Nephrol 2021; 34:63-73. [PMID: 32535831 PMCID: PMC7881969 DOI: 10.1007/s40620-020-00774-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/06/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND In patients with end stage renal disease and atrial fibrillation (AF), undergoing chronic dialysis, direct oral agents are contraindicated and warfarin does not fully prevent embolic events while increasing the bleeding risk. The high hemorrhagic risk represents the main problem in this population. Aim of the study was to estimate the safety and efficacy for thromboembolic prevention of left atrial appendage (LAA) occlusion in a cohort of dialysis patients with AF and high hemorrhagic risk. METHODS Ninety-two dialysis patients with AF who underwent LAA occlusion were recruited. For comparative purposes, two cohorts of dialysis patients with AF, one taking warfarin (oral anticoagulant therapy, OAT cohort, n = 114) and the other not taking any OAT (no-therapy cohort, n = 148) were included in the study. Primary endpoints were (1) incidence of peri-procedural complications, (2) incidence of 2-year thromboembolic and hemorrhagic events, (3) mortality at 2 years. In order to evaluate the effect of the LAA occlusion on the endpoints with respect to the OAT and No-therapy cohorts, a multivariable Cox regression model was applied adjusted for possible confounding factors. RESULTS The device was successfully implanted in 100% of cases. Two major peri-procedural complications were reported. No thromboembolic events occurred at 2-year follow-up. The adjusted multivariable Cox regression model showed no difference in bleeding risk in the OAT compared to the LAA occlusion cohort in the first 3 months of follow-up [HR 1.65 (95% CI 0.43-6.33)], when most of patients were taking two antiplatelet drugs. In the following 21 months the bleeding incidence became higher in OAT patients [HR 6.48 (95% CI 1.32-31.72)]. Overall mortality was greater in both the OAT [HR 2.76 (95% CI 1.31-5.86)] and No-Therapy [HR 3.09 (95% CI 1.59-5.98)] cohorts compared to LAA occlusion patients. CONCLUSIONS The study could open the way to a non-pharmacological option for thromboembolic protection in dialysis patients with AF and high bleeding risk.
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Affiliation(s)
- Simonetta Genovesi
- Dipartimento di Medicina e Chirurgia-School of Medicine and Surgery, Università di Milano-Bicocca-University of Milano-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy.
- Nephrology Unit, San Gerardo Hospital, Monza, Italy.
| | - Luca Porcu
- Laboratory of Methodology for Clinical Research, Oncology Department, Istituto di Ricerche Farmacologiche IRCCS Mario Negri, Milan, Italy
| | | | - Gavino Casu
- San Francesco Hospital, Nuoro. ATS Sardegna Nuoro, Nuoro, Italy
| | - Silvio Bertoli
- Dialysis and Nephrology Unit-IRCCS-Multimedica, Sesto S.Giovanni, Italy
| | - Antonio Sagone
- Electrophysiology Unit-IRCCS-Multimedica, Sesto S.Giovanni, Italy
| | | | - Federico Pieruzzi
- Dipartimento di Medicina e Chirurgia-School of Medicine and Surgery, Università di Milano-Bicocca-University of Milano-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
- Nephrology Unit, San Gerardo Hospital, Monza, Italy
| | - Giovanni Rovaris
- Interventional Electrophysiology Unit, San Gerardo Hospital, Monza, Italy
| | | | - Jacopo Oreglia
- Interventional Cardiology Unit, Niguarda Hospital, Milan, Italy
| | | | - Giulio Molon
- Cardiology Department, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Mario Gaggiotti
- Nephrology Unit, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | - Federica Ettori
- Cardiology Unit, ASST degli Spedali Civili di Brescia, Brescia, Italy
| | | | | | | | - Marco Breschi
- Cardiology Unit, USL Toscana Sud-Est, Grosseto, Italy
| | - Maurizio Gallieni
- Department of Nephrology and Dialysis, Luigi Sacco Hospital, Milan, Italy
| | - Gina Contaldo
- Dipartimento di Medicina e Chirurgia-School of Medicine and Surgery, Università di Milano-Bicocca-University of Milano-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
| | | | | | - Fabio Galli
- Laboratory of Methodology for Clinical Research, Oncology Department, Istituto di Ricerche Farmacologiche IRCCS Mario Negri, Milan, Italy
| | - Paola Rebora
- Dipartimento di Medicina e Chirurgia-School of Medicine and Surgery, Università di Milano-Bicocca-University of Milano-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
| | - Mariagrazia Valsecchi
- Dipartimento di Medicina e Chirurgia-School of Medicine and Surgery, Università di Milano-Bicocca-University of Milano-Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
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Gotzmann M, Choudhury DS, Hogeweg M, Heringhaus F, Mügge A, Pflaumbaum A. Risk stratification in patients undergoing interventional left atrial appendage occlusion-Prognostic impact of EuroSCORE II. Clin Cardiol 2020; 43:508-515. [PMID: 31967662 PMCID: PMC7244292 DOI: 10.1002/clc.23338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 12/23/2022] Open
Abstract
Background Interventional closure of the left atrial appendage (LAA) is an alternative option to stroke prophylaxis, particularly in multimorbid patients with a high risk of bleeding under oral anticoagulation. Due to the multiple comorbidities, the prognosis of patients is reduced, and the clinical benefit of the procedure is therefore questionable in the individual patient. Hypothesis The present study aims to identify independent preprocedural risk factors to improve risk stratification in these highly selected patients. Methods This study consecutively included 128 patients who received an interventional LAA occlusion with Amplatzer device (St Jude Medical, St Paul, Minnesota). The preinterventional risk assessment was performed with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. The primary endpoint was all‐cause mortality. Secondary endpoints were thromboembolic events and severe bleeding. Results During a follow‐up of 781 ± 498 days the primary endpoint (all‐cause mortality) was reached in 35 patients (27%). The only independent predictor of mid‐term mortality was a logistic EuroSCORE II > 2% (Hazard risk [HR] 4.55, confidence interval [CI] 1.599‐12.966, P = .005). In our study, 33 patients (26%) suffered from end‐stage renal disease which was not associated with increased mortality (P = .371), increased thromboembolic events (P = .475), or severe bleeding (P = .613). Conclusions In patients undergoing interventional LAA occlusion, preprocedural assessment of logistic EuroSCORE II provide independent prognostic information. This parameter might help to improve risk stratification in these highly selected patients. In contrast, terminal renal failure was not associated with a significantly worse outcome.
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Affiliation(s)
- Michael Gotzmann
- Cardiovascular Center, St. Josef Hospital Bochum, Ruhr-University, Bochum, Germany
| | - Dinah S Choudhury
- Department of Cardiology, Marien Hospital Witten, Ruhr University, Bochum, Germany
| | - Maximilian Hogeweg
- Cardiovascular Center, St. Josef Hospital Bochum, Ruhr-University, Bochum, Germany
| | - Florian Heringhaus
- Cardiovascular Center, St. Josef Hospital Bochum, Ruhr-University, Bochum, Germany
| | - Andreas Mügge
- Cardiovascular Center, St. Josef Hospital Bochum, Ruhr-University, Bochum, Germany
| | - Andreas Pflaumbaum
- Department of Cardiology, Marien Hospital Witten, Ruhr University, Bochum, Germany
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