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Rodriguez JF, Pachón-Londoño MJ, Areiza LA, Rodriguez WG. Zero-contrast left atrial appendage closure, a feasible alternative for patients with a high risk of contrast-induced nephropathy: Systematic literature review and meta-analysis. Heart Rhythm 2024:S1547-5271(24)02558-X. [PMID: 38750910 DOI: 10.1016/j.hrthm.2024.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is an alternative to reduce thrombotic risk in patients with nonvalvular atrial fibrillation. This procedure conventionally requires the use of a contrast agent. A significant proportion of patients who undergo this procedure have chronic kidney disease, with a high risk of contrast-induced nephropathy. OBJECTIVE We aimed to systematically review existing literature regarding the feasibility and safety of a zero-contrast LAAC technique. METHODS We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies comparing a zero-contrast LAAC technique with conventional LAAC up to April 2024. From each study, we extracted baseline characteristics, feasibility, and safety outcomes. A random model meta-analysis was used to compare outcomes between groups. RESULTS Five studies reporting data from 367 patients were included. A 100% successful implantation rate was reported in all the zero-contrast groups. The mean number of recaptures reached no significant difference between the groups (mean difference, -0.15; CI, -0.67 to 0.37; I2 = 0%; P = .58). The zero-contrast group had a significantly shorter fluoroscopy time (mean difference, -4.03; CI, -7.72 to -0.34; I2 = 67%; P = .03). Complications related to the procedure, peridevice leak, and device-associated thrombus rates were not significantly different between the groups. CONCLUSION Zero-contrast LAAC is a feasible alternative. The success and complication rates are consistent with those of conventional LAAC. Aside from the inherent benefit of zero-contrast exposure, this technique allows a reduction in fluoroscopy time.
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Affiliation(s)
| | | | - Luis A Areiza
- Hospital Universitario Mayor, Mederi, Bogotá, Colombia
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2
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Flores-Umanzor E, Asghar A, Cepas-Guillén PL, Farrell A, Keshvara R, Alvarez-Rodriguez L, Osten M, Freixa X, Horlick E, Abrahamyan L. Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis. Clin Res Cardiol 2023:10.1007/s00392-023-02359-1. [PMID: 38112741 DOI: 10.1007/s00392-023-02359-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative. OBJECTIVE This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD). METHODS Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies. RESULTS We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade. CONCLUSIONS Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO. Transcatheter Left Atrial Appendage Occlusion (laao) Can Prevent Cardioembolic Events In Chronic Kidney Disease (ckd) Patients. However, Ckd Patients, Particularly Those With End-stage Renal Disease/dialysis (esrd), May Face Increased Odds Of Acute Kidney Injury, In-hospital And Long-term Bleeding, And Mortality. Notably, These Adverse Outcomes In Ckd Patients May Be Linked To Their High Comorbidity Burden, Particularly In Those With Esrd, Rather Than The Laao Procedure Itself. Careful Patient Selection, Management, And Surveillance Involving Multidisciplinary Teams Are Essential For Ckd Patients Undergoing Laao To Ensure Maximum Clinical Benefit Transcatheter left atrial appendage occlusion (LAAO) can prevent cardioembolic events in chronic kidney disease (CKD) patients. However, CKD patients, particularly those with end-stage renal disease/dialysis (ESRD), may face increased odds of acute kidney injury, in-hospital and long-term bleeding, and mortality. Notably, these adverse outcomes in CKD patients may be linked to their high comorbidity burden, particularly in those with ESRD, rather than the LAAO procedure itself. Careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO to ensure maximum clinical benefit.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Areeba Asghar
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Pedro L Cepas-Guillén
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Leyre Alvarez-Rodriguez
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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Liu C, Han S, Cui K, Wang F. Efficacy and safety of patients with chronic kidney disease undergoing left atrial appendage closure for atrial fibrillation. PLoS One 2023; 18:e0287928. [PMID: 37883421 PMCID: PMC10602315 DOI: 10.1371/journal.pone.0287928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND The relative safety and efficacy of left atrial appendage closure (LAAC) for atrial fibrillation (AF) in patients with chronic kidney disease (CKD) have not been well defined. To evaluate the results in this cohort, we conducted a systematic review and meta-analysis of observational studies. METHODS We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to January 2023 for all relevant studies. Our inclusion criteria were met by twelve observational studies that included 61324 patients altogether. RESULTS Compared with no CKD group, in-hospital mortality (OR: 2.84, 95% CI: 2.12-3.81, p<0.01, I2 = 0%), acute kidney injury (AKI) (OR: 4.39,95% CI:4.00-4.83, P<0.01, I2 = 3%), major bleeding events (OR: 1.44, 95% CI: 1.29-1.60, p<0.01 I2 = 0%), and pericardial effusion/tamponade (OR 1.30; 95% CI 1.13-1.51, p < 0.01; I2 = 0%) were more common in the CKD group, especially in patients with end-stage renal disease (ESRD). No significant difference was observed in the occurrence of stroke (OR: 1.24, 95% CI: 0.86-1.78, P = 0.25, I2 = 0%), LAAC success rates (OR: 1.02, 95% CI: 0.33-3.16, p = 0.97, I2 = 58%) and vascular access complications (OR: 1.13, 95% CI: 0.91-1.39, p = 0.28, I2 = 0%) between the two groups. During the follow-up, there was no difference in the risk of stroke between the two groups. CONCLUSIONS CKD patients who receive LAAC have a greater risk of in-hospital mortality, AKI, pericardial effusion/tamponade, and major bleeding events than those without CKD, especially in patients with ESRD. No significant difference in the risk of stroke was found in the long-term follow-up after LAAC between the two groups, demonstrating a similar efficacy of LAAC to prevent stroke in CKD patients.
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Affiliation(s)
- Chaofan Liu
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fang Wang
- Guang’an Shi Zhongyi Yiyuan: Guang’an Hospital of Traditional Chinese Medicine, Beijing, China
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Chakravarty T, Leong D, Bhardwaj N, Slingwine C, Zung L, Friedman J, Berman D, Mondejar P, Rader F, Skaf S, Singh S, Makar M, Makkar RR. Zero-Contrast Percutaneous Left Atrial Appendage Occlusion With WATCHMAN FLX Device. JACC Clin Electrophysiol 2023:S2405-500X(23)00099-3. [PMID: 36951818 DOI: 10.1016/j.jacep.2022.12.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 12/31/2022] [Indexed: 03/24/2023]
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Das S, Lorente-Ros M, Wu L, Mehta D, Suri R. Safety of left atrial appendage closure in heart failure patients. J Cardiovasc Electrophysiol 2022; 33:2578-2584. [PMID: 36125496 DOI: 10.1111/jce.15682] [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: 02/16/2022] [Revised: 08/14/2022] [Accepted: 09/01/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Left atrial appendage closure (LAAC) is an intervention aimed at stroke prevention in nonvalvular atrial fibrillation (AF). There is a three-fold increased risk of stroke in patients with concomitant presence of AF and heart failure (HF). While anticoagulation is effective, only 60% receive it. We aimed at studying the safety of LAAC in HF patients using a national all-payer database. METHODS We queried the National Inpatient Sample for the year 2016-2018 for WATCHMAN device insertion using ICD 10 procedure codes. We divided the study population into HF and non-HF groups. Outcomes were compared using appropriate statistical tests, p< .05 was considered significant. RESULTS 34 385 LAAC procedures were identified of which 8530 (24.8%) were done in patients with HF. The mean (SD) age of the study population was 76 (7.9) years and 42% were female. There was no difference in mean age between HF and non-HF groups. Our findings indicate that there is no difference in inpatient mortality and cardiac complications between the HF and non-HF groups. However, noncardiac complications including acute kidney injury and respiratory failure were higher in the HF group. CONCLUSION LAAC appears to be a safe procedure in patients with HF. The study is limited by a short follow up period and long-term follow-up is required before definitive conclusions can be made.
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Affiliation(s)
- Subrat Das
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Marta Lorente-Ros
- Department of Medicine, Mount Sinai Morningside-West, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lingling Wu
- Divison of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Davendra Mehta
- Department of Cardiology, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ranjit Suri
- Department of Cardiology, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Afzal S, Piayda K, Hellhammer K, Veulemans V, Wolff G, Heidari H, Stüwe D, Kanschik D, Polzin A, Kelm M, Zeus T. Real-time echocardiography-fluoroscopy fusion imaging for left atrial appendage closure: prime time for fusion imaging? Acta Cardiol 2021; 76:1004-1012. [PMID: 33435834 DOI: 10.1080/00015385.2020.1870193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Real-time echocardiography-fluoroscopy fusion imaging (FI) merges real-time echocardiographic imaging with fluoroscopic images allowing intuitive anatomical spatial orientation during structural heart disease interventions. We aimed to assess the safety and efficacy of FI during percutaneous left atrial appendage closure (LAAC). METHODS 34 consecutive patients before (-FI) and 121 patients after (+FI) the introduction of FI for LAAC were included in a single-centre study. In-hospital safety parameters were analysed according to adverse event (AE) definition of the Munich consensus document and procedure-related parameters were assessed for efficacy. An ANCOVA was performed to investigate the influence of a learning curve. RESULTS Time until successful transseptal puncture was significantly reduced as well as total procedure time and the amount of contrast agent used (+FI/-FI:17 ± 6.35 min vs. 22 ± 8.33 min, p = 0.001; +FI/-FI: 50 min IQR 43 min - 60 min vs. 57 min IQR 45 min -70 min; p = 0.013; +FI/-FI: 70 mL, IQR 55 ml-90 mL vs. 152 mL, IQR 107 mL - 205 mL; p < 0.001). However, fluoroscopy time and dose-area product did not differ between both groups. There was no significant difference in the occurrence of in-hospital adverse events (+FI/-FI: 2.5% vs. 0%; p = 0.596). The ANCOVA revealed that the learning curve does not affect procedural efficacy parameters such as procedure time, time to transseptal puncture, amount of contrast agent and dose-area product. CONCLUSIONS FI for LAAC reduces the total procedure time, the time to successful transseptal puncture and periprocedural amount of contrast agent.
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Affiliation(s)
- Shazia Afzal
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Kerstin Piayda
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Katharina Hellhammer
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Verena Veulemans
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Houtan Heidari
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Dominique Stüwe
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Dominika Kanschik
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Amin Polzin
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
- CARID (Cardiovascular Research Institute Düsseldorf), Düsseldorf, Germany
| | - Tobias Zeus
- Division of Cardiology, Pulmonology and Vascular Medicine, University Medical Center Düsseldorf, Düsseldorf, Germany
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Ahuja KR, Ariss RW, Nazir S, Vyas R, Saad AM, Macciocca M, Moukarbel GV. The Association of Chronic Kidney Disease With Outcomes Following Percutaneous Left Atrial Appendage Closure. JACC Cardiovasc Interv 2021; 14:1830-1839. [PMID: 34412801 DOI: 10.1016/j.jcin.2021.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/17/2021] [Accepted: 06/08/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the associations of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with in-hospital and short-term outcomes using a large national database representative of contemporary clinical practice. BACKGROUND CKD and ESRD are associated with increased risk for stroke and bleeding in patients with atrial fibrillation on oral anticoagulation. Left atrial appendage closure (LAAC) may provide a reasonable alternative for these patients; however, the impact of CKD and ESRD on in-hospital and short-term outcomes following LAAC remain largely unknown. METHODS The Nationwide Readmissions Database was used to identify LAAC procedures from 2016 to 2017 in patients with no CKD, CKD (stages I-V), and ESRD. Multivariable logistic regression models were used to assess in-hospital and short-term outcomes. The primary outcome was in-hospital mortality. RESULTS Of 21,274 patients who underwent LAAC during the study period, 3,954 (18.6%) had CKD and 571 (2.7%) had ESRD. ESRD was associated with increased risk for in-hospital mortality compared with no CKD (3.3% vs 0.4%; adjusted odds ratio: 6.48; 95% confidence interval: 3.35-12.50; P < 0.001) and CKD (3.3% vs 0.5%; adjusted odds ratio: 11.43; 95% confidence interval: 4.77-27.39; P < 0.001). CKD was associated with increased risk for in-hospital acute kidney injury or hemodialysis and stroke or transient ischemic attack. ESRD and CKD were associated with increased readmissions extending to 90 days compared with no CKD, and ESRD was associated with increased readmissions compared with CKD. There was no difference with respect to other in-hospital outcomes. CONCLUSIONS ESRD is associated with higher in-hospital mortality, and CKD is associated with higher rates of stroke or transient ischemic attack in patients undergoing LAAC. Further research is needed to assess the impact of CKD and ESRD on long-term outcomes in these patients.
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Affiliation(s)
- Keerat Rai Ahuja
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - Robert W Ariss
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Salik Nazir
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Rohit Vyas
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Anas M Saad
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Macciocca
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - George V Moukarbel
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA.
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Nazir S, Ahuja KR, Ariss RW, Hassanein M, Schurmann P, Koneru S, Afshar H, Giorgberidze I, Moukarbel GV, Jneid H. Association of acute kidney injury with outcomes in patients undergoing percutaneous left atrial appendage closure. Catheter Cardiovasc Interv 2021; 98:E839-E846. [PMID: 33856101 DOI: 10.1002/ccd.29711] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/03/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVES Using a large nationally representative database, we aimed to examine risk factors for acute kidney injury (AKI) and its association with outcomes in patients undergoing percutaneous left atrial appendage closure (LAAC). BACKGROUND Previous small-scale studies have reported poor outcomes with AKI following percutaneous LAAC. METHODS We queried the Nationwide Readmission Database to identify LAAC procedures performed from 2016 to 2017. Multivariable logistic and linear regression models were used to identify risk factors for AKI and determine the association between AKI and clinical outcomes. The primary outcome of interest was in-hospital mortality. RESULTS Of 20,703 patients who underwent LAAC during the study period, 1,097 (5.3%) had a diagnosis of AKI. Chronic kidney disease, non-elective admission, coagulopathy, weight loss, prior coronary artery disease, heart failure, diabetes mellitus, and anemia were independently associated with an increased risk of AKI after LACC. In patients undergoing LAAC, AKI was associated with an increased risk of in-hospital mortality (adjusted odds ratio [aOR], 16.01; 95% CI, 8.48-30.21), stroke/transient ischemic attack (aOR, 2.50; 95% CI, 1.69-3.70), systemic embolization (aOR, 3.78; 95% CI, 1.64-8.70), bleeding/transfusion (aOR, 1.96; 95% CI, 1.50-2.56), vascular complications (aOR, 3.53; 95% CI, 1.94-6.42), pericardial tamponade requiring intervention (aOR, 6.83; 95% CI, 4.37-10.66), index length of stay (adjusted parameter estimate, 7.46; 95% CI, 7.02-7.92), and 180-day all-cause readmissions (aOR, 1.43; 95% CI, 1.09-1.88). CONCLUSION AKI in the setting of LAAC is uncommon but is associated with poor clinical outcomes. Further studies are needed to determine if a similar association exists for long-term outcomes.
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Affiliation(s)
- Salik Nazir
- Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Keerat Rai Ahuja
- Division of Cardiology, Reading Hospital-Tower Health, Reading, Pennsylvania
| | - Robert W Ariss
- Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Mohamed Hassanein
- Section of Nephrology and Hypertension, Cleveland Clinic, Cleveland, Ohio
| | - Paul Schurmann
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Srikanth Koneru
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | - Hamid Afshar
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
| | | | - George V Moukarbel
- Division of Cardiovascular Medicine, University of Toledo Medical Center, Toledo, Ohio
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, Texas
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Fastner C, Brachmann J, Lewalter T, Zeymer U, Sievert H, Borggrefe M, Nienaber CA, Weiß C, Pleger ST, Ince H, Maier J, Achenbach S, Sigusch HH, Hochadel M, Schneider S, Senges J, Akin I. Left atrial appendage closure in patients with chronic kidney disease: results from the German multicentre LAARGE registry. Clin Res Cardiol 2021; 110:12-20. [PMID: 32296971 PMCID: PMC7806558 DOI: 10.1007/s00392-020-01638-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 03/23/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Chronic kidney disease (CKD) is associated with an increased complication rate after cardiac interventions. Although CKD has a high prevalence among atrial fibrillation patients, the impact of CKD on periprocedural complications and the outcome after an interventional left atrial appendage closure (LAAC) is unclear. The present study, therefore, aimed to investigate whether CKD influences the procedure's effectiveness and safety. METHODS LAARGE is a prospective, non-randomised registry. LAAC was conducted with different standard commercial devices, and the follow-up period was one year. CKD was defined by an eGFR < 60 mL/min/1.73 m2, and subgroups were further analysed (i.e. eGFR < 15, 15-29, and 30-59 mL/min/1.73 m2, respectively). RESULTS Two hundred ninety-nine of 623 patients (48.0%) revealed a CKD. The prevalence of cardiovascular comorbidity, CHA2DS2-VASc score (4.9 vs. 4.2), and HAS-BLED score (4.3 vs. 3.5) was significantly higher in CKD patients (each p < 0.001). Implantation success was similarly high across all GFR groups (97.9%). Periprocedural MACCE (0.7 vs. 0.3%), and other major complications (4.7 vs. 3.7%) were comparably infrequent. Survival free of stroke was significantly lower among CKD patients within 1 year (82.0 vs. 93.0%; p < 0.001; consistent after adjustment for confounding factors), without significant accentuation in advanced CKD (i.e. eGFR < 30 mL/min/1.73 m2; p > 0.05 vs. eGFR 30-59 mL/min/1.73 m2). Non-fatal strokes were absolutely infrequent during follow-up (0 vs. 1.1%). Severe non-fatal bleedings were observed only among CKD patients (1.4 vs. 0%; p = 0.021). CONCLUSIONS Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and LAAC was associated with effective stroke prevention across all CKD stages.
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Affiliation(s)
- Christian Fastner
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Johannes Brachmann
- Department of Cardiology, Angiology, and Pneumology, Second Medical Clinic, Coburg Hospital, Coburg, Germany
| | - Thorsten Lewalter
- Department of Medicine, Cardiology, and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
- Anglia Ruskin University, Chelmsford, UK
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christoph A Nienaber
- Cardiology and Aortic Center, Royal Brompton and Harefield NHS Foundation, Trust at Imperial College, London, UK
| | - Christian Weiß
- Department of Cardiology, Klinikum Lüneburg, Lüneburg, Germany
| | - Sven T Pleger
- Department of Internal Medicine III, Cardiology, Angiology, and Pneumology, University Hospital Heidelberg, Heidelberg, Germany
| | - Hüseyin Ince
- Department of Cardiology, Rostock University Medical Center, Rostock, Germany
- Department of Cardiology, Vivantes Klinikum Am Urban & im Friedrichshain, Berlin, Germany
| | - Jens Maier
- Medical Department I, SLK-Kliniken Heilbronn GmbH, Klinikum am Gesundbrunnen, Heilbronn, Germany
| | | | - Holger H Sigusch
- Clinic for Internal Medicine I, Heinrich-Braun-Klinikum Zwickau gGmbH, Zwickau, Deutschland
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Steffen Schneider
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen am Rhein, Germany
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim (UMM), Faculty of Medicine Mannheim, University of Heidelberg, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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Schupp T, Bertsch T, von Zworowsky M, Kim SH, Weidner K, Rusnak J, Barth C, Reiser L, Taton G, Reichelt T, Ellguth D, Engelke N, Bollow A, Akin M, Mashayekhi K, Große Meininghaus D, Borggrefe M, Akin I, Behnes M. Prognostic impact of potassium levels in patients with ventricular tachyarrhythmias. Clin Res Cardiol 2020; 109:1292-1306. [PMID: 32236716 DOI: 10.1007/s00392-020-01624-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/24/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND The study sought to assess the prognostic impact of potassium levels (K) in patients with ventricular tachyarrhythmias. METHODS A large retrospective registry was used including all consecutive patients presenting with ventricular tachyarrhythmias on admission from 2002 to 2016. Patients with hypokalemia (i.e., K < 3.3 mmol/L), normokalemia (i.e., K 3.3-4.5 mmol/L), and hyperkalemia (i.e., K > 4.5 mmol/L) were compared applying multi-variable Cox regression models and propensity-score matching for evaluation of the primary endpoint of all-cause mortality at 3 years. Secondary endpoints were early cardiac death at 24 h, in-hospital death, death at 30 days, as well as the composite endpoint of early cardiac death at 24 h, recurrences of ventricular tachyarrhythmias, and appropriate ICD therapies at 3 years. RESULTS In 1990 consecutive patients with ventricular tachyarrhythmias, 63% of the patients presented with normokalemia, 30% with hyperkalemia, and 7% with hypokalemia. After propensity matching, both hypokalemic (HR = 1.545; 95% CI 0.970-2.459; p = 0.067) and hyperkalemic patients (HR = 1.371; 95% CI 1.094-1.718; p = 0.006) were associated with the primary endpoint of all-cause mortality at 3 years compared to normokalemic patients. Hyperkalemia was associated with even worse prognosis directly compared to hypokalemia (HR = 1.496; 95% CI 1.002-2.233; p = 0.049). In contrast, potassium measurements were not associated with the composite endpoint at 3 years. CONCLUSION In patients presenting with ventricular tachyarrhythmias, normokalemia was associated with best short- and long-term survival, whereas hyperkalemia and hypokalemia were associated with increased mortality at 30 days and at 3 years.
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Affiliation(s)
- Tobias Schupp
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Bertsch
- Institute of Clinical Chemistry, Laboratory Medicine and Transfusion Medicine, General Hospital Nuremberg, Paracelsus Medical University, Nuremberg, Germany
| | - Max von Zworowsky
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Seung-Hyun Kim
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Kathrin Weidner
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Jonas Rusnak
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Christian Barth
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Linda Reiser
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Gabriel Taton
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Thomas Reichelt
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Dominik Ellguth
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Niko Engelke
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Armin Bollow
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Muharrem Akin
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Kambis Mashayekhi
- Department of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany
| | | | - Martin Borggrefe
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany.
| | - Michael Behnes
- Department of Medicine, Faculty of Medicine Mannheim, European Center for AngioScience (ECAS), and DZHK (German Center for Cardiovascular Research) partner site, University Medical Centre Mannheim (UMM), University of Heidelberg, Heidelberg/Mannheim, Mannheim, Germany
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Percutaneous left atrial appendage closure using the TrueFusion™ fusion-imaging technology. Clin Res Cardiol 2019; 109:646-648. [PMID: 31686210 DOI: 10.1007/s00392-019-01566-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 10/23/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To describe percutaneous left atrial appendage closure (LAAc) in a patient with recurrent gastric ulcer bleeding with the help of the TrueFusion™ fusion-imaging system. METHOD AND RESULTS In a patient with paroxysmal atrial fibrillation, the need for an effective oral anticoagulation and recurrent gastrointestinal bleeding, left atrial appendage closure (LAAc) was performed under guidance of the TrueFusion™ fusion-imaging technology (Siemens Healthineers, Erlangen, Germany) to enhance procedural precision, save radiation time and contrast dye. Left atrial appendage closure was performed with the use of a 20 mm Amplatzer Amulet™ (Abbott Laboratories, Chicago, IL, USA) using the TrueFusion™ system under mild sedation with minimal use of contrast. Intraprocedural transesophageal echocardiography revealed complete LAA occlusion without residual flow. The patient was uneventfully discharged on the second postoperative day. CONCLUSION LAAc using an integrated approach combining ultrasound and live fluoroscopy, as provided by the TrueFusion™, is safe and feasible. Target-oriented device navigation and synchronized image orientation as provided by fusion imaging may potentially be beneficial regarding radiation time, contrast dye and periprocedural risk of suboptimal device positioning.
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