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Continisio S, Montonati C, Angelini F, Bocchino PP, Carbonaro C, Giacobbe F, Dusi V, De Filippo O, Ielasi A, Giannino G, Boldi E, Fabris T, D'Ascenzo F, De Ferrari GM, Tarantini G. Single versus dual antiplatelet therapy following percutaneous left atrial appendage closure-A systematic review and meta-analysis. Eur J Clin Invest 2024; 54:e14209. [PMID: 38597271 DOI: 10.1111/eci.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND In the last few years, percutaneous LAA occlusion (LAAO) has become a plausible alternative in atrial fibrillation (AF) patients with contraindications to anticoagulation therapy. Nevertheless, the optimal antiplatelet strategy following percutaneous LAAO remains to be defined. METHODS Studies comparing single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) following LAAO were systematically searched and screened. The outcomes of interest were ischemic stroke, device-related thrombus (DRT) and major bleeding. A random-effect meta-analysis was performed comparing outcomes in both groups. The moderator effect of baseline characteristics on outcomes was evaluated by univariate meta-regression analyses. RESULTS Sixteen observational studies with 3255 patients treated with antiplatelet therapy (SAPT, n = 1033; DAPT, n = 2222) after LAAO were included. Mean age was 74.5 ± 8.3 years, mean CHA2DS2-VASc and HAS-BLED scores were 4.3 ± 1.5 and 3.2 ± 1.0, respectively. At a weighted mean follow-up of 12.7 months, the occurrence of stroke (RR 1.33; 95% CI 0.64-2.77; p =.44), DRT (RR 1.52; 95% CI 0.90-2.58; p =.12), and the composite of stroke and DRT (RR 1.26; 95% CI 0.67-2.37; p =.47) did not differ significantly between SAPT and DAPT groups. The rate of major bleedings was also not different between groups (RR 1.41; 95% CI 0.64-3.12; p =.39). CONCLUSIONS Among AF patients at high bleeding risk undergoing percutaneous LAAO, a post-procedural minimalistic antiplatelet strategy with SAPT did not significantly differ from DAPT regimens regarding the rate of stroke, DRT and major bleeding.
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Affiliation(s)
- Saverio Continisio
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Carolina Montonati
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Carla Carbonaro
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | | | - Emiliano Boldi
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
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2
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Lee WC, Chang WT, Shih JY, Wu PJ, Fang CY, Chen HC, Fang YN, Fang HY. Impact of chronic kidney disease on left atrial appendage occlusion: A meta-analysis of procedural outcomes and complications. Medicine (Baltimore) 2024; 103:e38935. [PMID: 39029071 DOI: 10.1097/md.0000000000038935] [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: 07/21/2024] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) experience atrial fibrillation more frequently. The balance of medical management for stroke prevention and bleeding events presents a challenging issue in CKD population. Left atrial appendage occlusion (LAAO) may be an effective solution for stroke prevention in patients who experience frequent bleeding with oral anticoagulants. However, the specific impact of CKD on the procedural success, complications, and outcomes of LAAO implantations remains underexplored. METHODS We conducted a search of various databases for articles published before October 31, 2023. This search yielded 7 studies, comparing outcomes between CKD and non-CKD cohorts undergoing LAAO implantation. Our analysis focused on CHA2DS2-VASc scores, average eGFR, use of oral anticoagulants, procedural success rates, procedural complications, and associated outcomes. RESULTS The meta-analysis included data from 2576 patients, with 1131 identified as having CKD. The CKD group also had higher CHA2DS2-VASc scores (4.7 ± 1.4 vs 4.0 ± 1.5; P < .001) and HAS-BLED scores (3.8 ± 1.1 vs 3.1 ± 1.0; P < .001) than the non-CKD group. CKD patients showed a nonreduction in procedural success rates and a nonsignificant increase in total complications. The risks of stroke and transient ischemic attack, major bleeding, and cardiovascular mortality were not significantly different between the 2 groups. However, a significantly lower rate of total mortality was observed in the non-CKD group (odds ratio: 0.43; 95% confidence interval, 0.32-0.60). CONCLUSION While CKD is associated with a nonsignificant decrease in procedural success and a nonsignificant increase in complication risks, the outcomes of LAAO implantation are comparably favorable between CKD and non-CKD groups. Despite similar procedural outcomes, the CKD group exhibited a higher rate of all-cause mortality.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Jhih-Yuan Shih
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Jen-Ai Hospital, Taichung, Taiwan
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3
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Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024:ehae398. [PMID: 39027946 DOI: 10.1093/eurheartj/ehae398] [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: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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Lo Russo GV, Kara Balla A, Alarouri H, Liu CH, Zhour Adi M, Killu AM, Alkhouli M. Impact of Early Bleeding on Long-Term Mortality Following Left Atrial Appendage Occlusion. Heart Rhythm 2024:S1547-5271(24)02911-4. [PMID: 39032523 DOI: 10.1016/j.hrthm.2024.07.028] [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: 06/10/2024] [Revised: 06/28/2024] [Accepted: 07/13/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND Short-term antithrombotic therapy is recommended after left atrial appendage occlusion(LAAO) to reduce the risk of device-related thrombosis(DRT). However, patients referred for LAAO have excess bleeding risk. Yet, short-term bleeding events post-LAAO are not well characterized. OBJECTIVE We aimed to evaluate the incidence of early bleeding post-LAAO and its association with long-term mortality risk. We also sought to identify predictors of early bleeding. METHODS Patients who underwent LAAO at Mayo Clinic between 2018 and 2023 were included. Early bleeding was defined as bleeding that occurred within three months of discharge. A multivariable Cox proportional hazards model was used to assess the association between early bleeding and death and to estimate the hazard ratio(HR). Multivariable regression analysis was used to identify predictors of early bleeding. RESULTS Among the 592 patients included, 389(66%) were male, and mean age was 75.6 years. Eighty-three patients(14.0%) experienced early bleeding, with the majority having minimal(63.4%) or minor(17.3%) bleeding. At a median follow-up of 14.4 months(IQR 4.2-27.9), early bleeding after LAAO was associated with an increased risk of all-cause mortality (adjustedHR, 2.07; 95%CI, 1.15-3.75; P=0.02). A history of intracranial bleeding, non-paroxysmal atrial fibrillation, CHA2DS2VASc score, and early DRT were independent predictors of early bleeding. Anti-thrombotic therapy on discharge was not associated with early non-procedural bleeding. CONCLUSIONS One in seven patients experience a non-procedural bleeding event within 90 days after LAAO. Early bleeding after LAAO is associated with a higher all-cause mortality during mid-term follow-up. Further studies are needed to optimize the management of patients undergoing LAAO.
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Affiliation(s)
- Gerardo V Lo Russo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | | | - Hasan Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Chia-Hao Liu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Cardiology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | | | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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5
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Mesnier J, Cruz-González I, Guedeney P, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Cepas-Guillén P, Salinas P, Siquier-Padilla J, Estevez-Loureiro R, Laricchia A, O'Hara G, Montalescot G, Rodés-Cabau J. Early Nonprocedural Bleeding After Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2024:S1936-8798(24)00814-8. [PMID: 39023452 DOI: 10.1016/j.jcin.2024.05.032] [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: 02/19/2024] [Revised: 05/07/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Patients treated with left atrial appendage occlusion (LAAO) are at high bleeding risk. Intensive antithrombotic treatment is recommended after the procedure to prevent device-related thrombosis. OBJECTIVES This study sought to evaluate the incidence, consequences, and predictors of early nonprocedural bleeding after LAAO. METHODS This was a multicenter study including 1,649 patients undergoing LAAO in 9 centers. Early nonprocedural bleeding was defined as bleeding unrelated to the procedure occurring within 3 months after device implantation. The severity of bleeding was defined by the Valve Academic Research Consortium-2 classification. A sensitivity analysis was performed at 45 days. RESULTS A total of 121 (7.3%) patients experienced early nonprocedural bleeding events, and 69 (57.0%) were classified as major bleeding (4.2% of patients). Independent predictors of early nonprocedural bleeding were dual antiplatelet therapy (DAPT) at discharge (adjusted HR [aHR]: 1.61; 95% CI: 1.12-2.33; P = 0.01), prior gastrointestinal bleeding (aHR: 2.15; 95% CI: 1.38-3.35; P < 0.001), and multiple locations of prior bleeding (aHR: 2.33; 95% CI: 1.34-4.05; P < 0.001). DAPT at discharge was predictive of both all and major nonprocedural bleeding at 3 months and 45 days. After a median follow-up of 2.3 years (Q1-Q3: 1.1-4.1 years), early nonprocedural bleeding was independently associated with an increased risk of all-cause death (aHR: 1.53; 95% CI: 1.15-2.06; P < 0.001). This heightened mortality risk was similar at 45 days. CONCLUSIONS Early nonprocedural bleeding after LAAO occurred in ∼7% of patients within 3 months, with more than one-half being classified as major bleeding. Regardless of severity, early nonprocedural bleeding was associated with increased mortality. DAPT at discharge determined an increased risk of early nonprocedural bleeding after LAAO. These results emphasize the importance of bleeding risk for determining antithrombotic strategies after LAAO.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | | | - Vicente Peral
- Servicio de Cardiología, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Palma, Balearic Islands, Spain
| | | | - Antonio Mangieri
- Cardiocenter, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | - Pedro Cepas-Guillén
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Pablo Salinas
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Joan Siquier-Padilla
- Servicio de Cardiología, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Palma, Balearic Islands, Spain
| | | | - Alessandra Laricchia
- GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy; ASST Fatebenefratelli Sacco, Milan, Italy
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.
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6
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Hibbert B, Al-Abcha A. Left Atrial Appendage Closure: Optimizing Postprocedural Care to Optimize Outcomes. JACC Cardiovasc Interv 2024:S1936-8798(24)00807-0. [PMID: 39023455 DOI: 10.1016/j.jcin.2024.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Benjamin Hibbert
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Abdullah Al-Abcha
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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7
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Garg R, Mungee S, Baumann R. Incidental Complication From a Left Atrial Appendage Device. JAMA Cardiol 2024:2820250. [PMID: 38958942 DOI: 10.1001/jamacardio.2024.1571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
This case report describes a diagnosis of extracardiac mural thrombus and pulmonary emboli resulting from a left atrial appendage device in a patient with atrial fibrillation.
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Affiliation(s)
- Rimmy Garg
- University of Illinois College of Medicine Peoria, Peoria
| | - Sudhir Mungee
- University of Illinois College of Medicine Peoria, Peoria
- OSF Cardiovascular Institute, Peoria, Illinois
| | - Rebecca Baumann
- University of Illinois College of Medicine Peoria, Peoria
- OSF Cardiovascular Institute, Peoria, Illinois
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Tanaka T, Kawai K, Ellis CR, Srivastava M, Kawakami R, Konishi T, Shiraki T, Sekimoto T, Virmani R, Finn AV. Challenges and advances in device-related thrombus in left atrial appendage occlusion. Future Cardiol 2024:1-16. [PMID: 38948932 DOI: 10.1080/14796678.2024.2363063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO.
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Affiliation(s)
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD 20878, USA
| | | | - Mukta Srivastava
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
| | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD 20878, USA
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
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Chatani R, Kubo S, Tasaka H, Nishiura N, Mushiake K, Ono S, Maruo T, Kadota K. Transition from WATCHMAN generation-2.5 device to WATCHMAN FLX device for percutaneous left atrial appendage closure: Incidence and predictors of device-related thrombosis and short- to mid-term outcomes. Catheter Cardiovasc Interv 2024. [PMID: 38895767 DOI: 10.1002/ccd.31111] [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: 01/10/2024] [Revised: 04/18/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Patients with nonvalvular atrial fibrillation (AF) not suitable for long-term anticoagulant therapy undergo percutaneous left atrial appendage closure (LAAC) using the WATCHMAN device. The safety and efficacy of WATCHMAN-FLX (WM-FLX) compared with WATCHMAN-2.5 (WM-2.5), particularly in Asian populations, is unknown. METHODS We evaluated the background, procedure, and clinical outcomes of 199 patients who underwent LAAC between September 2019 and December 2022 and compared WM-2.5 (72 patients) with WM-FLX (127 patients). RESULTS The mean age was 76 years, with 128 men, and 100 had nonparoxysmal AF (non-PAF). The mean CHA2DS2-VASc, and HAS-BLED were 5.1, and 3.2 points, respectively. WM-FLX group demonstrated a shorter procedure time than WM-2.5 group (50 vs. 42 min, p = 0.001). The WM-FLX group demonstrated no procedural-related acute cardiac tamponade, which was significantly low (5.6% vs. 0%, p = 0.02), and a significantly higher rate of complete seal at 45-day (63% vs. 80%, p = 0.04). WM-FLX group had a significantly higher cumulative 1-year incidence of device-related thrombosis (DRT) than WM-2.5 group (3.4% vs. 7.0%, Log-rank p = 0.01). Univariate analysis identified two DRT risk factors in the WM-FLX group: non-PAF (odds ratio [OR] 7.72; 95% confidence interval [CI] 1.20-48.7; p = 0.04), and 35-mm device (OR 5.13; 95% CI 1.31-19.8; p = 0.02). CONCLUSIONS WM-FLX significantly improved the procedural quality and safety of LAAC. However, DRT remains an important issue even in the novel LAAC device, being a hazard for patients with high DRT risk, such as having non-PAF and using 35-mm devices.
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Affiliation(s)
- Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shunsuke Kubo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiroshi Tasaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Naoki Nishiura
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazunori Mushiake
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sachiyo Ono
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Maruo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
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10
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Vij V, Ruf TF, Thambo JB, Vogt L, Al-Sabri SMA, Nelles D, Schrickel JW, Beiert T, Nickenig G, von Bardeleben RS, Iriart X, Sedaghat A. Contrast-free left atrial appendage occlusion in patients using the LAMBRE™ device. Int J Cardiol 2024; 405:131939. [PMID: 38458388 DOI: 10.1016/j.ijcard.2024.131939] [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: 01/24/2024] [Revised: 02/22/2024] [Accepted: 03/05/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Advances in imaging have led to procedural optimization of left atrial appendage closure (LAAC). Contrast-free approaches, guided merely by echocardiography, have been established, however data on this topic remains scarce. In this analysis, we assessed contrast-free procedural results with the LAMBRE LAAC device. METHODS The multicenter retrospective BoBoMa (Bonn/Bordeaux/Mainz)-Registry included a total of 118 patients that underwent LAAC with LAMBRE devices omitting contrast-dye. Baseline and echocardiographic characteristics as well as intra- and postprocedural complications and outcomes were assessed. RESULTS Patients were at a mean age of 77.5 ± 7.5 years with high thromboembolic and bleeding risk (CHADS-VASc-score 4.6 ± 1.4, HAS-BLED-score 3.7 ± 1.0, respectively). Renal function was impaired with a mean glomerular filtration rate (GFR) of 50 ± 22 ml/min. Mean procedural time was 47.2 ± 37.5 minutes with a mean radiation dose of 4.75 ± 5.25 Gy*cm2. Device success, defined as proper deployment in a correct position, was achieved in 97.5% (115/118) of cases with repositioning of the occluder in 7.6% (9/118) and resizing in 3.4% (4/118) of cases. No relevant peri-device leakage (>3 mm) was observed with 42% of occluders being implanted in an ostial position. Periprocedural complications occurred in 6.8% (8/118) of cases, including two cases of device embolization and one case of clinically-relevant pericardial effusion requiring surgical intervention. Other complications included pericardial effusion (2.5%, 3/118) and vascular access site complications (1.7%, 2/118). CONCLUSION Echocardiography-guided contrast-free LAAC using the LAMBRE device is safe and feasible. Further prospective studies including the direct comparison of devices as well as imaging techniques are warranted in contrast-free LAAC.
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Affiliation(s)
- Vivian Vij
- Herzzentrum Bonn, University Hospital Bonn, Germany
| | | | | | - Lara Vogt
- Herzzentrum Bonn, University Hospital Bonn, Germany
| | | | | | | | | | | | | | | | - Alexander Sedaghat
- Herzzentrum Bonn, University Hospital Bonn, Germany; RheinAhrCardio, Praxis für Kardiologie, Bad-Neuenahr Ahrweiler, Germany.
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Tiroke LH, Kramer A, Poulsen MW, Jensen CD, Jensen JM, Nørgaard BL, Korsholm K, Nielsen-Kudsk JE. Long-term cardiac computed tomography follow-up after left atrial appendage occlusion. EUROINTERVENTION 2024; 20:e718-e727. [PMID: 38840576 PMCID: PMC11145311 DOI: 10.4244/eij-d-23-00802] [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] [Received: 09/22/2023] [Accepted: 01/05/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is performed increasingly, but long-term follow-up imaging data are lacking. AIMS The aim of this study was to evaluate the safety and durability of the Amplatzer Amulet device >4 years after LAAO. METHODS This was a prospective observational cohort study including 52 patients implanted with the Amplatzer Amulet device at Aarhus University Hospital, Denmark. A >4-year follow-up cardiac computed tomography (CT) scan after LAAO was performed and compared with the results from the 2-month and 12-month scans. The primary outcome was left atrial appendage (LAA) sealing based on distal LAA contrast patency and peridevice leakage (PDL), stratified into complete occlusion (grade 0 [G0]) and grade 1-3 leakage (G1-3), respectively. Secondary outcomes were low- and high-grade hypoattenuated thickening (HAT), device-related thrombosis (DRT) and device durability. RESULTS The median (interquartile range [IQR]) follow-up time from LAAO to the latest CT scan was 5.8 years (4.5; 6.3). At 2-month (n=52), 12-month (n=27) and >4-year CT follow-ups (n=52), rates of both complete occlusion (33%, 37%, 35%) and G2 leaks (52%, 52%, 48%) remained stable. Rates of G1 leaks varied (14%, 4%, 6%) and G3 leaks rose (2%, 7%, 12%) from earliest to latest follow-up. The median left atrial (LA) volume increased from 127 mL (96; 176) to 144 mL (108; 182) and 147 mL (107; 193). No DRT was found. The structural device integrity was preserved. CONCLUSIONS This study indicates a stable LAA sealing status throughout the follow-up period, emphasising the importance of the procedural result in avoiding PDL. Few patients displayed PDL progression, which might partly be related to LA remodelling with increasing volume. The long-term device durability appears excellent. Larger studies are warranted to confirm these findings.
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Affiliation(s)
- Lasse Hubertus Tiroke
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Mette Wørmer Poulsen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Caroline Damsgaard Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | | | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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12
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Nirmalan JG, Kramer A, Korsholm K, Jensen JM, Nielsen-Kudsk JE. Computed tomography-based device-sizing in Amplatzer Amulet left atrial appendage occlusion. J Interv Card Electrophysiol 2024; 67:785-795. [PMID: 37882993 PMCID: PMC11166793 DOI: 10.1007/s10840-023-01665-y] [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: 08/24/2023] [Accepted: 10/09/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Amplatzer Amulet is a frequently used device for left atrial appendage occlusion (LAAO). The current sizing protocol is based on the maximum diameter of the left atrial appendage (LAA) landing zone. However, mean, perimeter-, or area-derived diameter might be more accurate measures for device sizing. METHODS Retrospective analysis of 150 consecutive patients undergoing LAAO is guided by pre-procedural cardiac CT. A total of 117 patients were included; 7 were excluded due to renal failure and 26 due to closure with the sandwich technique. The maximum, mean, area-, and perimeter-derived diameters of the landing zone were derived from pre-procedural cardiac CT scans, and their accuracy to predict the implanted device size was investigated. The predicted device size was determined based on the currently recommended sizing algorithm. Peri-device leak (PDL) was assessed (grade 1-3) along with the underlying mechanism. RESULTS Device-sizing accuracy was superior for mean, area-, and perimeter derived diameters compared with the maximal diameter, especially for eccentric landing zones. Mean difference between predicted and actually implanted device size was 0.08 mm (± 2.77), 0.30 mm (± 2.40), - 0.39 mm (± 2.43), and - 2.55 mm (± 2.57) across mean, area-derived, perimeter-derived, and maximal diameter, respectively. Grade 3 peri-device leak was seen in 8.5% of implants without a significant association to the eccentricity of the landing zone. The leading mechanism for PDL was device malalignment. CONCLUSION Our results indicate mean, area-, and perimeter-derived diameters of the device landing zone to perform similar and superior in device-sizing accuracy compared with the maximum diameter.
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Affiliation(s)
- Jonatan Gerard Nirmalan
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Aarhus, Denmark
| | - Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Aarhus, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N, 8200, Aarhus, Denmark.
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Kayvanpour E, Kothe M, Kaya Z, Pleger S, Frey N, Meder B, Sedaghat-Hamedani F. Comparative Assessment of Percutaneous Left-Atrial Appendage Occlusion (LAAO) Devices-A Single Center Cohort Study. J Cardiovasc Dev Dis 2024; 11:158. [PMID: 38921657 PMCID: PMC11203807 DOI: 10.3390/jcdd11060158] [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: 04/12/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Percutaneous left-atrial appendage closure (LAAC) is an established method for preventing strokes in patients with atrial fibrillation, offering an alternative to oral anticoagulation. Various occluder devices have been developed to cater to individual anatomical needs and ensure a safe and effective procedure. In this retrospective, monocentric cohort study, we compare different LAAO devices with respect to clinical outcomes, LAA sealing properties, and device-related complications. METHODS We conducted a retrospective analysis of 270 patients who underwent percutaneous LAA closure in our center between 2009 and 2023. Patient data were extracted from medical records, including gender, age at implantation, indication, device type and size, laboratory values, LAA anatomy, periprocedural complications, ECG parameters, transthoracic and transesophageal echocardiography parameters (TTE and TEE), as well as medication at discharge. Moreover, fluoroscopy time and implantation duration, as well as post-implantation clinical events up to 1 year, were collected. Endpoints were bleeding events, recurrent stroke, thrombi on devices, and death. RESULTS The implanted devices were the Watchman 2.5, Watchman FLX, Amplatzer Cardiac Plug (ACP), and Amulet. The procedural success rate was 95.7% (n = 265), with cactus anatomy posing the most challenges across all devices. The mean patient age was 75.5 ± 7.7 years, with 64.5% being male. The median CHA2DS2-VASc score was 4.8 ± 1.5 and the median HAS-BLED score was 3.8 ± 1.0. Indications for LAA closure included past bleeding events and elevated bleeding risk. Periprocedural complications were most commonly bleeding at the puncture site, particularly after ACP implantation (p = 0.014). Significant peridevice leaks (PDL) were observed in 21.4% of simple sealing mechanism devices versus 0% in double sealing mechanism devices (p = 0.004). Thrombi were detected on devices in six patients, with no subsequent ischemic stroke or thromboembolic event. Comparative analysis revealed no significant differences in the occurrence of stroke, transient ischemic attack (TIA), thromboembolic events, device-related thrombi, or mortality among different device types. A 62.3% relative risk reduction in thromboembolic events and 38.6% in major bleedings could be observed over 568.2 patient years. CONCLUSIONS In summary, our study highlights the efficacy and safety of LAA closure using various occluder devices despite anatomical challenges. Our long-term follow-up findings support LAA closure as a promising option for stroke prevention in selected patient cohorts. Further research is needed to refine patient selection criteria and optimize outcomes in LAA closure procedures.
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Affiliation(s)
- Elham Kayvanpour
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
- DZHK (German Centre for Cardiovascular Research), 69120 Heidelberg, Germany
| | - Max Kothe
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
| | - Ziya Kaya
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
- DZHK (German Centre for Cardiovascular Research), 69120 Heidelberg, Germany
| | - Sven Pleger
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
| | - Norbert Frey
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
- DZHK (German Centre for Cardiovascular Research), 69120 Heidelberg, Germany
| | - Benjamin Meder
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
- DZHK (German Centre for Cardiovascular Research), 69120 Heidelberg, Germany
- Department of Genetics, Stanford Genome Technology Center, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Farbod Sedaghat-Hamedani
- Department of Internal Medicine III, Heidelberg University, 69120 Heidelberg, Germany; (E.K.)
- DZHK (German Centre for Cardiovascular Research), 69120 Heidelberg, Germany
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Danielli F, Berti F, Fanni BM, Gasparotti E, Celi S, Pennati G, Petrini L. Left atrial appendage occlusion: On the need of a numerical model to simulate the implant procedure. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024; 40:e3814. [PMID: 38504482 DOI: 10.1002/cnm.3814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/23/2024] [Accepted: 03/10/2024] [Indexed: 03/21/2024]
Abstract
Left atrial appendage occlusion (LAAO) is a percutaneous procedure to prevent thromboembolism in patients affected by atrial fibrillation. Despite its demonstrated efficacy, the LAA morphological complexity hinders the procedure, resulting in postprocedural drawbacks (device-related thrombus and peri-device leakage). Local anatomical features may cause difficulties in the device's positioning and affect the effectiveness of the device's implant. The current work proposes a detailed FE model of the LAAO useful to investigate implant scenarios and derive clinical indications. A high-fidelity model of the Watchman FLX device and simplified parametric conduits mimicking the zone of the LAA where the device is deployed were developed. Device-conduit interactions were evaluated by looking at clinical indicators such as device-wall gap, possible cause of leakage, and device protrusion. As expected, the positioning of the crimped device before the deployment was found to significantly affect the implant outcomes: clinician's choices can be improved if FE models are used to optimize the pre-operative planning. Remarkably, also the wall mechanical stiffness plays an important role. However, this parameter value is unknown for a specific LAA, a crucial point that must be correctly defined for developing an accurate FE model. Finally, numerical simulations outlined how the device's configuration on which the clinician relies to assess the implant success (i.e., the deployed configuration with the device still attached to the catheter) may differ from the actual final device's configuration, relevant for achieving a safe intervention.
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Affiliation(s)
- Francesca Danielli
- LaBS - Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Francesca Berti
- LaBS - Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | | | | | - Simona Celi
- BioCardioLab, Fondazione Toscana G. Monasterio, Massa, Italy
| | - Giancarlo Pennati
- LaBS - Laboratory of Biological Structure Mechanics, Department of Chemistry, Materials and Chemical Engineering "Giulio Natta", Politecnico di Milano, Milan, Italy
| | - Lorenza Petrini
- Department of Civil and Environmental Engineering, Politecnico di Milano, Milan, Italy
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15
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Armouti AO, Amin S, Rose DZ. Late device-related thrombus associated with occult malignancy years after left atrial appendage closure. J Stroke Cerebrovasc Dis 2024; 33:107618. [PMID: 38402694 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107618] [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: 11/27/2023] [Revised: 01/28/2024] [Accepted: 01/30/2024] [Indexed: 02/27/2024] Open
Abstract
INTRODUCTION The use of Left Atrial Appendage (LAA) occluder devices has been on the rise in patients with atrial fibrillation. Studies regarding the long-term risks of occluder devices remain sparse. MATERIALS & METHODS In this brief report, we discuss the unusual case of an 85-year-old female with long-term complication from Left Atrial Appendage (LAA) closure: Device-Related Thrombus (DRT) about two years after insertion. RESULTS Compared to the expected stroke rate without anticoagulation, patients with DRT on their LAAO device still had a 28 % relative reduction in ischemic stroke. This suggests that these strokes may have emanated from alternate etiologies other than the DRT. CONCLUSIONS Patients with active or known history of cancer appears to have a higher risk of DRT. More data is needed on this topic to augment awareness and understanding of LAAO complications and DRT management strategies.
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Affiliation(s)
- Ahmad O Armouti
- University of South Florida Morsani College of Medicine, Tampa, FL USA.
| | - Sheyar Amin
- University of South Florida Morsani College of Medicine, Tampa, FL USA.
| | - David Z Rose
- University of South Florida Morsani College of Medicine, Tampa, FL USA.
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16
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Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
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Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
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17
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MENG XS, WANG QS, WANG XY, LU X, MU Y, WANG J, SONG TT, CHEN YD, CHEN T, GUO J. Minimalistic approach to left atrial appendage occlusion guided by cardiac computed tomography angiography. J Geriatr Cardiol 2024; 21:431-442. [PMID: 38800546 PMCID: PMC11112155 DOI: 10.26599/1671-5411.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE To assess the feasibility and safety of the minimalistic approach to left atrial appendage occlusion (LAAO) guided by cardiac computed tomography angiography (CCTA). METHODS Ninety consecutive patients who underwent LAAO, with or without CCTA-guided, were matched (1:2). Each step of the LAAO procedure in the computed tomography (CT) guidance group (CT group) was directed by preprocedural CT planning. In the control group, LAAO was performed using the standard method. All patients were followed up for 12 months, and device surveillance was conducted using CCTA. RESULTS A total of 90 patients were included in the analysis, with 30 patients in the CT group and 60 matched patients in the control group. All patients were successfully implanted with Watchman devices. The mean ages for the CT group and the control group were 70.0 ± 9.4 years and 68.4 ± 11.9 years (P = 0.52), respectively. The procedure duration (45.6 ± 10.7 min vs. 58.8 ± 13.0 min, P < 0.001) and hospital stay (7.5 ± 2.4 day vs. 9.6 ± 2.8 day, P = 0.001) in the CT group was significantly shorter compared to the control group. However, the total radiation dose was higher in the CT group compared to the control group (904.9 ± 348.0 mGy vs. 711.9 ± 211.2 mGy, P = 0.002). There were no significant differences in periprocedural pericardial effusion (3.3% vs. 6.3%, P = 0.8) between the two groups. The rate of postprocedural adverse events (13.3% vs. 18.3%, P = 0.55) were comparable between both groups at 12 months follow-up. CONCLUSIONS CCTA is capable of detailed LAAO procedure planning. Minimalistic LAAO with preprocedural CCTA planning was feasible and safe, with shortened procedure time and acceptable increased radiation and contras consumption. For patients with contraindications to general anesthesia and/or transesophageal echocardiography, this promising method may be an alternative to conventional LAAO.
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Affiliation(s)
- Xian-Sai MENG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Qing-Song WANG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Xin-Yan WANG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Xu LU
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Yang MU
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing WANG
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ting-Ting SONG
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yun-Dai CHEN
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tao CHEN
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun GUO
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
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Kalaba F, Saba S, Kassar A, Machado C, Shah D. "A heart within the heart": A rare case of a large left atrial appendage occluder device-related thrombus. HeartRhythm Case Rep 2024; 10:263-265. [PMID: 38766611 PMCID: PMC11096434 DOI: 10.1016/j.hrcr.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Frank Kalaba
- Ascension Providence Cardiovascular Diseases Fellowship Program, Southfield, Michigan
| | - Souheil Saba
- Ascension Providence Cardiovascular Diseases Fellowship Program, Southfield, Michigan
| | - Ahmad Kassar
- Lebanese American University Medical Center, Ashrafieh, Lebanon
| | - Christian Machado
- Ascension Providence Cardiovascular Diseases Fellowship Program, Southfield, Michigan
| | - Dipak Shah
- Ascension Providence Cardiovascular Diseases Fellowship Program, Southfield, Michigan
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Nielsen-Kudsk JE, Kramer A, Andersen A, Kim WY, Korsholm K. First-in-human left atrial appendage closure using the WATCHMAN FLX Pro device: a case report. Eur Heart J Case Rep 2024; 8:ytae135. [PMID: 38617588 PMCID: PMC11014679 DOI: 10.1093/ehjcr/ytae135] [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: 07/20/2023] [Revised: 02/26/2024] [Accepted: 03/13/2024] [Indexed: 04/16/2024]
Abstract
Background Device-related thrombosis (DRT) is a known complication to left atrial appendage closure (LAAC). The surface of a LAAC device should ideally have antithrombotic properties. The novel WATCHMAN FLX Pro (WFP) incorporates a fluoropolymer-coated fabric membrane designed to increase thromboresistance and facilitate endothelialization. Such features could potentially allow for a minimal post-procedural antithrombotic regimen. Radiopaque platinum markers at the device shoulders and a large 40 mm device are other novel features of the WFP. Case summary A 75-year-old man with atrial fibrillation was referred for LAAC due to prior subdural haemorrhage during direct-acting anticoagulation treatment. He underwent the first-in-human WFP implantation as part of the WATCHMAN FLX Pro CT study (NCT05567172). Computed tomography (CT) was used for pre-planning, and the procedure was performed under local analgesia guided by intracardiac echocardiography from the left atrium (LA) without any complications. Post-procedural antithrombotic treatment consisted of acetylsalicylic acid 75 mg/day only, and 45-day CT, transoesophageal echocardiography (TEE), and magnetic resonance imaging demonstrated optimal device position with complete LAAC. Hypoattenuated thickening (6 mm) appeared on the device as a smooth surface in continuity with the left atrial wall on CT and TEE. A specific magnetic resonance T1-weighted scan, used for visualization of fresh thrombus, suggested this to represent tissue ingrowth rather than thrombus. Discussion The advanced follow-up imaging protocol suggested a good WFP implantation result with signs of tissue ingrowth at 45 days. The added radiopaque markers facilitated optimal deployment, evaluation of device stability during tug test, and assessment of device protrusion into the LA.
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Affiliation(s)
- Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Won Yong Kim
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
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Sawaya F, Abi-Saleh B, Hoteit A, Jdaidany J, Moumneh MB, Harbieh B, Khoury M, Aramouni S, Abdulhai F, Refaat M. Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation. Cureus 2024; 16:e55531. [PMID: 38576630 PMCID: PMC10993002 DOI: 10.7759/cureus.55531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott, Chicago, IL, USA) and Watchman device (Boston Scientific, Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device. OBJECTIVE The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices. METHODS Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death). RESULTS The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods. CONCLUSION There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.
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Affiliation(s)
- Fadi Sawaya
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Bernard Abi-Saleh
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Abbas Hoteit
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Jennifer Jdaidany
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | | | - Bernard Harbieh
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Maurice Khoury
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Salim Aramouni
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Farah Abdulhai
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
| | - Marwan Refaat
- Cardiology, American University of Beirut Medical Center, Beirut, LBN
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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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Yasmin F, Ali E, Moeed A, Zaidi F, Umar M, Virwani V. Safety and efficacy of percutaneous Watchman 2.5 device versus Amplatzer Amulet for left atrial appendage closure in patients with non-valvular atrial fibrillation: A systematic review and study-level meta-analysis. PLoS One 2024; 19:e0295804. [PMID: 38354181 PMCID: PMC10866506 DOI: 10.1371/journal.pone.0295804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION In patients with non-valvular atrial fibrillation (NVAF), mechanical occlusion of the left atrial appendage (LAA) using a permanently implanted device may be an effective alternative to oral anti-coagulants (OAC). To facilitate left atrial appendage closure (LAAC), multiple percutaneous devices have been proposed. Watchman Generation 2.5 and Amplatzer Amulet are the two most popular used devices for preventing stroke in patients with NVAF. We sought to compare safety and efficacy outcomes between Watchman 2.5 and Amplatzer Amulet in patients undergoing LAAC procedure. METHODS We carried out a comprehensive and systematic search of the databases PubMed and Scopus, for all studies that compared the safety and efficacy of Watchman 2.5 and Amplatzer Amulet devices, from inception, till June 2023. We performed the statistical analysis using Review Manager (V.5.4.1 Cochrane Collaboration, London, United Kingdom). The safety outcomes of interest included device success, device-related thrombus, device embolization perioperatively and at follow-up, perioperative pericardial perfusion events, and perioperative cardiac tamponade events. Efficacy outcomes were all-cause mortality perioperatively and at follow-up, cardiovascular (CV) mortality at follow-up, stroke, major and minor bleeding events at follow-up, transient ischemic attack (TIA) in follow-up period, thromboembolic events in follow-up period, and peri-device leakage in perioperative period. All data was analysed using a random-effects model, and presented as risk ratios (RRs) with 95% confidence intervals (95%CIs). RESULTS Regarding safety outcomes, device success was non-significantly reduced in Watchman group when compared with Amulet (RR 0.99, p = 0.57; I2 = 34%). In contrast, device-related thrombus was non-significantly increased in Watchman 2.5 group in comparison to Amulet (RR 1.44, p = 0.11; I2 = 0%). There was no significant difference between the devices in terms of device embolization in the perioperative (RR 0.36, p = 0.38; I2 = 22%) and follow-up (RR 2.24, p = 0.13; I2 = 0%) periods. Likewise, there was no significant difference in the risks of pericardial effusion (RR 0.98, p = 0.98; I2 = 0%), and cardiac tamponade (RR 0.65, p = 0.76; I2 = 62%) perioperatively. Regarding efficacy outcomes, no significant difference was observed in all-cause mortality between devices perioperatively (RR 0.51, p = 0.32; I2 = 0%) and at follow-up (RR 1.08, p = 0.56; I2 = 0%). CV-mortality was non-significantly reduced in Watchman group when compared with Amulet (RR 0.57, p = 0.20; I2 = 0%). The Amulet device was not superior to the Watchman device in terms of stroke at follow-up (RR 1.13, p = 0.63; I2 = 0%). Sub-group analysis showed comparable ischaemic and haemorrhagic stroke events between two devices. Furthermore, at follow-up, there was no significant difference in major (RR 1.06, p = 0.63; I2 = 0%) and minor bleeding events (RR 1.81, p = 0.17; I2 = 0%) between the two devices. No difference was observed for trans-ischemic attack (RR 1.89, p = 0.24; I2 = 0%) and thromboembolic events (RR 0.96, p = 0.96; I2 = 0%) at follow-up. No significant difference was observed between devices for peri-device leakage in perioperative period (RR 2.16, p = 0.05; I2 = 0%). CONCLUSION The data suggested that LAAC is safe and efficacious procedure irrespective of device used, with generally low complication rates. Watchman generation 2.5 remains non-superior to Amplatzer Amulet in terms of safety and efficacy outcomes.
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Affiliation(s)
- Farah Yasmin
- Yale University School of Medicine, New Haven, CT, United States of America
| | - Eman Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Abdul Moeed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Farwa Zaidi
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Umar
- IU Health Ball Memorial Hospital, Muncie, IN, United States of America
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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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Llagostera-Martín M, Cainzos M, Salvatella N, Cubero-Gallego H, Mas-Stachurska A, Sánchez-Carpintero A, Tizón-Marcos H, Calvo-Fernández A, Molina L, Vaquerizo B. Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:150-157. [PMID: 37879431 DOI: 10.1016/j.rec.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION AND OBJECTIVES The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. METHODS This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. RESULTS The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). CONCLUSIONS SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.
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Affiliation(s)
| | - Miguel Cainzos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | | | - Héctor Cubero-Gallego
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Aleksandra Mas-Stachurska
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Helena Tizón-Marcos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alicia Calvo-Fernández
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Luis Molina
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
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25
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Cantu-Martinez O, Bhargav R, Mainigi S. Recurrence of device-related thrombus 3 years after left atrial appendage occlusion. HeartRhythm Case Rep 2024; 10:128-131. [PMID: 38404978 PMCID: PMC10885687 DOI: 10.1016/j.hrcr.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024] Open
Affiliation(s)
- Omar Cantu-Martinez
- Department of Medicine, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ruchika Bhargav
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Cardiology, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
| | - Sumeet Mainigi
- Sidney Kimmel College of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Cardiology, Jefferson Einstein Medical Center, Philadelphia, Pennsylvania
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26
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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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27
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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: 9] [Impact Index Per Article: 9.0] [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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Narayanan CA, Al Taii H, Sabayon MD. Optical Coherence Tomography to Visualize Endothelialization in Left Atrial Appendage Closure: Optical Reality or Illusion? J Am Heart Assoc 2024; 13:e032974. [PMID: 38156595 PMCID: PMC10863796 DOI: 10.1161/jaha.123.032974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 12/30/2023]
Affiliation(s)
| | - Haider Al Taii
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Muhie Dean Sabayon
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
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Chen J, Chiu F, Chang S, Cheng H, Huang P, Wu C, Wang Y, Hwang J, Tsai C. Pattern of Endothelialization in Left Atrial Appendage Occluder by Optic Coherence Tomography: A Pilot Study. J Am Heart Assoc 2024; 13:e030080. [PMID: 38156658 PMCID: PMC10863799 DOI: 10.1161/jaha.123.030080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Implantation of the left atrial appendage occluder (LAAO) has been proven to prevent stroke effectively in patients with atrial fibrillation who cannot tolerate anticoagulants. Incomplete endothelization of LAAO may cause device-related thrombus, and currently no good image modality exists to clearly see LAAO endothelialization. We aimed to use coronary optic coherence tomography (OCT) to visualize LAAO endothelialization. METHODS AND RESULTS We enrolled 14 patients (72.8±9.4 years old) undergoing pulmonary vein isolation with a preexisting LAAO implanted more than 1 year ago (5 Watchman and 9 Amulet). After pulmonary vein isolation, we did OCT via steerable sheath and coronary guiding catheter to adjust OCT probe location and injected contrast medium to visualize the LAAO surface. In vitro testing was also performed to see the bare occluder. In vitro OCT showed the surface of the bare device as an interrupted granule pattern, which included the Watchman surface polytetrafluoroethylene membrane string, Amulet disc metal strut, and inner polytetrafluoroethylene membrane string. In the implanted Watchman, OCT showed endothelialization as a smooth surface layer with noninterrupted coarser granules. In the implanted Amulet, OCT showed endothelialization as thin (early) or thick (late) endothelialization layer covering struts with OCT shadows. Among patients with Watchman, 2 showed no, 2 early, and 1 complete endothelialization. Among patients with Amulet, 2 showed no, 3 early, and 4 late endothelialization. CONCLUSIONS We demonstrated the feasibility of OCT to visualize LAAO endothelization with high resolution. Further studies are needed to determine antithrombotic regimens if incomplete endothelization is detected. A new OCT catheter may be designed specifically for LAAO.
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Affiliation(s)
- Jien‐Jiun Chen
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Fu‐Chun Chiu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Sheng‐Nan Chang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Hsiao‐Liang Cheng
- Department of AnesthesiaNational Taiwan University HospitalTaipeiTaiwan
| | - Pang‐Shuo Huang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Cho‐Kai Wu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Yi‐Chih Wang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Juey‐Jen Hwang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Chia‐Ti Tsai
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Graduate Institute of Clinical MedicineNational Taiwan University College of Medicine, Cardiovascular Center, National Taiwan University HospitalTaipeiTaiwan
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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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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Yoon SH, Elgendy AY, Dallan LAP, Filby SJ. Amulet device implantation following incomplete left atrial appendage closure with Watchman legacy device. Catheter Cardiovasc Interv 2024; 103:226-229. [PMID: 37870093 DOI: 10.1002/ccd.30864] [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: 03/26/2023] [Revised: 08/17/2023] [Accepted: 10/05/2023] [Indexed: 10/24/2023]
Abstract
Peri-device leak after left atrial appendage closure (LAAC) is often treated with endovascular coils, plugs, or second occluders. This is the first study reporting the Amulet device used for peri-device leak. An 80-year-old male with paroxysmal atrial fibrillation and recurrent falls with head trauma who underwent LAAC with a 24 mm Watchman 2.5 device 3 years ago at another institution was referred to our clinic for management of the peri-device leak. Transesophageal echocardiogram showed persistent residual peri-device leak with 5 mm width along the Coumadin ridge aspect of the device. Computed tomography (CT) also showed the peri-device leak with width of 6 mm and complete opacification of left atrial appendage (LAA). Importantly, CT demonstrated that the Watchman 2.5 device was deployed at distal LAA, leaving the proximal part of LAA with length of 10 mm from ostium. Under general anesthesia, a 22 mm Amulet device was deployed successfully with complete sealing of LAA. Procedure planning is the key to minimize the risk of peri-device leak or device-related thrombosis. Careful assessment of LAA anatomy using multimodality images for peri-device leak after LAAC helped optimal treatment strategy including second LAAC with different type of devices.
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Affiliation(s)
- Sung-Han Yoon
- University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Akram Y Elgendy
- University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio, USA
| | - Steven J Filby
- University Hospitals Cleveland Medical Center, Harrington Heart and Vascular Institute, Cleveland, Ohio, 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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Batko J, Rusinek J, Słomka A, Litwinowicz R, Burysz M, Bartuś M, Lakkireddy DR, Lee RJ, Natorska J, Ząbczyk M, Kapelak B, Bartuś K. Postoperative Coagulation Changes in Patients after Epicardial Left Atrial Appendage Occlusion Varies Based on the Left Atrial Appendage Size. Diseases 2023; 12:8. [PMID: 38248359 PMCID: PMC10814509 DOI: 10.3390/diseases12010008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/23/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
Left atrial appendage occlusion affects systemic coagulation parameters, leading to additional patient-related benefits. The aim of this study was to investigate the differences in coagulation factor changes 6 months after epicardial left atrial appendage occlusion in patients with different LAA morphometries. This is the first study to analyze these relationships in detail. A prospective study of 22 consecutive patients was performed. Plasminogen, fibrinogen, tPA concentration, PAI-1, TAFI and computed tomography angiograms were performed. Patients were divided into subgroups based on left atrial appendage body and orifice diameter enlargement. The results of blood tests at baseline and six-month follow-up were compared. In a population with normal LAA body size and normal orifice diameter size, a significant decrease in analyzed clotting factors was observed between baseline and follow-up for all parameters except plasminogen. A significant decrease between baseline and follow-up was observed with enlarged LAA body size in all parameters except TAFI, in which it was insignificant and plasminogen, in which a significant increase was observed. Occlusion of the left atrial appendage is beneficial for systemic coagulation. Patients with a small LAA may benefit more from LAA closure in terms of stabilizing their coagulation factors associated with potential thromboembolic events in the future.
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Affiliation(s)
- Jakub Batko
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland;
| | - Jakub Rusinek
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Artur Słomka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, 85-094 Bydgoszcz, Poland;
- Department of Pathophysiology, Nicolaus Copernicus University in Toruń, Ludwik Rydygier Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland
| | - Radosław Litwinowicz
- CAROL—Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
| | - Marian Burysz
- Department of Cardiac Surgery, Regional Specialist Hospital, 86-300 Grudziądz, Poland
| | - Magdalena Bartuś
- Department of Pharmacology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Dhanunjaya R. Lakkireddy
- The Kansas City Heart Rhythm Institution and Research Foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Randall J. Lee
- Department of Medicine and Cardiovascular Research Institute, University of California, San Francisco, CA 94158, USA
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
| | - Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland; (J.N.); (M.Z.)
| | - Bogusław Kapelak
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, 31-008 Krakow, Poland
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Flores-Umanzor E, Asghar A, Cepas-Guillén PL, Farrell A, Keshvara R, Alvarez-Rodriguez L, Osten M, Freixa X, Horlick E, Abrahamyan L. Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis. Clin Res Cardiol 2023:10.1007/s00392-023-02359-1. [PMID: 38112741 DOI: 10.1007/s00392-023-02359-1] [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: 09/14/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative. OBJECTIVE This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD). METHODS Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies. RESULTS We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade. CONCLUSIONS Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO. Transcatheter Left Atrial Appendage Occlusion (laao) Can Prevent Cardioembolic Events In Chronic Kidney Disease (ckd) Patients. However, Ckd Patients, Particularly Those With End-stage Renal Disease/dialysis (esrd), May Face Increased Odds Of Acute Kidney Injury, In-hospital And Long-term Bleeding, And Mortality. Notably, These Adverse Outcomes In Ckd Patients May Be Linked To Their High Comorbidity Burden, Particularly In Those With Esrd, Rather Than The Laao Procedure Itself. Careful Patient Selection, Management, And Surveillance Involving Multidisciplinary Teams Are Essential For Ckd Patients Undergoing Laao To Ensure Maximum Clinical Benefit Transcatheter left atrial appendage occlusion (LAAO) can prevent cardioembolic events in chronic kidney disease (CKD) patients. However, CKD patients, particularly those with end-stage renal disease/dialysis (ESRD), may face increased odds of acute kidney injury, in-hospital and long-term bleeding, and mortality. Notably, these adverse outcomes in CKD patients may be linked to their high comorbidity burden, particularly in those with ESRD, rather than the LAAO procedure itself. Careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO to ensure maximum clinical benefit.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Areeba Asghar
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Pedro L Cepas-Guillén
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Leyre Alvarez-Rodriguez
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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Kowalska W, Mitręga K, Olma A, Podolecki T, Kalarus Z, Streb W. Anticoagulants versus Left Atrial Appendage Occlusion in Patients with Atrial Fibrillation and Co-Morbid Thrombocytopenia. J Clin Med 2023; 12:7637. [PMID: 38137707 PMCID: PMC10743658 DOI: 10.3390/jcm12247637] [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: 11/02/2023] [Revised: 11/23/2023] [Accepted: 11/29/2023] [Indexed: 12/24/2023] Open
Abstract
Left atrial appendage closure (LAAC) is an alternative approach to anticoagulants. Nonetheless, data regarding the outcomes of LAAC procedures in patients with thrombocytopenia remain lacking. The primary objective was to determine the incidence of the composite endpoint comprising ischemic stroke, intracranial hemorrhage, major bleeding, and cardiac cause of death among patients with atrial fibrillation (AF) and thrombocytopenia who were either undergoing LAAC or receiving oral anticoagulants. The secondary endpoint was the determination of total mortality. Data from a prospective, single-center registry of patients undergoing LAAC procedures were analyzed. A subset of 50 consecutive patients with thrombocytopenia were selected. Thrombocytopenia was defined as a thrombocyte count below 150,000. Subsequently, from patients hospitalized with AF receiving oral anticoagulants, 50 patients were further chosen based on propensity score matching, ensuring comparability with the study group. The primary endpoint occurred in 2% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.097). Additionally, a significant difference was noted in the occurrence of the secondary endpoint, which was observed in 0% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.025). In patients with thrombocytopenia the LAAC procedure improves prognosis compared with continued anticoagulant treatment.
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Affiliation(s)
- Wiktoria Kowalska
- Doctoral School, Division of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Katarzyna Mitręga
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Anna Olma
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
| | - Tomasz Podolecki
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Zbigniew Kalarus
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
| | - Witold Streb
- Department of Cardiology and Angiology, Silesian Center for Heart Diseases, 41-800 Zabrze, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, 40-055 Katowice, Poland
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39
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Nitta T, Wai JWW, Lee SH, Yii M, Chaiyaroj S, Ruaengsri C, Ramanathan T, Ishii Y, Jeong DS, Chang J, Hardjosworo ABA, Imai K, Shao Y. 2023 APHRS expert consensus statements on surgery for AF. J Arrhythm 2023; 39:841-852. [PMID: 38045465 PMCID: PMC10692856 DOI: 10.1002/joa3.12939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/14/2023] [Accepted: 10/02/2023] [Indexed: 12/05/2023] Open
Affiliation(s)
| | | | - Seung Hyun Lee
- Cardiovascular SurgeryYonsei University College of MedicineSeoulSouth Korea
| | - Michael Yii
- Cardiothoracic Surgery, Epworth Eastern Hospital, and St Vincent's Hospital MelbourneUniversity of MelbourneMelbourneVictoriaAustralia
| | | | | | | | - Yosuke Ishii
- Cardiovascular SurgeryNippon Medical SchoolTokyoJapan
| | - Dong Seop Jeong
- Thoracic and Cardiovascular Surgery, Samsung Medical CenterSungkyunkwan University School of MedicineSeoulSouth Korea
| | - Jen‐Ping Chang
- Thoracic and Cardiovascular SurgeryKaohsiung Chang Gung Memorial HospitalKaohsiungTaiwan
| | | | - Katsuhiko Imai
- Heart Center of National Hospital Organization Kure Medical Center and Chugoku Cancer CenterKure, HiroshimaJapan
| | - Yongfeng Shao
- Cardiovascular Surgery, Jiangsu Province HospitalNanjing Medical UniversityNanjingChina
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40
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Jiang X, Xiong Q, Yin Y, Ling Z. Left atrial appendage closure for stroke prevention in atrial fibrillation patients: A promise that came true. Pacing Clin Electrophysiol 2023; 46:1576-1585. [PMID: 37987556 DOI: 10.1111/pace.14877] [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: 09/27/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF), considering the high morbidity and mortality of AF-related ischemic strokes. With the plausible hypothesis that left atrial appendage is the main source of thrombus in AF patients, left atrial appendage closure (LAAC) has been regarded as a potential substitute to oral anticoagulation in order to meet the unmet needs for stroke prevention, particularly in patients with high bleeding risk. Notable advancements in safety, efficacy, and device innovation have been made in recent years, albeit concerns still remain regarding the insufficient efficacy data, device-related complications, and the need for procedural optimization. We aim to review current knowledge about LAAC and provide potential future directions for the remaining key issues.
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Affiliation(s)
- Xi Jiang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingsong Xiong
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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41
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Vij V, Cruz-González I, Galea R, Piayda K, Nelles D, Vogt L, Gloekler S, Fürholz M, Meier B, Räber L, O'Hara G, Arzamendi D, Agudelo V, Asmarats L, Freixa X, Flores-Umanzor E, De Backer O, Sondergaard L, Nombela-Franco L, McInerney A, Salinas P, Korsholm K, Nielsen-Kudsk JE, Afzal S, Zeus T, Operhalski F, Schmidt B, Montalescot G, Guedeney P, Iriart X, Miton N, Saw J, Gilhofer T, Fauchier L, Veliqi E, Meincke F, Petri N, Nordbeck P, Gonzalez-Ferreiro R, Bhatt DL, Laricchia A, Mangieri A, Omran H, Schrickel JW, Rodes-Cabau J, Nickenig G, Sievert H, Sedaghat A. Symptomatic vs. non-symptomatic device-related thrombus after LAAC: a sub-analysis from the multicenter EUROC-DRT registry. Clin Res Cardiol 2023; 112:1790-1799. [PMID: 37294311 PMCID: PMC10697873 DOI: 10.1007/s00392-023-02237-w] [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: 02/14/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) after left atrial appendage closure (LAAC) is associated with adverse outcomes, i.e. ischemic stroke or systemic embolism (SE). Data on predictors of stroke/SE in the context of DRT are limited. AIMS This study aimed to identify predisposing factors for stroke/SE in DRT patients. In addition, the temporal connection of stroke/SE to DRT diagnosis was analyzed. METHODS The EUROC-DRT registry included 176 patients, in whom DRT after LAAC were diagnosed. Patients with symptomatic DRT, defined as stroke/SE in the context of DRT diagnosis, were compared against patients with non-symptomatic DRT. Baseline characteristics, anti-thrombotic regimens, device position, and timing of stroke/SE were compared. RESULTS Stroke/SE occurred in 25/176 (14.2%) patients diagnosed with DRT (symptomatic DRT). Stroke/SE occurred after a median of 198 days (IQR 37-558) after LAAC. In 45.8% stroke/SE occurred within one month before/after DRT diagnosis (DRT-related stroke). Patients with symptomatic DRT had lower left ventricular ejection fractions (50.0 ± 9.1% vs. 54.2 ± 11.0%, p = 0.03) and higher rates of non-paroxysmal atrial fibrillation (84.0% vs. 64.9%, p = 0.06). Other baseline parameters and device positions were not different. Most ischemic events occurred among patients with single antiplatelet therapy (50%), however, stroke/SE was also observed under dual antiplatelet therapy (25%) or oral anticoagulation (20%). CONCLUSION Stroke/SE are documented in 14.2% and occur both in close temporal relation to the DRT finding and chronologically independently therefrom. Identification of risk factors remains cumbersome, putting all DRT patients at substantial risk for stroke/SE. Further studies are necessary to minimize the risk of DRT and ischemic events.
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Affiliation(s)
- Vivian Vij
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | | | | | - Dominik Nelles
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Lara Vogt
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | | | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | | | | | - Lluis Asmarats
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Ole De Backer
- Rigshospitalet, University Hospital Copenhagen, Copenhagen, Denmark
| | - Lars Sondergaard
- Rigshospitalet, University Hospital Copenhagen, Copenhagen, Denmark
| | | | | | | | | | | | - Shazia Afzal
- University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Boris Schmidt
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany
| | - Gilles Montalescot
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Paul Guedeney
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | | | | | | | | | | | | | | | - Nils Petri
- University Hospital Würzburg, Würzburg, Germany
| | | | | | | | - Alessandra Laricchia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | | | - Jan Wilko Schrickel
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Josep Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Georg Nickenig
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Alexander Sedaghat
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Rhein-Ahr-Cardio, Bad Neuenahr-Ahrweiler, Germany.
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42
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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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43
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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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44
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Mesnier J, Simard T, Jung RG, Lehenbauer KR, Piayda K, Pracon R, Jackson GG, Flores-Umanzor E, Faroux L, Korsholm K, Chun JKR, Chen S, Maarse M, Montrella K, Chaker Z, Spoon JN, Pastormerlo LE, Meincke F, Sawant AC, Moldovan CM, Qintar M, Aktas MK, Branca L, Radinovic A, Ram P, El-Zein RS, Flautt T, Ding WY, Sayegh B, Benito-González T, Lee OH, Badejoko SO, Paitazoglou C, Karim N, Zaghloul AM, Agarwal H, Kaplan RM, Alli O, Ahmed A, Suradi HS, Knight BP, Alla VM, Panaich SS, Wong T, Bergmann MW, Chothia R, Kim JS, Pérez de Prado A, Bazaz R, Gupta D, Valderrábano M, Sanchez CE, El Chami MF, Mazzone P, Adamo M, Ling F, Wang DD, O'Neill W, Wojakowski W, Pershad A, Berti S, Spoon DB, Kawsara A, Jabbour G, Boersma LVA, Schmidt B, Nielsen-Kudsk JE, Freixa X, Ellis CR, Fauchier L, Demkow M, Sievert H, Main ML, Hibbert B, Holmes DR, Alkhouli M, Rodés-Cabau J. Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes. JACC Cardiovasc Interv 2023; 16:2722-2732. [PMID: 38030358 DOI: 10.1016/j.jcin.2023.09.017] [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: 06/14/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Trevor Simard
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Richard G Jung
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kyle R Lehenbauer
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Kerstin Piayda
- CardioVascular Center Frankfurt, Frankfurt, Germany; Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Gießen, Germany
| | - Radoslaw Pracon
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | | | - Eduardo Flores-Umanzor
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Moniek Maarse
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Kristi Montrella
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Zakeih Chaker
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Jocelyn N Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Luigi E Pastormerlo
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Carmen M Moldovan
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Mohammed Qintar
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA; Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Mehmet K Aktas
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Luca Branca
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Radinovic
- Arrhythmology Department, San Raffaele University Hospital, Milan, Italy
| | - Pradhum Ram
- Emory University Hospital, Atlanta, Georgia, USA
| | - Rayan S El-Zein
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Bassel Sayegh
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | | | - Oh-Hyun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Solomon O Badejoko
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | | | - Nabeela Karim
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Ahmed M Zaghloul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Rachel M Kaplan
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Oluseun Alli
- Division of Cardiology, Novant Health Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Aamir Ahmed
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - Bradley P Knight
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Venkata M Alla
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Sidakpal S Panaich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tom Wong
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | | | - Rashaad Chothia
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Raveen Bazaz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Carlos E Sanchez
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Fred Ling
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Dee Dee Wang
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - William O'Neill
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Ashish Pershad
- Chandler Regional Medical Center, Chandler, Arizona, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Daniel B Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Akram Kawsara
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - George Jabbour
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Lucas V A Boersma
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | | | - Xavier Freixa
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | | | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau Faculté de Médecine, Université François Rabelais, Tours, France
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Horst Sievert
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | - Michael L Main
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Benjamin Hibbert
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain.
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Ryuzaki S, Kondo Y, Nakano M, Nakano M, Kajiyama T, Ito R, Kitagawa M, Sugawara M, Chiba T, Yoshino Y, Kobayashi Y. Antithrombotic Regimen After Percutaneous Left Atrial Appendage Closure - A Real-World Study. Circ J 2023; 87:1820-1827. [PMID: 37344404 DOI: 10.1253/circj.cj-22-0687] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/23/2023]
Abstract
BACKGROUND Antithrombotic therapy after left atrial appendage closure (LAAC) in patients at high risk of bleeding remains controversial. We present real-world clinical outcomes of LAAC.Methods and Results: Data from 74 consecutive patients who received LAAC therapy between January 2020 and June 2022 were analyzed. Patients received 1 of 3 antithrombotic therapies according to the bleeding risk category or clinical event. Regimen 1 was based on a prior study, regimen 2 comprised a lower antiplatelet drug dose without dual antiplatelet therapy, and regimen 3 was antiplatelet drug administration for as long as possible to patients with uncontrollable bleeding who were required to stop anticoagulant drugs. Overall, 73 (98.6%) procedures were successful. Of them, 16 (21.9%) patients were selected for regimen 1, 46 (63.0%) for regimen 2, and 11 (15.1%) for regimen 3. Device-related thrombosis (13% vs. 0% vs. 0%, P=0.0257) only occurred with regimen 1. There was no difference in major bleeding event rates (6% vs. 2% vs. 9%, P=0.53). CONCLUSIONS The post-LAAC antithrombotic regimen was modified without major concerns.
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Affiliation(s)
- Satoko Ryuzaki
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Miyo Nakano
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Masahiro Nakano
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine
| | - Takatsugu Kajiyama
- Department of Advanced Cardiorhythm Therapeutics, Chiba University Graduate School of Medicine
| | - Ryo Ito
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Mari Kitagawa
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Masafumi Sugawara
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Toshinori Chiba
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yutaka Yoshino
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine
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46
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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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Tsukioka Y, Jeevanandam V, Johnson B. Challenges and Insights in Managing Device-Related Thrombosis Post-WATCHMAN Implantation: A Case Report of Surgical Thrombectomy in an Elderly Jehovah's Witness Patient With Atrial Fibrillation. Cureus 2023; 15:e49266. [PMID: 38143626 PMCID: PMC10746858 DOI: 10.7759/cureus.49266] [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: 11/22/2023] [Indexed: 12/26/2023] Open
Abstract
The WATCHMAN device offers a viable alternative to long-term oral anticoagulation for stroke prevention in nonvalvular atrial fibrillation, particularly for high-risk patients. Despite its success, device-related thrombosis (DRT) remains a concern, potentially restricting its wider use. We present an 83-year-old female Jehovah's Witness with atrial fibrillation who, after successful WATCHMAN device implantation, suffered multiple transient ischemic attacks six months later. Initial investigation revealed a thrombus on a slightly exposed strut of the almost completely endothelialized device. Despite treatment with warfarin and rivaroxaban, urgent surgical intervention was ultimately required to remove the thrombus completely. This case illustrates the risk of thrombus formation even with minimal strut exposure and the challenges in managing DRT. It also highlights the necessity for diligent monitoring and potential reassessment of post-implantation anticoagulation protocols. Our report adds to the limited literature regarding surgical thrombectomy following WATCHMAN implantation and provides valuable insights for clinicians managing similar scenarios.
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Affiliation(s)
- Yusuke Tsukioka
- Cardiac/Thoracic/Vascular Surgery, University of Chicago Medicine, Chicago, USA
| | | | - Blaine Johnson
- Cardiac/Thoracic/Vascular Surgery, University of Chicago Medicine, Chicago, USA
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Yu Y, Du F, Zhao F, Hu H. Acute thrombus formation on the delivery sheath during left atrial appendage occlusion: Case reports with placement of cerebral protection devices. Clin Case Rep 2023; 11:e8113. [PMID: 38028044 PMCID: PMC10658510 DOI: 10.1002/ccr3.8113] [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: 09/18/2023] [Revised: 10/10/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Acute thrombus formation on the delivery sheath is rare condition during percutaneous left atrial appendage occlusion. We presented two cases that transesophageal echocardiography (TEE) showed a floating thrombus attached to the tip of delivery sheath during the procedure. Cerebral embolic protection devices were used to prevent neurological events after thrombus was detected. The neurological function was not impaired post-procedure.
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Affiliation(s)
- Yangyang Yu
- Department of CardiologyLanzhou University Second HospitalLanzhouChina
| | - Fang Du
- Department of CardiologyLanzhou University Second HospitalLanzhouChina
| | - Feng Zhao
- Department of CardiologyLanzhou University Second HospitalLanzhouChina
| | - Hao Hu
- Department of CardiologyLanzhou University Second HospitalLanzhouChina
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50
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Fukuda N, Imamura T, Tanaka S, Kataoka N, Ushijima R, Ueno H, Kinugawa K. Mid-Term Feasibility of Percutaneous Left Atrial Appendage Occlusion in Elderly Patients with Non-Valvular Atrial Fibrillation. J Clin Med 2023; 12:6024. [PMID: 37762964 PMCID: PMC10531715 DOI: 10.3390/jcm12186024] [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: 08/23/2023] [Revised: 09/12/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) therapy using the WATCHMAN system has been introduced to prevent thrombosis and minimize the use of anticoagulants in patients with non-valvular atrial fibrillation. Given the high risk of bleeding and stroke in elderly patients, these patients would be good candidates for this therapy. However, the efficacy and feasibility of LAAO therapy in elderly patients remains uncertain. METHODS Consecutive patients who underwent LAAO therapy using the WATCHMAN system in a large academic center between June 2020 and March 2023 were included. The safety and efficacy of LAAO therapy during the 1-year observation period in patients aged ≥85 years old were compared with those in the younger cohort. RESULTS A total of 188 patients (78.4 ± 6.9 years old, 133 male patients) were included. 34 patients were ≥85 years old, 96 were between 75 and 84 years old, and 58 were <75 years old. The elderly group had a higher CHA2DS2-VASc score and were at greater risk of falling-related bleeding compared with the younger cohort. The device implantations were successful in all patients except for one. During the 1-year observation period, one patient had a peri-device leak >5 mm and there were 6 device-related cases of thrombosis, whose incidence was not significantly different between the groups (p = 0.98). The cumulative incidences of bleeding and thrombotic events in the elderly group were as low as in the younger cohort (p > 0.05 for both). Most anticoagulants were terminated regardless of age. CONCLUSION The mid-term feasibility and efficacy of percutaneous LAAO therapy using the WATCHMAN system in elderly patients aged ≥85 years were as acceptable as in the younger cohort.
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Affiliation(s)
| | - Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama, Toyama 930-8555, Japan; (N.F.); (N.K.); (K.K.)
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