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Continisio S, Montonati C, Angelini F, Bocchino PP, Carbonaro C, Giacobbe F, Dusi V, De Filippo O, Ielasi A, Giannino G, Boldi E, Fabris T, D'Ascenzo F, De Ferrari GM, Tarantini G. Single versus dual antiplatelet therapy following percutaneous left atrial appendage closure-A systematic review and meta-analysis. Eur J Clin Invest 2024; 54:e14209. [PMID: 38597271 DOI: 10.1111/eci.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND In the last few years, percutaneous LAA occlusion (LAAO) has become a plausible alternative in atrial fibrillation (AF) patients with contraindications to anticoagulation therapy. Nevertheless, the optimal antiplatelet strategy following percutaneous LAAO remains to be defined. METHODS Studies comparing single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) following LAAO were systematically searched and screened. The outcomes of interest were ischemic stroke, device-related thrombus (DRT) and major bleeding. A random-effect meta-analysis was performed comparing outcomes in both groups. The moderator effect of baseline characteristics on outcomes was evaluated by univariate meta-regression analyses. RESULTS Sixteen observational studies with 3255 patients treated with antiplatelet therapy (SAPT, n = 1033; DAPT, n = 2222) after LAAO were included. Mean age was 74.5 ± 8.3 years, mean CHA2DS2-VASc and HAS-BLED scores were 4.3 ± 1.5 and 3.2 ± 1.0, respectively. At a weighted mean follow-up of 12.7 months, the occurrence of stroke (RR 1.33; 95% CI 0.64-2.77; p =.44), DRT (RR 1.52; 95% CI 0.90-2.58; p =.12), and the composite of stroke and DRT (RR 1.26; 95% CI 0.67-2.37; p =.47) did not differ significantly between SAPT and DAPT groups. The rate of major bleedings was also not different between groups (RR 1.41; 95% CI 0.64-3.12; p =.39). CONCLUSIONS Among AF patients at high bleeding risk undergoing percutaneous LAAO, a post-procedural minimalistic antiplatelet strategy with SAPT did not significantly differ from DAPT regimens regarding the rate of stroke, DRT and major bleeding.
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Affiliation(s)
- Saverio Continisio
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Carolina Montonati
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Carla Carbonaro
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | | | - Emiliano Boldi
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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Samaras A, Papazoglou AS, Balomenakis C, Bekiaridou A, Moysidis DV, Patsiou V, Orfanidis A, Giannakoulas G, Kassimis G, Fragakis N, Saw J, Landmesser U, Alkhouli MA, Tzikas A. Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis. Eur Heart J 2024; 45:214-229. [PMID: 38088437 DOI: 10.1093/eurheartj/ehad828] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/02/2023] [Accepted: 10/19/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND AND AIMS Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion. METHODS A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks. RESULTS Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively). CONCLUSIONS Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.
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Affiliation(s)
- Athanasios Samaras
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Andreas S Papazoglou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Balomenakis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Dimitrios V Moysidis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Orfanidis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | | | - Apostolos Tzikas
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- European Interbalkan Medical Center, Department of Cardiology, Asklipiou 10, Pylaia, Thessaloniki 57001, Greece
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Iriart X, Blanc G, Bouteiller XP, Legghe B, Bouyer B, Sridi-Cheniti S, Bustin A, Vasile C, Thambo JB, Elbaz M, Cochet H. Clinical Implications of CT-detected Hypoattenuation Thickening on Left Atrial Appendage Occlusion Devices. Radiology 2023; 308:e230462. [PMID: 37668517 DOI: 10.1148/radiol.230462] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
Background At follow-up CT after left atrial appendage occlusion (LAAO), hypoattenuation thickening (HAT) on the atrial aspect of the device is a common finding but the clinical implications require further study. Purpose To assess the association of HAT grade at follow-up CT with clinical characteristics and outcomes in patients who underwent LAAO. Materials and Methods This prospective study included consecutive participants with atrial fibrillation and who were at high risk for stroke (CHA2DS2-VASc score ≥4) who underwent LAAO and were administered pacifier or nonpacifier devices at two French medical centers between January 2012 and November 2020. Postprocedure CT images were evaluated by two radiologists in consensus and device-specific interpretation algorithms were applied to classify HAT as low grade (low suspicion of thrombosis) or high grade (high suspicion of thrombosis). The association between HAT grade and clinical characteristics was assessed using multinomial logistic regression, and variables associated with risk of stroke were assessed using a Cox proportional hazard model. Results This study included 412 participants (mean age, 76 years ± 8 [SD]; 284 male participants) who underwent follow-up CT at a mean of 4.2 months ± 1.7 after LAAO. Low-grade and high-grade HAT were depicted in 98 of 412 (23.8%) and 21 of 412 (5.1%) participants, respectively. High-grade HAT was associated with higher odds of antithrombotic drug discontinuation during follow-up (odds ratio, 9.5; 95% CI: 3.1, 29.1; P < .001), whereas low-grade HAT was associated with lower odds of persisting left atrial appendage patency (odds ratio, 0.46; 95% CI: 0.27, 0.79; P = .005). During a median follow-up of 17 months (IQR, 11-41 months), stroke occurred in 24 of 412 (5.8%) participants. High-grade HAT was associated with stroke (hazard ratio, 4.6; 95% CI: 1.5, 14.0; P = .008) and low-grade HAT (P = .62) was not. Conclusion Low-grade HAT was a more common finding at CT performed after LAAO CT (24%) than was high-grade HAT (5%), but it was associated with more favorable outcomes than high-grade HAT, which was associated with higher stroke risk. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Choe in this issue.
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Affiliation(s)
- Xavier Iriart
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Gregoire Blanc
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Xavier Paul Bouteiller
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Benoit Legghe
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Benjamin Bouyer
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Soumaya Sridi-Cheniti
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Aurélien Bustin
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Corina Vasile
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Jean-Benoit Thambo
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Meyer Elbaz
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Hubert Cochet
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
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Wang LM, Chen Y, Xu LL, Dai MF, Ke YJ, Wang BY, Zhou L, Zhang JF, Wu ZQ, Zhou YJ, Gu ZC, Xu H. Short-term antithrombotic strategies after left atrial appendage occlusion: a systematic review and network meta-analysis. Front Pharmacol 2023; 14:1159857. [PMID: 37719867 PMCID: PMC10502722 DOI: 10.3389/fphar.2023.1159857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Background: Percutaneous left atrial appendage occlusion (LAAO) has emerged as a stroke prevention strategy in patients with nonvalvular atrial fibrillation (NVAF), and these patients were required to receive antithrombotic therapy post-procedure. However, the optimal antithrombotic strategy after LAAO remains controversial. This study explored the safety and efficacy of different antithrombotic strategies after LAAO through a network comparison method. Methods: We systematically searched the MEDLINE, Embase, and Cochrane Library databases for studies that reported the interested efficacy and safety outcomes (stroke, device-related thrombus (DRT), and major bleeding) of different antithrombotic strategies [DAPT (dual antiplatelet therapy), DOACs (direct oral anticoagulants), and VKA (vitamin k antagonist)] in patients who had experienced LAAO. Pairwise comparisons and network meta-analysis were performed for the interested outcomes. Risk ratios (RRs) with their confidence intervals (CIs) were calculated using a random-effects model. The rank of the different strategies was calculated using the surface under the cumulative ranking curve (SUCRA). Results: Finally, 10 observational studies involving 1,674 patients were included. There was no significant difference in stroke, DRT, and major bleeding among the different antithrombotic strategies (DAPT, DOACs, and VKA). Furthermore, DAPT ranked the worst in terms of stroke (SUCRA: 19.8%), DRT (SUCRA: 3.6%), and major bleeding (SUCRA: 6.6%). VKA appeared to be superior to DOACs in terms of stroke (SUCRA: 74.9% vs. 55.3%) and DRT (SUCRA: 82.3% vs. 64.1%) while being slightly inferior to DOACs in terms of major bleeding (SUCRA: 71.0% vs. 72.4%). Conclusion: No significant difference was found among patients receiving DAPT, DOACs, and VKA in terms of stroke, DRT, and major bleeding events after LAAO. The SUCRA indicated that DAPT was ranked the worst among all antithrombotic strategies due to the higher risk of stroke, DRT, and major bleeding events, while VKAs were ranked the preferred antithrombotic strategy. However, DOACs are worthy of consideration due to their advantage of convenience.
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Affiliation(s)
- Li-Man Wang
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yan Chen
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Li-Li Xu
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Meng-Fei Dai
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yi-Jun Ke
- Department of Pharmacy, Anqing Municipal Hospital, Affiliated with Anhui Medical University, Anqing, China
| | - Bao-Yan Wang
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
| | - Lin Zhou
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
| | | | - Zhang-Qi Wu
- Nanjing Jinling High School International Department, Nanjing, China
| | - Yu-Jie Zhou
- Department of Respiratory and Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hang Xu
- Department of Pharmacy, China Pharmaceutical University Nanjing Drum Tower Hospital, Nanjing, China
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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Holmes DR, Korsholm K, Rodés-Cabau J, Saw J, Berti S, Alkhouli MA. Left atrial appendage occlusion. EUROINTERVENTION 2023; 18:e1038-e1065. [PMID: 36760206 PMCID: PMC9909459 DOI: 10.4244/eij-d-22-00627] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/03/2022] [Indexed: 02/08/2023]
Abstract
Prevention of stroke represents a goal of primary importance in health systems due to its associated morbidity and mortality. As several patient groups with increased stroke rates have been identified, multiple approaches have been developed and implemented: oral anticoagulation (OAC) for patients with atrial fibrillation, surgical and percutaneous revascularisation in patients with carotid disease, device closure for patients with patent foramen ovale, and now, left atrial appendage occlusion (LAAO) for selected patients with non-valvular atrial fibrillation (NVAF). The latter group of patients are the focus of this review which evaluates the pathophysiology, selection of patients, procedural performance, outcomes of treatment both during and post-procedure, adjunctive therapy, complications, and longer-term outcomes.
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Affiliation(s)
- David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jacqueline Saw
- Division of Interventional Cardiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Sergio Berti
- Cardiology Unit, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Mohamad A Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
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8
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Branca L, Tomasoni D, Cimino G, Cersosimo A, Lombardi CM, Chizzola G, Metra M, Adamo M. Impact and predictors of device-related thrombus after percutaneous left atrial appendage closure. J Cardiovasc Med (Hagerstown) 2023; 24:12-19. [PMID: 36440764 DOI: 10.2459/jcm.0000000000001394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Device-related thrombus (DRT) is a known complication occurring in up to 7% of patients undergoing percutaneous left atrial appendage closure (LAAC). Since the target population of LAAC is generally ineligible for oral anticoagulant therapies, DRT raises important concerns. The aim of this review will be to summarize available evidence on DRT after LAAC focusing on its possible impact on outcomes. Recent findings showed a tighter association between DRT and neurological ischemic events. Antithrombotic regimen adopted after LAAC may have a protective effect against DRT. Many patient-related and procedural factors have been identified as possible predictors of DRT. A tailored approach, which takes into account DRT, is needed in the patient selection for LAAC and in the postprocedural follow-up.
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Affiliation(s)
- Luca Branca
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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9
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Ge H, Zhang C, Qiao ZQ, Hao ZY, Li Z, Gu ZC, Jiang LS, He B, Pu J. Risk of device-related thrombosis following short-term oral anticoagulation with low-dose dabigatran versus warfarin after Watchman left atrial appendage occlusion. Sci Prog 2022; 105:368504221113194. [PMID: 35849447 PMCID: PMC10450492 DOI: 10.1177/00368504221113194] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) provides an alternative for poor candidates for long-term oral anticoagulation (OAC). To prevent device-related thrombosis (DRT), OAC should be continued for the first 45 days to allow complete endothelialization post-LAAO implantation. Whereas, evidence is limited on the feasibility and safety of direct oral anticoagulants (DOACs) used after LAAO. METHODS This was a retrospective observational single-center study of AF patients undergoing LAAO with a Watchman device and receiving either low-dose dabigatran (110mg twice daily) or warfarin in the peri- and post-procedural period for 45 days. Transesophageal echocardiography was scheduled to perform at 6 weeks, 6 months, and 12 months after the procedure to assess the stability of the device and to detect DRT. Incidence of thromboembolic and bleeding events were also evaluated during the follow-up period. RESULTS There were a total of 84 patients who successfully underwent Watchman implantation, with 38 patients (45.2%) receiving low-dose dabigatran and 46 patients (54.8%) using warfarin post-LAAO. Peri-procedural complications occurred in 10 patients, with 3 patients in the dabigatran group and 7 patients in the warfarin group (7.9% vs. 15.2%, p = 0.30). During the 12-month follow-up, 1 patient experienced major bleeding and 16 patients suffered minor bleeding in the warfarin group, while 5 patients treated with dabigatran had minor bleeding (34.8% vs. 13.2%, p = 0.02). Besides, 6 DRT (15.8%) were detected in dabigatran groups, and the incidence was higher than in the warfarin group (15.8% vs. 2.2%, p = 0.03). No DRT-related ischemic events were found. CONCLUSIONS This study suggested that short-term low-dose dabigatran (110 mg twice daily) could significantly decrease the risk of bleeding compared with warfarin at the expense of increased risk of DRT post-LAAO. Therefore, low-dose dabigatran should be used with caution for post-implant anticoagulation of LAAO. Further studies are urgently needed on the feasibility and safety of DOACs post-LAAO.
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Affiliation(s)
- Heng Ge
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Qing Qiao
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zi-Yong Hao
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zheng Li
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li-Sheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jun Pu
- Department of Cardiology, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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10
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Labori F, Bonander C, Persson J, Svensson M. Clinical follow-up of left atrial appendage occlusion in patients with atrial fibrillation ineligible of oral anticoagulation treatment-a systematic review and meta-analysis. J Interv Card Electrophysiol 2021; 61:215-225. [PMID: 33580847 PMCID: PMC8324592 DOI: 10.1007/s10840-021-00953-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/01/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE The recommended stroke prevention for patients with atrial fibrillation (AF) and increased risk of ischemic stroke is oral anticoagulation (OAC). Parts of the patient population are not eligible due to contraindication, and percutaneous left atrial occlusion (LAAO) can then be a preventive treatment option. The aim of this systematic review and meta-analysis is to estimate the long-term clinical effectiveness of LAAO as stroke prevention in patients with AF, increased risk of ischemic stroke, and contraindication to OAC. METHODS We performed a systematic review and meta-analysis, using Poisson random effect models, to estimate the incidence rate (events per 100 patient-years) of ischemic stroke, transient ischemic attack, major bleeding, and all-cause death after LAAO treatment. We also calculated the risk reduction of ischemic stroke with LAAO compared with no stroke prevention estimated through a predicted risk in an untreated population (5.5 per 100 patient-years). RESULTS We included 29 observational studies in our meta-analysis, including 7 951 individuals and 12 211 patient-years. The mean CHA2DS2-VASc score among the patients in the included studies is 4.32. The pooled incidence rate of ischemic stroke is 1.38 per 100 patient-years (95% CI 1.08; 1.77). According to a meta-regression model, the estimated incidence rate of ischemic stroke at CHA2DS2-VASc 4 is 1.39 per 100 patient-years. This implies a risk reduction of 74.7% with LAAO compared to predicated risk with no stroke prevention. CONCLUSIONS Our results suggest that LAAO is effective as stroke prevention for patients with AF, increased risk of stroke, and contraindication to oral anticoagulation.
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Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden.
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
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11
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Li SY, Wang J, Hui X, Zhu HJ, Wang BY, Xu H. Meta-analysis of postoperative antithrombotic therapy after left atrial appendage occlusion. J Int Med Res 2020; 48:300060520966478. [PMID: 33249962 PMCID: PMC7708721 DOI: 10.1177/0300060520966478] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective This meta-analysis explored the safety and effectiveness of different anticoagulant regimens after left atrial appendage occlusion (LAAO). Methods Databases, such as PubMed, MEDLINE, EMBASE, Web of Science, and Cochrane Library, were searched to identify eligible studies according to the inclusion criteria. The incidences of events, including device-related thrombus (DRT) formation, stroke, systemic thromboembolism, bleeding, cardiovascular mortality, and all-cause mortality, were analyzed using R version 3.2.3. Results The screening retrieved 32 studies, including 36 study groups and 4,474 patients. The incidence of outcomes after LAAO was calculated via meta-analysis. In the subgroup analysis, the rates of DRT formation, cardiovascular mortality, and all-cause mortality were significantly different among different antithrombotic methods. Single antiplatelet therapy was associated with the highest rate of adverse events, followed by dual antiplatelet therapy (DAPT). Vitamin K antagonists (VKAs) and new oral anticoagulants (NOACs) carried lower rates of adverse events. Conclusions Anticoagulant therapy had better safety and efficacy than antiplatelet therapy. Thus, for patients with nonabsolute anticoagulant contraindications, anticoagulant therapy rather than DAPT should be actively selected. NOACs displayed potential for further development, and these treatments might represent alternatives to VKAs in the future.
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Affiliation(s)
- Shu-Yue Li
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Jiangsu Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Jiangsu Nanjing, China
| | - Juan Wang
- Department of Pharmacy, Xinjiang Yili Friendship Hospital, Xinjiang Yili China
| | - Xiang Hui
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Jiangsu Nanjing, China.,School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Jiangsu Nanjing, China
| | - Huai-Jun Zhu
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Jiangsu Nanjing, China
| | - Bao-Yan Wang
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Jiangsu Nanjing, China
| | - Hang Xu
- Department of Pharmacy, Nanjing Drum Tower Hospital Affiliated to Nanjing University Medical School, Jiangsu Nanjing, China
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12
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Kleinecke C, Gloekler S, Meier B. Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation: an update on patient outcomes. Expert Rev Cardiovasc Ther 2020; 18:517-530. [DOI: 10.1080/14779072.2020.1794820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Caroline Kleinecke
- Cardiology, Internal Medicine Department, Klinikum Lichtenfels, Lichtenfels, Germany
| | - Steffen Gloekler
- Cardiology, Internal Medicine Department, Klinikum Hochrhein, Waldshut-Tiengen, Germany and Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
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13
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Liu XX, Kleinecke C, Busch S, Allakkis W, Mohrez Y, Cheikh-Ibrahim M, Mahnkopf C, Brachmann J, Schnupp S, Gloekler S, Yu J, Ma C. Propensity-matched comparison of antiplatelet versus anticoagulant after left atrial appendage closure with the Watchman. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1242-1251. [PMID: 32779203 DOI: 10.1111/pace.14032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Optimal antithrombotic therapy following left atrial appendage closure (LAAC) with the Watchman occluder remains uncertain. This study retrospectively compared clinical outcomes of a 3-month dual antiplatelet therapy (DAPT group) and a protocol of anticoagulation plus aspirin for 45 days followed by DAPT for 6 months (ACT group) after LAAC with the Watchman device. METHODS Of two Watchman registries (Coburg and Lichtenfels hospitals, Germany), 220 and 304 consecutive patients with successful LAAC were included. Patients in Coburg hospital received DAPT while they received ACT in Lichtenfels. After a 1:1 propensity score matching, 174 (DAPT) versus 174 (ACT) patients were compared by use of the primary efficacy endpoint of thromboembolic events and cardiovascular/unexplained death, the primary safety endpoint of nonprocedural related major bleeding events at follow-up, and the combined hazard endpoint, a composite of all above-mentioned hazards. RESULTS The mean age 77.5 ± 7.2 (DAPT) versus 77.3 ± 7.1 (ACT) years, CHA2 DS2 -VASc score 4.6 ± 1.5 versus 4.7 ± 1.6, and HAS-BLED score 3.3 ± 0.8 versus 3.3 ± 0.8 were similar. After 12 months, the clinical efficacy (13/174, 7.4% [DAPT] vs 11/174, 6.3% [ACT]; hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.38-1.86; P = .66) and safety (6/174, 3.4% vs 8/174, 4.5%; HR, 0.86; 95% CI, 0.29-2.56; P = .79) as well as the combined hazard endpoint (18/174, 10.3% vs 18/174, 10.3%; HR,1.01; 95% CI, 0.53-1.95; P = .97) were comparable. CONCLUSIONS This study suggests comparable efficacy and safety of 3-month DAPT versus 6 weeks ACT plus aspirin following LAAC with the Watchman.
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Affiliation(s)
- Xiao-Xia Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Caroline Kleinecke
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | - Sonia Busch
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | - Wasim Allakkis
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | - Yamen Mohrez
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | | | | | | | | | - Steffen Gloekler
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Jiangtao Yu
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany.,Clinic for General Internal Medicine and Cardiology, Marienhof Katholisches Klinikum, Koblenz. Montabaur, Koblenz, Germany
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
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14
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Osman M, Busu T, Osman K, Khan SU, Daniels M, Holmes DR, Alkhouli M. Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2020; 6:494-506. [PMID: 32439033 PMCID: PMC7988890 DOI: 10.1016/j.jacep.2019.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO). BACKGROUND Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated. METHODS A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model. RESULTS A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices. CONCLUSIONS In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Tatiana Busu
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khansa Osman
- Michigan Health Specialist, Michigan State University, Flint, Michigan, USA
| | - Safi U Khan
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Matthew Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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15
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Pouru JP, Jaakkola S, Lund J, Biancari F, Saraste A, Airaksinen KEJ. Effectiveness of Only Aspirin or Clopidogrel Following Percutaneous Left Atrial Appendage Closure. Am J Cardiol 2019; 124:1894-1899. [PMID: 31668344 DOI: 10.1016/j.amjcard.2019.08.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
Abstract
Percutaneous left atrial appendage closure (LAAC) offers a feasible option for stroke prevention in patients with atrial fibrillation (AF), but the optimal antithrombotic treatment strategy for patients with strict contraindications to oral anticoagulation (OAC) remains uncertain. We sought to evaluate short- and long-term outcome after percutaneous LAAC in these very patients discharged on single antiplatelet therapy (SAPT) alone. All consenting AF patients who underwent LAAC from February 2009 to August 2018 in Turku University Hospital, Finland, were enrolled into a prospectively maintained registry. Only patients discharged on SAPT alone were considered for the present analysis. Patients were prospectively followed up to 5 years. The primary end points were thromboembolic event (stroke, transient ischemic attack, or systemic embolism) and intracranial bleeding. Of the 165 LAAC patients, 81 patients (mean age 75 ± 7 years; 44% women; CHA₂DS₂-VASc 4.8 ± 1.4; HAS-BLED 3.2 ± 0.8) were discharged on SAPT only (77 with aspirin 100 mg) after successful LAAC using Amplatzer devices. The duration of SAPT was ≤6 months in 61 (75%) patients. The most common contraindication to OAC was previous intracranial bleeding in 48 (59%) patients. During a mean follow-up of 2.9 years, there were 6 thromboembolic events (2.7 of 100 patient-years; 73% lower-than-predicted rate of thromboembolism). Eight patients (3.6 of 100 patient-years) had a major bleeding event after discharge, and 4 patients had intracerebral bleeding (1.7 of 100 patient-years). At 6-month landmark analysis, freedom from thromboembolism and intracranial bleeding at 3-year follow-up was similar in those with discontinued and life-long SAPT (95.1% vs 88.9% and 97.6% vs 91.7%, respectively). In conclusion, long-term outcome is satisfactory after LAAC in selected AF patients with strict contraindications to OAC receiving short-term SAPT. However, adverse events are not infrequent during early postoperative months.
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Affiliation(s)
- Jussi-Pekka Pouru
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Samuli Jaakkola
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Juha Lund
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland; Research Unit of Surgery, Anesthesiology and Critical Care, University of Oulu, Oulu, Finland
| | - Antti Saraste
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
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16
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Cochet H, Iriart X, Sridi S, Camaioni C, Corneloup O, Montaudon M, Laurent F, Selmi W, Renou P, Jalal Z, Thambo JB. Left atrial appendage patency and device-related thrombus after percutaneous left atrial appendage occlusion: a computed tomography study. Eur Heart J Cardiovasc Imaging 2019; 19:1351-1361. [PMID: 29415203 DOI: 10.1093/ehjci/jey010] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 01/12/2018] [Indexed: 11/14/2022] Open
Abstract
Aims Transoesophageal echocardiography studies have reported frequent peri-device leaks and device-related thrombi (DRT) after percutaneous left atrial appendage (LAA) occlusion. We assessed the prevalence, characteristics and correlates of leaks and DRT on cardiac computed tomography (CT) after LAA occlusion. Methods and results Consecutive patients underwent cardiac CT before LAA occlusion to assess left atrial (LA) volume, LAA shape, and landing zone diameter. Follow-up CT was performed after >3 months to assess device implantation criteria, device leaks and DRT. CT findings were related to patient and device characteristics, as well as to outcome during follow-up. One-hundred and seventeen patients (age 74 ± 9, 37% women, CHA2DS2VASc 4.4 ± 1.3, and HASBLED 3.5 ± 1.0) were implanted with Amplatzer cardiac plug (ACP)/Amulet (71%) or Watchman (29%). LAA patency was detected in 44% on arterial phase CT images and 69% on venous phase images. The most common leak location was postero-inferior. LAA patency related to LA dilatation, left ventricular ejection fraction impairment, non-chicken wing LAA shape, large landing zone diameter, incomplete device lobe thrombosis, and disc/lobe misalignment in patients with ACP/Amulet. DRT were detected in 19 (16%), most being laminated and of antero-superior location. DRT did not relate to clinical or imaging characteristics nor to implantation criteria, but to total thrombosis of device lobe. Over a mean 13 months follow-up, stroke/transient ischaemic attack occurred in eight patients, unrelated to DRT or LAA patency. Conclusion LAA patency on CT is common after LAA occlusion, particularly on venous phase images. Leaks relate to LA/LAA size at baseline, and device malposition and incomplete thrombosis at follow-up. DRT is also quite common but poorly predicted by patient and device-related factors.
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Affiliation(s)
- Hubert Cochet
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France.,Imaging Research Team, IHU LIRYC, Université de Bordeaux - Inserm U1045, Avenue du Haut Lévêque, Bordeaux-Pessac, France
| | - Xavier Iriart
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Soumaya Sridi
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Claudia Camaioni
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Olivier Corneloup
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Michel Montaudon
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France.,Imaging Research Team, IHU LIRYC, Université de Bordeaux - Inserm U1045, Avenue du Haut Lévêque, Bordeaux-Pessac, France
| | - François Laurent
- Department of Cardiovascular Imaging, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France.,Imaging Research Team, IHU LIRYC, Université de Bordeaux - Inserm U1045, Avenue du Haut Lévêque, Bordeaux-Pessac, France
| | - Wieme Selmi
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Pauline Renou
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Zakaria Jalal
- Imaging Research Team, IHU LIRYC, Université de Bordeaux - Inserm U1045, Avenue du Haut Lévêque, Bordeaux-Pessac, France.,Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
| | - Jean-Benoît Thambo
- Imaging Research Team, IHU LIRYC, Université de Bordeaux - Inserm U1045, Avenue du Haut Lévêque, Bordeaux-Pessac, France.,Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut-Lévêque, CHU de Bordeaux, Avenue de Magellan, Bordeaux-Pessac, France
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17
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Gasperetti A, Fassini G, Tundo F, Zucchetti M, Dessanai M, Tondo C. A left atrial appendage closure combined procedure review: Past, present, and future perspectives. J Cardiovasc Electrophysiol 2019; 30:1345-1351. [PMID: 31042321 DOI: 10.1111/jce.13957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVE Atrial fibrillation (AF) represents the most common cardiac arrhythmia worldwide; it poses a great burden in terms of quality of life reduction and yearly stroke risk. Left atrial appendage closure (LAAC) is a stroke prevention strategy that has been proven a viable alternative to antithrombotic regimens in nonvalvular AF patients. LAAC can be performed as a standalone procedure or alongside a concomitant AF transcatheter ablation, in a procedure known as "Combined procedure". Aim of this study is to summarize the scientific evidence backing this combined strategy. METHODS We reviewed the whole Medline indexed combined procedure literature, to summarize all the combined procedure study data. RESULTS Nine published studies regarding combined procedure were found. Data, aims, and scientific rationales were reported and commented. CONCLUSION LAA combined procedure appears to be a safe and effective procedure; a careful patient selection is necessary to maximize its benefit.
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Affiliation(s)
- Alessio Gasperetti
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Gaetano Fassini
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Fabrizio Tundo
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Martina Zucchetti
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mariantonietta Dessanai
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Claudio Tondo
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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18
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Nusca A, Bressi E, Colaiori I, Miglionico M, Di Sciascio G. Antiplatelet therapy in valvular and structural heart disease interventions. Cardiovasc Diagn Ther 2018; 8:678-693. [PMID: 30498690 DOI: 10.21037/cdt.2018.06.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.
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Affiliation(s)
- Annunziata Nusca
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Edoardo Bressi
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Iginio Colaiori
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Marco Miglionico
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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19
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Dieker W, Behnes M, Fastner C, Sartorius B, Wenke A, Sing-Gill I, El-Battrawy I, Kuschyk J, Papavassiliu T, Hoffmann U, Mashayekhi K, Schoenberg SO, Borggrefe M, Henzler T, Akin I. Impact of left atrial appendage morphology on thrombus formation after successful left atrial appendage occlusion: Assessment with cardiac-computed-tomography. Sci Rep 2018; 8:1670. [PMID: 29374188 PMCID: PMC5786001 DOI: 10.1038/s41598-018-19385-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 12/27/2017] [Indexed: 11/09/2022] Open
Abstract
A standardized imaging algorithm by cardiac computed tomography angiography (cCTA) (LOVE-view) was used in 30 patients to evaluate the influence of different left atrial appendage (LAA) morphologies on development of thrombosis in the LAA 6 months after implantation of an occlusion device (Watchman or Amplatzer-Cardiac-Plug) in patients with non-valvular atrial fibrillation, CHA2DS2-VASc-Score >1 and a contraindication for oral anticoagulation. The distribution of different LAA morphologies was 40% windsock, 17% broccoli and 43% chicken wing type. There was no significant difference in the level of thrombosis regarding LAA morphology or the type of chosen occlusion device. The rates of complete LAA thrombosis was 40% in broccoli type, 33% in windsock and 15% in chicken wing type. Independently of LAA type, 13% had none and 60% incomplete thrombosis. The ratio of density (LA/LAA) was 0.14 in patients with complete thrombosis and 0.67 in those with none or incomplete thrombosis. cCTA and the LOVE-view-imaging-algorithm were shown to be a valuable method for standardized imaging in clinical routine in a greater set of patients. Surprisingly thrombosis of the occluded LAA was still in progress in most cases at 6 months, whereas further studies are needed defining its clinical consequences, especially for the selection of the optimal post-procedural antithrombotic treatment strategy.
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Affiliation(s)
- Wulf Dieker
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Annika Wenke
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ishar Sing-Gill
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jürgen Kuschyk
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Theano Papavassiliu
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Kambis Mashayekhi
- Division of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Centre Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
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20
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Affiliation(s)
- Lluis Asmarats
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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21
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Nietlispach F, Moarof I, Taramasso M, Maisano F, Meier B. Left atrial appendage occlusion. EUROINTERVENTION 2017; 13:AA78-AA84. [DOI: 10.4244/eij-d-17-00412] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Fastner C, Behnes M, Ansari U, El-Battrawy I, Borggrefe M. Interventional Left Atrial Appendage Closure: Focus on Practical Implications. Interv Cardiol 2017. [DOI: 10.5772/67773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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