Atrial appendage closure in patients with heart failure and atrial fibrillation: industry-independent single-centre study

Long-term prognosis and prognostic factors after primary prophylactic implantable cardioverter-defibrillator therapy

BACKGROUND

Little is known regarding which patients with ischemic cardiomyopathy (ICM) should be considered for prophylactic therapies, such as an implantable cardioverter-defibrillator (ICD), in the primary percutaneous intervention era. The aim of this study was to investigate the influence of non-sustained ventricular tachycardia (NSVT) on major adverse cardiac events (MACE) in heart failure with reduced ejection fraction (HFrEF) patients.

METHODS

We retrospectively analyzed patients of ICM and non-ICM who underwent ICD implantation at our institute from October 2006 to August 2020. MACE were defined as composite outcome of cardiovascular death, heart failure hospitalization, and appropriate ICD therapies.

RESULTS

A total of 167 patients were enrolled [male, 138 (83 %); age, 62.1 ± 11.7 years; left ventricular ejection fraction, 23.5 ± 6.1 %; left ventricular diastolic diameter, 67.4 ± 9.0 mm; atrial fibrillation, 47 (28 %); NSVT, 124 (74 %); use of class III antiarrhythmic drugs, 55 (33 %); ischemic cardiomyopathy, 56 (34 %); cardiac resynchronization therapy, 73 (44 %)]. The median follow-up duration was 61 months. MACE occurred with 71 patients (43 %). When comparing baseline characteristics of the patients, left ventricular ejection fraction (p = 0.02) and atrial fibrillation (p = 0.04) were significantly associated with MACE. The multivariable Cox analysis for the target variable MACE identified atrial fibrillation (hazard ratio 2.00; 95 % confidence index 1.18-3.37; p = 0.01) as an independent predictor for MACE.

CONCLUSIONS

Prior NSVT before ICD implantation was not an independent predictor of future MACE in patients with HFrEF with primary prophylactic ICD. In contrast, atrial fibrillation was associated with worse prognosis. To predict the prognosis of patients with primary prophylactic ICD, these factors should be assessed as comprehensive risk stratification factors for MACE.

Atrial Fibrillation and Heart Failure With Reduced Ejection Fraction: New Assessment of an Old Problem

Atrial fibrillation (AF) and heart failure (HF)-specifically, heart failure with reduced ejection fraction (HFrEF)-often coexist, and each contributes to the propagation of the other. This relationship extends from the mechanistic and physiological to clinical syndromes, quality of life, and long-term cardiovascular outcomes. The risk factors for AF and HF overlap and create a critical opportunity to prevent adverse outcomes among patients at greatest risk for either condition. Increasing recognition of the linkages between AF and HF have led to widespread interest in designing diagnostic, predictive, and interventional strategies targeting all aspects of disease, from identifying genetic predisposition to addressing social determinants of health. Advances across this spectrum culminated in updated multisociety guidelines for management of AF, which includes specific consideration of comorbid AF and HF. This review expands on these guidelines by further highlighting relevant clinical trial findings and providing additional context for the evolving recommendations for management in this important and growing population.

Safety and effectiveness of left atrial appendage closure in atrial fibrillation patients with different types of heart failure

BACKGROUND

Both atrial fibrillation (AF) and heart failure (HF) are common cardiovascular diseases. If the two exist together, the risk of stroke, hospitalization for HF and all-cause death is increased. Currently, research on left atrial appendage closure (LAAC) in patients with AF and HF is limited and controversial. This study was designed to investigate the safety and effectiveness of LAAC in AF patients with different types of HF.

METHODS

Patients with non-valvular atrial fibrillation (NVAF) and HF who underwent LAAC in the First Affiliated Hospital of Army Medical University from August 2014 to July 2021 were enrolled. According to left ventricular ejection fraction (LVEF), the study divided into HF with reduced ejection fraction (LVEF < 50%, HFrEF) group and HF with preserved ejection fraction (LVEF ≥ 50%, HFpEF) group. The data we collected from patients included: gender, age, comorbid diseases, CHA2DS2-VASc score, HAS-BLED score, NT-proBNP level, residual shunt, cardiac catheterization results, occluder size, postoperative medication regimen, transthoracic echocardiography (TTE) results and transesophageal echocardiography (TEE) results, etc. Patients were followed up for stroke, bleeding, device related thrombus (DRT), pericardial tamponade, hospitalization for HF, and all-cause death within 2 years after surgery. Statistical methods were used to compare the differences in clinical outcome of LAAC in AF patients with different types of HF.

RESULTS

Overall, 288 NVAF patients with HF were enrolled in this study, including 142 males and 146 females. There were 74 patients in the HFrEF group and 214 patients in the HFpEF group. All patients successfully underwent LAAC. The CHA2DS2-VASc score and HAS-BLED score of HFrEF group were lower than those of HFpEF group. A total of 288 LAAC devices were implanted. The average diameter of the occluders was 27.2 ± 3.5 mm in the HFrEF group and 26.8 ± 3.3 mm in the HFpEF group, and there was no statistical difference between the two groups (P = 0.470). Also, there was no statistically significant difference in the occurrence of residual shunts between the two groups as detected by TEE after surgery (P = 0.341). LVEF was significantly higher in HFrEF group at 3 days, 3 months and 1 year after operation than before (P < 0.001). At 45-60 days after surgery, we found DRT in 9 patients and there were 4 patients (5.4%) in HFrEF group and 5 patients (2.3%) in HFpEF group, with no significant difference between the two groups (P = 0.357). One patient with DRT had stroke. The incidence of stroke was 11.1% in patients with DRT and 0.7% in patients without DRT (P = 0.670). There was one case of postoperative pericardial tamponade, which was improved by pericardiocentesis at 24 h after surgery in the HFpEF group, and there was no significant difference between the two groups (P = 1.000). During a mean follow-up period of 49.7 ± 22.4 months, there were no significant differences in the incidence of stroke, bleeding, DRT and HF exacerbation between the two groups. We found a statistical difference in the improvement of HF between HFrEF group and HFpEF group (P < 0.05).

CONCLUSIONS

LAAC is safe and effective in AF patients with different types of HF. The improvement of cardiac function after LAAC is more pronounced in HFrEF group than in HFpEF group.

Prognostic impact of increase in left atrial volume following left atrial appendage closure: Insights from the OCEAN-LAAC registry

Background

Percutaneous left atrial appendage closure (LAAC) is an effective therapy to prevent thromboembolic events among patients with atrial fibrillation (AF). However, since the left atrial appendage (LAA) contributes to left atrial volume and serves as a buffer for increasing left atrial pressure, this procedure may impair left atrium (LA) compliance, enlarge LA, and deteriorate diastolic function. In this study, we sought to investigate the change in left atrial volume index (LAVI) following LAAC and its effect on prognosis.

Methods and Results

We analyzed 225 patients from the OCEAN-LAAC registry, an ongoing, multicenter Japanese study. Comparing LAVI measurements at baseline and 6 months after LAAC, no significant increase was observed (55.0 [44.0, 70.0] ml/m2 vs. 55.0 [42.0, 75.6] ml/m2; P = 0.31). However, some patients underwent LAVI increase. Particularly, a smaller LAVI (odds ratio [OR]: 0.98 [95 % confidence interval (CI): 0.97-0.996]) and elevated tricuspid regurgitation pressure (TRPG) at baseline (OR: 1.04 [95 % CI: 1.00 - 1.08]) were significantly related to the increase in LAVI at 6-month follow-up. In addition, a 5 ml/m2 increase in LAVI was significantly associated with subsequent heart failure hospitalization (HFH) (hazard ratio: 3.37 [95 % CI: 1.18-9.65]). This association, however, was not observed in patients with lower baseline LAVI (≤55 ml/m2) but was only seen in those with a baseline LAVI over 55 ml/m2.

Conclusion

Our study demonstrated an increase in LAVI after LAAC was related to smaller LAVI or elevated TRPG at baseline. The LAVI increase was significantly associated with subsequent HFH.

Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis

Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.

Combined Radiofrequency Ablation and Left Atrial Appendage Closure in Atrial Fibrillation and Systolic Heart Failure

BACKGROUND

Managing patients with atrial fibrillation (AF) and comorbid heart failure (HF) with reduced (HFrEF) or mildly reduced ejection fraction (HFmrEF) is of clinical importance but a great challenge. This study aimed to evaluate the clinical benefit of the combined radiofrequency catheter ablation (RFCA) and left atrial appendage closure (LAAC) procedure in AF patients complicated with systolic HF.

METHODS

AF patients with HFrEF or HFmrEF who underwent the combined RFCA and LAAC procedure were prospectively enrolled in the LAACablation registry. The procedural complications and long-term outcomes were evaluated. Another cohort of AF patients with systolic HF who did not undergo either RFCA or LAAC were used for prognosis comparison.

RESULTS

Among 802 AF patients who underwent the combined procedure, 65 patients were comorbid with systolic HF (25 with HFrEF and 40 with HFmrEF). The overall procedural complication rate was 9.2%, which was mainly attributed to acute decompensated HF (6.2%). Accompanied with markedly reduced AF burden (from median [25th, 75th percentile]: 100 [100, 100] to 0 [0, 1.2]%, p < 0.001), upward trajectories of cardiac function were observed in 51 (78.4%) patients, showing improvement in New York Heart Classification (p < 0.01), natriuretic peptide levels (from 1492 [809, 3259] to 413 [163, 880] pg/mL, p < 0.001) and left ventricular EF (from 42.6 ± 5.3 to 53.8 ± 8.2%, p < 0.001). During the 27-month follow-up period, death, thromboembolism, major bleeding, and HF rehospitalization were observed in three, one, one, and four patients, respectively. The observed event rates showed a significant reduction compared with the non-procedure AF-HF cohort (n = 138; for composite endpoint: hazard ratio: 2.509, 95% confidence interval: 1.415-4.449, p = 0.002) and with the respective rates predicted by risk scores.

CONCLUSIONS

Combining RFCA and LAAC achieves acceptable safety and credible long-term efficacy in AF patients with systolic HF. Further randomized studies are warranted in a larger patient cohort.

A review of the impact, pathophysiology, and management of atrial fibrillation in patients with heart failure with preserved ejection fraction

Patients with heart failure with preserved ejection fraction (HFpEF) and atrial fibrillation (AF) have increased mortality and increased risk of stroke. Due to the heterogeneous nature of both disease processes, it is difficult to ascertain whether the diagnosis and progression of AF is the cause of deterioration or if it is a symptom of worsening heart failure. This presents physicians with a clinical conundrum of whether optimizing their heart failure will decrease the overall AF burden or if restoration of sinus rhythm is necessary to optimize patients with HFpEF. In this paper, we will review the impact of AF in patients with HFpEF, the pathophysiology and heterogeneity of HFpEF and AF, and the management of these patients. As HFpEF and AF become more prevalent, managing these disease processes needs standardization to improve outcomes. Further research is needed to understand the complex interplay between AF and HFpEF to help determine the best management strategy.

Effects of different interventions on prognosis and quality of life in patients with atrial fibrillation

OBJECTIVE

To compare the effects of different intervention measures on prognosis and quality of life in patients with atrial fibrillation, in order to provide clinical basis for diagnosis and treatment.

METHODS

A total of 160 patients who visited several hospitals including Shanghai Xinhua Hospital from June 2019 to June 2021 were selected. Among them, 40 cases were in the drug treatment group (DRUG group), 40 cases in the radiofrequency ablation group (Radiofrequency ablation, RFA group), and 40 cases in the catheter ablation combined with percutaneous left atrial appendage occlusion group (""one-stop"" procedure group) and 40 cases in the percutaneous left atrial appendage closure group (Left atrial appendage closure, LAAC group). The Minnesota quality of life score (MLHFQ), ejection fraction (LVEF), and left atrial anterior and posterior diameters (LAD) were compared between the groups at 1-year follow-up, and the differences in adverse events were compared between the groups.

RESULTS

(1) After a 1-year follow-up, overall comparison, the MLHFQ scores and the LVEF and the LAD among the four groups were statistically different (p < .01); (2) Multiple comparisons, ① the MLHFQ scores: The RFA group was the lowest, the "one-stop" operation group was lower than the DRUG group, the LAAC group was the highest (p < .01). ② LVEF: The RFA group was the highest, the "one-stop" procedure group was higher than the drug treatment group, the LAAC group was the lowest (p < .01). ③ LAD: the RFA group and the "one-stop" procedure group were smaller than the DRUG group, the DRUG group was smaller than the LAAC group (p < .01).(3) Compared with the baseline data after 1-year follow-up in each group, in the RFA group and in the "one-stop" procedure group, the MLHFQ scores was decreased, the LVEF was increased, and the LAD was decreased (p < .01); in the DRUG group: the difference was not statistically significant (p > .05); in the LAAC group, the MLHFQ scores was increased, the LVEF was decreased, and the LAD was increased (p < .01). (4) There were significant differences in the incidence of adverse events among the four groups (p < .01), the lowest in the RFA group and the highest in the LAAC group.

CONCLUSION

Compared with drug treatment, radiofrequency ablation and "one-stop" procedure group can improve the quality of life of patients with atrial fibrillation, improve cardiac function, and reduce the occurrence of adverse events. Percutaneous left atrial appendage occlusion affects patients' quality of life and improves cardiac function, and increases the incidence of adverse events.

Prediction model based on machine learning for short- and long-term adverse events in left atrial appendage closure

Background

At present, the prediction of adverse events (AE) had practical significance in clinic and the accuracy of AE prediction model after left atrial appendage closure (LAAC) needed to be improved. To identify a good prediction model based on machine learning for short- and long-term AE after LAAC.

Methods

In this study, 869 patients were included from the Department of Cardiovascular Medicine of Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital during 2017 and 2021. Univariate and multivariate analyses were conducted for short-term AE after LAAC to determine possible risk factors related with AE. We compared 8 machine learning algorithms for prediction short-term AE, and XGBoost was found to have the best performance. In addition, Cox-regression was used for long-term AE to find out the risk factors and establish a prediction model.

Results

In univariate and multivariate analysis, body mass index (BMI) [odds ratio (OR) =0.91], congestive heart failure, hypertension, age ≥75 years, diabetes, stroke₂ attack (CHADS₂) score (OR =0.49) and bleeding history or predisposition, labile international normalized ratio (INR), elderly, drug/alcohol usage (BLED) score (OR =1.71) were shown to be significant risk factors for short-term AE. The XGbosst algorithm was used to predict short-term AE based on 15 possible risk factors. For long-term AE, Cox regression was used for the prediction. The CHADS₂ score [hazard ratio (HR) =1.43], hypertension (HR =2.18), age more than 75 (HR =0.49), diabetes (HR =0.57), BLED score (HR=0.28), stroke (HR =19.8), hepatopathy (HR =3.97), nephropathy (HR =2.93), INR instability (HR =4.18), drinking (HR =2.67), and drugs (HR =2.36) were significant risk factors for long-term AE. The XGBoost had a good receiver operating characteristic (ROC) curve and area under the curve (AUC) was 0.85. The accuracy of the XGBoost model stayed at nearly 0.95.

Conclusions

In short- and long-term AE, CHADS₂ score and BLED score were the most obvious risk factors. Several other risk factors also played roles in AE of LAAC. The incidence of long-term AE is under 15% and LAAC is effective and safe. The XGBoost model had good prediction accuracy and ROC curve.