1
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Madsen OJ, Lamberts M, Olesen JB, Hansen ML, Kümler T, Grove EL, Andersen NH, Fosbøl E, De Backer O, Strange JE. Trends in percutaneous left atrial appendage occlusion and 1-year mortality 2013-2021: A nationwide observational study. Int J Cardiol 2024; 408:132098. [PMID: 38679168 DOI: 10.1016/j.ijcard.2024.132098] [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: 01/14/2024] [Revised: 04/10/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in patients with atrial fibrillation and anticoagulant-related complications. Yet, real-life studies evaluating changes in patient characteristics and indications for LAAO remain scarce. METHODS To evaluate changes in patient characteristics and indications for LAAO defined as 2-year history of intracerebral bleeding, any ischemic stroke/systemic embolism (SE), any non-intracerebral bleeding, other indication, and 1-year mortality. All patients undergoing percutaneous LAAO in Denmark from 2013 to 2021 were stratified into the following year groups: 2013-2015, 2016-2018, and 2019-2021. RESULTS In total, 1465 patients underwent LAAO. Age remained stable (2013-2015: 74 years versus 2019-2021: 75 years). Patients' comorbidity burden declined, exemplified by CHA2DS2-VASc ≥4 and HAS-BLED ≥3 decreased from 56.7% and 63.7% in 2013-2015 to 40.3% and 45.8% in 2019-2021. Indications for LAAO changed over time with other indication comprising 44.7% in 2019-2021; up from 26.9% in 2013-2015. Conversely, fewer patients had an indication of any ischemic stroke/SE (2013-2015: 30.8% vs 2019-2021: 20.3%) or any non-intracerebral bleeding (2013-2015: 29.4% vs 2019-2021: 23.4%). 1-year mortality was 11.3% for any non-intracerebral bleeding and 6.2% for other indication. CONCLUSION The LAAO patient-profile has changed considerably. Age remained stable, while comorbidity burden decreased during the period 2013-2021. LAAO is increasingly used in patients with no clinical event history and mortality differs according to indication. Selection of patients to LAAO should be done carefully, and contemporary real-life studies investigating clinical practice could add important insights.
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Affiliation(s)
- Olivia J Madsen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark.
| | - Morten Lamberts
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
| | - Jonas B Olesen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
| | - Morten L Hansen
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark
| | - Thomas Kümler
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark; Complication Research, Steno Diabetes Center Copenhagen, Capital Region of Denmark, Denmark
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Niels H Andersen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ole De Backer
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte Hospital, Denmark; Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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2
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Friedman DJ, Du C, Zimmerman S, Tan Z, Lin Z, Vemulapalli S, Kosinski A, Piccini JP, Pereira L, Minges KE, Faridi KF, Masoudi FA, Curtis JP, Freeman JV. Procedure Volume and Outcomes With WATCHMAN Left Atrial Appendage Occlusion. Circ Cardiovasc Interv 2024; 17:e013466. [PMID: 38889251 PMCID: PMC11189610 DOI: 10.1161/circinterventions.123.013466] [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] [Received: 12/04/2023] [Accepted: 02/27/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Procedure volumes are associated with outcomes for many cardiovascular procedures, leading to guidelines on minimum volume thresholds for certain procedures; however, the volume-outcome relationship with left atrial appendage occlusion is poorly understood. As such, we sought to determine the relationship between hospital and physician volume and WATCHMAN left atrial appendage occlusion procedural success overall and with the new generation WATCHMAN FLX device. METHODS We performed an analysis of WATCHMAN procedures (January 2019 to October 2021) from the National Cardiovascular Data Registry LAAO Registry. Three-level hierarchical generalized linear models were used to assess the adjusted relationship between procedure volume and procedural success (device released with peridevice leak <5 mm, no in-hospital major adverse events). RESULTS Among 87 480 patients (76.2±8.0 years; 58.8% men; mean CHA2DS2-VASc score, 4.8±1.5) from 693 hospitals, the procedural success rate was 94.2%. With hospital volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (odds ratio [OR], 0.66 [CI, 0.57-0.77]) and Q2 (OR, 0.78 [CI, 0.69-0.90]) but not Q3 (OR, 0.95 [CI, 0.84-1.07]). With physician volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (OR, 0.72 [CI, 0.63-0.82]), Q2 (OR, 0.79 [CI, 0.71-0.89]), and Q3 (OR, 0.88 [CI, 0.79-0.97]). Among WATCHMAN FLX procedures, there was attenuation of the volume-outcome relationships, with statistically significant but modest absolute differences of only ≈1% across volume quartiles. CONCLUSIONS In this contemporary national analysis, greater hospital and physician WATCHMAN volumes were associated with increased procedure success. The WATCHMAN FLX transition was associated with increased procedural success and less heterogeneity in outcomes across volume quartiles. These findings indicate the importance of understanding the volume-outcome relationship for individual left atrial appendage occlusion devices.
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Affiliation(s)
- Daniel J. Friedman
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Sarah Zimmerman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Zhen Tan
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | | | - Andrzej Kosinski
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Lucy Pereira
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
| | - Karl E. Minges
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Department of Population Health and Leadership, University of New Haven, West Haven, CT, USA
| | - Kamil F. Faridi
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Jeptha P. Curtis
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James V. Freeman
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
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3
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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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4
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Jung M, Kim SW, Park JW. Trends in percutaneous left atrial appendage occlusion and 1-year mortality 2013-2021: A nationwide observational study. Int J Cardiol 2024; 410:132222. [PMID: 38823530 DOI: 10.1016/j.ijcard.2024.132222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Affiliation(s)
- Moonki Jung
- Heart and Brain Hospital, Chung-Ang University Gwangmyeong Center, Gwangmyeong and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Sang-Wook Kim
- Heart and Brain Hospital, Chung-Ang University Gwangmyeong Center, Gwangmyeong and Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jai-Wun Park
- Department of Cardiology, Charité University Medicine, Campus Benjamin Franklin, Berlin, Germany.
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5
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Makkar A, Alkhouli M, Ellis CR, Shah AP, Coylewright M, Freeman JV, Anderson JA, Gage R, Lakkireddy D. Feasibility of Amulet occluder implantation after failed left atrial appendage occlusion attempt: Insights from the EMERGE LAA postapproval study. Heart Rhythm 2024:S1547-5271(24)02541-4. [PMID: 38768843 DOI: 10.1016/j.hrthm.2024.05.004] [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] [Received: 03/22/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although expertise in left atrial appendage occlusion (LAAO) has grown, certain intricate anatomies may pose challenges, rendering them unsuitable for LAAO with the selected device. OBJECTIVE This analysis aimed to characterize outcomes of patients with prior failed percutaneous LAAO procedures who underwent a subsequent attempt with an Amulet occluder in the EMERGE LAA postapproval study. METHODS Patients enrolled in the National Cardiovascular Data Registry LAAO Registry who had an Amulet occluder implantation attempt between Food and Drug Administration approval (August 14, 2021) and June 30, 2023, were evaluated. A safety end point through 7 days or hospital discharge (whichever was later) and major adverse events through 45 days were reported. RESULTS A total of 8591 patients underwent attempted Amulet occluder implantation, of whom 244 patients had prior failed LAAO. Implantation success was 88.9% and 96.2% in patients with prior failed LAAO and index LAAO, respectively (P < .001). The safety composite end point was low, occurring in 1.6% and 0.8% of patients with prior failed LAAO and index LAAO, respectively (P = .148). Any major adverse event through 45 days occurred in 7.4% and 6.3% of prior failed LAAO and index LAAO patient cohorts, respectively (P = .497); most adverse events were similar between the groups (P > .05). At 45 days, peridevice leak ≤3 mm was achieved in >90% of patients in either group. CONCLUSION A high degree of implantation success with a low rate of adverse events can be achieved with the Amulet occluder. The findings imply that the dual occlusive mechanism Amulet occluder facilitates successful closure, even in challenging anatomic scenarios.
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Affiliation(s)
- Akash Makkar
- Arizona Heart Arrhythmia Associates, Phoenix, Arizona.
| | | | | | | | - Megan Coylewright
- Erlanger and University of Tennessee Health Science Center, College of Medicine, Chattanooga, Tennessee
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Ryan Gage
- Abbott Structural Heart, Plymouth, Minnesota
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6
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Nakashima M, Yamamoto M, Sago M, Tanaka S, Chatani R, Asami M, Hachinohe D, Naganuma T, Ohno Y, Tani T, Okamatsu H, Mizutani K, Watanabe Y, Izumo M, Saji M, Mizuno S, Ueno H, Kubo S, Shirai S, Hayashida K. Comparative Data of Procedural and Midterm Outcomes in Patients Who Underwent Percutaneous Left Atrial Appendage Closure Between the WATCHMAN FLX and WATCHMAN 2.5 Devices - Insight From the OCEAN-LAAC Registry. Circ J 2024:CJ-24-0062. [PMID: 38763735 DOI: 10.1253/circj.cj-24-0062] [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: 05/21/2024]
Abstract
BACKGROUND Limited data are available regarding clinical outcomes after percutaneous left atrial appendage closure using WATCHMAN FLX (WM-FLX) and WATCHMAN-2.5 (WM2.5) devices in Asian patients.Methods and Results: Data of 1,464 consecutive patients (WM-FLX, n=909; WM2.5, n=555) were extracted from a Japanese multicenter registry, and clinical data were compared between the 2 groups. No in-hospital deaths, periprocedural stroke, or device embolization occurred. Procedural success was significantly higher in the WM-FLX than WM2.5 group (95.8% vs. 91.9%; P=0.002) owing to the lower incidence of periprocedural pericardial effusion (0.55% vs. 1.8%; P=0.021). No significant differences in all-cause death, postprocedural stroke, and device-related thrombus were observed between the 2 groups. However, the cumulative bleeding rate at 1 year was substantially lower in the WM-FLX group (7.8% vs. 16.4%; P<0.001). Landmark analysis of bleeding events highlighted lower bleeding rates in the WM-FLX than WM2.5 group within the first 6 months (6.4% vs. 14.8%; P<0.001), with comparable bleeding rates over the 6- to 12-month period (1.5% vs. 3.2%, respectively; P=0.065). CONCLUSIONS This study demonstrated higher early safety and lower 1-year bleeding rates in the WM-FLX than WM2.5 group. The lower bleeding events with WM-FLX are likely due to multiple factors other than purely difference in devices, such as postprocedural drug regimen.
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Affiliation(s)
| | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center
- Department of Cardiology, Nagoya Heart Center
- Department of Cardiology, Gifu Heart Center
| | - Mitsuru Sago
- Department of Cardiology, Toyohashi Heart Center
| | - Shuhei Tanaka
- Department of Cardiology, Toyama University Hospital
| | - Ryuki Chatani
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Daisuke Hachinohe
- Department of Cardiology, Sapporo Heart Center, Sapporo Cardio Vascular Clinic
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine
| | - Tomoyuki Tani
- Department of Cardiology, Sapporo East Tokushukai Hospital
| | | | - Kazuki Mizutani
- Division of Cardiology, Department of Medicine, Kindai University Faculty of Medicine
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital
| | - Hiroshi Ueno
- Department of Cardiology, Toyama University Hospital
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
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7
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Golzarian H, Pasley BA, Shah SR, Thiel AM, Knous M, Kleman AC, Saum JL, Hempfling GL, Otto M, Otto T, Racer L, Martz D, Gemmel DJ, Laird AD, Cole WC, Parsa P, Imm C, Patel SM. Single-Operator Left atrial appendage Occlusion utilizing Conscious sedation TEE, Lack of Outpatient pre-imaging, and Same-day Expedited discharge (SOLO-CLOSE): A comparison with conventional approach. Catheter Cardiovasc Interv 2024. [PMID: 38736248 DOI: 10.1002/ccd.31073] [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] [Received: 03/27/2024] [Revised: 04/24/2024] [Accepted: 04/29/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) with WATCHMAN currently requires preprocedural imaging, general anesthesia, and inpatient overnight admission. We sought to facilitate simplification of LAAO. AIMS We describe and compare SOLO-CLOSE (single-operator LAA occlusion utilizing conscious sedation TEE, lack of outpatient pre-imaging, and same-day expedited discharge) with the conventional approach (CA). METHODS A single-center retrospective analysis of 163 patients undergoing LAAO between January 2017 and April 2022 was conducted. The SOLO-CLOSE protocol was enacted on December 1, 2020. Before this date, we utilized the CA. The primary efficacy endpoint was defined as successful LAAO with ≤5 mm peri-device leak at time of closure. The primary safety endpoint was the composite incidence of all-cause deaths, any cerebrovascular accident (CVA), device embolization, pericardial effusion, or major postprocedure bleeding within 7 days of the index procedure. Procedure times, 7-day readmission rates, and cost analytics were collected as well. RESULTS Baseline characteristics were similar in both cohorts. Congestive heart failure (37.5% vs. 11.1%) and malignancy (28.8% vs. 12.5%) were higher in SOLO-CLOSE. Median CHA2D2SVASc score was 5 in both cohorts. The primary efficacy endpoint was met 100% in both cohorts. Primary safety endpoint was similar between cohorts (p = 0.078). Mean procedure time was 30 min shorter in SOLO-CLOSE (p < 0.01). Seven-day readmissions for SOLO-CLOSE was zero. After SOLO-CLOSE implementation, there was a 188% increase in positive contribution margin per case. CONCLUSIONS The SOLO-CLOSE methodology offers similar efficacy and safety when compared to the CA, while improving clinical efficiency, reducing procedural times, and increasing economic benefit.
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Affiliation(s)
- Hafez Golzarian
- Department of Internal Medicine, Internal Medicine Residency Program, Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Benjamin A Pasley
- Department of Internal Medicine, Internal Medicine Residency Program, Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Sidra R Shah
- Department of Internal Medicine, Internal Medicine Residency Program, Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Arielle M Thiel
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Mallory Knous
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Anna C Kleman
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Jamie L Saum
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Gerri L Hempfling
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Michael Otto
- Department of Cardiothoracic & Vascular Surgery, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Todd Otto
- Department of Cardiothoracic & Vascular Surgery, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Lisa Racer
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Denise Martz
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - David J Gemmel
- Department of Internal Medicine, Graduate Medical Education Research, Bon Secours Mercy Health-St. Elizabeth Youngstown Hospital, Youngstown, Ohio, USA
| | - Amanda D Laird
- Department of Critical Care, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - William C Cole
- Department of Critical Care, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Prabhakar Parsa
- Department of Anesthesia, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Craig Imm
- Department of Anesthesia, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
| | - Sandeep M Patel
- Department of Cardiology, Structural Heart & Intervention Center, Bon Secours Mercy Health-St. Rita's Medical Center, Lima, Ohio, USA
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8
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Caccia A, Ruzzenenti G, Bellantonio V, Falco R, Kotinas AS, Preda A, Mazzone P. Challenging Silent Cerebral Embolism during Left Atrial Appendage Occlusion: A Lesson from Recent Studies. Cardiology 2024:1-2. [PMID: 38588645 DOI: 10.1159/000538337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Accepted: 03/08/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Andrea Caccia
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Giacomo Ruzzenenti
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Raffaele Falco
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | | | - Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, Milan, Italy,
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9
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Procopio A, Radico F, Gragnano F, Ghiglieno C, Fassini G, Filtz A, Barbarossa A, Sacchetta D, Faustino M, Ricci F, Russo AD, Calabrò P, Patti G, Gallina S, Renda G. A real-world multicenter study on left atrial appendage occlusion: The Italian multi-device experience. IJC HEART & VASCULATURE 2024; 51:101391. [PMID: 38560514 PMCID: PMC10979264 DOI: 10.1016/j.ijcha.2024.101391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/12/2024] [Accepted: 03/17/2024] [Indexed: 04/04/2024]
Abstract
Background Transcatheter left atrial appendage occlusion (LAAO) has emerged as an alternative treatment for stroke prevention in patients with atrial fibrillation (AF) at high risk of thromboembolism, who cannot tolerate long-term oral anticoagulation (OAC). Questions persist regarding effectiveness and safety of this treatment and the optimal post-interventional antithrombotic regimen after LAAO. Methods We retrospectively gathered data from 428 patients who underwent percutaneous LAAO in 6 Italian high-volume centres, aimed at describing the real-world utilization, safety, and effectiveness of LAAO procedures, also assessing the clinical outcomes associated with different antithrombotic strategies. Results Among the entire population, 20 (4.7 %) patients experienced a combination of pericardial effusion and periprocedural major bleeding: 8 (1.9 %) pericardial effusion, 1 (0.3 %) fatal bleeding, and 3 (0.7 %) non-fatal procedural major bleeding. Patients were discharged with different antithrombotic regimens: dual (DAPT) (27 %) or single (SAPT) (26 %) antiplatelet therapy, OAC (27 %), other antithrombotic regimens (14 %). Very few patients were not prescribed with antithrombotic drugs (6 %). At a medium 523 ± 58 days follow-up, 14 patients (3.3 %) experienced all-cause death, 6 patients (1.4 %) cardiovascular death, 3 patients (0.7 %) major bleeding, 10 patients (2.6 %) clinically relevant non-major bleeding, and 3 patients (0.7 %) ischemic stroke. At survival analysis, with DAPT as the reference group, OAC therapy was associated with better outcomes. Conclusions Our findings confirm that LAAO is a safe procedure. Different individualized post-discharge antithrombotic regimens are now adopted, likely driven by the perceived thrombotic and hemorrhagic risk. The incidence of both ischemic and bleeding events tends to be low.
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Affiliation(s)
| | | | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. Sant'Anna e San Sebastiano, F. Palasciano, Caserta, Italy
| | - Chiara Ghiglieno
- Division of Cardiology, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Gaetano Fassini
- Department of Clinical Electrophysiology & Cardiac Pacing Heart Rhythm Center at Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Annalisa Filtz
- Department of Clinical Electrophysiology & Cardiac Pacing Heart Rhythm Center at Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Alessandro Barbarossa
- Cardiology ed Arrhythmology Clinic, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | | | | | - Fabrizio Ricci
- Heart Department, ASL 02 Abruzzo, Chieti, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Antonio Dello Russo
- Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Caserta, Italy
- Division of Clinical Cardiology, A.O.R.N. Sant'Anna e San Sebastiano, F. Palasciano, Caserta, Italy
| | - Giuseppe Patti
- Division of Cardiology, Maggiore della Carità Hospital, University of Eastern Piedmont, Novara, Italy
| | - Sabina Gallina
- Heart Department, ASL 02 Abruzzo, Chieti, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Giulia Renda
- Heart Department, ASL 02 Abruzzo, Chieti, Italy
- Department of Neuroscience, Imaging and Clinical Sciences, G. d'Annunzio University of Chieti-Pescara, Chieti, Italy
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10
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Darden D, Bilal Munir M, Zimmerman S, Eskander M, Pothineni NVK, Gopinathannair R, Kabra R, Lakkireddy D, Duong T, Han FT, Freeman JV, Hsu JC. Frailty and associated outcomes in patients undergoing percutaneous left atrial appendage occlusion: findings from the NCDR LAAO registry. J Interv Card Electrophysiol 2024; 67:625-635. [PMID: 37858000 DOI: 10.1007/s10840-023-01662-1] [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: 07/22/2023] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Frailty is associated with significant morbidity and mortality and may have clinical implications in an advanced age population with atrial fibrillation undergoing left atrial appendage occlusion (LAAO). We sought to develop a novel frailty scale to predict worse outcomes in patients undergoing LAAO. METHODS Patients in the NCDR LAAO Registry between 2016 and 2021 receiving percutaneous LAAO devices were categorized as non-frail (0 points), pre-frail (1-3 points), or frail (4-5 points) based on a 5-point scale representing multiple domains of frailty: hemoglobin <13.0 g/dL in male, <12.0 g/dL in female; creatinine ≥1.2 mg/dL; albumin <3.5 g/dL; body mass index <20 kg/m2; and increased risk of falls. RESULTS Of 57,728 patients, 44,360 (76.8%) were pre-frail and 7693 (13.3%) were frail. Compared to non-frail, pre-frail and frail patients were older, had a higher burden of co-morbidities, and more disability based on the Modified Rankin Scale. Compared to non-frail patients after adjustment, frail patients were at higher risk of in-hospital major complication (OR 1.29, 95% 1.02-1.62, p = 0.01), any complication (OR 1.29, 95% CI 1.09-1.52, p = 0.0005), and death (OR 5.79, 95% CI 1.75-19.17, p = 0.001), while no difference was observed in pre-frail patients. At 45-day follow-up, there was no difference in the risk of complications in frail patients as compared to non-frail, although mortality was significantly higher (OR 3.01, 95% CI 1.97-4.85, p < 0.0001). CONCLUSION A simple and practical frailty scale accurately predicts adverse events in patients undergoing LAAO. The 13% of patients considered frail were at significantly higher risk of in-hospital adverse events and 45-day mortality.
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Affiliation(s)
- Douglas Darden
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, 66211, USA.
| | - M Bilal Munir
- Division of Cardiology, Department of Medicine, University of California Davis, Sacramento, CA, USA
| | - Sarah Zimmerman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Rakesh Gopinathannair
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, 66211, USA
| | - Rajesh Kabra
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, 66211, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute, 5100 W 110th St, Suite 200, Overland Park, KS, 66211, USA
| | - Thao Duong
- Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas City, MO, USA
| | - Frederick T Han
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Jonathan C Hsu
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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11
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Faridi KF, Ong EL, Zimmerman S, Varosy PD, Friedman DJ, Hsu JC, Kusumoto F, Mortazavi BJ, Minges KE, Pereira L, Lakkireddy D, Koutras C, Denton B, Mobayed J, Curtis JP, Freeman JV. Predicting Major Adverse Events in Patients Undergoing Transcatheter Left Atrial Appendage Occlusion. Circ Arrhythm Electrophysiol 2024; 17:e012424. [PMID: 38390713 PMCID: PMC11021146 DOI: 10.1161/circep.123.012424] [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] [Received: 08/28/2023] [Accepted: 01/31/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND The National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry (LAAO) includes the vast majority of transcatheter LAAO procedures performed in the United States. The objective of this study was to develop a model predicting adverse events among patients undergoing LAAO with Watchman FLX. METHODS Data from 41 001 LAAO procedures with Watchman FLX from July 2020 to September 2021 were used to develop and validate a model predicting in-hospital major adverse events. Randomly selected development (70%, n=28 530) and validation (30%, n=12 471) cohorts were analyzed with 1000 bootstrapped samples, using forward stepwise logistic regression to create the final model. A simplified bedside risk score was also developed using this model. RESULTS Increased age, female sex, low preprocedure hemoglobin, no prior attempt at atrial fibrillation termination, and increased fall risk most strongly predicted in-hospital major adverse events and were included in the final model along with other clinically relevant variables. The median in-hospital risk-standardized adverse event rate was 1.50% (range, 1.03%-2.84%; interquartile range, 1.42%-1.64%). The model demonstrated moderate discrimination (development C-index, 0.67 [95% CI, 0.65-0.70] and validation C-index, 0.66 [95% CI, 0.62-0.70]) with good calibration. The simplified risk score was well calibrated with risk of in-hospital major adverse events ranging from 0.26% to 3.90% for a score of 0 to 8, respectively. CONCLUSIONS A transcatheter LAAO risk model using National Cardiovascular Data Registry and LAAO Registry data can predict in-hospital major adverse events, demonstrated consistency across hospitals and can be used for quality improvement efforts. A simple bedside risk score was similarly predictive and may inform shared decision-making.
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Affiliation(s)
- Kamil F. Faridi
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Emily L. Ong
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
| | - Sarah Zimmerman
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Paul D. Varosy
- Cardiology Section, VA Eastern Colorado Hlth Care System, Aurora, CO
| | | | - Jonathan C. Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Univ of California San Diego Health System, La Jolla, CA
| | - Fred Kusumoto
- Dept of Cardiovascular Disease, Mayo Clinic, Jacksonville, FL
| | - Bobak J. Mortazavi
- Dept of Computer Science & Engineering, Texas A&M Univ, College Station, TX
| | - Karl E. Minges
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - Lucy Pereira
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | | | | | - Beth Denton
- American College of Cardiology, Washington, DC
| | | | - Jeptha P. Curtis
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
| | - James V. Freeman
- Section of Cardiovascular Medicine, Dept of Medicine, Yale School of Medicine
- Ctr for Outcomes Rsrch & Evaluation, Yale New Haven Health, New Haven, CT
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12
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Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [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: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
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13
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Yu C, Li H, Lei C, Wang Y, Chen S, Zhao Y, Zheng Z. Epicardial left atrial appendage clipping versus direct oral anticoagulant to reduce stroke risk in non-paroxysmal atrial fibrillation (LAA-CLIP): rationale, design and study protocol for a multicentre randomised controlled trial. BMJ Open 2024; 14:e083153. [PMID: 38448081 PMCID: PMC10916171 DOI: 10.1136/bmjopen-2023-083153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024] Open
Abstract
INTRODUCTION The prevalence of atrial fibrillation (AF) is increasing globally, and stroke prevention is the key to reduce the morbidity and mortality related to AF. Currently, direct oral anticoagulants (DOACs) are the primary options for stroke prevention, while it increases risk of bleeding. Left atrial appendage (LAA) is suspected as a vital source of cerebral emboli and may lead to ischaemic stroke, and thoracoscopic LAA clipping procedure provides an alternative option for stroke prevention in high-risk patients. However, high-quality evidence comparing LAA clipping to DOACs in terms of stroke prevention is lacking. This trial is designed to assess whether the efficacy of thoracoscopic LAA clipping is superior to DOACs for stroke prevention in AF patients at high risk of thrombosis (CHA2DS2-VASc≥2 in men and ≥3 in women)[CHA2DS2-VASc stands for "congestive heart failure, hypertension, age ≥75 (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female)"]. METHODS AND ANALYSIS This is a prospective, multicentre, open-labelled, randomised controlled study. This trial will randomly assign 290 patients with non-paroxysmal AF to thoracoscopic LAA clipping group or DOAC therapy group in a 1:1 randomisation. The primary endpoint is defined as a composite endpoint event consisting of stroke, systemic embolism, all-cause mortality, major bleeding events and clinically relevant non-major bleeding events at 24 months after randomisation. The secondary endpoints consist of the components of the primary composite endpoint, surgery-related adverse events and minor bleeding events. ETHICS AND DISSEMINATION The central ethics committee at Fuwai Hospital approved the trial entitled "Epicardial left atrial appendage clipping versus direct oral anticoagulant to reduce stroke risk in non-paroxysmal atrial fibrillation (LAA-CLIP trial)". The results of this study will be disseminated through publications in peer-reviewed journals and conference presentations. TRIAL REGISTRATION NUMBER NCT06021808.
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Affiliation(s)
- Chunyu Yu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Haojie Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Chuxiang Lei
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yang Wang
- Medical Research & Biometrics Center, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Sipeng Chen
- Department of Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Yan Zhao
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
| | - Zhe Zheng
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, People's Republic of China
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14
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Maksym J, Grabowski M, Mazurek T. Percutaneous left atrial appendage closure with the Watchman device: a systematic review. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2024; 20:18-29. [PMID: 38616940 PMCID: PMC11008520 DOI: 10.5114/aic.2024.136406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 01/03/2024] [Indexed: 04/16/2024] Open
Abstract
Atrial fibrillation (AF) is the most commonly observed arrhythmia in the world and its prevalence increases with age. The main and most severe complication of AF is ischemic stroke. Oral anticoagulation (OAC) therapy is the standard of care for stroke prevention in the high risk population. Initiation of this treatment is associated with a substantial risk of bleeding complications. Moreover, there is a group of patients who cannot tolerate OAC. In patients with AF the left atrial appendage (LAA) is the main source of thrombus formation. Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular AF. The procedure aims to reduce the risk of thromboembolism without increasing the risk of bleeding. Over the last few years, the safety and long-term efficacy of the procedure in specific populations have increased and more patients are being treated. The Watchman device is the most studied device in this field. Randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using the WATCHMAN 2.5 device to OAC (Boston Scientific, Marlborough, MA, USA). The new generation device, WATCHMAN FLX, was introduced and its use was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved problems remain, including device-related thrombosis, the post-LAAC antithrombotic regimen, and peri-device leakage. This review will focus on LAAC with the Watchman device for stroke prevention in AF patients. Current status, available literature, clinical safety and efficacy will be summarized.
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Affiliation(s)
- Jakub Maksym
- First Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Grabowski
- First Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Tomasz Mazurek
- First Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
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15
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Ono S, Maruo T, Kubo S, Kadota K. Validation study of new left atrial appendage closure device measurement by two-dimensional and three-dimensional transesophageal echocardiography. J Echocardiogr 2024; 22:16-24. [PMID: 37644318 DOI: 10.1007/s12574-023-00619-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/08/2023] [Accepted: 08/02/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND In left atrial appendage closure using WATCHMAN FLX, accurate device measurement by transesophageal echocardiography (TEE) is important. We aimed to experimentally validate appropriate methods of device measurement with two-dimensional (2D) and three-dimensional (3D) TEE compared with actual size. METHODS We prepared a full range of device sizes (20, 24, 27, 31, 35 mm), each with five different compression rates. Each device was measured by 2D and 3D TEE at depths of 2, 4, and 6 cm in vitro using inner, outer, and middle line methods. We compared the difference between the actual size by caliper and measurements at each compression rate and depth by the three methods in 2D and 3D TEE. RESULTS A total of 450 patterns of measurements were analyzed. The differences using the middle line method were much less than those using the inner and outer line methods in 2D and 3D TEE (2D TEE: 0.45 ± 0.36 vs. 2.55 ± 0.99 vs. 2.59 ± 0.72 mm, p < 0.01; 3D TEE: 0.34 ± 0.27 vs. 2.38 ± 0.69 vs. 1.86 ± 0.77 mm, p < 0.01). Moreover, the differences in measurements by 3D TEE were more accurate than those of 2D TEE in the inner (2.47 ± 1.86 vs. 1.86 ± 0.77 mm, p < 0.01) and middle (0.58 ± 0.37 vs. 0.34 ± 0.27 mm, p < 0.01) line methods. CONCLUSIONS Middle line method by 3D TEE is the most reliable approach for device measurement at left atrial appendage closure using WATCHMAN FLX device.
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Affiliation(s)
- Sachiyo Ono
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan.
| | - Takeshi Maruo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
| | - Kazushige Kadota
- Department of Cardiology, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-0052, Japan
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16
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Lin KJ, Singer DE, Avorn J, Heist EK, Sreedhara SK, Anand P, Zhang Y, Tsacogianis TN, Schneeweiss S. Patient Characteristics Associated With Using Transcatheter Left Atrial Appendage Occlusion Versus Oral Anticoagulants for Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2024; 17:e010279. [PMID: 38440888 PMCID: PMC10950527 DOI: 10.1161/circoutcomes.123.010279] [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] [Received: 06/06/2023] [Accepted: 11/30/2023] [Indexed: 03/06/2024]
Abstract
BACKGROUND Transcatheter left atrial appendage occlusion (LAAO) is an alternative to oral anticoagulants (OACs) for stroke prevention in patients with atrial fibrillation, but the predictors of LAAO use in routine care are unclear. We aimed to assess the utilization trends of LAAO and compare the change in characteristics of LAAO users versus OACs since its marketing. METHODS Using the US Medicare claims database (March 15, 2015, to December 31, 2020), we identified patients with atrial fibrillation, ≥65 years, and CHA2DS2-VASc score ≥2 (men) or ≥3 (women), with either first implantation of an LAAO device or initiation of OACs, including apixaban, dabigatran, rivaroxaban, edoxaban, or warfarin. Patient characteristics, measured 365 days before the first LAAO or OAC use date, were compared using logistic regression. RESULTS There were 30 058 LAAO recipients (mean age, 77.74 years; female, 42.1%) and 792 600 OAC initiators (mean age, 78.48; female, 53.3%). In 2020, patients had higher odds of initiating LAAO use than in 2015 (0.52 versus 9.32%; adjusted odds ratio [aOR], 13.64 [95% CI, 12.56-14.81]). Old age (ie, >85 versus 65-75 years; aOR, 0.84 [95% CI, 0.80-0.88]), female sex (aOR, 0.74 [95% CI, 0.71-0.76]), Black race (aOR, 0.63 [95% CI, 0.58-0.68]) versus White race, and Medicaid eligibility (aOR, 0.61 [95% CI, 0.58-0.64]) were associated with lower odds of receiving LAAO. Among clinical characteristics, frailty, cancer, fractures, and venous thromboembolism were associated with lower odds of LAAO use, while history of intracranial and extracranial bleeding, coagulopathy, and falls were associated with higher odds of receiving LAAO. CONCLUSIONS Among patients with atrial fibrillation receiving stroke-preventive therapy, LAAO use increased rapidly from 2015 to 2020 and was positively associated with the risk factors for OAC complications but negatively associated with old age, advanced frailty, and cancer. Black race and female sex were associated with a lower likelihood of receiving LAAO.
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Affiliation(s)
- Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Daniel E Singer
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Jerry Avorn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - E. Kevin Heist
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School
| | - Sushama Kattinakere Sreedhara
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Priyanka Anand
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Yichi Zhang
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Theodore N. Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School
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Gupte T, Al-Sadawi M, Luke T, Smith EK, Mehta N, Liang JJ, Chugh A, Morady F, Romano MA, Oral H, Ghannam M. Clinical outcomes of patients referred for left atrial appendage exclusion who did and did not undergo the procedure. Heart Rhythm 2024:S1547-5271(24)00216-9. [PMID: 38403234 DOI: 10.1016/j.hrthm.2024.02.044] [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] [Received: 11/02/2023] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Left atrial appendage exclusion (LAAE) is an effective alternative to long-term anticoagulation in patients with atrial fibrillation. Not all patients considered for LAAE undergo the procedure because of ineligibility, anatomic or medical constraints, and preference of the patient. OBJECTIVE The objective of this study was to report on the management strategies and long-term clinical outcomes of patients referred to a dedicated multidisciplinary LAAE clinic, including all who subsequently did and did not undergo LAAE. METHODS This was a retrospective analysis of prospectively acquired data from all patients referred to the comprehensive multidisciplinary LAAE clinic at the University of Michigan between 2016 and 2022. A consecutive 301 patients (age, 75 ± 8 years; 106 women) with atrial fibrillation were evaluated. LAAE was performed in 168 patients (56%) with use of the Watchman device in 146 (49%) and surgically in 22 (7%). LAAE was not performed in 133 patients (44%, no-LAAE group) because of ineligibility in 62 (21%), anatomic constraints in 23 (7%), and preference of the patient in 48 (36%). The CHA2DS2-VASc score (4.7 ± 1.5 vs 4.1 ± 1.6; P = .002) and HAS-BLED score (3.4 ± 1.0 vs 2.8 ± 1.1; P < .001) were higher in the LAAE groups. RESULTS Anticoagulant therapy was discontinued in 137 of 146 (94%) and 61 of 133 (61%) in the Watchman and no-LAAE groups, respectively (P < .001). During a median follow-up of 2.2 years (interquartile range, 1.2-4.0 years), in the LAAE (n = 168) and no-LAAE (n = 133) groups, respectively, 39 (23%) vs 29 (22%) deaths, 13 (8%) vs 5 (4%) thromboembolic events, and 24 (14%) vs 23 (17%) bleeding complications occurred. Continued long-term anticoagulation was not a predictor of clinical outcomes. CONCLUSION After a comprehensive evaluation in a multidisciplinary clinic, ∼50% of the patients referred for LAAE did not proceed with LAAE and resumed anticoagulation.
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Affiliation(s)
- Trisha Gupte
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Mohammed Al-Sadawi
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Tiffany Luke
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Eryn K Smith
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Nimita Mehta
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Jackson J Liang
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Aman Chugh
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Fred Morady
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Michael Ghannam
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
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Milutinovic S, Lopez-Mattei J, Rosen J, Agarwal A, Escárcega RO. Circumflex to Left Atrial Appendage Fistula Associated With Watchman FLX Closure Device. JACC Case Rep 2024; 29:102202. [PMID: 38379660 PMCID: PMC10874893 DOI: 10.1016/j.jaccas.2023.102202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/07/2023] [Accepted: 12/11/2023] [Indexed: 02/22/2024]
Abstract
An 82-year-old man who had undergone Watchman FLX (Boston Scientific) device implantation presented with dyspnea. Multimodality evaluation demonstrated a small fistula from the proximal circumflex artery to the left atrial appendage. Anatomically, the left circumflex artery is close to the atrial appendage; therefore, it is plausible that fistula formation could be a late complication of implantation of the device.
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Affiliation(s)
- Stefan Milutinovic
- Florida State University College of Medicine Internal Medicine Residency Program at Lee Health, Cape Coral, Florida, USA
| | | | - Jeffrey Rosen
- Lee Health Heart Institute, Fort Myers, Florida, USA
- Florida Heart Associates, Fort Myers, Florida, USA
| | - Anuj Agarwal
- Lee Health Heart Institute, Fort Myers, Florida, USA
- Florida Heart Associates, Fort Myers, Florida, USA
| | - Ricardo O. Escárcega
- Florida State University College of Medicine Internal Medicine Residency Program at Lee Health, Cape Coral, Florida, USA
- Lee Health Heart Institute, Fort Myers, Florida, USA
- Florida Heart Associates, Fort Myers, Florida, USA
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Martin SS, Aday AW, Almarzooq ZI, Anderson CAM, Arora P, Avery CL, Baker-Smith CM, Barone Gibbs B, Beaton AZ, Boehme AK, Commodore-Mensah Y, Currie ME, Elkind MSV, Evenson KR, Generoso G, Heard DG, Hiremath S, Johansen MC, Kalani R, Kazi DS, Ko D, Liu J, Magnani JW, Michos ED, Mussolino ME, Navaneethan SD, Parikh NI, Perman SM, Poudel R, Rezk-Hanna M, Roth GA, Shah NS, St-Onge MP, Thacker EL, Tsao CW, Urbut SM, Van Spall HGC, Voeks JH, Wang NY, Wong ND, Wong SS, Yaffe K, Palaniappan LP. 2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association. Circulation 2024; 149:e347-e913. [PMID: 38264914 DOI: 10.1161/cir.0000000000001209] [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] [Indexed: 01/25/2024]
Abstract
BACKGROUND The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs). METHODS The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains. RESULTS Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics. CONCLUSIONS The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.
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20
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Yao PC, Fei ZT, Chen M, Mo BF, Zhang R, Yang YL, Sun J, Wang QS, Li YG. Incidence, impact and predictors of residual device patency after left atrial appendage closure with the LACbes device. Int J Cardiol 2024; 397:131640. [PMID: 38065326 DOI: 10.1016/j.ijcard.2023.131640] [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: 08/11/2023] [Revised: 11/09/2023] [Accepted: 12/03/2023] [Indexed: 12/22/2023]
Abstract
BACKGROUND The residual device patency (RDP) after left atrial appendage closure (LAAC) with the LACbes device has not been specifically explored in atrial fibrillation (AF) patients. This study aims to explore the incidence, impact and predictors of RDP detected by cardiac computed tomography angiography (CCTA) post LAAC. METHODS AF patients implanted with the LACbes device were prospectively enrolled. CCTA device surveillance was performed at 3 months post-procedure. Major adverse events (MAEs), including stroke/transient ischemic attack, major bleeding and all-cause death, were evaluated. RESULTS Among 141 patients with CCTA surveillance, 56 (39.7%) showed no visible leak and 85 (60.3%) showed RDP. During the median follow-up of 443 [232, 706] days, the presence of RDP was not associated with an increased risk of MAEs (adjusted hazard ratio [HR]: 4.07, 95% confidence interval [CI]: 0.49-34.24, p = 0.196), while peri-device leak (PDL) at the lobe was associated with heightened risks of MAEs (adjusted HR: 6.85, 95% CI: 1.62-28.89, p = 0.009). In patients with PDL at the lobe, antiplatelet after 6 months (HR: 0.20, 95% CI: 0.05-0.91, p = 0.038) was independent protective predictor of MAEs. Besides, current smoking (odds ratio [OR]: 7.52, 95% CI: 2.68-21.08, p < 0.001) and maximum diameter of LAA orifice (OR: 1.16, 95% CI: 1.00-1.34, p = 0.048) were independent predictors of PDL at the lobe. CONCLUSIONS Presence of PDL at the device lobe detected by CCTA at 3-month post LAAC with LACbes is associated with unfavorable prognosis in AF patients. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03788941.
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Affiliation(s)
- Peng-Cheng Yao
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen-Tao Fei
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mu Chen
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bin-Feng Mo
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Rui Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu-Li Yang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qun-Shan Wang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Reddy VY, Zhong Y, McGovern AM, Amorosi SL, Gavaghan MB, Hertz DS, Low K, Freeman S, Holmes Jr DR. Comparative Costs to Medicare and Medicare Beneficiaries of Alternative AF Stroke Risk Reduction Strategies. CLINICOECONOMICS AND OUTCOMES RESEARCH 2024; 16:81-96. [PMID: 38374959 PMCID: PMC10875168 DOI: 10.2147/ceor.s440556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Accepted: 11/28/2023] [Indexed: 02/21/2024] Open
Abstract
Background As healthcare costs are increasingly being shifted from payers to patients, it is important to understand the economic consequences of therapeutic strategies to both payers and patients. Objective To determine the relative costs to Medicare and Medicare beneficiaries (patients) of warfarin, non-vitamin K oral anticoagulants (NOACs), and left atrial appendage closure (LAAC) for stroke risk reduction in nonvalvular atrial fibrillation. Methods An economic model was developed to assess costs at 5 and 10 years. For warfarin and NOACs, inputs were derived from published meta-analyses; for LAAC with the Watchman device, inputs were derived from pooled 5-year PROTECT AF and PREVAIL trial results. The model captured therapy costs vs clinical event costs, including procedural complications and follow-up clinical outcomes. Costs were based on 2023 Medicare reimbursement and copayment rates. Results At 10 years, overall LAAC costs ($48,337) were lower than those of NOACs ($81,198) and warfarin ($52,359). Overall LAAC costs were lower than those of NOACs by year 5 and warfarin by year 9. At 5 years, patient LAAC costs were lowest at $4,764, compared to $7,146 and $6,453 for NOACs and warfarin, respectively. LAAC patient costs were lower than those of NOACs by year 3 and warfarin by year 4. Clinical events comprised 96% of overall warfarin costs vs 48% for LAAC and 40% for NOACs. Conclusion LAAC yielded the lowest overall and patient costs. Warfarin costs were largely driven by clinical events, which may represent an unplanned financial burden for patients. These considerations should be incorporated into shared decision-making discussions about stroke prophylaxis strategies.
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Affiliation(s)
- Vivek Y Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Yue Zhong
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Alysha M McGovern
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
| | - Stacey L Amorosi
- Health Economics and Market Access, Boston Scientific, Marlborough, MA, USA
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22
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Zhang J, Li C, Zhou L, Sang C, Li S, Ma C. Characteristics and outcome of patients with left atrial appendage closure in China: a single-center experience. BMC Cardiovasc Disord 2024; 24:108. [PMID: 38355458 PMCID: PMC10865656 DOI: 10.1186/s12872-023-03651-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/01/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clinical characteristics and long-term data on the safety and efficacy of LAAC in preventing cerebrovascular accident and thromboembolism among Chinese patients with non-valvular AF (NVAF) remain limited. METHODS Data of consecutive NVAF patients who underwent LAAC at Beijing Anzhen Hospital, Capital Medical University, from June 1, 2014, to December 31, 2021, were collected and analyzed retrospectively. The primary effectiveness endpoint was the composite endpoint of stroke/transient ischemic attack, systemic embolism, and death from cardiovascular causes. The primary safety endpoint is the severe bleeding defined by the LAAC Munich consensus. RESULTS Of the 222 patients enrolled, the mean age was 66.90 ± 9.62 years, with a majority being male (77.03%). Many patients are non-paroxysmal AF (71.19%) with a median duration of AF of 4.00 years. The mean CHA2DS2-VASc score was 3.78 ± 1.49, and the mean HAS-BLED score was 1.68 ± 0.86. Thromboembolic events (76.58%) were the most common indication for LAAC. The device, technical, and procedural success rates were 98.65%, 98.65%, and 93.69%, respectively. The anticoagulation continuation rate was 56.36%, 31.25%, and 22.60% at 3-, 6- and 12 months post-procedure, respectively. Throughout a mean 2.81 years of follow-up, the incidence of the primary efficacy endpoint was 4.27 per 100 patient-years, predominantly attributable to stroke/TIA (3.12 per 100 PYs). Five patients experienced major bleeding during the follow-up period. Post-procedure imaging revealed minimal complications, with only one substantial peri-device leak. Device-related thrombus occurred in 2.33% of patients, resolving with anticoagulation. CONCLUSION The study demonstrates that LAAC is a safe and effective alternative option for Chinese patients with AF, with a high success rate, few complications as well as fewer long-term adverse outcome events.
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Affiliation(s)
- Jingrui Zhang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changyi Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Lu Zhou
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
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Alkhouli M, Makkar A, Freeman JV, Ellis CR, Shah AP, Gada H, Coylewright M, Lo M, Agarwal H, Lakkireddy D. Amulet Occluder Implantation in Patients With Failed Prior Left Atrial Appendage Occlusion: EMERGE LAA Insights. JACC Cardiovasc Interv 2024; 17:457-459. [PMID: 38355277 DOI: 10.1016/j.jcin.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 11/09/2023] [Accepted: 12/11/2023] [Indexed: 02/16/2024]
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24
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Pastormerlo LE, De Caterina AR, Esposito A, Korsholm K, Berti S. State-of-the-Art of Transcatheter Left Atrial Appendage Occlusion. J Clin Med 2024; 13:939. [PMID: 38398253 PMCID: PMC10889674 DOI: 10.3390/jcm13040939] [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: 01/07/2024] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in patients with atrial fibrillation, especially in patients with absolute/relative contraindications to these therapies. This review will cover three main aspects of the procedure. In the fist part of the manuscript, we focus on patient selection. We describe three main categories of patients with primary indication to LAAO, namely patients with previous or at a high risk of intracerebral bleeding, patients with a history of major gastrointestinal bleeding and patients with end-stage renal disease and absolute contraindication to novel oral anticoagulants. Some other potential indications are also described. In the second part of the manuscript, we review available devices, trying to highlight different aspects and potential specific advantages. The last section overviews different ways for pre-, intra- and postprocedural imaging, in order to improve procedural safety and efficacy and ameliorate patient outcome. The characteristics of available contemporary devices and the role of imaging in procedural planning, intraprocedural guidance and follow-up are described.
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Affiliation(s)
- Luigi Emilio Pastormerlo
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
| | | | - Augusto Esposito
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, C319, 8200 Aarhus, Denmark
| | - Sergio Berti
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
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López-Tejero S, Antúnez-Muiños P, Fraile-Gómez P, Sousa GBD, Rodríguez-Collado J, Herrero-Garibi J, Blanco-Fernández F, Diego-Nieto A, Delgado-Lapeira GC, Del Villar-Moro MCP, Martín-Moreiras J, Sánchez-Fernández PL, Cruz-González I. Left atrial appendage occlusion in patients suffering from advanced chronic kidney disease (stage 4 and 5). Long-term follow-up. Catheter Cardiovasc Interv 2024; 103:499-510. [PMID: 38168895 DOI: 10.1002/ccd.30946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
INTRODUCTION AND OBJECTIVES Advanced chronic kidney disease (A-CKD) combined with atrial fibrillation increases the risk of both thrombogenic and bleeding events. Left atrial appendage occlusion (LAAO) may be an alternative to oral anticoagulation to prevent thromboembolic events. We aimed to evaluate the outcomes of LAAO in patients with A-CKD. METHODS Comparison at long-term follow-up of patients diagnosed with and without A-CKD (eGFR<30 mL/min/1.73 m2 ) who underwent LAAO between 2009 and May 2022. RESULTS Five hundred seventy-three patients were included. Eighty-one (14%) were diagnosed with A-CKD. There were no differences in sex, age, and cardiovascular risk factors, except for diabetes which was more frequent in patients with A-CKD. The control group had higher rates of stroke, both ischemic and hemorrhagic. There were no differences in the CHA2 DS2 -VASc score, although A-CKD patients had a higher bleeding risk according to the HASBLED scale. Global procedural success was 99.1%. At follow-up, there were no differences in stroke rate: at 1-year (HR: 1.22, IC-95%: 0.14-10.42, p = 0.861); at 5-years (HR: 0.60, IC-95%: 0.08-4.58, p = 0.594). Although bleeding events were higher in the A-CKD group, no differences were found in major bleeding (defined BARC ≥ 3) at 1-year (HR: 1.34, IC-95%: 0.63-2.88, p = 0.464) or at 5-years follow-up (HR: 1.30, IC-95%: 0.69-2.48, p = 0.434). Mortality rate at 5 years was higher in the A-CKD patients (HR: 1.84, IC-95%: 1.18-2.87, p = 0.012). CONCLUSIONS LAAO is an effective and safe treatment in A-CKD patients to prevent ischemic events and bleeding. This strategy could be an alternative to oral anticoagulation in this high-risk group of patients.
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Affiliation(s)
- Sergio López-Tejero
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Pablo Antúnez-Muiños
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Pilar Fraile-Gómez
- Department of Nephrology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
| | - Gilles Barreira-de Sousa
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Javier Rodríguez-Collado
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Jesús Herrero-Garibi
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Fabián Blanco-Fernández
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Alejandro Diego-Nieto
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | | | - M Candelas Pérez Del Villar-Moro
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Javier Martín-Moreiras
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Pedro L Sánchez-Fernández
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
| | - Ignacio Cruz-González
- Department of Cardiology, Complejo asistencial universitario de Salamanca (CAUSA), Salamanca, Spain
- Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBER-CV), Spain
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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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Alkhouli M, Freeman JV, Ellis CR, Shah AP, Gada H, Coylewright M, Lo M, Makkar A, Agarwal H, Lakkireddy D. First Experience With Amulet in the United States: Early Insights From EMERGE LAA Postapproval Study. JACC Cardiovasc Interv 2024:S1936-8798(23)01553-4. [PMID: 38310499 DOI: 10.1016/j.jcin.2023.11.027] [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] [Received: 07/09/2023] [Revised: 11/15/2023] [Accepted: 11/16/2023] [Indexed: 02/05/2024]
Abstract
BACKGROUND The Food and Drug Administration approved the Amulet occluder (Abbott) after demonstrating safety and effectiveness in the Amulet IDE (AMPLATZER Amulet LAA Occluder) trial. OBJECTIVES The aim of the EMERGE Left Atrial Appendage study is to evaluate early postapproval outcomes of the Amulet occluder in the United States using data from the National Cardiovascular Data Registry Left Atrial Appendage Occlusion Registry. METHODS Patients with a commercial Amulet occluder implant attempt between Food and Drug Administration approval (August 14, 2021) and December 31, 2022, were included. The safety composite endpoint included all-cause death, ischemic stroke, systemic embolism, or device/procedure-related events requiring open cardiac surgery or endovascular intervention between device implantation and 7 days or hospital discharge (whichever is later). Major adverse events through 45 days were also reported and stratified by operator experience (early [<10 cases], moderate [10-29 cases], and high [30+ cases]). RESULTS A total of 5,499 patients underwent attempted Amulet occluder implantation. Implant success was 95.8%, and complete closure was 97.2% post-left atrial appendage occlusion and 87.1% at 45 days. A safety composite endpoint event occurred in 0.76% patients. Any major adverse event occurred in 2.9% and 5.7% of patients in-hospital and through 45 days, respectively, driven by major bleeding and pericardial effusion (PE) requiring intervention. PE requiring surgery or percutaneous intervention decreased significantly with increasing experience both in-hospital (early vs high operator experience 1.8% vs 1.1%; P = 0.006) and at 45 days (2.3% vs 1.5%; P = 0.012). CONCLUSIONS The EMERGE Left Atrial Appendage study demonstrates favorable safety and effectiveness of the Amulet occluder in the real-world setting. More experienced operators had improved implant success and fewer PEs, suggesting a learning curve effect implanting this dual occlusive mechanism device.
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Affiliation(s)
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Atman P Shah
- The University of Chicago, Chicago, Illinois, USA
| | - Hemal Gada
- University of Pittsburgh Medical Center, Wormleysburg, Pennsylvania, USA
| | - Megan Coylewright
- Erlanger and University of Tennessee Health Science Center, College of Medicine, Chattanooga, Tennessee
| | - Monica Lo
- Arkansas Heart Hospital, Little Rock, Arkansas, USA
| | - Akash Makkar
- Arizona Heart Arrhythmia Associates, Phoenix, Arizona, USA
| | - Himanshu Agarwal
- CHI Creighton University School of Medicine, Bergan Mercy Hospital, Omaha, Nebraska, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Overland Park, Kansas, USA
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Samaras A, Papazoglou AS, Balomenakis C, Bekiaridou A, Moysidis DV, Patsiou V, Orfanidis A, Giannakoulas G, Kassimis G, Fragakis N, Saw J, Landmesser U, Alkhouli MA, Tzikas A. Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis. Eur Heart J 2024; 45:214-229. [PMID: 38088437 DOI: 10.1093/eurheartj/ehad828] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/02/2023] [Accepted: 10/19/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND AND AIMS Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion. METHODS A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks. RESULTS Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively). CONCLUSIONS Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.
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Affiliation(s)
- Athanasios Samaras
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Andreas S Papazoglou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Balomenakis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Dimitrios V Moysidis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Orfanidis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | | | - Apostolos Tzikas
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- European Interbalkan Medical Center, Department of Cardiology, Asklipiou 10, Pylaia, Thessaloniki 57001, Greece
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Fastner C, Müller C, Brachmann J, Lewalter T, Akin I, Sievert H, Käunicke M, Zeymer U, Hochadel M, Schneider S, Senges J, Erkapic D, Weiß C. Is spontaneous echo contrast associated with device-related thrombus or embolic events after left atrial appendage occlusion? - Insights from the multicenter German LAARGE registry. J Interv Card Electrophysiol 2024; 67:119-128. [PMID: 37261553 PMCID: PMC10770218 DOI: 10.1007/s10840-023-01567-z] [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] [Received: 02/28/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Interventional left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for prophylaxis of thromboembolic events (TEs) in nonvalvular atrial fibrillation patients, predominantly in those with high bleeding risk and contraindications for long-term OAC. Although spontaneous echo contrast (SEC) is a well-known risk factor for atrial thrombus formation, little is known about whether this means an increased risk of device-related thrombus (DRT) or TEs following LAAO. METHODS This substudy of the prospective, multicenter German LAARGE registry assessed two groups according to absence (SEC -) or presence of SEC (SEC +) in preprocedural cardiac imaging. Clinical and echocardiographic parameters were registered up to 1 year after LAAO. RESULTS Five hundred eighty-eight patients (SEC - 85.5 vs. SEC + 14.5%) were included. More SEC + patients were implanted for OAC non-compliance (11.8 vs. 4.6%, p = 0.008) and a higher proportion received only antiplatelet therapy without OAC at hospital discharge (96.5 vs. 86.0%, p = 0.007). The SEC + patients had larger LA diameters (50 (47; 54) vs. 47 (43; 51) mm, p < 0.001), wider LAA ostia (21 (19; 23) vs. 20 (17; 22) mm at 45°, p = 0.011), and lower left ventricular ejection fraction (50 (45; 60) vs. 60 (50; 60) %, p < 0.001) on admission. Procedural success was very high in both groups (98.1%, p = 1.00). Periprocedural major adverse cardiac and cerebrovascular events and other major complications were rare in both groups (3.8 vs. 4.7%, p = 0.76). At follow-up, DRT was only detected in the SEC - group (3.8 vs. 0%, p = 1.00). The rates of TEs (SEC - 1.2 vs. SEC + 0%, p = 1.00) after hospital discharge and 1-year mortality (SEC - 12.0 vs. SEC + 11.8%, p = 0.96) were not significantly different between the two groups. CONCLUSIONS Presence of SEC at baseline was not associated with an increased rate of DRT or TEs at 1-year follow-up after LAAO in LAARGE.
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Affiliation(s)
- Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Claus Müller
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
| | - Johannes Brachmann
- REGIOMED-Kliniken, Coburg, Germany and University of Split, School of Medicine, Split, Croatia
| | - Thorsten Lewalter
- Department of Medicine, Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Matthias Käunicke
- Department of Cardiology, University of Witten/Herdecke, Katholisches Klinikum Essen, Essen, Germany
| | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | | | | | - Jochen Senges
- Stiftung Institut Für Herzinfarktforschung, Ludwigshafen, Germany
| | - Damir Erkapic
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Siegen, Siegen, Germany and Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Christian Weiß
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
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Rajiah PS. Imaging Evaluation Following Transcatheter Left Atrial Appendage Closure. Semin Roentgenol 2024; 59:121-134. [PMID: 38388091 DOI: 10.1053/j.ro.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 02/24/2024]
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Aladin AI, Arar T, Lubaina F, Bhogal S, Zhang C, Wermers JP, Ben-Dor I, Satler LF, Rogers T, Slack M, Waksman R. Gender disparities related to clinical characteristics and outcomes of patients undergoing transseptal procedures. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 58:45-49. [PMID: 37393190 DOI: 10.1016/j.carrev.2023.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/03/2023]
Abstract
PURPOSE Explore gender disparities in patients undergoing transseptal puncture (TSP) for selected transcatheter cardiac intervention procedures. METHODS Patients who underwent TSP from January 2015 through September 2021 were reviewed. Primary outcomes were procedural and in-hospital major adverse events. Secondary endpoints were procedural success and hospitalization length of stay (LOS) >1 day. Unadjusted and multivariable-adjusted logistic regression analyses were performed to assess gender differences for in-hospital adverse events. RESULTS The study cohort comprised 510 patients (mean [SD] age, 74 [14.0] years); 246 women (48 %) underwent TSP for left atrial appendage occlusion (LAAO) or transcatheter edge-to-edge-repair (TEER). Compared with men, women were younger, had higher CHA2DS2-VASc scores, and were more likely to have had a prior ischemic stroke, but were less likely to have paroxysmal atrial fibrillation. After multivariable adjustment, there were no differences between genders in aborted or canceled procedures (odds ratio [OR]: 0.43; 95 % confidence interval [CI]: 0.10-1.96; p = 0.277), any adverse events (OR: 1.00; 95 % CI: 0.58-1.70; p = 0.98), major adverse events (OR: 1.60; 95 % CI: 0.90-2.80; p = 0.11), or death (OR: 1.00; 95 % CI: 0.20-5.00; p = 0.31). Subgroup analysis for LAAO procedures showed that at 30 days, women had higher rates of adverse events, major adverse cardiac events, and LOS >1 day. CONCLUSIONS Men and women showed no differences in procedural success and in-hospital adverse outcomes in unadjusted analysis and after multivariable adjustment, despite women having a higher risk profile among patients undergoing TSP. However, compared with men, women undergoing LAAO experienced a higher rate of in-hospital adverse events irrespective of TSP.
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Affiliation(s)
- Amer I Aladin
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Tareq Arar
- Department of Internal Medicine, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Fnu Lubaina
- Department of Internal Medicine, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Sukhdeep Bhogal
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Cheng Zhang
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Jason P Wermers
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Itsik Ben-Dor
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Lowell F Satler
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA
| | - Toby Rogers
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institute of Health, Bethesda, MD, USA
| | - Michael Slack
- Division of Pediatric Cardiology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ron Waksman
- Section of Interventional Cardiology, MedStar Georgetown University/Washington Hospital Center, Washington, DC, USA.
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Rana MA, Yoon S, Dallan LAP, Tashtish N, Attizzani GF, Rashid I, Rajagopalan S, Arruda M, Filby SJ. Midterm follow-up after computed tomography angiography planned left atrial appendage closure. Catheter Cardiovasc Interv 2024; 103:129-136. [PMID: 37786977 DOI: 10.1002/ccd.30843] [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: 02/27/2023] [Revised: 07/25/2023] [Accepted: 08/31/2023] [Indexed: 10/04/2023]
Abstract
BACKGROUND While studies have shown the advantages of computed tomography angiography (CTA) over transesophageal echocardiography (TEE) in left atrial appendage closure (LAAC) preprocedural planning for WATCHMAN™ legacy and FLX devices, there has been no reported long-term data for this approach. OBJECTIVES We sought to evaluate long-term outcomes using CTA-based preprocedural planning for LAAC using the WATCHMAN™ device. METHODS A prospective analysis of 231 consecutive patients who underwent LAAC in a single, large academic hospital in the United States was conducted over a 5-year period. CTA-guided preprocedural planning was performed in all. Procedural success, adverse events, length of procedure, number of devices used, and length of stay were evaluated. Rates of death, cerebral embolism, systemic embolism, and major and minor bleeding were recorded. Adjusted predicted stroke and major bleeding rates were derived from CHA2DS2-Vasc and HAS-BLED scores, respectively. RESULTS From January 26, 2017, to November 23, 2021, 231 patients underwent LAAC with CTA preprocedural planning by two operating physicians. The mean age of patients was 76.5 ± 8.4. 59.7% of patients were male. Mean CHA2DS2VASc and HAS-BLED scores were 4.5 ± 1.4 and 3.9 ± 0.9, respectively. All procedures were performed with intracardiac echo (100%). The procedural success rate was 99.1%. The CTA sizing strategy accurately predicted the implant size in 93.5% of patients. Mean number of devices used was 1.10 ± 0.3. Peri-procedural complication rate was 2.2%. 6 patients were lost to follow-up. Mean follow-up was 608.94 days with a total of 377.04 patient years. Median follow-up period of 368 days (interquartile range: 209-1067 days). There were 51 deaths from all causes (13.52 per 100 patient-years), 10 cases of cerebral embolism (2.65 per 100 patient-years), 2 cases of systemic embolism (0.53 per 100 patient-years), 17 cases of major bleeding (4.50 per 100 patient-years), and 31 cases of minor bleeding (8.2 per 100 patient-years). All-cause mortality at 1, 2, and 3 years was 12.7%, 20.9%, and 29.2%, respectively. CV event rates at 1, 2, and 3 years were 2.1%, 6.6%, and 10.5%, respectively. CONCLUSIONS CTA-based preprocedural planning is accurate in predicting device size for LAAC and associated with excellent clinical outcomes at 5 years.
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Affiliation(s)
- Mohammad Atif Rana
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sunghan Yoon
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Nour Tashtish
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Guilherme F Attizzani
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanjay Rajagopalan
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mauricio Arruda
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven J Filby
- Division of Cardiology, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Lu MLR, De Lurgio DB. Left atrial appendage closure: the journey today and tomorrow. Curr Opin Cardiol 2024; 39:20-26. [PMID: 37874028 DOI: 10.1097/hco.0000000000001091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
PURPOSE OF REVIEW This review aims to discuss the rationale behind the development of percutaneous LAAC devices as a treatment option for atrial fibrillation patients ineligible for long-term anticoagulation. The evolution of LAAC, from early experiences and challenges to risk mitigation and improved devices and techniques, will be examined. Furthermore, the review will explore our current understanding of the potential and limitations of LAAC in stroke prevention. RECENT FINDINGS Multiple trials confirm LAAC device safety and efficacy for stroke prevention, but peri-device leak and thrombus remain concerns postimplantation. Even small leaks pose increased stroke risk. While guidelines suggest short-term anticoagulation postimplant; real-world data show equivalent efficacy with dual antiplatelet regimen. SUMMARY LAAC device design has evolved and now serve as a viable option for stroke prevention in high-risk atrial fibrillation patients, offering protection in the absence of anticoagulation.
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Staal DP, Maarse M, Aarnink E, Huijboom MFM, Abeln BGS, Rensing BJMW, Swaans MJ, Van Dijk VF, Boersma LVA. Percutaneous left atrial appendage occlusion in patients with a cardiac implantable electronic device. J Interv Card Electrophysiol 2023; 66:1971-1978. [PMID: 36856972 PMCID: PMC10694092 DOI: 10.1007/s10840-023-01512-0] [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: 12/05/2022] [Accepted: 02/14/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) may be a viable option for stroke prevention in patients with non-valvular atrial fibrillation and a contraindication for oral anticoagulation. No evidence evaluating the safety of this procedure in patients with a cardiac implantable electronic device (CIED) exists. The aim of this study was to evaluate whether CIED function is affected by LAAO and to explore LAAO procedural characteristics and complications in patients with a CIED. METHODS This single-center cohort study included consecutive patients scheduled for percutaneous LAAO. Patients with a CIED prior to LAAO were selected and compared to the patients without CIED, concerning procedural characteristics and peri-procedural complications. In the group of patients with CIEDs, essential pacemaker integrity parameters were compared before and after the procedure to detect possible micro and macro lead displacements. RESULTS Thirty-one patients with CIED were scheduled for LAAO (age 73.7 ± 5.4 years, 65% males, CHA2DS2-VASc 4.3 ± 1.5, and HAS-BLED 3.3 ± 1.0). The 245 patients without CIED were younger, and HAS-BLED-score was slightly lower (69.4 ± 8.2 years, p < 0.001; 2.8 ± 1.0, p = 0.022). Patients without CIED more frequently underwent LAAO combined with catheter ablation (p = 0.002). All other procedural characteristics were comparable between both groups. No visible lead displacement was observed on chest X-ray after LAAO. Additionally, no differences in impedance, threshold, or intracardiac sensing in various CIED lead locations were found prior versus post LAAO. CONCLUSION This study supports the feasibility and safety of LAAO in patients with a CIED.
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Affiliation(s)
- D P Staal
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands.
| | - M Maarse
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, AMC Amsterdam, Amsterdam, the Netherlands
| | - E Aarnink
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, AMC Amsterdam, Amsterdam, the Netherlands
| | - M F M Huijboom
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, AMC Amsterdam, Amsterdam, the Netherlands
| | - B G S Abeln
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, AMC Amsterdam, Amsterdam, the Netherlands
| | - B J M W Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - M J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - V F Van Dijk
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - L V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Department of Cardiology, AMC Amsterdam, Amsterdam, the Netherlands
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Kir D, Van Houten HK, Walvatne KN, Behnken EM, Alkhouli MA, Graff-Radford J, Melduni RM, Gersh BJ, Friedman PA, Shah ND, Noseworthy PA, Yao X. Physicians' perspectives on percutaneous left atrial appendage occlusion for patients with atrial fibrillation. Am Heart J 2023; 266:14-24. [PMID: 37567353 DOI: 10.1016/j.ahj.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 07/02/2023] [Accepted: 07/25/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND There has been an increasing uptake of transcatheter left atrial appendage occlusion (LAAO) for stroke reduction in atrial fibrillation. OBJECTIVES To investigate the perceptions and approaches among a nationally representative sample of physicians. METHODS Using the American Medical Association Physician Masterfile, we selected a random sample of 500 physicians from each of the specialties: general cardiologists, interventional cardiologists, electrophysiologists, and vascular neurologists. The participants received the survey by mail up to three times from November 9, 2021 to January 14, 2022. In addition to the questions about experiences, perceptions, and approaches, physicians were randomly assigned to 1 of the 4 versions of a patient vignette: white man, white woman, black man, and black woman, to investigate potential bias in decision-making. RESULTS The top three reasons for considering LAAO were: a history of intracranial bleeding (94.3%), a history of major extracranial bleeding (91.8%), and gastrointestinal lesions (59.0%), whereas the top three reasons for withholding LAAO were: other indications for long-term oral anticoagulation (87.7%), a low bleeding risk (77.0%), and a low stroke risk (65.6%). For the reasons limiting recommendations for LAAO, 59.8% mentioned procedural risks, 42.6% mentioned "limiting efficacy data comparing LAAO to NOAC" and 32.8% mentioned "limited safety data comparing LAAO to NOAC." There was no difference in physicians' decision-making by patients' race, gender, or the concordance between patients' and physicians' race or gender. CONCLUSIONS In the first U.S. national physician survey of LAAO, individual physicians' perspectives varied greatly, which provided information that will help customize future educational activities for different audiences. CONDENSED ABSTRACT Although diverse practice patterns of LAAO have been documented, little is known about the reasoning or perceptions that drive these variations. Unlike prior surveys that were directed to Centers that performed LAAO, the current survey obtained insights from individual physicians, not only those who perform the procedures (interventional cardiologists and electrophysiologists) but also those who are closely involved in the decision-making and referral process (general cardiologists and vascular neurologists). The findings identify key evidence gaps and help prioritize future studies to establish a consistent and evidence-based best practice for AF stroke prevention.
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Affiliation(s)
- Devika Kir
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN
| | - Holly K Van Houten
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Kelli N Walvatne
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Emma M Behnken
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN
| | | | | | | | - Bernard J Gersh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN
| | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN
| | | | - Peter A Noseworthy
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Xiaoxi Yao
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester MN; Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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Ferro EG, Alkhouli M, Nair DG, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Price MJ, Roy K, Allocco DJ, Yeh RW, Piccini JP. Intracardiac vs Transesophageal Echocardiography for Left Atrial Appendage Occlusion With Watchman FLX in the U.S. JACC Clin Electrophysiol 2023; 9:2587-2599. [PMID: 37831030 DOI: 10.1016/j.jacep.2023.08.004] [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: 03/02/2023] [Revised: 05/25/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Intraprocedural imaging is critical for device delivery in transcatheter left atrial appendage occlusion (LAAO). Although pivotal trials of LAAO devices were conducted using transesophageal echocardiography (TEE), intracardiac echocardiography (ICE) is an emerging imaging modality. OBJECTIVES This study compared outcomes after ICE- and TEE-guided Watchman FLX implantation in the SURPASS (SURveillance Post Approval AnalySiS Plan) nationwide LAAO registry. METHODS Baseline characteristics were compared using chi-square and t-tests. Outcomes were reported in unadjusted and adjusted comparisons via propensity weighting. RESULTS Between August 2020 and September 2021, LAAO was attempted in 39,759 patients at 698 sites, including 2,272 cases (5.7%) with ICE and 31,835 (80.0%) with TEE. ICE and TEE patients had similar baseline characteristics and mean procedural times (ICE 82 minutes vs TEE 78 minutes). ICE patients were less likely to receive general anesthesia (54% vs 98%, P < 0.01). Successful device implantation (98.3% vs 97.6%) and complete seal rates at 45 days were similar (n = 25,280; 83% vs 82%). Most adverse event rates were similar; unadjusted mortality rates at 45 days were 1.1% for ICE vs 0.8% for TEE (P = 0.14), and 1.0% vs 0.7% (P = 0.27) in adjusted analyses. Even after adjustment, pericardial effusion rates requiring intervention were significantly higher with ICE at 45 days (1.0% vs 0.5%; P = 0.02). This rate decreased as operators performed more ICE-guided procedures, although 82% of operators had performed <10 ICE-guided procedures overall. CONCLUSIONS In the largest comparison to date, ICE use was infrequent. ICE and TEE both achieved high rates of complete LAAO. ICE was associated with significantly higher rates of pericardial effusion requiring intervention.
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Affiliation(s)
- Enrico G Ferro
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Devi G Nair
- St Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, and Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - Kristine Roy
- Boston Scientific Corporation, Marlborough, Massachusetts, USA
| | | | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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Nagasaka T, Nakamura M. Left Atrial Appendage Closure: A Narrative Review. Cardiol Ther 2023; 12:615-635. [PMID: 37938523 DOI: 10.1007/s40119-023-00337-2] [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: 07/26/2023] [Accepted: 10/09/2023] [Indexed: 11/09/2023] Open
Abstract
Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Thakker R, Faluk MA, Modi S, Ahmad M. Echocardiography in Percutaneous Left Atrial Appendage Occlusion and Related Complications. Echocardiography 2023; 40:1325-1335. [PMID: 38009379 DOI: 10.1111/echo.15722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 11/13/2023] [Indexed: 11/28/2023] Open
Abstract
Atrial fibrillation (AF) is a devastating disease with a large global prevalence. The left atrial appendage (LAA) is a major source of thrombi in patients with AF. Echocardiography plays an important role in identifying LAA thrombi and has become an invaluable imaging tool in planning for LAA occlusion (LAAO) in patients intolerant to anticoagulation. This review article will discuss the role of echocardiography in selecting patients for LAAO, intraprocedural monitoring, and identifying procedure-related complications.
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Affiliation(s)
- Ravi Thakker
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | - Mohammed Ali Faluk
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Masood Ahmad
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas, USA
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Ding X, Xiang K, Qian C, Hou X, Wu F. Intracardiac echocardiography is a promising strategy for guiding closure of the left atrial appendage. Health Sci Rep 2023; 6:e1762. [PMID: 38116174 PMCID: PMC10728371 DOI: 10.1002/hsr2.1762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/09/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
Background and Aims Percutaneous transcatheter left atrial appendage (LAA) closure (LAAC) is an effective approach for preventing ischemic stroke in nonvalvular atrial fibrillation patients. Intracardiac echocardiography (ICE), a new imaging modality, is a promising strategy for guiding LAAC. This review highlights the various strategies for ICE-guided-LAAC as an option for clinical policy. Methods A comprehensive literature search was conducted of PubMed, ScienceDirect, Ovid Web of Science, SpringerLink, and other notable databases to identify recent peer-reviewed clinical trials, reviews, and research articles related to ICE and its application in the guidance of LAAC. Results Various methods are used to evaluate the spatial structure and dimensions of the LAA. The main techniques for guiding LAAC are transesophageal echocardiography (TEE), cardiac computed tomography (CTA), and ICE. Among these techniques, the advantages of ICE typically include (1) multiangle and real-time assessment of intracardiac structure, (2) a reduction in procedural fluoroscopy, (3) reduced operation time and improved workflow in the catheterization laboratory, and (4) the avoidance of general anesthesia and the early detection of complications. Conclusion ICE is a promising strategy for the guidance of LAAC. Among the most advanced and recent technological innovations in cardiovascular imaging in general and volume imaging in particular, ICE offers greater efficacy and safety.
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Affiliation(s)
- Xueyan Ding
- Department of CardiologySir Run Run Shaw Hospital Zhejiang University School of MedicineHangzhouZhejiangP.R. China
| | - Kefa Xiang
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Congli Qian
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
| | - Xu Hou
- Bengbu Medical CollegeBengbuAnhuiP.R. China
| | - Feng Wu
- Department of Cardiology, The 72nd Group Army HospitalHuzhou UniversityHuzhouZhejiangP.R. China
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40
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Wei CR, Lim R, Khan S, Ahsan SA, Al Omari M, Sherpa ND, Rashid Z, Khan A. Comparison of the Efficacy and Safety of Left Atrial Appendage Closure and Direct Oral Anticoagulants for Atrial Fibrillation: A Meta-Analysis of Randomized Control Trials and Observational Studies. Cureus 2023; 15:e49827. [PMID: 38164321 PMCID: PMC10758171 DOI: 10.7759/cureus.49827] [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] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
The aim of this study was to compare the efficacy and safety of left atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF). This meta-analysis was conducted as per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 guidelines. Two investigators performed an online database search on PubMed, Web of Science, and Scopus databases from inception to October 31, 2023, without any language or time restrictions. Outcomes assessed in this meta-analysis included all-cause mortality, cardiovascular mortality, stroke, and major bleeding events. Eight studies were included in this meta-analysis, enrolling 7,629 participants with AF (4,287 in the DOAC group and 3,342 in the LAAC group). The pooled analysis showed that the risk of all-cause mortality was significantly higher in patients in the DOAC group compared to LAAC (relative risk (RR): 1.87, 95% confidence interval (CI): 1.50 to 2.34). The risk of cardiovascular mortality was 1.60 times higher in patients receiving DOACs compared to those receiving LAAC (RR: 1.60, 95% CI: 1.12 to 2.28). The risk of stroke was not significantly different between the two groups (RR: 1.15, 95% CI: 0.95 to 1.41). In conclusion, LAAC for AF patients proves to be safe and effective for stroke prevention, exhibiting a superior profile in terms of all-cause mortality, cardiovascular events, and major bleeding compared to oral anticoagulation (OAC). These findings prompt consideration of LAAC as a preferred treatment for cardiovascular event prevention in high-bleeding-risk patients.
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Affiliation(s)
- Calvin R Wei
- Research and Development, Shing Huei Group, Taipei, TWN
| | - Roy Lim
- Internal Medicine, Mount Sinai Hospital, Chicago, USA
| | - Sara Khan
- Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | | | - Nima D Sherpa
- Medicine, Jahural Islam Medical College and Hospital, Bajitpur, BGD
| | - Zarwa Rashid
- Medicine, King Edward Medical University, Lahore, PAK
| | - Areeba Khan
- Critical Care Medicine, United Medical and Dental College, Karachi, PAK
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Alkhouli M, Alarouri H, Kramer A, Korsholm K, Collins J, De Backer O, Hatoum H, Nielsen-Kudsk JE. Device-Related Thrombus After Left Atrial Appendage Occlusion: Clinical Impact, Predictors, Classification, and Management. JACC Cardiovasc Interv 2023; 16:2695-2707. [PMID: 38030357 DOI: 10.1016/j.jcin.2023.10.046] [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: 08/28/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
Despite the unprecedented advances in the left atrial appendage occlusion field, device-related thrombus (DRT) remains an unresolved issue with the therapy. This paper aims to provide a state-of-the-art review of the literature on the incidence, clinical impact, predictors and management of DRT and propose a novel classification of DRT and hypoattenuated thickening.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Hasan Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anders Kramer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeremy Collins
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
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Coylewright M, Holmes DR, Kapadia SR, Hsu JC, Gibson DN, Freeman JV, Yeh RW, Piccini JP, Price MJ, Allocco DJ, Nair DG. DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis. JACC Cardiovasc Interv 2023; 16:2708-2718. [PMID: 37943200 DOI: 10.1016/j.jcin.2023.08.013] [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: 03/24/2023] [Revised: 07/18/2023] [Accepted: 08/08/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding. OBJECTIVES This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO. METHODS Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45 days were evaluated. RESULTS In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT = 3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT = 3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT = 2.48% vs DOAC/aspirin = 3.25%; P = 0.04 and DAPT = 2.25% vs warfarin/aspirin = 2.22%; P = 0.93). CONCLUSIONS In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.
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Affiliation(s)
- Megan Coylewright
- University of Tennessee Health Science Center College of Medicine-Chattanooga and Erlanger Health System, Chattanooga, Tennessee, USA.
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Samir R Kapadia
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan C Hsu
- Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, California, USA
| | - Douglas N Gibson
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - Robert W Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jonathan P Piccini
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA
| | | | - Devi G Nair
- Department of Cardiac Electrophysiology, St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
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Streb W, Lasek-Bal A, Mitręga K, Kowalczyk J, Podolecki T, Kowalska W, Olma A, Sobczyk A, Kalarus Z. Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: study protocol for a LAAC-SBI trial. Trials 2023; 24:749. [PMID: 37996955 PMCID: PMC10666419 DOI: 10.1186/s13063-023-07766-3] [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: 08/18/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Left atrial appendage closure (LAAC) procedures prevent cardioembolic stroke in patients with atrial fibrillation who have contraindications to oral anticoagulant medications. However, these procedures carry certain risks of peri-procedural complications. One such complication is silent brain infarcts (SBI), which can lead to cognitive impairment and mood disturbances. The implementation of mechanical neuroprotection systems during LAAC procedures may reduce the risk of SBI and associated cognitive and mood disorders. METHODS The LAAC-SBI trial is a prospective, multicenter, randomized, and double-blind interventional study. The study aims to enroll a total of 240 patients, with 120 patients allocated to each group. The study group will evaluate the use of the Sentinel CPS during LAAC, while the control group will undergo LAAC procedures without the Sentinel CPS. The primary endpoint of the study is the number of new SBIs or stroke foci detected by diffusion-weighted magnetic resonance imaging (DW MRI). Secondary endpoints include deterioration of cognitive function, development of dementia syndrome, and occurrence of depressive disorders. These endpoints will be assessed using questionnaire tools such as the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), and Hospital Anxiety and Depression Scale (HADS). The observational period for patients in the study is 2 years. DISCUSSION If the study demonstrates a favorable outcome with reduced incidence of SBI and improved cognitive and mood outcomes in patients receiving cerebral protection devices during LAAC, it will have significant implications for clinical management standards. This would support the use of neuroprotection devices not only for LAAC but also in procedures such as atrial fibrillation ablation or transcatheter mitral valve interventions, where the risk of embolic events and subsequent brain injury may also be present. TRIAL REGISTRATION ClinicalTrials.gov NCT05369195. Registration on 11.05.2022.
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Affiliation(s)
- Witold Streb
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland.
| | - Anetta Lasek-Bal
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Mitręga
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Jacek Kowalczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Tomasz Podolecki
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Wiktoria Kowalska
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Anna Olma
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Agata Sobczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
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Ashraf M, Allaqaband SQ, Bajwa T, Mortada ME, Sra J, Jan MF. Age-Based Trends in the Outcomes of Percutaneous Left Atrial Appendage Occlusion: Insights from a Real-World Database. Am J Cardiol 2023; 207:322-327. [PMID: 37774473 DOI: 10.1016/j.amjcard.2023.08.177] [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: 03/22/2023] [Revised: 08/07/2023] [Accepted: 08/27/2023] [Indexed: 10/01/2023]
Abstract
The age-based trends in-hospital outcomes in patients with percutaneous left atrial appendage occlusion (LAAO) are unknown. Using the National Readmission Database from 2016 to 2019, patients who underwent LAAO were divided into 2 age groups: 60 to 79 and ≥80 years. The primary objective was to evaluate the age-based trends in the outcomes related to LAAO. The secondary objectives were to evaluate the mean cost and total cumulative cost of readmissions in both age groups in 2019. We identified 58,818 patients who underwent LAAO, of whom 36,964 (63%) were aged 60 to 79 years, and 21,854 (37%) were ≥80 years. The hospital mortality, pericardial complications, acute kidney injury, and in-hospital cardiac arrest did not change over time. The risk-adjusted postoperative stroke and bleeding requiring blood transfusion decreased in patients aged ≥80 years (p trend 0.03 for both outcomes). The length of stay decreased, and early discharge rates increased over time in both the unadjusted and risk-adjusted models in both age groups. The risk-adjusted 90-day readmission rates also decreased in patients aged ≥80 years. The inflation-adjusted cost did not change over time on the unadjusted and adjusted analyses. The total cumulative all-cause 90-readmission cost for both groups in 2019 was $31.7 million. Most outcomes after LAAO either improved or did not change from 2016 to 2019. Hospital mortality has remained <0.5% consistently since 2016. The risk-adjusted postoperative stroke, bleeding, and 90-day readmission rates improved in elderly vulnerable patients aged ≥80 years. The inflation-adjusted cost did not improve despite the decreasing length of stay and improving early discharge rates.
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Affiliation(s)
- Muddasir Ashraf
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - Suhail Q Allaqaband
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - Tanvir Bajwa
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - M Eyman Mortada
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - Jasbir Sra
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin
| | - M Fuad Jan
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers; University of Wisconsin School of Medicine and Public Health, Milwaukee, Wisconsin.
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Sulague RM, Whitham T, Danganan LML, Effiom V, Candelario K, Latif N, Hameed I. The Left Atrial Appendage and Atrial Fibrillation-A Contemporary Review. J Clin Med 2023; 12:6909. [PMID: 37959374 PMCID: PMC10650862 DOI: 10.3390/jcm12216909] [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: 10/02/2023] [Revised: 10/28/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023] Open
Abstract
In patients with atrial fibrillation, the left atrial appendage may serve as the site of thrombus formation due to stasis that occurs within the appendage because of its shape and trabeculations. Although thrombus formation can be reduced by using anticoagulants, this may be contraindicated in some patients. The need for a better alternative treatment prompted the study of left atrial appendage occlusion for thromboembolism prophylaxis. Due to this, procedures that excise or occlude the left atrial appendage have gained attention because of their ability to prevent thromboembolic events. This article provides a comprehensive review of the left atrial appendage and its associated procedures' clinical utility.
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Affiliation(s)
- Ralf Martz Sulague
- Graduate School of Arts and Sciences, Georgetown University, Washington, DC 20057, USA;
| | - Tarik Whitham
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH 44272, USA;
| | | | - Victory Effiom
- College of Medical Sciences, University of Calabar, Calabar 540271, Nigeria;
| | - Katherine Candelario
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Nida Latif
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
| | - Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar Street, New Haven, CT 06510, USA; (K.C.); (N.L.)
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Nelles D, Amli H, Sugiura A, Vij V, Beiert T, Nickenig G, Kütting D, Schrickel JW, Sedaghat A. The CT derived angle between the transseptal puncture site and the left atrial appendage as a predictor for complex interventional occlusion procedures. Echocardiography 2023; 40:1227-1236. [PMID: 37788148 DOI: 10.1111/echo.15699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE To evaluate the role of the CT-derived angle between the intra-atrial septum (IAS) and the left atrial appendage (LAA) on procedural complexity and clinical outcomes in left atrial appendage occlusion (LAAO) procedures. BACKGROUND Given the broad variations in anatomy, LAAO remains one of the most challenging interventional procedures in structural heart disease. In recent years, preprocedural cardiac tomography (CT) has evolved as a valuable tool; however, prediction of procedural complexity remains cumbersome. METHODS We retrospectively analyzed 47 patients that underwent LAAO at our center in whom pre-procedural cardiac CT-scans were available. Among other baseline parameters, we measured the angle between the LAA ostium and the preferred transseptal puncture site at the IAS. We compared patients with an angle above and below the median regarding procedural characteristics and procedural outcome. RESULTS The median angle between the LAA and the IAS was 127.3° (IQR: 120.9-141.3). LAAO took longer in patients with a measured angle below the median (55.0 ± 22.7 min vs. 41.3 ± 17.5 min; p = .04), resulting in longer radiation times (13.0 ± 5.3 min vs. 9.8 ± 5.7 min; p = .04) and more contrast use (61.1 ± 47.5 mL vs. 33.6 ± 24.7 mL; p = .05). Moreover, the necessity for a sheath exchange was significantly higher (30.4% vs. 4.2%, p = .02) and device repositioning or device resizing trended to be more frequent (26.1% vs. 8.3%; p = .1 and 21.7% vs. 8.3%; p = .2). There were no differences in procedural outcome, device-position and peri-device leak (PDL). CONCLUSIONS The angle between the transseptal puncture site and the LAA ostium may serve as a predictor for more demanding LAAO interventions. In our study a steeper angle led to a prolonged procedure resulting in higher doses of contrast and radiation, but was not associated with a worse procedural outcome.
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Affiliation(s)
- Dominik Nelles
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Hazem Amli
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Vivian Vij
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Thomas Beiert
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Jan Wilko Schrickel
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Alexander Sedaghat
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
- RheinAhrCardio - Praxis für Kardiologie, Bad Neuenahr-Ahrweiler, Germany
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Kewcharoen J, Shah K, Bhardwaj R, Contractor T, Turagam MK, Mandapati R, Lakkireddy D, Garg J. Adverse events associated with amplatzer left atrial appendage occlusion delivery system: A Food and Drug Administration MAUDE database study. J Cardiovasc Electrophysiol 2023; 34:2382-2385. [PMID: 37679961 DOI: 10.1111/jce.16053] [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: 05/11/2023] [Revised: 08/04/2023] [Accepted: 08/26/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Dual occlusive closure mechanism (disc and lobe type), Amulet device (Abbott; a second-generation device that has replaced Amplatzer Cardiac Plug) was approved by the Food and Drug Administration (FDA) in August 2021 for percutaneous left atrial appendage occlusion (LAAO). However, real-world safety data on the delivery system (Amplatzer Cardiac Plug and Amplatzer Amulet device) are lacking. OBJECTIVE We sought to assess the type of adverse events associated with the Amplatzer LAAO delivery system using the FDA Manufacturer and User Facility Device Experience (MAUDE) database. METHODS A MAUDE database search was conducted on March 31, 2023, for reports received between February 2013 and March 2023 to capture all adverse events. RESULTS A total of 59 adverse events were reported, of which 58 were sheath-related events, and one was a wire-related event. The most commonly encountered issue was air embolism (19%, 11 events), followed by sheath thrombosis (13.8%, eight events, two of which were also associated with device thrombosis), kinked sheath (10.3%, six events), and sheath deformation (8.6%, five events). Patient-related adverse events included pericardial effusion requiring pericardiocentesis (22.4%, 13 events), vascular complications (20.7%, 12 events), and device dislodgement (5.2%, three events). CONCLUSION LAAO-related adverse events are increasingly being reported using the Amplatzer LAAO delivery sheath. It is anticipated that improvements in device technology, the advent of steerable sheaths, and operator experience will minimize these complications.
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Affiliation(s)
- Jakrin Kewcharoen
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Kuldeep Shah
- Division of Cardiology, Cardiac Arrhythmia Service, MercyOne Siouxland Heart and Vascular Center, Sioux City, Iowa, USA
| | - Rahul Bhardwaj
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Tahmeed Contractor
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Mohit K Turagam
- Division of Cardiology, Cardiac Arrhythmia Service, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ravi Mandapati
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiology, Cardiac Arrhythmia Service, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas, USA
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
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Blanco-Fernández F, Antúnez-Muiños PJ, Núñez-García JC, López-Tejero S, Barreira-de Sousa GJ, García-Monsalvo M, Antúnez-Ballesteros M, Maree A, González-Calle D, Rodríguez-Collado J, Barreiro-Pérez M, Díaz-Peláez E, Pérez del Villar-Moro MC, Sánchez-Fernández PL, Cruz-González I. Effectiveness and Safety of an Outpatient Program for Percutaneous Left Atrial Appendage Occlusion. J Clin Med 2023; 12:6728. [PMID: 37959194 PMCID: PMC10648316 DOI: 10.3390/jcm12216728] [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: 09/12/2023] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a safe and effective alternative to oral anticoagulation for thromboprophylaxis in patients with nonvalvular atrial fibrillation. Technological development in devices and imaging techniques, as well as accumulated experience, have increased procedural success rates and decreased complications. Same-day discharge protocols have been proposed in the field of structural heart disease, but this approach has not been studied in detail for the LAAO procedure. AIM The aim of this study is to assess the safety and efficacy of an outpatient program for LAAO when compared to the conventional treatment approach. METHODS We present a retrospective, non-randomized single-center study of 262 consecutive patients undergoing LAAO. Patients were divided into two groups, the first (n = 131) followed a conventional protocol (CP), and the second (n = 131) an outpatient protocol (OP). The primary composite endpoint comprised MACCE (death, stroke, and bleeding), cardiac tamponade, vascular complication, or attendance in the emergency department after hospital discharge at 30 days. RESULTS The overall success rate was 99.6%, with a periprocedural complication rate of 2.29%. With regards to the CP versus OP group, there were no differences between incidences of the primary composite endpoint (6.1% PC vs. 3.0% PA, p = 0.24), or after an analysis, with propensity score matching. No differences were observed in the individual endpoints. There was a decrease in hospital length of stay in the same-day discharge group (p < 0.01). CONCLUSIONS A same-day discharge LAAO program is safe, effective, and feasible when compared to the conventional strategy. Moreover, it reduces hospital length of stay, which might have clinical and economic benefits.
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Affiliation(s)
- Fabián Blanco-Fernández
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Pablo J. Antúnez-Muiños
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - Sergio López-Tejero
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Gilles J. Barreira-de Sousa
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Mónica García-Monsalvo
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Milena Antúnez-Ballesteros
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - David González-Calle
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Javier Rodríguez-Collado
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - Elena Díaz-Peláez
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - María C. Pérez del Villar-Moro
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Pedro L. Sánchez-Fernández
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Ignacio Cruz-González
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
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Hewage SA, Noviyani R, Brain D, Sharma P, Parsonage W, McPhail SM, Barnett A, Kularatna S. Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:76. [PMID: 37872572 PMCID: PMC10591401 DOI: 10.1186/s12962-023-00486-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 10/10/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations. METHODS We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively. RESULTS In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common. CONCLUSIONS While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.
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Affiliation(s)
- Sumudu A Hewage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia.
| | - Rini Noviyani
- Department of Pharmacy, Udayana University, Bali, Indonesia
| | - David Brain
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Cardiology department, Royal Brisbane and Women's Hospital, Herston, QLD, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, QLD, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Queensland University of Technology, No.61, Musk Avenue, Kelvin Grove, QLD, 4059, Australia
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Rachieru C, Luca CT, Văcărescu C, Petrescu L, Cirin L, Cozma D. Future Perspectives to Improve CHA 2DS 2VASc Score: The Role of Left Atrium Remodelling, Inflammation and Genetics in Anticoagulation of Atrial Fibrillation. Clin Interv Aging 2023; 18:1737-1748. [PMID: 37873054 PMCID: PMC10590594 DOI: 10.2147/cia.s427748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/07/2023] [Indexed: 10/25/2023] Open
Abstract
In 10% of ischemic strokes, non-valvular atrial fibrillation (NVAF) is detected retroactively. Milder, or even asymptomatic forms of NVAF have shown high mortality, thrombotic risk, and deterioration of cognitive function. The current guidelines for the diagnosis and treatment of AF contain "grey areas", such as the one related to anticoagulant treatment in men with CHA2DS2-VASc score 1 and women with score 2. Moreover, parameters such as renal function, patient weight or left atrium remodelling are missing from the recommended guidelines scores. Vulnerable categories of patients including the elderly population, high hemorrhagic risk patients or patients with newly diagnosed paroxysmal episodes of atrial high rate at device interrogation are at risk of underestimation of the thrombotic risk. This review presents a systematic exposure of the most important gaps in evaluation of thrombotic and hemorrhagic risk in patients with NVAF. The authors propose new algorithms and risk factors that should be taken into consideration for an accurate thrombotic and hemorrhagic risk estimation, especially in vulnerable categories of patients.
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Affiliation(s)
- Ciprian Rachieru
- Faculty of Medicine, Department of Internal Medicine I, Discipline of Medical Semiology I “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Internal Medicine Department, County Emergency Hospital, Timisoara, 300079, Romania
- Center for Advanced Research in Cardiovascular Pathology and Hemostaseology, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Constantin-Tudor Luca
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
| | - Cristina Văcărescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
| | - Lucian Petrescu
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Liviu Cirin
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
| | - Dragos Cozma
- Cardiology Department, “Victor Babes” University of Medicine and Pharmacy, Timisoara, 300041, Romania
- Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
- Research Center of the Institute of Cardiovascular Diseases Timisoara, Timisoara, 300310, Romania
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