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Rajiah PS. Imaging Evaluation Following Transcatheter Left Atrial Appendage Closure. Semin Roentgenol 2024; 59:121-134. [PMID: 38388091 DOI: 10.1053/j.ro.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 02/24/2024]
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Malhotra P. Use of Computed Tomography for Left Atrial Appendage Occlusion Procedure Planning and Post-Procedure Assessment. Interv Cardiol Clin 2024; 13:19-28. [PMID: 37980064 DOI: 10.1016/j.iccl.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an alternative to systemic anticoagulation in patients with non-valvular atrial fibrillation with increased risk for thromboembolic events. Pre- and post-procedural imaging is essential for technical success, allowing practitioners to identify contraindications, select appropriate devices, and recognize procedural complications. Although transesophageal echocardiography has traditionally served as the preeminent imaging modality in LAAO, cardiac computed tomography imaging has emerged as a noninvasive surrogate given its excellent isotropic spatial resolution, multiplanar reconstruction capability, rapid temporal resolution, and large field of view.
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Affiliation(s)
- Pankaj Malhotra
- Department of Imaging, Mark Taper Imaging Center, Cedars Sinai Medical Center, 8700 Beverly Boulevard, Taper M335, Los Angeles, CA 90048, USA; Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, USA.
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Lakkireddy D, Thaler D, Ellis CR, Swarup V, Gambhir A, Hermiller J, Nielsen-Kudsk JE, Worthley S, Nair D, Schmidt B, Horton R, Gupta N, Anderson JA, Gage R, Alkhouli M, Windecker S. 3-Year Outcomes From the Amplatzer Amulet Left Atrial Appendage Occluder Randomized Controlled Trial (Amulet IDE). JACC Cardiovasc Interv 2023; 16:1902-1913. [PMID: 37587599 DOI: 10.1016/j.jcin.2023.06.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND The Amulet (Abbott) left atrial appendage occluder investigational device exemption trial is the largest randomized trial evaluating the safety and effectiveness of the Amulet left atrial appendage occluder compared with the Watchman 2.5 device (Boston Scientific) through 5 years. OBJECTIVES This analysis evaluated the device effect on 3-year outcomes in the Amulet investigational device exemption trial. METHODS The medication regimen and key clinical outcomes were reported through 3 years including: 1) the composite of ischemic stroke or systemic embolism (SE); 2) the composite of all strokes, SE, or cardiovascular (CV) death; 3) major bleeding; and 4) all-cause death and CV death. RESULTS A total of 1,878 patients at 108 sites were randomized. A significantly higher percentage of patients were free of oral anticoagulation usage at 3 years with Amulet (96.2%) vs Watchman (92.5%) (P < 0.01). Clinical outcomes were comparable for the composite of ischemic stroke or SE (5.0% vs 4.6%; P = 0.69); the composite of all strokes, SE, or CV death (11.1% vs 12.7%; P = 0.31); major bleeding (16.1% vs 14.7%; P = 0.46); all-cause death (14.6% vs 17.9%; P = 0.08); and CV death (6.6% vs 8.5%; P = 0.14) for Amulet and Watchman, respectively. Through 3 years, device factors (device-related thrombus or peridevice leak ≥3 mm) preceded ischemic stroke events and CV deaths more frequently in Watchman compared with Amulet patients. CONCLUSIONS The Amulet occluder demonstrated continued safety and effectiveness with over 96% free of oral anticoagulation usage through 3 years in a high-risk population compared to the Watchman device. (AMPLATZER Amulet LAA Occluder Trial [Amulet IDE]; NCT02879448).
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Affiliation(s)
- Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA.
| | - David Thaler
- Tufts Medical Center, Boston, Massachusetts, USA
| | | | - Vijendra Swarup
- Arizona Cardiovascular Research Center, Phoenix, Arizona, USA
| | - Alok Gambhir
- Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | | | | | | | - Devi Nair
- St Bernards Healthcare Cardiology Associates, Batesville, Arizona, USA
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | | | - Nigel Gupta
- Los Angeles Medical Center, Los Angeles, California, USA
| | | | - Ryan Gage
- Abbott Structural Heart, Plymouth, Minnesota, USA
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Lakkireddy D, Nielsen-Kudsk JE, Windecker S, Thaler D, Price MJ, Gambhir A, Gupta N, Koulogiannis K, Marcoff L, Mediratta A, Anderson JA, Gage R, Ellis CR. Mechanisms, predictors, and evolution of severe peri-device leaks with two different left atrial appendage occluders. Europace 2023; 25:euad237. [PMID: 37584233 PMCID: PMC10427960 DOI: 10.1093/europace/euad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023] Open
Abstract
AIMS Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized head-to-head trial comparing the Amulet and Watchman 2.5 LAAO devices with fundamentally different designs. The predictors and mechanistic factors impacting differences in PDLs within the Amulet IDE trial are assessed in the current analysis. METHODS AND RESULTS An independent core lab analysed all images for the presence or absence of severe PDL (>5 mm). The incidence, mechanistic factors, predictors using propensity score-matched controls, and evolution of severe PDLs through 18 months were assessed. Of the 1878 patients randomized in the trial, the Amulet occluder had significantly fewer severe PDLs than the Watchman device at 45 days (1.1 vs. 3.2%, P < 0.001) and 12 months (0.1 vs. 1.1%, P < 0.001). Off-axis deployment or missed lobes were leading mechanistic PDL factors in each device group. Larger left atrial appendage (LAA) dimensions including orifice diameter, landing zone diameter, and depth predicted severe PDL with the Watchman device, with no significant anatomical limitations noted with the Amulet occluder. Procedural and device implant predictors were found with the Amulet occluder attributed to the learning curve with the device. A majority of Watchman device severe PDLs did not resolve over time through 18 months. CONCLUSION The dual-occlusive Amplatzer Amulet LAA occluder provided improved LAA closure compared with the Watchman 2.5 device. Predictors and temporal observations of severe PDLs were identified in the Amulet IDE trial. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov Unique identifier NCT02879448.
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Affiliation(s)
- Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 100th St, Suite-200, Overland Park, KS 66211, USA
| | | | - Stephan Windecker
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Alok Gambhir
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA
| | - Nigel Gupta
- Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Leo Marcoff
- Cardiovascular Core Lab at Morristown Medical Center, Morristown, NJ, USA
| | - Anuj Mediratta
- Cardiovascular Core Lab at Morristown Medical Center, Morristown, NJ, USA
| | | | - Ryan Gage
- Abbott Structural Heart, Plymouth, MN, USA
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Tejman-Yarden S, Freidin D, Nagar N, Parmet Y, Abed M, Vazhgovsky O, Yogev D, Ganchrow BID D, Mazor-Drey E, Chatterji S, Beinart R, Barbash I, Guetta V, Goitein O. Virtual reality utilization for left atrial appendage occluder device size prediction. Heliyon 2023; 9:e14790. [PMID: 37089380 PMCID: PMC10114146 DOI: 10.1016/j.heliyon.2023.e14790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 03/07/2023] [Accepted: 03/16/2023] [Indexed: 04/07/2023] Open
Abstract
Aim To explore the feasibility and accuracy of virtual reality (VR) derived from cardiac computed angiography (CCTA) data to predict left atrial appendage occlusion (LAAO) device size. Method Retrospective data of patients who underwent LAAO according to clinical indication were reviewed; all patients underwent a pre-procedural CCTA. Measurements of the left atrial appendage (LAA) orifice diameters by CCTA, VR, and transesophageal echocardiography (TEE) (acquired during the procedure) were compared to the implanted device size. The LAA perimeter was calculated using the Ramanujan approximation. Statistical analyses included Lin's Concordance Correlation Coefficient (ρ c ), the mean difference, and the mean square error (MSE). Results The sample was composed of 20 patients (mean age 75.7 ± 7.5 years, 60% males) who underwent successful LAAO insertion (ACP™ N = 8, Watchman™ N = 12). The CCTA, VR, and TEE maximal diameter ρ c was 0.52, 0.78 and 0.60, respectively with mean differences of +0.92 ± 4.0 mm, -1.12 ± 2.3 mm, and -3.45 ± 2.69 mm, respectively. The CCTA, VR, and TEE perimeter calculations ρ c were 0.49, 0.54, and 0.39 respectively with mean differences of +4.69 ± 11.5 mm, -9.88 ± 8.0 mm, and -16.79 ± 7.8 respectively. Discussion A VR visualization of the LAA ostium in different perspectives allows for a better understanding of its funnel-shaped structure. VR measurement of the maximal ostium diameter had the strongest correlation with the diameter of the inserted device. VR may thus provide new imaging possibilities for the evaluation of complex pre-procedural structures such as the LAA.
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Kaplan AV, Devellian C, Kim JH, Rotschafer J, Levine A, Sommer RJ, Gray WA. Foam-based Left Atrial Appendage Closure (CLAAS) Device: Evaluation in a Chronic Canine Model. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100555. [PMID: 39129799 PMCID: PMC11308788 DOI: 10.1016/j.jscai.2022.100555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/25/2022] [Accepted: 11/14/2022] [Indexed: 08/13/2024]
Abstract
Background The Conformal Left Atrial Appendage System (CLAAS) is a transcatheter implant designed to occlude the left atrial appendage to prevent stroke in patients with nonvalvular atrial fibrillation. The implant incorporates a novel polyurethane polycarbonate-urea foam matrix to enhance device performance. The objective of this study was to characterize the thrombogenicity, sealing, implant integrity, local tissue response, and systemic toxicity of the implant in a healthy canine model. Methods Devices were evaluated in a chronic canine model using echocardiographic and fluoroscopic guidance (n = 8). Postprocedural echocardiographic evaluation was performed at case completion and at 2, 45, 90, and 150 days. Animals were sacrificed at 90 (n = 4) and 150 (n = 4) days. Necropsy included gross, x-ray, and histologic examination. Results CLAAS implants were implanted in all animals successfully on the basis of fluoroscopic, intracardiac echo, and transthoracic echo criteria. Although 2 animals were noted to have leaks (1 at implantation and 1 at day 90 post procedure before sacrifice), both were of <5 mm. All left atrial appendages were completely sealed on gross examination. No device-related thrombus, pericardial effusion, or evidence of distal organ emboli was observed. All implants maintained their structural integrity and were well integrated within the tissue. There was no histologic evidence of toxicity noted in the downstream organs or tissues. Conclusions The CLAAS implant can be deployed providing a good seal for up to 150 days without signs of local or systemic toxicity in a canine model.
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Affiliation(s)
- Aaron V. Kaplan
- Heart & Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
- Conformal Medical, Inc, Nashua, New Hampshire
| | | | - Jamie H. Kim
- Catholic Medical Center, Manchester, New Hampshire
| | | | - Andy Levine
- Conformal Medical, Inc, Nashua, New Hampshire
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Incidence, Predictors, and Clinical Outcomes of Device-Related Thrombus in the Amulet IDE Trial. JACC Clin Electrophysiol 2023; 9:96-107. [PMID: 36697204 DOI: 10.1016/j.jacep.2022.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Revised: 07/13/2022] [Accepted: 07/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) following left atrial appendage occlusion (LAAO) can lead to adverse clinical outcomes. DRT rates and outcomes from randomized trials are limited. OBJECTIVES This analysis investigated the incidence, predictors, and clinical outcomes of DRT following LAAO in the Amulet IDE (AMPLATZER Amulet LAA Occluder Trial) trial. METHODS Successful implants occurred in 903 patients with an Amulet occluder (dual occlusive mechanism device) and 885 patients with a Watchman device (single occlusive mechanism device). These patients were then followed through 18 months and DRT was assessed by transesophageal echocardiography. RESULTS The overall incidence of DRT was 3.9% (n = 70) with 3.4% (n = 30) in dual occlusive mechanism device patients and 4.8% (n = 40) in single occlusive mechanism device patients. Most DRTs (n = 19 of 31) were identified early (≤45 days) on the dual occlusive mechanism device, whereas most of the DRTs (n = 31 of 42) were identified late (>45 days) on the single occlusive mechanism device. Strong predictors of DRT included atrial fibrillation at time of procedure (HR: 2.44; 95% CI: 1.42-4.22; P < 0.01), female sex (HR: 1.65; 95% CI: 1.01-2.71; P = 0.04), and older age (HR: 1.04; 95% CI: 1.01-1.08; P = 0.02). There were no stroke events following DRT in the dual occlusive mechanism device group and 3 stroke events following DRT in the single occlusive mechanism device group. Patients with DRT were at a greater risk for cardiovascular mortality compared with non-DRT patients (8.7% vs 3.9%; HR: 2.33; 95% CI: 1.01-5.39; P = 0.04). CONCLUSIONS Incidence of DRT following LAAO was low. Early DRTs are seen with the dual occlusive mechanism device and late DRTs are seen with the single occlusive mechanism device. Increased cardiovascular mortality risk in patients with DRT should be further investigated. (AMPLATZER Amulet LAA Occluder Trial; NCT02879448).
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Peridevice Leak After Transcatheter Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2022; 15:2127-2138. [DOI: 10.1016/j.jcin.2022.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/03/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022]
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Alkhouli M, Russo AM, Thaler D, Windecker S, Anderson JA, Gage R, Lakkireddy D. Sex Differences in Safety and Effectiveness of Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2022; 15:2143-2155. [DOI: 10.1016/j.jcin.2022.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/29/2022] [Accepted: 06/29/2022] [Indexed: 11/06/2022]
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Lakkireddy D, Thaler D, Ellis CR, Swarup V, Sondergaard L, Carroll J, Gold MR, Hermiller J, Diener HC, Schmidt B, MacDonald L, Mansour M, Maini B, Anderson JA, Gage R, Windecker S. Outcomes of the roll-in cohort of the Amulet IDE trial of left atrial appendage occlusion. Heart Rhythm O2 2022; 3:493-500. [DOI: 10.1016/j.hroo.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/12/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022] Open
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Gonzalez-Casal D, Datino T, Soto N, González-Panizo J, Sánchez-Quintana D, Macias Y, Cabrera JÁ. Anatomy of the left atrial appendage for the interventional cardiologist. Herzschrittmacherther Elektrophysiol 2022; 33:195-202. [PMID: 35606533 DOI: 10.1007/s00399-022-00866-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
Exact knowledge of the anatomy of the left atrial appendage (LAA) is crucial for LAA isolation by catheter ablation and for interventional LAA occlusion in patients with atrial fibrillation. This review outlines the current anatomical understanding of LAA morphology from ostium to distal lobes, myocardial fiber orientation and wall structure, and adjacent structures such as the left upper pulmonary vein with the Coumadin ridge, the circumflex artery with its side branches, the aortic root, pulmonary artery, and the pericardial space. Insight into these details will facilitate these interventions and reduce the risk of complications.
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Affiliation(s)
- David Gonzalez-Casal
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Tomás Datino
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Nina Soto
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Jorge González-Panizo
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain
| | - Damián Sánchez-Quintana
- Departamento de Anatomía Humana y Biología Celular, Facultad de Medicina, Universidad de Extremadura, Badajoz, Spain
| | - Yolanda Macias
- Departamento de Terapéutica Médica y Quirúrgica, Facultad de Veterinaria, Universidad de Extremadura, Cáceres, Spain
| | - José-Ángel Cabrera
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, Madrid, Spain.
- Departamento de Cardiología, Hospital Universitario Quirón-Salud Madrid and Complejo Hospitalario Ruber Juan Bravo, Universidad Europea de Madrid, CIBER Enfermedades Cardiovasculares (CIBERCV), 1 Diego de Velázquez, Pozuelo de Alarcón, Madrid, Spain.
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Ben H, Changsheng M, Shulin W. 2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:535-555. [PMID: 35032332 PMCID: PMC9314806 DOI: 10.1111/pace.14448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).
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Affiliation(s)
- He Ben
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ma Changsheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wu Shulin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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Lakkireddy D, Thaler D, Ellis CR, Swarup V, Sondergaard L, Carroll J, Gold MR, Hermiller J, Diener HC, Schmidt B, MacDonald L, Mansour M, Maini B, O'Brien L, Windecker S. Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial. Circulation 2021; 144:1543-1552. [PMID: 34459659 PMCID: PMC8570346 DOI: 10.1161/circulationaha.121.057063] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Supplemental Digital Content is available in the text. Percutaneous closure of the left atrial appendage (LAA) is an alternative to chronic oral anticoagulation to reduce stroke risk in patients with nonvalvular atrial fibrillation. The Amulet IDE trial (Amplatzer Amulet Left Atrial Appendage Occluder IDE Trial) was designed to evaluate the safety and effectiveness of the dual-seal mechanism of the Amulet LAA occluder compared with the Watchman device.
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Affiliation(s)
| | | | | | | | | | - John Carroll
- University of Colorado Hospital, Anschultz Medical Campus, Aurora (J.C.)
| | - Michael R Gold
- Medical University of South Carolina, Charleston (M.R.G.)
| | | | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany (B.S.)
| | - Lee MacDonald
- South Denver Cardiology Associates P.C., Littleton, CO (L.M.)
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Collado FMS, Lama von Buchwald CM, Anderson CK, Madan N, Suradi HS, Huang HD, Jneid H, Kavinsky CJ. Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022274. [PMID: 34668395 PMCID: PMC8751840 DOI: 10.1161/jaha.121.022274] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.
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Marroquin L, Tirado-Conte G, Pracoń R, Streb W, Gutierrez H, Boccuzzi G, Arzamendi-Aizpurua D, Cruz-González I, Ruiz-Nodar JM, Kim JS, Freixa X, Lopez-Minguez JR, De Backer O, Ruiz-Salmeron R, Dominguez A, McInerney A, Peral V, Estevez-Loureiro R, Fernandez-Nofrerias E, Freitas-Ferraz AB, Saia F, Huczek Z, Gheorghe L, Salinas P, Demkow M, Delgado-Arana JR, Fernandez Peregrina E, Kalarus Z, Elvira Laffond A, Jang Y, Fernandez Camacho JC, Lee OH, Hernández-Garcia JM, Mas-Llado C, Caneiro Queija B, Amat-Santos IJ, Dabrowski M, Rodés-Cabau J, Nombela Franco L. Management and outcomes of patients with left atrial appendage thrombus prior to percutaneous closure. Heart 2021; 108:1098-1106. [PMID: 34686564 PMCID: PMC9240333 DOI: 10.1136/heartjnl-2021-319811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/27/2021] [Indexed: 12/03/2022] Open
Abstract
Objective Left atrial appendage (LAA) thrombus has heretofore been considered a contraindication to percutaneous LAA closure (LAAC). Data regarding its management are very limited. The aim of this study was to analyse the medical and invasive treatment of patients referred for LAAC in the presence of LAA thrombus. Methods This multicentre observational registry included 126 consecutive patients referred for LAAC with LAA thrombus on preprocedural imaging. Treatment strategies included intensification of antithrombotic therapy (IAT) or direct LAAC. The primary and secondary endpoints were a composite of bleeding, stroke and death at 18 months, and procedural success, respectively. Results IAT was the preferred strategy in 57.9% of patients, with total thrombus resolution observed in 60.3% and 75.3% after initial and subsequent IAT, respectively. Bleeding complications and stroke during IAT occurred in 9.6% and 2.9%, respectively, compared with 3.8% bleeding and no embolic events in the direct LAAC group before the procedure. Procedural success was 90.5% (96.2% vs 86.3% in direct LAAC and IAT group, respectively, p=0.072), without cases of in-hospital thromboembolic complications. The primary endpoint occurred in 29.3% and device-related thrombosis was found in 12.8%, without significant difference according to treatment strategy. Bleeding complications at 18 months occurred in 22.5% vs 10.5% in the IAT and direct LAAC group, respectively (p=0.102). Conclusion In the presence of LAA thrombus, IAT was the initial management strategy in half of our cohort, with initial thrombus resolution in 60% of these, but with a relatively high bleeding rate (~10%). Direct LAAC was feasible, with high procedural success and absence of periprocedural embolic complications. However, a high rate of device-related thrombosis was detected during follow-up.
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Affiliation(s)
- Luis Marroquin
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Gabriela Tirado-Conte
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | - Witold Streb
- Silesian Centre for Heart Disease, Zabrze, Poland
| | | | | | | | | | | | - Jung-Sun Kim
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | - Xavier Freixa
- Cardiology, Hospital Clinic of Barcelona, Barcelona, Spain
| | | | | | | | - Antonio Dominguez
- Cardiology, Hospital Universitario Virgen de la Victoria, Malaga, Spain
| | - Angela McInerney
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Vicente Peral
- Cardiology, Hospital Universitario Son Espases, Health Research Institute of the Balearic Islands (IdISBa), Palma de Mallorca, Spain
| | | | | | | | - Francesco Saia
- Cardiology, University Hospital of Bologna, Bologna, Italy
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Livia Gheorghe
- Cardiology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Pablo Salinas
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Warsaw, Poland
| | | | | | | | - Ana Elvira Laffond
- Cardiology, Hospital Universitario de Salamanca, IBSAL, CIBER CV, Salamanca, Spain
| | - Yangsoo Jang
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | | | - Oh-Hyun Lee
- Severance Cardiovascular Hospital, Yonsei, Korea (the Republic of)
| | | | - Caterina Mas-Llado
- Cardiology, Hospital Universitario Son Espases, Health Research Institute of the Balearic Islands (IdISBa), Palma de Mallorca, Spain
| | | | | | - Maciej Dabrowski
- Interventional Cardiology and Angiology Clinic, National Institute of Cardiology, Warsaw, Poland
| | - Josep Rodés-Cabau
- Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec, Ontario, Canada
| | - Luis Nombela Franco
- Interventional Cardiology. Cardiovascular Institute, Hospital Clinico San Carlos, IdISSC, Madrid, Spain
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Tacher V, Sifaoui I, Kharrat R, Dacher JN, Chevance V, Gallet R, Teiger E, Kobeiter H, Le Pennec V, Jacquier A, Mandry D, Macron L, Derbel H, Deux JF. The use of cardiac computed tomography angiography in the assessment of percutaneous left atrial appendage closure - Review and experts recommendations endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle. Diagn Interv Imaging 2021; 102:586-592. [PMID: 34147390 DOI: 10.1016/j.diii.2021.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022]
Abstract
Atrial fibrillation is the most common cause of arrhythmia which is responsible for over 15% of ischemic strokes, most of these being secondary to migration of a left atrial appendage (LAA) thrombus. In patient with contraindication to anticoagulant therapy, percutaneous closure system placement may be indicated. Cardiac computed tomography (CT) angiography plays a central role in the initial assessment as well as in the follow-up. The purpose of the pre-implantation cardiac CT angiography is to evaluate the anatomy of the LAA in order to select the most suitable prosthesis and check for any contraindication to device implantation. Image analysis is divided into four steps that include analysis of the approach; search for a thrombus in the LAA; investigation of the anatomy of the LAA (morphology of the LAA, dimensions of the LAA and choice of device) and cardiac and thoracic assessments. Follow-up involves CT examination to check for correct placement of the device and to detect any complications. On the basis of the results of currently available published research, a panel of experts has issued recommendations regarding cardiac CT angiography prior to percutaneous LAA closure device placement, which were further endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV).
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Affiliation(s)
- Vania Tacher
- Unité Inserm U955, Équipe 18, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France; Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France.
| | - Islem Sifaoui
- Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Rym Kharrat
- Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Jean-Nicolas Dacher
- Inserm U1096, Department of Radiology, CHU de Rouen, Normandie University, UNIROUEN, 76000 Rouen, France
| | - Virgile Chevance
- Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Romain Gallet
- Unité Inserm U955, Interventional Cardiology Department, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Emmanuel Teiger
- Unité Inserm U955, Interventional Cardiology Department, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Hicham Kobeiter
- Unité Inserm U955, Équipe 18, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France; Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Vincent Le Pennec
- Department of Radiology, University Hospital of Caen, 14118 Caen, France
| | - Alexis Jacquier
- Department of Radiology and Cardiovascular Imaging, UMR 7339, CNRS, CRMBM-CEMEREM (Centre de Résonance Magnétique Biologique et Médicale-Centre d'Exploration Métaboliques par Résonance Magnétique), Aix-Marseille Université, 13000 Marseille, France
| | - Damien Mandry
- Department of Radiology, CHRU Nancy and Université de Lorraine, 54000 Nancy, France
| | - Laurent Macron
- Department of Radiology, Centre Cardiologique du Nord, 93000 Saint-Denis, France
| | - Haytham Derbel
- Unité Inserm U955, Équipe 18, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France; Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
| | - Jean-François Deux
- Unité Inserm U955, Équipe 18, Université Paris Est, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France; Department of Radiology, Hôpital Henri-Mondor, AP-HP, 94010 Créteil, France
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17
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One year outcome and analysis of peri-device leak of left atrial appendage occlusion devices. J Interv Card Electrophysiol 2021; 64:27-34. [PMID: 34002319 DOI: 10.1007/s10840-021-01002-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 04/25/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The prevalence of peri-device leak (PDL) of left atrial appendage occlusion (LAAO) devices has been previously reported. However, there have been only few data that compared different existing devices. The aim of this study was to assess the incidence of PDL with both devices WATCHMAN®, Boston Scientific and AMPLATZER Amulet®, Abbott Laboratories and to evaluate the clinical outcome at 12 months. METHODS Consecutive patients who underwent LAAO between January 2018 and 2020 were randomly assigned to either WATCHMAN or AMPLATZER Amulet implantation based on a systematic 2-week alternation between both devices. LAA measurements were assessed using cardiac computed tomography angiography (CCTA) prior to and transesophageal echocardiography (TEE) during the procedure. At 8 weeks post-LAAO, patients underwent TEE and/or CCTA to identify the presence of PDL and/or device-related complications. Patients were then followed for 12 months to identify major adverse cardiovascular/embolic events. RESULTS The cohort consisted of 51 patients (25 WATCHMAN, 26 AMPLATZER Amulet; mean age 76 ± 7 years; male gender 76%). Both groups were identically matched for demographics, comorbidities, and indication for LAAO. There were 19 patients who had PDL (13 WATCHMAN vs. 6 AMPLATZER Amulet, P-value = 0.033). Of them, 8 (15%) patients had significant PDL (7 WATCHMAN vs. 1 AMPLATZER Amulet, P-value = 0.018). On CCTA, the landing zone maximal diameter of the AMPLATZER Amulet device had the strongest correlation with the final deployed device size (Spearman's rho 0.92, P-value < 0.0001). In the multivariate analysis, male gender and device type were independent predictors of any PDL (P-values 0.016 and 0.031, respectively). On a mean follow-up of 12 months, the total number of events was more prevalent in the WATCHMAN group (P-value 0.008), but the incidence of cardio-embolic events reached borderline significance (16% vs. 0%, P-value = 0.051). CONCLUSIONS Among patients who underwent LAAO, almost 15% had significant PDL with the majority belonging to the WATCHMAN group. Still, larger studies are warranted to evaluate its effectiveness in stroke prevention.
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Rajiah P, Alkhouli M, Thaden J, Foley T, Williamson E, Ranganath P. Pre- and Postprocedural CT of Transcatheter Left Atrial Appendage Closure Devices. Radiographics 2021; 41:680-698. [PMID: 33939541 DOI: 10.1148/rg.2021200136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Transcatheter left atrial appendage (LAA) closure is an alternative to long-term anticoagulation therapy in selected patients with nonvalvular atrial fibrillation who have an increased risk for stroke. LAA closure devices can be implanted by means of either an endocardial or a combined endocardial and epicardial approach. Preprocedural imaging is key to identifying contraindications, accurately sizing the device, and minimizing complications. Transesophageal echocardiography (TEE) has been the reference standard imaging modality to assess the anatomy for LAA closure and to provide intraprocedural guidance. However, CT has emerged as a less-invasive alternative to TEE for pre- and postprocedural imaging. CT is comparable to TEE for exclusion of thrombus but is superior to TEE for the delineation of complex LAA anatomy, measurement for device sizing, and evaluation of pulmonary venous and extracardiac structures. CT provides accurate measurements of the LAA ostial diameter, landing zone diameter, and LAA length, which are vital for accurate sizing of the device. CT allows evaluation of the relationship with the pulmonary veins and other adjacent structures that can be injured during the procedure. CT also simulates procedural fluoroscopic angles and provides evaluation of the interatrial septum, which is punctured during LAA closure. CT also provides a more convenient method for the evaluation of postprocedural complications such as incomplete closure, peridevice leaking, device-related thrombus, and device dislodgement. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Prabhakar Rajiah
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Mohamad Alkhouli
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Jeremy Thaden
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Thomas Foley
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Eric Williamson
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
| | - Praveen Ranganath
- From the Department of Radiology (P. Rajiah, T.F., E.W.) and Department of Cardiology (M.A., J.T.), Mayo Clinic, 200 1st St SW, Rochester, MN 55905; and Department of Radiology, UT Southwestern Medical Center, Dallas, Tex (P. Ranganath)
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19
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Galea R, De Marco F, Aminian A, Meneveau N, Anselme F, Gräni C, Huber AT, Teiger E, Iriart X, Angelillis M, Brugger N, Spirito A, Corpataux N, Franzone A, Vranckx P, Fischer U, Pedrazzini G, Bedogni F, Windecker S, Räber L, Valgimigli M. Design and Rationale of the Swiss-Apero Randomized Clinical Trial: Comparison of Amplatzer Amulet vs Watchman Device in Patients Undergoing Left Atrial Appendage Closure. J Cardiovasc Transl Res 2021; 14:930-940. [PMID: 33884564 DOI: 10.1007/s12265-020-10095-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/16/2020] [Indexed: 12/29/2022]
Abstract
Residual or newly acquired leaks are routinely appraised after left atrial appendage closure (LAAC). The Watchman and the Amulet are the two most frequently used devices for LAAC but no randomized study has so far assessed their comparative leak rates after intervention. The "Comparison of Amplatzer Amulet vs Watchman devices in patients undergoing left atrial appendage closure" (Swiss-Apero, clinicaltrial.gov NCT03399851) is an academic-sponsored multicenter, randomized clinical trial comparing Amulet versus Watchman/FLX devices among patients undergoing a clinically indicated LAAC. The study is designed to assess the superiority of Amulet vs. Watchman/FLX in terms of leaks detected by cardiac computed tomography angiography (CCTA) at 45 days (primary endpoint) and 13 months (secondary endpoint) after intervention by an imaging Core Laboratory. The Swiss-Apero study is the first randomized clinical trial comparing Amulet and Watchman/FLX with respect to the prevalence of post-procedural leak as assessed with CCTA.
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Affiliation(s)
- Roberto Galea
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico De Marco
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Nicolas Meneveau
- Besancon University Hospital, EA3920, University of Burgundy Franche-Comté, Besancon, France
| | - Frederic Anselme
- Department of Cardiology, University Hospital of Rouen, Rouen, France
| | - Christoph Gräni
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian T Huber
- Department of Diagnostic, Interventional and Pediatric Radiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Emmanuel Teiger
- Department of Cardiology, Henri-Mondor Hospital, Public Assistance Hospitals of Paris, Créteil, France
| | - Xavier Iriart
- Department of Pediatric and Adult Congenital Cardiology, Hôpital Cardiologique du Haut- Lévêque, CHU de Bordeaux, Bordeaux-Pessac, France
| | - Marco Angelillis
- Cardiac Thoracic and Vascular Department, University of Pisa, Pisa, Italy
| | - Nicolas Brugger
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Spirito
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Noé Corpataux
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Anna Franzone
- Department of Advanced Biomedical Sciences, University Federico II University, Naples, Italy
| | - Pascal Vranckx
- Department of Cardiology and Critical Care Medicine, Hartcentrum Hasselt, Jessa Ziekenhuis, Hasselt, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Urs Fischer
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giovanni Pedrazzini
- Cardiocentro Ticino, Via Tesserete 48, 6900, Lugano, Switzerland.,Department of Biomedical Sciences, University of Italian Switzerland, 6900, Lugano, Switzerland
| | - Francesco Bedogni
- Department of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland. .,Cardiocentro Ticino, Via Tesserete 48, 6900, Lugano, Switzerland.
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20
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Freeman JV, Varosy P, Price MJ, Slotwiner D, Kusumoto FM, Rammohan C, Kavinsky CJ, Turi ZG, Akar J, Koutras C, Curtis JP, Masoudi FA. The NCDR Left Atrial Appendage Occlusion Registry. J Am Coll Cardiol 2020; 75:1503-1518. [PMID: 32238316 DOI: 10.1016/j.jacc.2019.12.040] [Citation(s) in RCA: 226] [Impact Index Per Article: 56.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 10/31/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) to prevent stroke in patients with atrial fibrillation has been evaluated in 2 randomized trials; post-approval clinical data are limited. OBJECTIVES The purpose of this study was to describe the National Cardiovascular Data Registry (NCDR) LAAO Registry and present patient, hospital, and physician characteristics and in-hospital adverse event rates for Watchman procedures in the United States during its first 3 years. METHODS The authors describe the LAAO Registry structure and governance, the outcome adjudication processes, and the data quality and collection processes. They characterize the patient population, performing hospitals, and in-hospital adverse event rates. RESULTS A total of 38,158 procedures from 495 hospitals performed by 1,318 physicians in the United States were included between January 2016 and December 2018. The mean patient age was 76.1 ± 8.1 years, the mean CHA2DS2-VASc (congestive heart failure, hypertension, 65 years of age and older, diabetes mellitus, previous stroke or transient ischemic attack, vascular disease, 65 to 74 years of age, female) score was 4.6 ± 1.5, and the mean HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly) score was 3.0 ± 1.1. The median annual number of LAAO procedures performed for hospitals was 30 (interquartile range: 18 to 44) and for physicians was 12 (interquartile range: 8 to 20). Procedures were canceled or aborted in 7% of cases; among cases in which a device was deployed, 98.1% were implanted with <5-mm leak. Major in-hospital adverse events occurred in 2.16% of patients; the most common complications were pericardial effusion requiring intervention (1.39%) and major bleeding (1.25%), whereas stroke (0.17%) and death (0.19%) were rare. CONCLUSIONS The LAAO Registry has enrolled >38,000 patients implanted with the device. Patients were generally older with more comorbidities than those enrolled in the pivotal trials; however, major in-hospital adverse event rates were lower than reported in those trials.
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Affiliation(s)
- James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut.
| | - Paul Varosy
- Division of Cardiology, University of Colorado School of Medicine, Denver, Colorado
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California
| | - David Slotwiner
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York
| | - Fred M Kusumoto
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida
| | - Chidambaram Rammohan
- Division of Cardiovascular Medicine, Palo Alto Medical Foundation, El Camino Hospital, Mountain View, California
| | - Clifford J Kavinsky
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois
| | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Joseph Akar
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | | | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado School of Medicine, Denver, Colorado
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21
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Abstract
Ischemic strokes related to atrial fibrillation are highly prevalent, presenting with severe neurologic syndromes and associated with high risk of recurrence. Although advances have been made in both primary and secondary stroke prevention for patients with atrial fibrillation, the long-term risks for stroke recurrence and bleeding complications from antithrombotic treatment remain substantial. We summarize the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focus on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials. Non–vitamin K antagonist oral anticoagulants have been proven to be safer and equally effective compared with warfarin in stroke prevention for patients with nonvalvular atrial fibrillation. Non–vitamin K antagonist oral anticoagulants are being investigated for the treatment of patients with atrial fibrillation and rheumatic heart disease, for the treatment of patients with recent embolic stroke of undetermined source and indirect evidence of cardiac embolism, and in the prevention of vascular-mediated cognitive decline in patients with atrial fibrillation. Multiple clinical trials are assessing the optimal timing of non–vitamin K antagonist oral anticoagulant initiation after a recent ischemic stroke and the benefit:harm ratio of non–vitamin K antagonist oral anticoagulant treatment in patients with atrial fibrillation and history of previous intracranial bleeding. Ongoing trials are addressing the usefulness of left atrial appendage occlusion in both primary and secondary stroke prevention for patients with atrial fibrillation, including those with high risk of bleeding. The additive value of prolonged cardiac monitoring for subclinical atrial fibrillation detection through smartphone applications or implantable cardiac devices, together with the optimal medical management of individuals with covert paroxysmal atrial fibrillation, is a topic of intensive research interest. Colchicine treatment and factor XIa inhibition constitute 2 novel pharmacologic approaches that might provide future treatment options in the secondary prevention of cardioembolic stroke attributable to atrial fibrillation.
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Affiliation(s)
- Aristeidis H Katsanos
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeff S. Healey
- Division of Cardiology, Population Health Research Institute, McMaster University, Hamilton, Canada (J.S.H.)
| | - Robert G. Hart
- Division of Neurology, McMaster University and Population Health Research Institute, Hamilton Health Sciences, Canada (A.H.K., R.G.H.)
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22
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Karki R, Friedman PA, Killu AM. The Future of Percutaneous Epicardial Interventions. Card Electrophysiol Clin 2020; 12:419-430. [PMID: 32771195 DOI: 10.1016/j.ccep.2020.04.007] [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: 01/06/2023]
Abstract
The pericardial space provides a unique vantage point to access different cardiac structures for diagnosis and treatment of arrhythmias and other nonelectrophysiologic conditions, such as heart failure. There have been notable innovations to improve safety of percutaneous pericardial access and its use for various procedures. Percutaneous pericardial device therapies for pacing and defibrillation have been in development, success of which will be a significant advance in treatment of bradyarrhythmias, cardiac resynchronization therapy, and prevention of arrhythmic deaths. There is need for continued efforts in development and expansion of this technique and a systematic approach to monitor efficacy and safety outcomes.
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Affiliation(s)
- Roshan Karki
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street, Rochester, MN 55905, USA. https://twitter.com/roshankarkimd
| | - Paul A Friedman
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street, Rochester, MN 55905, USA. https://twitter.com/drpaulfriedman
| | - Ammar M Killu
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, 200 1st Street, Rochester, MN 55905, USA.
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23
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Diener HC, Landmesser U. Percutaneous left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. FUTURE NEUROLOGY 2020. [DOI: 10.2217/fnl-2020-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Patients with atrial fibrillation (AF) have a fivefold higher risk of stroke than persons in sinus rhythm. Effective stroke prevention is achieved with oral anticoagulants such as vitamin K antagonists or nonvitamin K oral anticoagulants. An alternative for stroke prevention in patients with AF is the closure of the left atrial appendage (LAA) with a percutaneously applied closure system. The two large randomized studies PROTECT-AF and PREVAIL failed to show superiority of LAA closure over anticoagulation in patients with AF. Meta-analyses of studies and registries, however, suggest that LAA closure has particular advantages with regard to the reduction of severe bleeding complications. Currently, several prospective randomized studies are being conducted in different patient populations to evaluate the benefit of LAA closure in comparison to standard of care. Currently, LAA closure is recommended in patients after intracranial hemorrhage, with advanced renal failure, after severe gastrointestinal bleeding, in patients with a high risk of recurrent ischemic stroke and elderly patients with high risk of bleeding and falling.
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Affiliation(s)
- Hans-Christoph Diener
- Institute for Medical Informatics, Biometry & Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Ulf Landmesser
- Department of Cardiology, Campus Benjamin Franklin (CBF), Charité – Universitätsmedizin Berlin, Berlin, Germany; Berlin Institute of Health (BIH), German Center of Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
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24
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Left Atrial Appendage Mechanical Exclusion: Procedural Planning Using Cardiovascular Computed Tomographic Angiography. J Thorac Imaging 2020; 35:W107-W118. [PMID: 32235186 DOI: 10.1097/rti.0000000000000504] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Left atrial appendage (LAA) mechanical exclusion is being investigated for nonpharmacologic stroke risk reduction in selected patients with atrial fibrillation. There are multiple potential approaches in various stages of development and clinical application, each of which depends on specific cardiothoracic anatomic characteristics for optimal performance. Multiple imaging modalities can be utilized for application of this technology, with transesophageal echocardiography used for intraprocedural guidance. Cardiovascular computed tomographic angiography can act as a virtual patient avatar, allowing for the assessment of cardiac structures in the context of surrounding cardiac, coronary vascular, thoracic vascular, and visceral and skeletal anatomy, aiding preprocedural decision-making, planning, and follow-up. Although transesophageal echocardiography is used for intraprocedural guidance, computed tomographic angiography may be a useful adjunct for preprocedure assessment of LAA sizing and anatomic obstacles or contraindications to deployment, aiding in the assessment of optimal approaches. Potential approaches to LAA exclusion include endovascular occlusion, epicardial ligation, primary minimally invasive intercostal thoracotomy with thoracoscopic LAA ligation or appendectomy, and minimally invasive or open closure as part of cardiothoracic surgery for other indications. The goals of these procedures are complete isolation or exclusion of the entire appendage without leaving a residual appendage stump or residual flow with avoidance of acute or chronic damage to surrounding cardiovascular structures. The cardiovascular imager plays an important role in the preprocedural and postprocedural assessment of the patient undergoing LAA exclusion.
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25
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Abstract
PURPOSE OF REVIEW Intracranial hemorrhage remains one of the most feared acute neurological emergencies. However, apart from the acute management, secondary risk factor management and prevention of ischemic events remains ambiguous. We present a thorough review of the current data available regarding management of antithrombotics after intracranial hemorrhage. RECENT FINDINGS The most robust evidence comes from the investigators of the RESTART trial which reassured the safety of resuming antiplatelet therapy after ICH, namely in patients with prior indication and treatment with antithrombotics. We conclude that based on available data, the risk of recurrent ICH is probably too small to exceed the found benefits of antiplatelet therapy in the secondary prevention of ischemic vascular disease.
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