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Scharf C. [Fermeture de l'oreillette gauche - une alternative à l'anticoagulation permanente en cas de fibrillation auriculaire?]. PRAXIS 2022; 111:884-888. [PMID: 36415982 DOI: 10.1024/1661-8157/a003930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Left Atrial Appendage Closure- An Alternative to Continuous Anticoagulation for Atrial Fibrillation? Abstract. Approximately 25% of all ischemic insults are caused by cardiac emboli in atrial fibrillation. Therefore, in patients with atrial fibrillation, oral anticoagulation is initiated or transesophageal echocardiography is performed before electroconversion to exclude blood clots in the heart. This shows that virtually all cardiac thrombi (>90%) are localized in the atrial ear. Therefore, for many decades surgeons have been removing the atrial tube during open heart surgery to eliminate it as a source of emboli. As a minimally invasive alternative, various screens for percutaneous closure of the atrial ear have been developed in the past 10-20 years. The requirements, techniques, and results will be discussed in the following article.
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Chen Z, Bai W, Li C, Wang H, Tang H, Qin Y, Rao L. Left Atrial Appendage Parameters Assessed by Real-Time Three-Dimensional Transesophageal Echocardiography Predict Thromboembolic Risk in Patients With Nonvalvular Atrial Fibrillation. JOURNAL OF ULTRASOUND IN MEDICINE 2017; 36:1119-1128. [PMID: 28233335 DOI: 10.7863/ultra.16.05070] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/12/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES In nonvalvular atrial fibrillation (NVAF) patients, the effect of left atrial appendage (LAA) morphology, structure, and hemodynamic characteristics evaluated by real-time 3D transesophageal echocardiography (RT3D-TEE) on thromboembolic risk has not been elucidated. METHODS A total of 444 NVAF patients who underwent clinically indicated RT3D-TEE were enrolled in the study. The orifice size, orifice area, depth, and volume measurements of the LAA were assessed using Philips QLAB 9.0. The LAA characteristics were compared among different CHA2 DS2 -VASc thromboembolic risk subgroups, as well as between the thromboembolic event and nonevent groups. RESULTS The orifice size, orifice area, and end-diastolic volumes of the LAA were increased with an increasing CHA2 DS2 -VASc risk score in the NVAF patients, whereas the emptying rate was decreased. The NVAF patients with LAA thrombus exhibited a significantly increased end-diastolic volume (7.39 ± 3.47 versus 5.21 ± 2.59 mL, P = .003) and higher prevalence of the cauliflower shaped LAA (64.3% versus 25%, P = .004) compared with those without thrombus. Logistic regression indicated that the LAA end-diastolic volume (P = .002; odds ratio 1.556; 95% confidence interval 1.176-2.057) and cauliflower shape (P = .001; odds ratio, 10.177; 95% confidence interval, 2.458-42.140) were independent predictors of thromboembolic events in patients with NVAF following adjustment for the CHA2 DS2 -VASc score. CONCLUSIONS The LAA end-diastolic volume and cauliflower phenotype predict thromboembolic events independent of the CHA2 DS2 -VASc score, and these data improve stroke prediction in NVAF patients.
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Affiliation(s)
- Zhongxiu Chen
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Wenjuan Bai
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Chen Li
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hui Wang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Hong Tang
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yupei Qin
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Li Rao
- Department of Cardiology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Yan LL, Li C, Chen J, Miranda JJ, Luo R, Bettger J, Zhu Y, Feigin V, O'Donnell M, Zhao D, Wu Y. Prevention, management, and rehabilitation of stroke in low- and middle-income countries. eNeurologicalSci 2016; 2:21-30. [PMID: 29473058 PMCID: PMC5818135 DOI: 10.1016/j.ensci.2016.02.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/26/2016] [Accepted: 02/29/2016] [Indexed: 12/28/2022] Open
Abstract
Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.
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Affiliation(s)
- Lijing L. Yan
- Global Health Research Center, Duke Kunshan University, Kunshan, China
- Duke Global Health Institute, Duke University, Durham, USA
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Chaoyun Li
- Global Health Research Center, Duke Kunshan University, Kunshan, China
| | - Jie Chen
- Institute for Medical Humanities, Peking University Health Science Center, Beijing, China
| | - J. Jaime Miranda
- CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Medicine, School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rong Luo
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Janet Bettger
- Duke School of Nursing, Duke University, Durham, USA
- Duke Clinical Research Institute, Duke University, Durham, USA
| | - Yishan Zhu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
| | - Valery Feigin
- National Institute for Stroke and Applied Neuroscience, Auckland University of Technology, Auckland, New Zealand
| | | | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yangfeng Wu
- The George Institute for Global Health at Peking University Health Science Center, Beijing, China
- Department of Epidemiology and Biostatistics, Peking University School of Public Health and Clinical Research Institute, Beijing, China
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Stroke prevention following modified endoscopic ablation and appendectomy for atrial fibrillation. Heart Vessels 2015; 31:1529-36. [PMID: 26391680 DOI: 10.1007/s00380-015-0749-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/09/2015] [Indexed: 10/23/2022]
Abstract
We reported the results of stroke prevention following modified endoscopic procedure for atrial fibrillation. 82 patients underwent modified endoscopic procedure for atrial fibrillation (AF), in whom 47 had paroxysmal, 28 had persistent, and 7 had long-standing atrial fibrillation. CHA2DS2VASC median score was 3 (range from 0 to 8). The procedure was performed on the beating heart, through 3 ports on the left chest wall. Pulmonary vein isolation and ablation of the left atrium were achieved by bipolar radiofrequency ablation. Left atrial appendage (LAA) was excluded by stapler. Brain CT, cardiac CT and 24-h Holter monitoring were performed following the procedure. The procedure was successfully completed for all patients. The mean duration was 122 ± 40.1 min. LAA was excluded after appendectomy and checked by intraoperative transesophageal echocardiography. The mean follow-up duration was 24.3 ± 3.5 months. No patients showed signs and symptoms of transient ischemic attack or stroke. No new positive findings were demonstrated by recurring brain CT scan performed after the procedure. Cardiac CT confirmed the absence of LAA and thrombosis in the left atrium. 87.8 % (72/82) of all patients were in sinus rhythm. Our results demonstrate that the modified endoscopic procedure is a safe, effective, and appropriate treatment for AF, which restores sinus rhythm and may be associated with the prevention of AF-related stroke.
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Alli O, Holmes D. Republished: Left atrial appendage occlusion. Postgrad Med J 2015; 91:527-34. [DOI: 10.1136/postgradmedj-2014-306255rep] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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DeSimone CV, Prakriti BG, Tri J, Syed F, Sm AN, Asirvatham SJ. A Review Of The Relevant Embryology, Pathohistology, And Anatomy Of The Left Atrial Appendage For The Invasive Cardiac Electrophysiologist. J Atr Fibrillation 2015; 8:1129. [PMID: 27957182 DOI: 10.4022/jafib.1129] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 06/09/2015] [Accepted: 06/27/2015] [Indexed: 01/23/2023]
Abstract
The three-dimensional morphology of the left atrial appendage provides the substrate for thrombus generation, and is a harbinger for embolic material due to its direct connection to the left-sided circulation. Appreciating the development of the appendage from mesodermal layer to its adult form provides the basis to improve exclusion from the atrial circulation, and thereby can lead to a significant reduction in stroke risk. This process also provides insight into the role of the left atrial appendage as an endocrine organ, its involvement in fluid homeostasis, and its connection to the autonomic nervous system. Knowledge of the surrounding structural arrangement is critical to identify landmarks from both an endocardial and epicardial perspective to improve targeted device placement. Furthermore, correlation of the left atrial appendage body, neck, and ostium to the surrounding anatomy can also improve both procedural efficacy and safety. In addition, a working knowledge of the regional anatomy adds a prudent degree of awareness for procedural complications, and allows for early identification and timely intervention as these situations arise. A detailed understanding of the left atrial appendage embryology, histology, and gross anatomy is imperative to identify the correct device and approach for each individual patient. In addition, this increased awareness can identify areas that are in need of further innovation, and thus provide the ability to adapt and refine existing technologies to overcome pitfalls currently facing catheter-based approaches.
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Affiliation(s)
| | - Bs Gaba Prakriti
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jason Tri
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Faisal Syed
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amit Noheria Sm
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Samuel J Asirvatham
- Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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Cardiac CT Prior to Left Atrial Appendage Closure Device Implantation and Percutaneous Mitral Valve Interventions. CURRENT CARDIOVASCULAR IMAGING REPORTS 2014. [DOI: 10.1007/s12410-014-9295-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Kar S, Hou D, Jones R, Werner D, Swanson L, Tischler B, Stein K, Huibregtse B, Ladich E, Kutys R, Virmani R. Impact of Watchman and Amplatzer Devices on Left Atrial Appendage Adjacent Structures and Healing Response in a Canine Model. JACC Cardiovasc Interv 2014; 7:801-9. [DOI: 10.1016/j.jcin.2014.03.003] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/27/2014] [Accepted: 03/13/2014] [Indexed: 11/29/2022]
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Romero J, Perez IE, Krumerman A, Garcia MJ, Lucariello RJ. Left atrial appendage closure devices. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:45-52. [PMID: 24963274 PMCID: PMC4064949 DOI: 10.4137/cmc.s14043] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2014] [Revised: 03/24/2014] [Accepted: 03/26/2014] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) increases the risk for thromboembolic stroke five-fold. The left atrial appendage (LAA) has been shown to be the main source of thrombus formation in the majority of strokes associated with AF. Oral anticoagulation with warfarin and novel anticoagulants remains the standard of care; however, it has several limitations, including bleeding and poor compliance. Occlusion of the LAA has been shown to be an alternative therapeutic approach to drug therapy. The purpose of this article is to review the different techniques and devices that have emerged for the purpose of occluding this structure, with a particular emphasis on the efficacy and safety studies published to date in the medical literature.
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Affiliation(s)
- Jorge Romero
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Irving E Perez
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrew Krumerman
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Mario J Garcia
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Richard J Lucariello
- Department of Medicine, Division of Cardiology, Albert Einstein College of Medicine, Bronx, NY, USA
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De Backer O, Arnous S, Ihlemann N, Vejlstrup N, Jørgensen E, Pehrson S, Krieger TDW, Meier P, Søndergaard L, Franzen OW. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart 2014; 1:e000020. [PMID: 25332785 PMCID: PMC4195925 DOI: 10.1136/openhrt-2013-000020] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/13/2014] [Accepted: 04/29/2014] [Indexed: 12/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. One of its most devastating complications is the development of thromboembolism leading to fatal or disabling stroke. Oral anticoagulation (OAC, warfarin) is the standard treatment for stroke prevention in patients with AF with an increased stroke risk. However, there are several obstacles to long-term OAC therapy, including the risk of serious bleeding, several drug–drug interactions and the need for frequent blood testing. Although newer oral anticoagulants have been developed, these drugs also face issues of major bleeding and non-compliance. Therefore, alternative treatment options for stroke prevention in patients with AF with a high stroke risk are needed. Percutaneous left atrial appendage (LAA) occlusion is an evolving therapy, which should be taken into consideration in those patients with non-valvular AF with a high stroke risk and contraindications for OAC. This article aims to discuss the rationale for LAA closure, the available LAA occlusion devices and their clinical evidence until now. Moreover, we discuss the importance of proper patient selection, the role of various imaging techniques and the need for a more tailored postprocedural antithrombotic therapy.
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Affiliation(s)
- O De Backer
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Arnous
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Ihlemann
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Vejlstrup
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - E Jørgensen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Pehrson
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - T D W Krieger
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - P Meier
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - L Søndergaard
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - O W Franzen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
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Morley JE. Mild Cognitive Impairment—A Treatable Condition. J Am Med Dir Assoc 2014; 15:1-5. [DOI: 10.1016/j.jamda.2013.11.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 11/04/2013] [Indexed: 01/24/2023]
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Holmes DR, Lakkireddy DR, Whitlock RP, Waksman R, Mack MJ. Left atrial appendage occlusion: opportunities and challenges. J Am Coll Cardiol 2013; 63:291-8. [PMID: 24076495 DOI: 10.1016/j.jacc.2013.08.1631] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/23/2013] [Accepted: 08/27/2013] [Indexed: 12/17/2022]
Abstract
Stroke prevention in patients with atrial fibrillation is a growing clinical dilemma as the incidence of the arrhythmia increases and risk profiles worsen. Strategies in patients with nonvalvular atrial fibrillation have included anticoagulation with a variety of drugs. Knowledge that stroke in this setting typically results from thrombus in the left atrial appendage has led to the development of mechanical approaches, both catheter-based and surgical, to occlude that structure. Such a device, if it were safe and effective, might avoid the need for anticoagulation and prevent stroke in the large number of patients who are currently not treated with anticoagulants. Regulatory approval has been difficult due to trial design challenges, balance of the risk-benefit ratio, specific patient populations studied, selection of treatment in the control group, and specific endpoints and statistical analyses selected. Accumulating data from randomized trials and registries with longer-term follow-up continues to support a role for left atrial appendage exclusion from the central circulation as an alternative to anticoagulation in carefully-selected patient populations.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| | - Dhanunjaya R Lakkireddy
- Section of Electrophysiology, Bloch Heart Rhythm Center, KU Cardiovascular Research Institute, Mid America Cardiology, University of Kansas Hospital, Kansas City, Kansas
| | - Richard P Whitlock
- Department of Surgery, Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ron Waksman
- Department of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
| | - Michael J Mack
- Department of Cardiovascular Medicine, Baylor Healthcare System, Dallas, Texas
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Cayla G, Morange PE, Chambost H, Schved JF. Management of cardiovascular disease in haemophilia. Thromb Res 2013; 132:8-14. [DOI: 10.1016/j.thromres.2013.05.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Revised: 05/02/2013] [Accepted: 05/05/2013] [Indexed: 02/07/2023]
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