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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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Mohanty S, Natale A. Reply to the letter from Kataoka et al. J Cardiovasc Electrophysiol 2024. [PMID: 39004812 DOI: 10.1111/jce.16368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 06/28/2024] [Indexed: 07/16/2024]
Affiliation(s)
- Sanghamitra Mohanty
- Division of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Division of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
- Department of interventional electrophysiology, Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Division of Cardiology, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
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Mohanty S, Torlapati PG, La Fazia VM, Kurt M, Gianni C, MacDonald B, Mayedo A, Allison J, Bassiouny M, Gallinghouse GJ, Burkhardt JD, Horton R, Di Biase L, Al-Ahmad A, Natale A. Best anticoagulation strategy with and without appendage occlusion for stroke-prophylaxis in postablation atrial fibrillation patients with cardiac amyloidosis. J Cardiovasc Electrophysiol 2024; 35:1422-1428. [PMID: 38751010 DOI: 10.1111/jce.16308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/29/2024] [Accepted: 05/04/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION Both atrial fibrillation (AF) and amyloidosis increase stroke risk. We evaluated the best anticoagulation strategy in AF patients with coexistent amyloidosis. METHODS Consecutive AF patients with concomitant amyloidosis were divided into two groups based on the postablation stroke-prophylaxis approach; group 1: left atrial appendage occlusion (LAAO) in eligible patients and group 2: oral anticoagulation (OAC). Group 1 patients were further divided into Gr. 1A: LAAO + half-does NOAC (HD-NOAC) for 6 months followed by aspirin 81 mg/day and Gr. 1B: LAAO + HD-NOAC. In group 1 patients, with complete occlusion at the 45-day transesophageal echocardiogram, patients were switched to aspirin, 81 mg/day at 6 months. In case of leak, or dense "smoke" in the left atrium (LA) or enlarged LA, they were placed on long-term half-dose (HD) NOAC. Group 2 patients remained on full-dose NOAC during the whole study period. RESULTS A total of 92 patients were included in the analysis; group 1: 56 and group 2: 36. After the 45-day TEE, 31 patients from group 1 remained on baby-aspirin and 25 on HD NOAC. At 1-year follow-up, four stroke, one TIA and six device-thrombus were reported in group 1A, compared to none in patients in group 1B (5/31 vs. 0/25, p = .03). No bleeding events were reported in group 1, whereas group 2 had five bleeding events (one subdural hematoma, one retinal hemorrhage, and four GI bleedings). Additionally, one stroke was reported in group 2 that happened during brief discontinuation of OAC. CONCLUSION In patients with coexistent AF and amyloidosis, half-dose NOAC following LAAO was observed to be the safest stroke-prophylaxis strategy.
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Affiliation(s)
- Sanghamitra Mohanty
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Prem Geeta Torlapati
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Vincenzo Mirco La Fazia
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Merve Kurt
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
- Department of Internal Medicine, Mount Auburn Hospital, Cambridge, Massachusetts, USA
| | - Carola Gianni
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Bryan MacDonald
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Angel Mayedo
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - John Allison
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Mohamed Bassiouny
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - G Joseph Gallinghouse
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - John D Burkhardt
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Rodney Horton
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Luigi Di Biase
- Department of Electrophysiology, Albert Einstein College of Medicine at Montefiore Hospital, New York, New York, USA
| | - Amin Al-Ahmad
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
- Department of Interventional Electrophysiology, Interventional Electrophysiology, Scripps Clinic, San Diego, California, USA
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
- Department of Biomedicine and Prevention, Division of Cardiology, University of Tor Vergata, Rome, Italy
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Tanaka T, Kawai K, Ellis CR, Srivastava M, Kawakami R, Konishi T, Shiraki T, Sekimoto T, Virmani R, Finn AV. Challenges and advances in device-related thrombus in left atrial appendage occlusion. Future Cardiol 2024:1-16. [PMID: 38948932 DOI: 10.1080/14796678.2024.2363063] [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: 01/03/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO.
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Affiliation(s)
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD 20878, USA
| | | | - Mukta Srivastava
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
| | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD 20878, USA
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
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Yao Y, Li Y, Jin Q, Li X, Zhang X, Lv Q. Perioperative Treatment with Rivaroxaban and Dabigatran on Changes of Coagulation and Platelet Activation Biomarkers following Left Atrial Appendage Closure. Cardiovasc Ther 2024; 2024:4405152. [PMID: 38505191 PMCID: PMC10950400 DOI: 10.1155/2024/4405152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/12/2023] [Accepted: 01/13/2024] [Indexed: 03/21/2024] Open
Abstract
Insufficient data exist regarding the investigation of the impact of novel oral anticoagulants (NOACs) on coagulation activation biomarkers in the context of left atrial appendage closure (LAAC) and device-related thrombosis (DRT). The study was designed to investigate the changes and presence of coagulation activation biomarkers between different antithrombotic strategies following LAAC. A total of 120 nonvalvular atrial fibrillation patients intolerant of long-term anticoagulants, who underwent successful WATCHMAN closure implantation, were enrolled (rivaroxaban, n = 82; dabigatran, n = 38). Blood samples were obtained from left atrium (LA) and left atrial appendage (LAA) during the operation and fasting blood samples on the same day of LAAC and 45 days after discharge. The biochemical indicators, thrombin-antithrombin complex (TAT), soluble P-selectin (sP-selectin), von Willebrand factor (vWF), and CD40 ligand (CD40L), were measured by enzyme-linked immunosorbent assay. The primary endpoints of this study were the efficacy and safety characteristics of different antithrombotic strategies, including DRT incidence, stroke or transient ischemic attack, systemic embolism, and clinical major and nonmajor bleeding complications during the follow-up of 180 days. The results revealed that TAT, vWF, sP-selectin, and CD40L levels in vein were significantly reduced by 2.4% (p = 0.043), 5.0% (p < 0.001), 8.7% (p < 0.001), and 2.5% (p = 0.043) from their baseline levels after rivaroxaban treatment. Conversely, no significant changes were detected in the dabigatran group. Furthermore, the plasma levels of platelet activation biomarkers (CD40L and sP-selectin) in both LA and LAA groups were significantly lower after anticoagulation with rivaroxaban, as compared to dabigatran treatment (CD40L: 554.62 ± 155.54 vs. 445.02 ± 130.04 for LA p = 0.0013, 578.51 ± 156.28 vs. 480.13 ± 164.37 for LAA p = 0.0052; sP-selectin: 2849.07 ± 846.69 vs. 2225.54 ± 799.96 for LA p = 0.0105, 2915.52 ± 1402.40 vs. 2203.41 ± 1061.67 for LAA p = 0.0022). Notably, the present study suggests that rivaroxaban may be more effective in the prevention of DRT for patients undergoing LAAC.
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Affiliation(s)
- Yao Yao
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Yanli Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qinchun Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiaoye Li
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Xiaochun Zhang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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Zhou Q, Liu X, Gu ZC, Yang X, Huang XH, Wu YZ, Tao YY, Wei M. Short-term antiplatelet versus anticoagulant therapy after left atrial appendage closure: a systematic review and meta-analysis. J Thromb Thrombolysis 2024; 57:194-203. [PMID: 38180590 DOI: 10.1007/s11239-023-02919-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/30/2023] [Indexed: 01/06/2024]
Abstract
This meta-analysis compared the efficacy and safety of different antithrombotic regimens after left atrial appendage closure (LAAC). PubMed, Embase, Medline, Cochrane Library databases were systematically searched from their inception to March 2023. Patients were divided into short-term oral anticoagulation (OAC) group and antiplatelet therapy (APT) group. The incidence of events were performed using RevMan 5.4. The events including device-related thrombus (DRT), ischemic stroke/systemic embolization (SE), major bleeding, any bleeding, any major adverse event and all-cause mortality. Subgroup analysis were based on OAC alone or OAC plus single antiplatelet therapy (SAPT) in OAC group. Oral anticoagulants include warfarin and direct oral anticoagulant (DOAC). Fourteen studies with 35,166 patients were included. We found that the incidence of DRT (OR = 0.49, 95% CI 0.36-0.66, P<0.0001) and all-cause mortality (OR = 0.71, 95% CI 0.57-0.89, P = 0.002) were significantly lower in OAC group than APT group. However, there was no statistical differences in the incidence rates of ischemic stroke/SE (OR = 0.77, 95% CI 0.49-1.20, P = 0.25), major bleeding (OR = 0.84, 95% CI 0.55-1.27, P = 0.84), any bleeding (OR = 0.83, 95% CI 0.56-1.22, P = 0.34) and any major adverse event (OR = 0.56, 95% CI 0.30-1.03, P = 0.06) in the two groups. Subgroup analysis found that the incidence of DRT, all-cause mortality and any major adverse event in OAC monotherapy were lower than that in APT group (P<0.05), but not statistically different from other outcome. The incidence of DRT, all-cause mortality, any major adverse event and any bleeding in DOAC were significantly better than APT group (P<0.05). While warfarin only has better incidence of DRT than APT (P<0.05), there was no statistical difference between the two groups in other outcome (P>0.05). The incidence of DRT was significantly lower than APT group (P<0.05), major bleeding were higher, and the rest of the outcome did not show any statistically significant differences(P>0.05) when OAC plus SAPT. Based on the existing data, short-term OAC may be favored over APT for patients who undergo LAAC. DOAC monotherapy may be favored over warfarin monotherapy or OAC plus APT, when selecting anticoagulant therapies.
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Affiliation(s)
- Qiang Zhou
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Xiang Liu
- Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xian Yang
- Department of Pharmacy, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Xiao-Hui Huang
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Yan-Zi Wu
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Ying-Ying Tao
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China
| | - Meng Wei
- Department of Clinical Pharmacy, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, China.
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Kramer A, Patti G, Nielsen-Kudsk JE, Berti S, Korsholm K. Left Atrial Appendage Occlusion and Post-procedural Antithrombotic Management. J Clin Med 2024; 13:803. [PMID: 38337496 PMCID: PMC10856063 DOI: 10.3390/jcm13030803] [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: 01/03/2024] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45-90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 13100 Vercelli, Italy;
- Department of Thoracic and Cardiovascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Sergio Berti
- Department of Interventional and Diagnostic Cardiology, Fondazione CNR-Regione Toscana G, Monasterio, Ospedale del Cuore, 54100 Massa, Italy;
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
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Di Biase L, Lakkireddy DJ, Marazzato J, Velasco A, Diaz JC, Navara R, Chrispin J, Rajagopalan B, Natale A, Mohanty S, Zhang X, Della Rocca D, Dalal A, Park K, Wiley J, Batchelor W, Cheung JW, Dangas G, Mehran R, Romero J. Antithrombotic Therapy for Patients Undergoing Cardiac Electrophysiological and Interventional Procedures: JACC State-of-the-Art Review. J Am Coll Cardiol 2024; 83:82-108. [PMID: 38171713 DOI: 10.1016/j.jacc.2023.09.831] [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: 02/22/2023] [Revised: 08/24/2023] [Accepted: 09/21/2023] [Indexed: 01/05/2024]
Abstract
Electrophysiological and interventional procedures have been increasingly used to reduce morbidity and mortality in patients experiencing cardiovascular diseases. Although antithrombotic therapies are critical to reduce the risk of stroke or other thromboembolic events, they can nonetheless increase the bleeding hazard. This is even more true in an aging population undergoing cardiac procedures in which the combination of oral anticoagulants and antiplatelet therapies would further increase the hemorrhagic risk. Hence, the timing, dose, and combination of antithrombotic therapies should be carefully chosen in each case. However, the maze of society guidelines and consensus documents published so far have progressively led to a hazier scenario in this setting. Aim of this review is to provide-in a single document-a quick, evidenced-based practical summary of the antithrombotic approaches used in different cardiac electrophysiology and interventional procedures to guide the busy clinician and the cardiac proceduralist in their everyday practice.
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Affiliation(s)
- Luigi Di Biase
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA.
| | | | - Jacopo Marazzato
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Alejandro Velasco
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Juan Carlos Diaz
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Rachita Navara
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | | | - Xiaodong Zhang
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Aarti Dalal
- Division of Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ki Park
- Department of Cardiovascular Medicine, University of Florida, Gainesville, Florida, USA
| | - Jose Wiley
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jim W Cheung
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York, USA
| | - George Dangas
- Division of Cardiology, Mount Sinai Medical Center, New York, New York, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jorge Romero
- Cardiac Arrhythmia Center, Division of Cardiology, Department of Medicine, Montefiore-Einstein Center for Heart and Vascular Care, Albert Einstein College of Medicine, Bronx, New York, USA
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Zhou Q, Liu X, Yang X, Huang XH, Wu YZ, Tao YY, Wei M. Effectiveness and safety of short-term anticoagulant regimens after left atrial appendage occlusion: A systematic review and meta-analysis. Thromb Res 2024; 233:88-98. [PMID: 38035647 DOI: 10.1016/j.thromres.2023.10.021] [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: 04/17/2023] [Revised: 10/12/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Left atrial appendage occlusion (LAAO) provides an alternative for poor candidates of long-term oral anticoagulant (OAC) therapy; however, anticoagulant therapy after surgical procedures has limited use due to associated uncertainties. We aimed to evaluate the effectiveness and safety of the short-term use of direct oral anticoagulant (DOAC) and warfarin after LAAO. METHOD Electronic databases such as PubMed, Embase, Medline, and Cochrane Library databases were searched up to November 11, 2022. Our study compared DOAC therapy and warfarin in patients after LAAO. A meta-analysis was conducted with the Review Manager software (version 5.4). RESULTS The meta-analysis included 13 cohort studies with a total of 32,607 patients. Our findings indicated that the incidence of stroke/TIA/SE, peri-device leaks>5 mm, device-related thrombosis, and all-cause mortality were not significantly different between the two groups after LAAO (P > 0.05). The DOAC group had a significantly lower incidence of major bleeding (OR = 0.83, 95 % CI: 0.74-0.94, P = 0.003), any bleeding (OR = 0.34, 95 % CI: 0.23-0.51, P < 0.001), stroke/TIA/SE and major bleeding (OR = 0.57, 95 % CI: 0.34-0.95, P = 0.03), and any major adverse event (OR = 0.89, 95 % CI:0.82-0.97, P = 0.010) than the warfarin group. The subgroup analysis revealed that the rate of stroke/TIA/SE was similar in the two groups in terms of the different regions, follow-up time, study type, anticoagulant strategy, and bleeding risk. The incidence of major bleeding in the DOAC group was significantly lower than that in the warfarin group in North America, as well as at follow-up period ≤6 months, retrospective cohort, HAS-BLED average score ≥ 3. In addition, the risk of major bleeding was higher with the combination of OAC and single antiplatelet therapy (SAPT) than with OAC alone. Finally, in the North American region, retrospective cohort, and HAS-BLED average score ≥ 3, the incidence of any serious adverse event in the DOAC group was still significantly lower than that in the warfarin group. CONCLUSION Compared to warfarin, DOAC reduced the risk of major bleeding and any serious adverse event in patients after LAAO. This advantage was particularly notable in North America and high-risk populations for bleeding. In addition, the incidence of device-related thrombosis, peri-device leaks, stroke/TIA/SE and all-cause mortality were similar in both groups. The risk of major bleeding was lower in patients taking OAC alone compared with those taking OAC plus SAPT, without increasing the risk of thrombosis.
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Affiliation(s)
- Qiang Zhou
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiang Liu
- Department of Pharmacy and Traditional Chinese Pharmacy, Jiangsu College of Nursing, Huaian, China
| | - Xian Yang
- Department of Pharmacy, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xiao-Hui Huang
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yan-Zi Wu
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Ying-Ying Tao
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Meng Wei
- Department of Clinical Pharmacy, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China.
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10
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Carvalho PEP, Gewehr DM, Miyawaki IA, Nogueira A, Felix N, Garot P, Darmon A, Mazzone P, Preda A, Nascimento BR, Kubrusly LF, Cardoso R. Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion. J Am Coll Cardiol 2023; 82:1765-1773. [PMID: 37611779 DOI: 10.1016/j.jacc.2023.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF) remains uncertain. OBJECTIVES In this study, the authors sought to compare the efficacy and safety of various antithrombotic strategies after LAAO. METHODS We searched the Medline, Cochrane, EMBASE, LILACS, and ClinicalTrials.gov databases for studies reporting outcomes after LAAO, stratified by antithrombotic therapy prescribed at postprocedural discharge. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random effects model network meta-analysis to estimate the OR and 95% CI for each comparison. P-scores provided a ranking of treatments. RESULTS Forty-one studies comprising 12,451 patients with nonvalvular AF were included. DAPT, DOAC, DOAC plus SAPT, and VKA were significantly superior to no therapy to prevent device-related thrombosis. DOAC was associated with lower all-cause mortality than VKA (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Compared with SAPT, DAPT was associated with fewer thromboembolic events (OR: 0.50; 95% CI: 0.29-0.88; P = 0.02), without a difference in major bleeding. In the analysis of P-scores, DOAC monotherapy was the strategy most likely to have lower thromboembolic events and major bleeding. CONCLUSIONS In this network meta-analysis comparing initial antithrombotic therapies after LAAO, monotherapy with DOAC had the highest likelihood of lower thromboembolic events and major bleeding. DAPT was associated with a lower incidence of thromboembolic events compared with SAPT and may be a preferred option in patients unable to tolerate anticoagulation.
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Affiliation(s)
- Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Alleh Nogueira
- Department of Medicine, Medical and Public Health School of Bahia, Salvador, Brazil
| | - Nicole Felix
- Department of Medicine, Federal University of Campina Grande, Campina Grande, Brazil
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
| | | | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Bruno R Nascimento
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; Interventional Cardiology Department, Hospital Madre Teresa, Belo Horizonte, Brazil
| | | | - Rhanderson Cardoso
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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11
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Halperin JL, Rothman KJ. Initial Antithrombotic Therapy After Percutaneous Left Atrial Appendage Occlusion: Shifting Approaches to a Moving Target. J Am Coll Cardiol 2023; 82:1774-1776. [PMID: 37879781 DOI: 10.1016/j.jacc.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA.
| | - Kenneth J Rothman
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
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12
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Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, Hoang Trinh K, O'Hara G, Rodés-Cabau J. Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives. Circ Cardiovasc Interv 2023; 16:e012812. [PMID: 37192309 DOI: 10.1161/circinterventions.122.012812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Pedro Cepas-Guillén
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Xavier Freixa
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Eduardo Flores-Umanzor
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
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13
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Ma Y, Guo L, Hu M, Yan Q, Liu H, Yi F. Left atrial appendage occlusion combined with cryoballoon or radiofrequency ablation: One-year follow-up comparison. Front Cardiovasc Med 2023; 10:1153158. [PMID: 37180810 PMCID: PMC10169712 DOI: 10.3389/fcvm.2023.1153158] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Background A one-stop procedure involving catheter ablation and left atrial appendage occlusion (LAAO) is an option for high-risk atrial fibrillation patients. Few studies have reported the efficacy and safety of cryoballoon ablation (CBA) combined with LAAO, and no studies have compared the combination of LAAO with CBA or radiofrequency ablation (RFA). Methods A total of 112 patients were enrolled in the present study; 45 patients received CBA combined with LAAO (group 1), and 67 patients received RFA combined with LAAO (group 2). Patient follow-up was performed for 1 year to detect peri-device leaks (PDLs) and safety outcomes (defined as a composite of peri-procedural and follow-up adverse events). Results The number of PDLs at the median 59 days follow-up was comparable between the two groups (33.3% in group 1 vs. 37.3% in group 2, p = 0.693). Safety outcomes were also comparable between the two groups (6.7% in group 1 vs. 7.5% in group 2, p = 1.000). Multivariable regression showed that PDLs risk and safety outcomes were all similar between the two groups. Subgroup analysis of PDLs indicated no significant differences. Follow-up safety outcomes were related to anticoagulant medication, and patients without PDLs were more likely to discontinue antithrombotic therapy. The total procedure and ablation times were all significantly shorter for group 1. Conclusion When compared with left atrial appendage occlusion combined with radiofrequency, left atrial appendage occlusion combined with cryoballoon ablation has the same risk of peri-device leaks and safety outcomes, but the procedure time was significantly reduced.
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Affiliation(s)
| | | | | | | | | | - Fu Yi
- Department of Cardiology, Xijing Hospital, Air Force Medical University, Shaanxi, China
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14
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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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15
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Reduced- or Half-Dose Rivaroxaban Following Left Atrial Appendage Closure: A Feasible Antithrombotic Therapy in Patients at High Risk of Bleeding? J Clin Med 2023; 12:jcm12030847. [PMID: 36769499 PMCID: PMC9917793 DOI: 10.3390/jcm12030847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
The optimal antithrombotic strategy after percutaneous left atrial appendage closure (LAAC) has not yet been established. The advisability of administering low-dose direct oral anticoagulation after LAAC to patients at high risk of bleeding is uncertain. Thus, in the present study, we evaluated the safety and effectiveness of reduced-(15 mg) or half-dose rivaroxaban (10 mg) versus warfarin regarding real-world risks of thromboembolism, bleeding, and device-related thrombosis (DRT) after LAAC. Patients with non-valvular atrial fibrillation and HASBLED ≥ 3 who had undergone successful LAAC device implantation from October 2014 to April 2020 were screened and those who had received 10 mg or 15 mg rivaroxaban or warfarin therapy were enrolled. The patients were followed up 45 days and 6 months after LAAC to evaluate outcomes, including death, thromboembolism, major bleeding, and DRT. Of 457 patients with HASBLED ≥ 3 who had undergone LAAC, 115 had received warfarin and 342 rivaroxaban (15 mg: N = 164; 10 mg: N = 178). There were no significant differences in the incidence of thromboembolism or DRT between the warfarin and both doses of rivaroxaban groups (all p > 0.05). The incidence of major bleeding was significantly higher in the warfarin group than in either the reduced- or half-dose rivaroxaban groups (warfarin vs. rivaroxaban 15 mg: 2.6% vs. 0%, p = 0.030; warfarin vs. rivaroxaban 10 mg: 2.6% vs. 0%, p = 0.038). Either reduced- or half-dose rivaroxaban may be an effective and safe alternative to warfarin therapy in patients with LAAC and who are at high risk of bleeding, the risk of thromboembolism being similar and of major bleeding lower for both doses of rivaroxaban.
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16
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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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17
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Vukomanovic D, Unzek S, Malik K, Taase A, Zawaneh M, Weiss P, Fang K, Tung R. Massive Device-Related Thrombus After LAA Occlusion: Intraoperative Insights Into Mechanism. JACC Case Rep 2022; 4:1409-1413. [PMID: 36388709 PMCID: PMC9664007 DOI: 10.1016/j.jaccas.2022.07.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/12/2022] [Accepted: 07/27/2022] [Indexed: 01/11/2023]
Abstract
In patients with a contraindication to oral anticoagulation, the left atrial appendage occlusion devices are an approved alternative. Device-related thrombus is a recognized complication, but underlying mechanisms are incompletely understood. In this case series, the authors describe potentially the same mechanism of thrombosis with intraoperative images of incomplete endothelialization. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Damir Vukomanovic
- Department of Internal Medicine, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
- Address for correspondence: Dr Damir Vukomanovic, The University of Arizona College of Medicine-Phoenix, 1111 East McDowell Road, Phoenix, Arizona 85006, USA.
| | - Samuel Unzek
- Division of Cardiology, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Kashif Malik
- Department of General Surgery, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Alicia Taase
- Department of General Surgery, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Michael Zawaneh
- Division of Cardiology, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Peter Weiss
- Division of Cardiology, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Kenith Fang
- Department of Cardiothoracic Surgery, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
| | - Roderick Tung
- Division of Cardiology, University of Arizona College of Medicine, Banner University Medical Center-Phoenix, Phoenix, Arizona, USA
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18
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Simard TJ, Hibbert B, Alkhouli MA, Abraham NS, Holmes DR. Device-related thrombus following left atrial appendage occlusion. EUROINTERVENTION 2022; 18:224-232. [PMID: 35440430 DOI: 10.4244/eij-d-21-01010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Thrombus formation on intracardiac devices remains a subject of importance, with rates in the 2-5% range. Device-related thrombus (DRT) following left atrial appendage occlusion is an area of particular concern considering its association with embolic events. DRT continues to present numerous questions, including the optimal definition, incidence, risk factors, monitoring, therapy, and clinical outcomes - all subjects of ongoing assessment. Herein, we discuss these considerations, building upon the relevant historical context and pathophysiologic insights while discussing the future considerations in this rapidly evolving field.
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Affiliation(s)
- Trevor J Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Hibbert
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Neena S Abraham
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Mesnier J, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Mas-Lladó C, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Early Discontinuation of Antithrombotic Treatment Following Left Atrial Appendage Closure. Am J Cardiol 2022; 171:91-98. [PMID: 35317927 DOI: 10.1016/j.amjcard.2022.01.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 01/24/2022] [Accepted: 01/26/2022] [Indexed: 01/04/2023]
Abstract
Although antithrombotic treatment is recommended after left atrial appendage closure (LAAC), some patients require discontinuation of antithrombotic treatment after LAAC without evidence on the safety of such a strategy. We sought to evaluate outcomes of patients who had early antithrombotic treatment discontinuation after LAAC. This is a multicenter study including 1,082 patients who underwent successful LAAC. Early discontinuation of antithrombotic treatment was defined as discontinuation of all antiplatelet/anticoagulant treatment within 6 months following the procedure. A propensity-matched analysis was used to compare outcomes of patients with and without early antithrombotic treatment discontinuation. A total of 148 patients (13.7%) had early antithrombotic treatment discontinuation. In the entire population, antithrombotic treatment discontinuation patients exhibited a lower CHA2DS2-VASc score (p <0.001) and a higher rate of previous gastrointestinal bleeding episodes (p = 0.01) compared with patients without discontinuation. After a median follow-up of 2.1 (1,1-3.1) years after antithrombotic treatment discontinuation, the rates of death, ischemic stroke, and major bleeding were 12.1, 0.6, and 3.3 per 100 patient-years. In 119 matched pairs with similar baseline characteristics, antithrombotic treatment discontinuation patients had a similar risk of death (hazard ratio [HR] 1.06, 95% confidence interval [CI] 0.65 to 1.71, p = 0.82), ischemic stroke (HR 0.39, 95% CI 0.04 to 3.79, p = 0.42) and major bleeding (HR 1.48, 95% CI 0.56 to 3.88, p = 0.43) compared with those without discontinuation. In conclusion, antithrombotic treatment was discontinued in 1 of 7 selected patients within 6 months after LAAC, and this was not associated with an increased risk of death or thromboembolic events after a median follow-up of 2 years. These data support the safety of shorter periods of antithrombotic therapy after LAAC in high bleeding risk patients based on clinician judgment. Further trials are warranted.
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Aarnink EW, Huijboom MF, Bor WL, Maarse M, Zheng KL, ten Cate H, Ten Berg JM, Boersma LV. Hemostatic biomarkers and antithrombotic strategy in percutaneous left atrial interventions: State-of-the-art review. Thromb Res 2022; 215:41-51. [DOI: 10.1016/j.thromres.2022.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/29/2022] [Accepted: 05/16/2022] [Indexed: 11/24/2022]
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21
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Single versus Dual Antiplatelet Therapy following Left Atrial Appendage Occlusion in Patients with High Bleeding Risk. Curr Probl Cardiol 2022; 47:101269. [DOI: 10.1016/j.cpcardiol.2022.101269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/23/2022] [Indexed: 11/17/2022]
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22
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Dognin N, Salaun E, Champagne C, Domain G, O'Hara G, Philippon F, Paradis JM, Faroux L, Beaudoin J, O'Connor K, Bernier M, Rodés-Cabau J, Champagne J. Percutaneous left atrial appendage closure in patients with primary hemostasis disorders and atrial fibrillation. J Interv Card Electrophysiol 2021; 64:497-509. [PMID: 34822043 DOI: 10.1007/s10840-021-01073-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 10/04/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND OR PURPOSE We report our single-center experience with percutaneous left atrial appendage closure (LAAC) in patients with non-valvular atrial fibrillation (NVAF) and primary hemostasis disorders (HD). METHODS Consecutive patients with primary HD who underwent a percutaneous LAAC were included. Baseline characteristics, procedural data, and clinical outcomes were prospectively collected and compared with the overall LAAC cohort without HD. RESULTS Since 2013, among 229 LAAC, 17 patients (7%) had a primary HD: thrombocytopenia (n = 5), myelodysplastic syndrome (n = 6), von Willebrand syndrome (n = 4), type A hemophilia (n = 1), and dysfibrinogenemia (n = 1). The HD population's age ranged from 61 to 87 years, and the median CHA2DS2VASc was 5. Periprocedural plasmatic management was required in 47% of patients. The immediate LAAC implantation success rate was 100%. Patients received a direct oral anticoagulant (DOA) (n = 9), dual antiplatelet (n = 6), aspirin (n = 1), or no therapy (n = 1) during the first six postoperative weeks, followed with single antiplatelet (n = 16) or no therapy (n = 1) during lifelong. After 20 months, the technical success rate and procedural success rate were 100% and 94%. Zero device-/procedure-related complication and only one life-threatening bleeding occurred. Compared to patients without HD (n = 212), a baseline history of bleeding was less frequent (53% vs 91%, p < 0.001), and more patients received a perioperative blood transfusion (47% vs 4%, p < 0.001) in the HD group. The efficacy and safety outcomes did not differ between HD and non-HD cohorts. CONCLUSIONS Percutaneous LAAC in primary HD carriers appeared as safe and as effective as in overall LAAC population for stroke and bleeding prevention at midterm follow-up. Percutaneous left atrial appendage closure in patients with atrial fibrillation and primary hemostasis disorders. The percutaneous LAAC in primary hemostasis disorders and AF carriers requires a multidisciplinary approach. Cardiologist, anesthesiologist, and hematologist discussion is a cornerstone to assess anticoagulant contraindication, LAAC feasibility, periprocedural management, and follow-up (high). This multidisciplinary care is illustrated by the case of a 61-year-old male with hemophilia type A and recurrent hemarthrosis. Pre-LAAC assessment confirmed procedural indication and cactus LAA anatomy (left). After plasmatic management with factor VIII infusion, a WATCHMAN™ no. 21 was successfully implanted (middle). During follow-up, without antithrombotic regime, no ischemic or hemorrhagic complication occurred (right). LAA, left atrial appendage; LAAC, left atrial appendage closure; TEE, transesophageal echocardiography. Percutaneous LAAC in primary HD carriers appeared as safe and as effective as in overall LAAC population for stroke and bleeding prevention at midterm follow-up.
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Affiliation(s)
- Nicolas Dognin
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada.
| | - Erwan Salaun
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Catherine Champagne
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Guillaume Domain
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Gilles O'Hara
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - François Philippon
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jean-Michel Paradis
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Laurent Faroux
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jonathan Beaudoin
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Kim O'Connor
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Mathieu Bernier
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Josep Rodés-Cabau
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
| | - Jean Champagne
- Service de Cardiologie, Institut Universitaire de Cardiologie Et de Pneumologie de Québec, 2725 Chemin de Sainte-Foy, Québec City, Québec, G1V 4G5, Canada
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23
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Half-Dose Direct Oral Anticoagulation Versus Standard Antithrombotic Therapy After Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2021; 14:2353-2364. [PMID: 34656496 DOI: 10.1016/j.jcin.2021.07.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/28/2021] [Accepted: 07/06/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study evaluated the long-term efficacy of a standard antithrombotic strategy versus half-dose direct oral anticoagulation (DOAC) after Watchman implantation. BACKGROUND No consensus currently exists on the selection of the most effective antithrombotic strategy to prevent device-related thrombosis (DRT) in patients undergoing endocardial left atrial appendage closure. METHODS After successful left atrial appendage closure, consecutive patients were prescribed a standard antithrombotic strategy (SAT) or long-term half-dose DOAC (hdDOAC). The primary composite endpoint was DRT and thromboembolic (TE) and bleeding events. RESULTS Overall, 555 patients (mean age 75 ± 8 years, 63% male; median CHA2DS2-VASc [congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score 4 [interquartile range (IQR): 3-6]; median HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] score 3 [IQR: 2-4]) were included. Patients were categorized into 2 groups (SAT: n = 357 vs hdDOAC: n = 198). Baseline clinical characteristics were similar between groups. The median follow-up duration was 13 months (IQR: 12-15 months). DRT occurred in 12 (2.1%) patients, all in the SAT group (3.4% vs 0.0%; log-rank P = 0.009). The risk of nonprocedural major bleeding was significantly more favorable in the hdDOAC group (0.5% vs. 3.9%; log-rank P = 0.018). The rate of the primary composite endpoint of DRT and TE and major bleeding events was 9.5% in SAT patients and 1.0% in hdDOAC patients (HR: 9.8; 95% CI: 2.3-40.7; P = 0.002). CONCLUSIONS After successful Watchman implantation, long-term half-dose DOAC significantly reduced the risk of the composite endpoint of DRT and TE and major bleeding events compared with a standard, antiplatelet-based, antithrombotic therapy.
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24
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Cepas-Guillen PL, Flores-Umanzor E, Regueiro A, Brugaletta S, Ibañez C, Sanchis L, Sitges M, Rodés-Cabau J, Sabaté M, Freixa X. Low Dose of Direct Oral Anticoagulants after Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 2021; 8:jcdd8110142. [PMID: 34821695 PMCID: PMC8623304 DOI: 10.3390/jcdd8110142] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal antithrombotic strategy following left atrial appendage occlusion (LAAO) is not yet clearly established. Low-dose non-vitamin K antagonist oral anticoagulants (NOAC) might represent a valid alternative, but data regarding their usage is scarce. The aim of this study was to examine the efficacy and safety of low-dose NOAC compared to single (SAPT) or dual antiplatelet therapies (DAPT) after LAAO. We included consecutive patients with non-valvular atrial fibrillation who underwent LAAO and received low-dose apixaban, SAPT, or DAPT at discharge. The primary objective of this study included an efficacy endpoint (thromboembolic events and device related thrombosis (DRT)) and a safety endpoint (incidence of major bleeding) within the first three months after LAAO. A total of 139 patients were included. This group involved SAPT in 26 (18%), DAPT in 73 (53%), and apixaban in 40 (29%) patients. Follow-up at three-months showed no significant differences in the primary efficacy endpoint (2 (8%) SAPT, 3 (4%) DAPT and 0 (0%) apixaban; p value = 0.25). In contrast, the primary safety endpoint occurred more frequently in DAPT patients (7 (10%) DAPT, 0 (0%), SAPT and 0 with apixaban; p value = 0.03). Combining both efficacy and safety outcomes, low dose apixaban had a lower rate of events (2 (8%) with SAPT, 9 (12%) with DAPT and 0 (0%) with apixaban; p = 0.046). Low-dose apixaban after LAAO may be a valid alternative to DAPT and SAPT as depicted by the reduction in the occurrence of major bleedings and combined DRT/major bleedings respectively. Randomized data will be necessary to validate this strategy.
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Affiliation(s)
- Pedro Luis Cepas-Guillen
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Eduardo Flores-Umanzor
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Ander Regueiro
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Salvatore Brugaletta
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Cristina Ibañez
- Anesthesiology Department, Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Laura Sanchis
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Marta Sitges
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Josep Rodés-Cabau
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Quebec Heart and Lung Institute, Quebec City, QC G1V 4G5, Canada
| | - Manel Sabaté
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Correspondence: ; Tel.: +34-932275519
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25
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Faroux L, Cruz-González I, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Regueiro A, McInerney A, Mas-Lladó C, Estevez-Loureiro R, Laricchia A, O'Hara G, Rodés-Cabau J. Short-term direct oral anticoagulation or dual antiplatelet therapy following left atrial appendage closure in patients with relative contraindications to chronic anticoagulation therapy. Int J Cardiol 2021; 333:77-82. [PMID: 33647365 DOI: 10.1016/j.ijcard.2021.02.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 02/04/2021] [Accepted: 02/19/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Biological data suggest that short-term anticoagulation would be more effective than dual antiplatelet therapy (DAPT) to reduce the thrombotic risk following left atrial appendage closure (LAAC). This study sought to assess the safety and efficacy of direct oral anticoagulation (DOAC) versus DAPT immediately post-LAAC. METHODS Multicenter study including 592 consecutive patients with relative contraindication to chronic anticoagulation who underwent LAAC and received either DAPT or DOAC for 1-3 months. Each patient receiving DOAC was matched with 2 patients on DAPT based on propensity-score (propensity-matched population of 285 patients). Outcomes recorded were death, stroke, non-procedural related severe bleeding, serious adverse event (SAE: composite of death, stroke, bleeding) and early (within 3 months post-LAAC) device-related thrombosis (DRT). RESULTS Early outcomes (within 3-month post-LAAC) did not significantly differ between groups, but a numerically higher rate of early death (3.7% vs. 1.1%), non-procedural related severe bleeding (7.4% vs. 3.2%), and SAE (11.1% vs. 5.3%) were observed in patients receiving DAPT. After a median follow-up of 22 (8-38) months, similar outcomes were observed in DAPT and DOAC groups regarding death (HR: 1.18; 95% CI: 0.58-2.37; p = 0.652), stroke (HR: 1.01; 95% CI: 0.22-5.45; p = 0.908), non-procedural related severe bleeding (HR: 1.68; 95% CI: 0.69-4.12; p = 0.257), and SAE (HR: 1.28; 95% CI: 0.73-2.24; p = 0.383). DRT was identified in 4 patients (2.6%) receiving DAPT versus 0 patient receiving DOAC (p = 0.162). CONCLUSIONS Short-term DOAC following LAAC in patients with contraindications to chronic anticoagulation was safe and tended to associate with a lower rate of SAE and DRT compared to DAPT.
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Affiliation(s)
- Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | | | - Vicente Peral
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | | | | | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Angela McInerney
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Caterina Mas-Lladó
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, Palma, Spain
| | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
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26
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Drakopoulou M, Soulaidopoulos S, Stathogiannis K, Oikonomou G, Papanikolaou A, Toutouzas K, Tousoulis D. Antiplatelet and Antithrombotic Therapy After Patent Foramen Oval and Atrial Septal Defect Closure. Curr Pharm Des 2021; 26:2769-2779. [PMID: 32338207 DOI: 10.2174/1385272824999200427083838] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/18/2020] [Indexed: 12/18/2022]
Abstract
Pathologies of the atrial septum include different interatrial communications varying from patent foramen ovale (PFO) to actual defects. Atrial septal defects (ASDs) may be localized within the fossa ovalis such as the secundum type ASD or outside the region of fossa ovalis, such as the ostium primum defect and sinus venosus defect. Over the last decades, the percutaneous closure of interatrial shunts has become a feasible and safe method. During these procedures, the delicate balance between thrombotic risk, device sealing process and bleeding risk is crucial. In this review, we sought to describe current available data on the antiplatelet and antithrombotic management of patients after percutaneous ASD or PFO closure.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Georgios Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Aggelos Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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27
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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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28
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Patti G, Sticchi A, Verolino G, Pasceri V, Vizzi V, Brscic E, Casu G, Golino P, Russo V, Rapacciuolo A, Boccuzzi G, Mangieri A, Pagnotta PA, Colombo A. Safety and Efficacy of Single Versus Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion. Am J Cardiol 2020; 134:83-90. [PMID: 32892987 DOI: 10.1016/j.amjcard.2020.08.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.
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29
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Asmarats L, O’Hara G, Champagne J, Paradis JM, Bernier M, O’Connor K, Beaudoin J, Junquera L, Del Val D, Muntané-Carol G, Côté M, Rodés-Cabau J. Short-Term Oral Anticoagulation Versus Antiplatelet Therapy Following Transcatheter Left Atrial Appendage Closure. Circ Cardiovasc Interv 2020; 13:e009039. [DOI: 10.1161/circinterventions.120.009039] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The impact of antithrombotic therapy on coagulation system activation after left atrial appendage closure (LAAC) remains unknown. This study sought to compare changes in coagulation markers associated with short-term oral anticoagulation (OAC) versus antiplatelet therapy (APT) following LAAC.
Methods:
Prospective study including 78 atrial fibrillation patients undergoing LAAC with the Watchman device. F1+2 (prothrombin fragment 1+2) and TAT (thrombin-antithrombin III) were assessed immediately before the procedure, and at 7, 30, and 180 days after LAAC.
Results:
Forty-eight patients were discharged on APT (dual: 31, single: 17) and 30 on OAC (direct anticoagulants: 26, vitamin K antagonists: 4), with no differences in baseline-procedural characteristics between groups except for higher spontaneous echocardiography contrast in the OAC group. OAC significantly reduced coagulation activation within 7 days post-LAAC compared with APT (23% [95% CI, 5%–41%] versus 82% [95% CI, 54%–111%] increase for F1+2,
P
=0.007; 52% [95% CI, 15%–89%] versus 183% [95% CI, 118%–248%] increase for TAT,
P
=0.048), with all patients in both groups progressively returning to baseline values at 30 and 180 days. Spontaneous echocardiography contrast pre-LAAC was associated with an enhanced activation of the coagulation system post-LAAC (144 [48–192] versus 52 [24–111] nmol/L,
P
=0.062 for F1+2; 299 [254–390] versus 78 [19–240] ng/mL,
P
=0.002 for TAT). Device-related thrombosis occurred in 5 patients (6.4%), and all of them were receiving APT at the time of transesophageal echocardiography (10.2% versus 0% if OAC at the time of transesophageal echocardiography,
P
=0.151). Patients with device thrombosis exhibited a greater coagulation activation 7 days post-LAAC (
P
=0.038 and
P
=0.108 for F1+2 and TAT, respectively).
Conclusions:
OAC (versus APT) was associated with a significant attenuation of coagulation system activation post-LAAC. Spontaneous echocardiography contrast pre-LAAC associated with enhanced coagulation activation post-LAAC, which in turn increased the risk of device thrombosis. These results highlight the urgent need for randomized trials comparing OAC versus APT post-LAAC.
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Affiliation(s)
- Lluis Asmarats
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Gilles O’Hara
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Jean Champagne
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Jean-Michel Paradis
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Mathieu Bernier
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Kim O’Connor
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Jonathan Beaudoin
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Lucia Junquera
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - David Del Val
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Guillem Muntané-Carol
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Mélanie Côté
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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30
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Ozeke O, Cay S, Ozcan F, Topaloglu S, Aras D. The point of no return for percutaneous left atrial appendage closure: Towards to CHA
2
DS
2
‐VALAAc Score? PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2019; 42:764-766. [DOI: 10.1111/pace.13681] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Ozcan Ozeke
- Department of CardiologyAnkara City HospitalHealth Sciences University Ankara Turkey
| | - Serkan Cay
- Department of CardiologyAnkara City HospitalHealth Sciences University Ankara Turkey
| | - Firat Ozcan
- Department of CardiologyAnkara City HospitalHealth Sciences University Ankara Turkey
| | - Serkan Topaloglu
- Department of CardiologyAnkara City HospitalHealth Sciences University Ankara Turkey
| | - Dursun Aras
- Department of CardiologyAnkara City HospitalHealth Sciences University Ankara Turkey
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31
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Percutaneous Left Atrial Appendage Closure With the Ultraseal Device. JACC Cardiovasc Interv 2018; 11:1932-1941. [DOI: 10.1016/j.jcin.2018.05.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 05/01/2018] [Accepted: 05/15/2018] [Indexed: 11/22/2022]
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32
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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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