1
|
Ahmed H, Ismayl M, Palicherla A, Heppler M, Petraskova T, Kousa O, Vargha J. A case report of postcardioversion device-related thrombus in a patient with left atrial appendage occlusion device on apixaban. Ann Med Surg (Lond) 2024; 86:1729-1733. [PMID: 38463065 PMCID: PMC10923387 DOI: 10.1097/ms9.0000000000001735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/08/2024] [Indexed: 03/12/2024] Open
Abstract
Background Current guidelines recommend proceeding with cardioversion, without the explicit need for preprocedural transesophageal echocardiography (TEE), in patients compliant with oral anticoagulation for at least 3 weeks. The relevance of these guidelines remains unclear in those undergoing repeat cardioversion. Case summary A 66-year-old male with a history of atrial fibrillation (AF) and a left atrial appendage occlusion (LAAO) device, compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm, 10 days before symptom onset, with TEE unremarkable at the time. An ECG revealed that the patient converted back into AF and a repeat cardioversion was scheduled. At the patient's request, a TEE was obtained, revealing a new 2 cm×1 cm thrombus in the left atrium above the WATCHMAN device. Cardioversion was canceled and the patient was hospitalized for AF management. Discussion Cardioverted patients are at risk for thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium, which occurs immediately after cardioversion and can persist for several weeks. The likelihood of a thrombus is further propagated by individual risk factors for stroke. Conclusion Anticoagulation does not eliminate the risk of thrombus formation in those with increased risk factors for stroke. Further studies are warranted to assess the need for routine TEE, after cardioversion, in those with stroke risk factors on anticoagulation or who have LAAO.
Collapse
Affiliation(s)
- Hasaan Ahmed
- Department of Medicine, Division of Internal Medicine
| | - Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | | | | | | | - Omar Kousa
- Department of Medicine, Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, Nebraska
| | - Jalal Vargha
- Department of Medicine, Division of Cardiovascular Disease, Creighton University School of Medicine, Omaha, Nebraska
| |
Collapse
|
2
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
3
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
|
4
|
Meng XS, Chen T, Wang XY, Lu X, Hu J, Shen J, Guo J. Feasibility and safety of the direct current cardioversion at the time of left atrial appendage occlusion for patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1219611. [PMID: 37745133 PMCID: PMC10514907 DOI: 10.3389/fcvm.2023.1219611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background With an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms. Objectives The purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF. Methods Forty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching. Results In the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up. Conclusions The DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Jun Guo
- Department of Cardiovascular, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| |
Collapse
|
5
|
Bhuta S, Shaaban A, Binda NC, Antaki J, Augostini RS, Kalbfleisch SJ, Savona SJ, Okabe T, Houmsse M, Afzal MR, Daoud EG, Hummel JD. Direct current cardioversion practices following percutaneous left atrial appendage closure. J Cardiovasc Electrophysiol 2023; 34:1698-1705. [PMID: 37493499 DOI: 10.1111/jce.15999] [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: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Among patients with non-valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear. OBJECTIVE The purpose of this study is to evaluate the real-world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre- and post-DCCV in patients with AF status post percutaneous LAAC. METHODS This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre-DCCV, OAC use pre- and post-DCCV, incidence of left atrial thrombus (LAT) or device-related thrombus (DRT), incidence of peri-device leak (PDL), and DCCV-related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days. RESULTS A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as "non-guideline based" due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV-related complications within 30 days. DISCUSSION There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.
Collapse
Affiliation(s)
- Sapan Bhuta
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adnan Shaaban
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nkongho C Binda
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Antaki
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Toshimasa Okabe
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| |
Collapse
|
6
|
Isakadze N, Calkins H. What is the best approach to peri-cardioversion imaging and anticoagulation therapy among patients with left atrial appendage closure? J Cardiovasc Electrophysiol 2023; 34:1706-1707. [PMID: 37483118 DOI: 10.1111/jce.16012] [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: 07/08/2023] [Accepted: 07/11/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Nino Isakadze
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Hugh Calkins
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Tsai CF, Huang PS, Chiu FC, Chen JJ, Chang SN, Hsu JC, Chua SK, Cheng HL, Wang YC, Hwang JJ, Tsai CT. Bailout left atrial appendage occluder for pulmonary vein isolation and electrical cardioversion in patients with atrial fibrillation and left atrial appendage thrombus: a pilot study. Clin Res Cardiol 2022:10.1007/s00392-022-02085-0. [PMID: 36056218 DOI: 10.1007/s00392-022-02085-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cardioversion and catheter-based circumferential pulmonary vein isolation (CPVI) are established rhythm control treatment strategies for patients with atrial fibrillation (AF). However, these treatments are contraindicated for AF patients with a left atrial appendage (LAA) thrombus. METHODS We conducted the first-in-man case series study to evaluate the feasibility and safety of performing cardioversion or CPVI in AF patients with LAA thrombus immediately after implantation of LAA Occluder (LAAO) in a combined procedure. In our multi-center LAAO registry of 310 patients, 27 symptomatic and drug-refractory AF patients underwent a combined procedure of LAAO and CPVI, among whom 10 (mean age 68 ± 16 years, 6 men) having anticoagulant-resistant LAA thrombus received a bailout procedure of LAAO implantation first then CPVI, and the other 17 patients without LAA thrombus received CPVI first then LAAO for comparison. RESULTS The mean CHA2DS2-VASc score and HAS-BLED score were comparable between these two groups. In patients with LAA thrombus, we put carotid filters and did a no-touch technique, neither advancing the wire and sheath into the LAA nor performing LAA angiography. After LAAO implantation, the connecting cable was still connected to the occluder when cardioversion was performed. During CPVI, the occluder location was registered in the LA geometry by three-dimensional mapping to guide the catheter not to touch the LAAO. The procedure was successful in all the patients without intra-procedural complications. After a mean follow-up of 1.7 ± 0.7 years, there was no device embolization, peri-device leak ≧ 5 mm or stroke event in both groups. The AF recurrence rate was also similar between the two groups (P = 0.697). CONCLUSION We demonstrated that cardioversion or CPVI is doable in symptomatic AF patients with LAA thrombus if LAA was occluded ahead as a bailout procedure.
Collapse
Affiliation(s)
- Chin-Feng Tsai
- School of Medicine, Chung Shan Medical University, Taichung City, 401, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chung Shan Medical University Hospital, Taichung City, 401, Taiwan
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, 640, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei City, 100, Taiwan
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, 640, Taiwan
| | - Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, 640, Taiwan
| | - Sheng-Nan Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, 640, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei City, 100, Taiwan
| | - Jung-Cheng Hsu
- Division of Cardiology, Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, 220, Taiwan
| | - Su-Kiat Chua
- Division of Cardiology, Department of Internal Medicine, Shin-Kong Memorial Wu Ho-Su Hospital, Taipei City, 111, Taiwan
| | - Hsiao-Liang Cheng
- Department of Anesthesia, National Taiwan University Hospital, Taipei City, 100, Taiwan
| | - Yi-Chih Wang
- Cardiovascular Center, National Taiwan University Hospital, Taipei City, 100, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 100, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu City, 640, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei City, 100, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 100, Taiwan
| | - Chia-Ti Tsai
- Cardiovascular Center, National Taiwan University Hospital, Taipei City, 100, Taiwan. .,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei City, 100, Taiwan.
| |
Collapse
|
8
|
Mao Z, Zhong Y. Prognostic risk factors in patients with refractory heart failure treated with continuous veno-venous hemofiltration. Ther Apher Dial 2022; 26:1106-1113. [PMID: 35133069 DOI: 10.1111/1744-9987.13812] [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: 07/26/2021] [Revised: 01/12/2022] [Accepted: 02/05/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Investigation of the prognostic factors in patients with refractory heart failure (HF) undergoing continuous veno-venous hemofiltration (CVVH). METHODS Clinical data of 146 patients with refractory HF between May 2018 and December 2020 were retrospectively analyzed and divided into survival and death groups according to the prognosis. Vital signs, inflammatory markers, and renal function parameters were compared before and after treatment. RESULTS Central venous pressure levels were lower, whereas serum levels of brain natriuretic peptide, oxygen saturation, and cardiac output were higher after treatment (P < 0.05). Heart rate, systolic and diastolic blood pressures, serum levels of C-reactive protein, interleukin-6, tumor necrosis factor-α, interleukin-8, blood urea nitrogen, creatinine, and 24-h urinary protein were lower after treatment (P < 0.05). CONCLUSION CVVH improved renal function and regulated blood pressure and vital signs in patients with refractory HF. Age, APACHE II score, disease duration, and hypotension were risk factors affecting the prognosis. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Zhengzhi Mao
- Hemodialysis Room, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| | - Yanyan Zhong
- Emergency Center, The First People's Hospital of Wenling, Wenling, Zhejiang, China
| |
Collapse
|
9
|
Narasimhan B, Aedma SK, Bhatia K, Garg J, Kanuri SH, Turagam MK, Lakkireddy D. Current practice and future prospects in left atrial appendage occlusion. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1236-1252. [PMID: 34085712 DOI: 10.1111/pace.14284] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/30/2021] [Accepted: 05/30/2021] [Indexed: 01/31/2023]
Abstract
The thromboembolic complications of Atrial fibrillation (AF) remain a major problem in contemporary clinical practice. Despite advances and developments in anticoagulation strategies, therapy is complicated by the high risk of bleeding complications and need for meticulous medication compliance. Over the past few decades, the left atrial appendage has emerged as a promising therapeutic target to prevent thromboembolic events while mitigating bleeding complications and compliance issues. Emerging data indicates that it is a safe, effective and feasible alternative to systemic anticoagulation in patients with non-valvular AF. A number of devices have been developed for endocardial or epicardial based isolation of the left atrial appendage. Increasing experience has improved overall procedural safety and ease while simultaneously reducing device related complication rates. Furthermore, increasing recognition of the non-mechanical advantages of this procedure has led to further interest in its utility for further indications beyond the prevention of thromboembolic complications. In this review, we present a comprehensive overview of the evolution of left atrial appendage occlusion, commercially available devices and the role of this modality in the current management of AF. We also provide a brief outline of the landmark trials supporting this approach as well as the ongoing research and future prospects of left atrial appendage occlusion.
Collapse
Affiliation(s)
- Bharat Narasimhan
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | | | - Kirtipal Bhatia
- Icahn School of Medicine at Mount Sinai, New York, New York, USA.,St. Luke's-Roosevelt -Mount Sinai, New York, New York, USA
| | - Jalaj Garg
- Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | | | - Mohit K Turagam
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | |
Collapse
|
10
|
Baumeister TB, Helfen A, Wickenbrock I, Perings C. Vorhofflimmern und NOAK-Therapie: Benötigen wir eine transösophageale Echokardiografie vor Kardioversion? AKTUELLE KARDIOLOGIE 2021. [DOI: 10.1055/a-1470-2151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungVorhofflimmern ist ein häufiger Grund für einen Schlaganfall. Insbesondere Patienten ohne
adäquate Antikoagulation haben ein erhöhtes Risiko für thromboembolische Ereignisse (ca.
5–7%). Es liegt eine Assoziation zwischen Kardioversionen und embolischen Ereignissen vor.
Durch eine orale Antikoagulation (OAK) mit Nicht-Vitamin-K-Antagonisten (NOAK) kann dieses
Risiko auf unter 1% reduziert werden. Es gibt 2 unterschiedliche Kardioversionsstrategien. Zum
einen kann eine Kardioversion nach 3-wöchiger effektiver Antikoagulation ohne weitere
Bildgebung durchgeführt werden. Zum anderen kann nach Ausschluss einer intrakardialen
Thrombenbildung durch eine TEE umgehend sicher kardiovertiert werden. Bei Vorhofflimmern
sollte nach der Kardioversion eine effektive Antikoagulation für mindestens 4 Wochen erfolgen,
unabhängig vom CHA2DS2-VASc-Score. Eine Bildgebung mittels TEE ist
notwendig, wenn die Dauer einer effektiven Antikoagulation <3 Wochen ist, Unsicherheiten
bezüglich der regelmäßigen und lückenlosen Medikamenteneinnahme bestehen oder ein hohes Risiko
für linksatriale Thromben besteht.
Collapse
Affiliation(s)
- Timo-Benjamin Baumeister
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Andreas Helfen
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Ingo Wickenbrock
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| | - Christian Perings
- Klinik für Kardiologie, Elektrophysiologie, Pneumologie und internistische Intensivmedizin, Katholisches Klinikum Lünen Werne GmbH, St. Marien-Hospital Lünen, Lünen, Deutschland
| |
Collapse
|
11
|
Maarse M, Wintgens LIS, Ponomarenko A, Phillips KP, Romanov AB, Ballesteros G, Swaans MJ, Folkeringa RJ, Garcia-Bolao I, Boersma LVA. Impact of anticoagulation strategy after left atrial appendage occlusion in patients requiring direct current cardioversion. J Cardiovasc Electrophysiol 2021; 32:737-744. [PMID: 33448508 DOI: 10.1111/jce.14889] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Current guidelines recommend adequate anticoagulation for at least 3 weeks pre- and 4 weeks post-direct current cardioversion (DCCV) to reduce thrombo-embolic risk in patients with atrial fibrillation (AF) lasting greater than 48 h. No specific recommendations exist for DCCV in patients that have undergone left atrial appendage occlusion (LAAO), many of whom are ineligible for anticoagulation. This study aims to observe the efficacy and safety of DCCV post-LAAO in everyday clinical practice. METHODS This prospective multicenter registry included DCCVs in patients post-LAAO. Imaging strategy or anticoagulation treatment around DCCV were analyzed. Complications during 30-day follow-up were registered. DCCVs performed in accordance with current guidelines for the general AF population were compared to DCCVs performed deviating from these guidelines. RESULTS In 93 patients (age 65 ± 17 years, CHA2 DS2 -VASC 3.0 ± 1.3) 284 DCCVs were performed between 2010 and 2018, in 271 sinus rhythm was restored. A wide variety of imaging or anticoagulation strategies around DCCV was observed; in 128 episodes strategies deviated from current guidelines. No thrombo-embolic events were observed after any DCCV during 30-day follow-up. In 34 DCCVs trans-esophageal echocardiography (TOE) was performed before DCCV to exclude cardiac thrombi and/or (re-)verify adequate device positioning. In two patients without post-LAAO imaging before DCCV, a device rotation or embolization was observed during scheduled TOE after LAAO. CONCLUSION DCCV in AF patients after LAAO is highly effective. No thrombo-embolic events were observed in any patient in this observational cohort, regardless of the periprocedural anticoagulation or imaging strategy. Confirmation of adequate device positioning at least once before DCCV seems recommendable.
Collapse
Affiliation(s)
- Moniek Maarse
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Lisette I S Wintgens
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Andrey Ponomarenko
- Department of Arrhythmia and Electrophysiology Laboratory, E. Meshalkin National Medical Research Center of the Ministry of Health, Novosibirsk, Russian Federation
| | - Karen P Phillips
- Department of Cardiology, Greenslopes Private Hospital, HeartCare Partners, Greenslopes, Brisbane, Australia
| | - Aleksandr B Romanov
- Department of Arrhythmia and Electrophysiology Laboratory, E. Meshalkin National Medical Research Center of the Ministry of Health, Novosibirsk, Russian Federation
| | - Gabriel Ballesteros
- Servicio de Cardiología, Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Richard J Folkeringa
- Department of Cardiology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Ignacio Garcia-Bolao
- Unidad de Arritmias, Servicio de Cardiologia, University Clinic of Navarra, Pamplona, Navarra, Spain
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Cardiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
12
|
Kleinecke C, Gloekler S, Meier B. Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation: an update on patient outcomes. Expert Rev Cardiovasc Ther 2020; 18:517-530. [DOI: 10.1080/14779072.2020.1794820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Caroline Kleinecke
- Cardiology, Internal Medicine Department, Klinikum Lichtenfels, Lichtenfels, Germany
| | - Steffen Gloekler
- Cardiology, Internal Medicine Department, Klinikum Hochrhein, Waldshut-Tiengen, Germany and Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| |
Collapse
|
13
|
Murtaza G, Boda U, Turagam MK, Della Rocca DG, Akella K, Gopinathannair R, Lakkireddy D. Risks and Benefits of Removal of the Left Atrial Appendage. Curr Cardiol Rep 2020; 22:129. [PMID: 32910248 DOI: 10.1007/s11886-020-01387-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
PURPOSE OF REVIEW In patients with atrial fibrillation who are unable to take novel oral anticoagulants for stroke prophylaxis due to bleeding risk or other contraindications, left atrial appendage (LAA) occlusion and exclusion devices have shown benefit. In this review, we highlight the risks and benefits associated with LAA removal. RECENT FINDINGS LAA, once considered a vestigial organ, has been shown to have physiological, anatomical, and arrhythmogenic properties. Device-related complications such as pericardial effusion, device embolization, device-related thrombus, while uncommon, are still present. With increased operator experience related to appendage occlusion, overall procedural complications have declined. Further refinements in device technology will help decrease complications. While benefits of appendage removal are plenty, procedural complications need to be weighed into the equation when making decisions regarding LAA occlusion.
Collapse
Affiliation(s)
- Ghulam Murtaza
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Urooge Boda
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Mohit K Turagam
- Department of Cardiovascular Diseases, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Krishna Akella
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute (KCHRI) & Research Foundation, Overland Park Regional Medical Center, HCA MidWest, 12200, W 106th Street, Overland Park, KS, 66215, USA.
| |
Collapse
|
14
|
Mandrola J, Lip GYH, Foy A. A Time to Stop and Think Before the Shock. J Am Coll Cardiol 2019; 74:2275-2277. [PMID: 31672184 DOI: 10.1016/j.jacc.2019.08.1044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 08/19/2019] [Indexed: 10/25/2022]
Affiliation(s)
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andrew Foy
- Penn State University College of Medicine, Hershey, Pennsylvania
| |
Collapse
|