1
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Monroe CL, Abdelhafez YG, Atsina K, Aman E, Nardo L, Madani MH. Evaluation of responses to cardiac imaging questions by the artificial intelligence large language model ChatGPT. Clin Imaging 2024; 112:110193. [PMID: 38820977 DOI: 10.1016/j.clinimag.2024.110193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/22/2024] [Accepted: 05/20/2024] [Indexed: 06/02/2024]
Abstract
PURPOSE To assess ChatGPT's ability as a resource for educating patients on various aspects of cardiac imaging, including diagnosis, imaging modalities, indications, interpretation of radiology reports, and management. METHODS 30 questions were posed to ChatGPT-3.5 and ChatGPT-4 three times in three separate chat sessions. Responses were scored as correct, incorrect, or clinically misleading categories by three observers-two board certified cardiologists and one board certified radiologist with cardiac imaging subspecialization. Consistency of responses across the three sessions was also evaluated. Final categorization was based on majority vote between at least two of the three observers. RESULTS ChatGPT-3.5 answered seventeen of twenty eight questions correctly (61 %) by majority vote. Twenty one of twenty eight questions were answered correctly (75 %) by ChatGPT-4 by majority vote. Majority vote for correctness was not achieved for two questions. Twenty six of thirty questions were answered consistently by ChatGPT-3.5 (87 %). Twenty nine of thirty questions were answered consistently by ChatGPT-4 (97 %). ChatGPT-3.5 had both consistent and correct responses to seventeen of twenty eight questions (61 %). ChatGPT-4 had both consistent and correct responses to twenty of twenty eight questions (71 %). CONCLUSION ChatGPT-4 had overall better performance than ChatGTP-3.5 when answering cardiac imaging questions with regard to correctness and consistency of responses. While both ChatGPT-3.5 and ChatGPT-4 answers over half of cardiac imaging questions correctly, inaccurate, clinically misleading and inconsistent responses suggest the need for further refinement before its application for educating patients about cardiac imaging.
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Affiliation(s)
- Cynthia L Monroe
- College of Medicine, California Northstate University, 9700 W Taron Dr, Elk Grove, CA 95757, USA
| | - Yasser G Abdelhafez
- Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817, USA
| | - Kwame Atsina
- Division of Cardiovascular Medicine, University of California, Davis Medical Center, 4860 Y St, Suite 0200, Sacramento, CA 95817, USA
| | - Edris Aman
- Division of Cardiovascular Medicine, University of California, Davis Medical Center, 4860 Y St, Suite 0200, Sacramento, CA 95817, USA
| | - Lorenzo Nardo
- Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817, USA
| | - Mohammad H Madani
- Department of Radiology, University of California, Davis Medical Center, 4860 Y St, Suite 3100, Sacramento, CA 95817, USA.
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2
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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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3
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Huang Y, Su Q, Su H, Yang L. Concerns regarding the safety and efficacy of the LAmbre device in patients with large LAA orifice diameter. J Formos Med Assoc 2024:S0929-6646(24)00309-7. [PMID: 38981811 DOI: 10.1016/j.jfma.2024.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Accepted: 07/02/2024] [Indexed: 07/11/2024] Open
Affiliation(s)
- Yuan Huang
- Department of Cardiology, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Hedi Road, Nanning, Guangxi, 530021, China
| | - Qiang Su
- Department of Cardiology, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Hedi Road, Nanning, Guangxi, 530021, China
| | - Huabin Su
- Department of Cardiology, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Hedi Road, Nanning, Guangxi, 530021, China
| | - Lihua Yang
- Department of Cardiology, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, No. 85 Hedi Road, Nanning, Guangxi, 530021, China.
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Stout K, Craig C, Rivington J, Lyden E, Payne JJ, Goldsweig AM. Clinical Protocol for Selecting Intracardiac or Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion. Am J Cardiol 2024; 222:87-94. [PMID: 38642870 DOI: 10.1016/j.amjcard.2024.04.023] [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: 02/04/2024] [Revised: 03/24/2024] [Accepted: 04/15/2024] [Indexed: 04/22/2024]
Abstract
Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echo (TEE) to guide left atrial appendage occlusion (LAAO). We established a protocol to select patients appropriate for ICE guidance. Patients who underwent LAAO with the Watchman or Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) from January 2018 to March 2022 at a large United States center were included. The novel protocol prospectively selected TEE or ICE guidance beginning in January 2020; previous LAAO procedures were retrospectively included. ICE was selected for patients with uninterrupted anticoagulation and appropriate LAA anatomy, renal function, and moderate sedation tolerance. In-hospital outcomes with successful implantation without conversion to TEE guidance, no peridevice leak, and no procedural complications were compared. Composite 1-year outcome included freedom from peridevice leak, device-related thrombus, stroke, and all-cause mortality. A total of 234 patients were included; the mean age was 76.1 ± 8.3 years old, and 42.3% were female. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (risk difference 0.102, 96.8% vs 86.5%, 95% confidence interval 0.003 to 0.203, p = 0.029). In comparison to the TEE-guided group, ICE-guided procedures were shorter (89.1 ± 26.3 vs 99.8 ± 30.0 min, p = 0.0087) with less general anesthesia (26.6% vs 98.8%, p <0.0001). One-year composite adverse outcomes did not differ significantly (80.7% vs 88.9%, p = 0.17). In conclusion, the protocol to select appropriate patients for ICE versus TEE guidance for LAAO is safe and effective. Larger studies are indicated to validate this approach to improve outcomes, shorten procedures, and avoid general anesthesia.
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Affiliation(s)
- Kara Stout
- Division of Cardiovascular Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia; Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Calvin Craig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jaclyn Rivington
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elizabeth Lyden
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jason J Payne
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Department of Cardiology, Baystate Medical Center, Springfield, Massachusetts
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Tang GHL, Zaid S, Hahn RT, Aggarwal V, Alkhouli M, Aman E, Berti S, Chandrashekhar YS, Chadderdon SM, D'Agostino A, Fam NP, Ho EC, Kliger C, Kodali SK, Krishnamoorthy P, Latib A, Lerakis S, Lim DS, Mahadevan VS, Nair DG, Narula J, O'Gara PT, Packer DL, Praz F, Rogers JH, Ruf TF, Sanchez CE, Sharma A, Singh GD, van Mieghem NM, Vannan MA, Yadav PK, Ya'Qoub L, Zahr FE, von Bardeleben RS. Structural Heart Imaging Using 3-Dimensional Intracardiac Echocardiography: JACC Cardiovascular Imaging Position Statement. JACC Cardiovasc Imaging 2024:S1936-878X(24)00202-X. [PMID: 38970594 DOI: 10.1016/j.jcmg.2024.05.012] [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: 04/02/2024] [Revised: 05/21/2024] [Accepted: 05/23/2024] [Indexed: 07/08/2024]
Abstract
3-dimensional (3D) intracardiac echocardiography (ICE) is emerging as a promising complement and potential alternative to transesophageal echocardiography for imaging guidance in structural heart interventions. To establish standardized practices, our multidisciplinary expert position statement serves as a comprehensive guide for the appropriate indications and utilization of 3D-ICE in various structural heart procedures. The paper covers essential aspects such as the fundamentals of 3D-ICE imaging, basic views, and workflow recommendations specifically tailored for ICE-guided structural heart procedures, such as transeptal puncture, device closure of intracardiac structures, and transcatheter mitral and tricuspid valve interventions. Current challenges, future directions, and training requirements to ensure operator proficiency are also discussed, thereby promoting the safety and efficacy of this innovative imaging modality to support expanding its future clinical applications.
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Affiliation(s)
| | - Syed Zaid
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York, New York, USA
| | - Vratika Aggarwal
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Edris Aman
- University of California, Davis Medical Center, Sacramento, California, USA
| | - Sergio Berti
- G. Pasquinucci Heart Hospital, Fondazione CNR-G. Monasterio, Massa, Italy
| | - Y S Chandrashekhar
- Minneapolis Veterans Affairs Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | | | | | - Neil P Fam
- St. Michael's Hospital, Toronto, Ontario, Canada
| | - Edwin C Ho
- Montefiore Medical Center, Bronx, New York, USA
| | - Chad Kliger
- Lenox Hill Hospital, New York, New York, USA
| | - Susheel K Kodali
- Columbia University Irving Medical Center, New York, New York, USA
| | | | - Azeem Latib
- Montefiore Medical Center, Bronx, New York, USA
| | | | - D Scott Lim
- University of Virginia, Charlottesville, Virginia, USA
| | - Vaikom S Mahadevan
- University of Massachusetts Chan School of Medicine, Worchester, Massachusetts, USA
| | - Devi G Nair
- St. Bernard's Heart and Vascular Center, Jonesboro, Arkansas, USA
| | - Jagat Narula
- University of Texas Health Houston, Houston, Texas, USA
| | | | | | - Fabien Praz
- Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jason H Rogers
- University of California, Davis Medical Center, Sacramento, California, USA
| | | | | | - Alok Sharma
- Minneapolis Veterans Affairs Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gagan D Singh
- University of California, Davis Medical Center, Sacramento, California, USA
| | | | | | | | - Lina Ya'Qoub
- University of California, San Francisco Medical Center, San Francisco, California, USA
| | - Firas E Zahr
- Oregon Health and Science University, Portland, Oregon, USA
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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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7
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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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Bhuta S, Carlen A, Savona SJ, Augostini RS, Kalbfleisch SJ, Houmsse M, Daoud EG, Hummel JD, Afzal MR. Incidence and temporal evolution of delayed peridevice leak after left atrial appendage closure. Heart Rhythm 2024:S1547-5271(24)02629-8. [PMID: 38797310 DOI: 10.1016/j.hrthm.2024.05.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/02/2024] [Accepted: 05/15/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Peridevice leak (PDL) after left atrial appendage closure (LAAC) portends adverse outcomes. OBJECTIVE The purpose of this study was to assess the incidence, predictors, clinical implications, and temporal evolution of PDL after LAAC. METHODS This single-center retrospective study included all patients who underwent LAAC with Watchman FLX and had no PDL detected at the time of implantation. The primary end point was the incidence of new PDL at initial imaging. The composite secondary end point included continued oral anticoagulation after initial imaging, device-related thrombus, stroke or transient ischemic attack, major bleeding, and need for PDL closure at longest follow-up. Temporal evolution of PDL was assessed in patients with available surveillance imaging. RESULTS Of the 355 patients who completed imaging at 47 days (interquartile range [IQR] 44-50 days), 139 (39%) had new PDL with a mean leak size of 3.2 ± 1.4 mm (median 3.0 mm; IQR 2.0-4.0 mm; range 1.0-9.0 mm). Multiple deployment attempts and larger device size were positive predictors of PDL, while increased contrast volume administration was a negative predictor of PDL. The composite secondary end point occurred in 42 (30%) patients with PDL and 33 (15%) patients without PDL (P < .001). Of the 139 patients with PDL, 43 (31%) had surveillance imaging where the leak size regressed from 3.7 ± 1.8 mm at 46 days (IQR 44-51 days) to 1.7 ± 2.0 mm at 189 days (IQR 158-285 days) (P < .001). The leak size regressed in 33 (77%), remained stable in 4 (9%), and progressed in 6 (14%) cases. CONCLUSION Despite design improvements, LAAC with Watchman FLX demonstrates a significant incidence of PDL with meaningful clinical implications. Regardless of initial size, most leaks regressed over time.
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Affiliation(s)
- Sapan Bhuta
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Austin Carlen
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Salvatore J Savona
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Ralph S Augostini
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Steven J Kalbfleisch
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Mahmoud Houmsse
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Emile G Daoud
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - John D Hummel
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Muhammad R Afzal
- Electrophysiology Section, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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Chen T, Lu X, Wang X, Chen Q, Zhao R, Zhang W, Song T, Guo J, Chen Y. Peri-device leakage and delayed endothelialization of the Watchman device: a computed tomography study. Eur Radiol 2024:10.1007/s00330-024-10778-5. [PMID: 38780765 DOI: 10.1007/s00330-024-10778-5] [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: 12/22/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES This study aimed to explore the endothelialization process and assess the potential association between endothelialization and peri-device leak (PDL) following Watchman implantation via a quantitative method. METHODS This is a single-center retrospective study of consecutive patients undergoing LAAO between December 2015 and November 2021. Device endothelialization, compared between PDL and non-PDL group, were quantitatively analyzed based on hypoattenuated thickening in cardiac computed tomography angiography (CCTA). Advancement in endothelialization over time were explored using the Cochran-Armitage test and generalized estimating equation approach. Potential risk factors of delayed endothelialization were analyzed using the Cox proportional-hazards model. RESULTS A total of 172 patients (mean age, 68 years ± 10 [standard deviation], 114 men) were finally included. The average endothelialization ratio of the study population was 89.8 ± 7.2 percent. In the follow-up period of postprocedural 3 months to more than 12 months, an incremental trend of endothelialization over time was observed with the ratio of 85.8 ± 8.0, 89.6 ± 7.6, 92.2 ± 4.5, 94.3 ± 2.9 percent, respectively (p < 0.0001). Notably, patients without PDL exhibited a swifter advancement in endothelialization compared to those with PDL, irrespective of device size. The multivariable Cox regression model showed that PDL (HR = 2.113, 95%CI: 1.300-3.435, p = 0.003), DSP (HR = 1.717, 95%CI: 1.113-2.647, p = 0.014) were independent risk factors of delayed endothelialization. CONCLUSION CCTA holds promise as an effective means of quantitatively assessing device endothelialization. Endothelialization advanced gradually over time, with PDL potentially impeding device endothelialization. CLINICAL RELEVANCE STATEMENT A comprehensive understanding of the correlation between endothelialization ratio, time, and residual shunt can establish a more dependable foundation for determining the appropriate anticoagulation treatment following left atrial appendage closure. KEY POINTS Current recommendations for postleft atrial appendage occlusion anti-platelet and anticoagulation therapy are based on animal studies. Cardiac computed tomography angiography (CCTA) combined with the UNet neural network model enables the quantitative assessment of device endothelialization. This technique will allow for additional studies to better understand device endothelialization to optimize treatments in this population.
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Affiliation(s)
- Tao Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Xu Lu
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
- Outpatient Department, The 44th Sanatorium of Retired Cadres in Haidian District, 19 Dahuisi Road, Haidian District, Beijing, 100086, China
| | - Xinyan Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Qi Chen
- Department of Health Statistics, Naval Medical University, 800 Xiangyin Road, Yangpu District, Shanghai, 200433, China
| | - Runtao Zhao
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Wei Zhang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Tingting Song
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Jun Guo
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China.
| | - Yundai Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
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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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11
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Makkar A, Alkhouli M, Ellis CR, Shah AP, Coylewright M, Freeman JV, Anderson JA, Gage R, Lakkireddy D. Feasibility of Amulet occluder implantation after failed left atrial appendage occlusion attempt: Insights from the EMERGE LAA postapproval study. Heart Rhythm 2024:S1547-5271(24)02541-4. [PMID: 38768843 DOI: 10.1016/j.hrthm.2024.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Although expertise in left atrial appendage occlusion (LAAO) has grown, certain intricate anatomies may pose challenges, rendering them unsuitable for LAAO with the selected device. OBJECTIVE This analysis aimed to characterize outcomes of patients with prior failed percutaneous LAAO procedures who underwent a subsequent attempt with an Amulet occluder in the EMERGE LAA postapproval study. METHODS Patients enrolled in the National Cardiovascular Data Registry LAAO Registry who had an Amulet occluder implantation attempt between Food and Drug Administration approval (August 14, 2021) and June 30, 2023, were evaluated. A safety end point through 7 days or hospital discharge (whichever was later) and major adverse events through 45 days were reported. RESULTS A total of 8591 patients underwent attempted Amulet occluder implantation, of whom 244 patients had prior failed LAAO. Implantation success was 88.9% and 96.2% in patients with prior failed LAAO and index LAAO, respectively (P < .001). The safety composite end point was low, occurring in 1.6% and 0.8% of patients with prior failed LAAO and index LAAO, respectively (P = .148). Any major adverse event through 45 days occurred in 7.4% and 6.3% of prior failed LAAO and index LAAO patient cohorts, respectively (P = .497); most adverse events were similar between the groups (P > .05). At 45 days, peridevice leak ≤3 mm was achieved in >90% of patients in either group. CONCLUSION A high degree of implantation success with a low rate of adverse events can be achieved with the Amulet occluder. The findings imply that the dual occlusive mechanism Amulet occluder facilitates successful closure, even in challenging anatomic scenarios.
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Affiliation(s)
- Akash Makkar
- Arizona Heart Arrhythmia Associates, Phoenix, Arizona.
| | | | | | | | - Megan Coylewright
- Erlanger and University of Tennessee Health Science Center, College of Medicine, Chattanooga, Tennessee
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | | | - Ryan Gage
- Abbott Structural Heart, Plymouth, Minnesota
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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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Chen M, Yao PC, Fei ZT, Wang QS, Yu YC, Zhang PP, Li W, Zhang R, Mo BF, Zhao MZ, Yu Y, Yang M, Zhao Y, Gong CQ, Sun J, Li YG. Prognostic Impact of Left Atrial Appendage Patency After Device Closure. Circ Cardiovasc Interv 2024; 17:e013579. [PMID: 38629273 PMCID: PMC11097947 DOI: 10.1161/circinterventions.123.013579] [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: 09/23/2023] [Accepted: 02/02/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND The prognostic impact of left atrial appendage (LAA) patency, including those with and without visible peri-device leak (PDL), post-LAA closure in patients with atrial fibrillation, remains elusive. METHODS Patients with atrial fibrillation implanted with the WATCHMAN 2.5 device were prospectively enrolled. The device surveillance by cardiac computed tomography angiography was performed at 3 months post-procedure. Adverse events, including stroke/transient ischemic attack (TIA), major bleeding, cardiovascular death, all-cause death, and the combined major adverse events (MAEs), were compared between patients with complete closure and LAA patency. RESULTS Among 519 patients with cardiac computed tomography angiography surveillance at 3 months post-LAA closure, 271 (52.2%) showed complete closure, and LAA patency was detected in 248 (47.8%) patients, including 196 (37.8%) with visible PDL and 52 (10.0%) without visible PDL. During a median of 1193 (787-1543) days follow-up, the presence of LAA patency was associated with increased risks of stroke/TIA (adjusted hazard ratio for baseline differences, 3.22 [95% CI, 1.17-8.83]; P=0.023) and MAEs (adjusted hazard ratio, 1.12 [95% CI, 1.06-1.17]; P=0.003). Specifically, LAA patency with visible PDL was associated with increased risks of stroke/TIA (hazard ratio, 3.66 [95% CI, 1.29-10.42]; P=0.015) and MAEs (hazard ratio, 3.71 [95% CI, 1.71-8.07]; P=0.001), although LAA patency without visible PDL showed higher risks of MAEs (hazard ratio, 3.59 [95% CI, 1.28-10.09]; P=0.015). Incidences of stroke/TIA (2.8% versus 3.0% versus 6.7% versus 22.2%; P=0.010), cardiovascular death (0.9% versus 0% versus 1.7% versus 11.1%; P=0.005), and MAEs (4.6% versus 9.0% versus 11.7% versus 22.2%; P=0.017) increased with larger PDL (0, >0 to ≤3, >3 to ≤5, or >5 mm). Older age and discontinuing antiplatelet therapy at 6 months were independent predictors of stroke/TIA and MAEs in patients with LAA patency. CONCLUSIONS LAA patency detected by cardiac computed tomography angiography at 3 months post-LAA closure is associated with unfavorable prognosis in patients with atrial fibrillation implanted with WATCHMAN 2.5 device. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03788941.
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Affiliation(s)
- Mu Chen
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Peng-Cheng Yao
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Zhen-Tao Fei
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Qun-Shan Wang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Yi-Chi Yu
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Peng-Pai Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Wei Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Rui Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Bin-Feng Mo
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Ming-Zhe Zhao
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Yi Yu
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Mei Yang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Yan Zhao
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Chang-Qi Gong
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, China
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14
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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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15
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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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Yoon SH, Amoah JK, Galo J, Dallan LAP, Arruda M, Rashid I, Rajagopalan S, Filby SJ. Incidence, progression, and predictors of left atrial appendage sealing after Watchman FLX device implantation with computed tomographic assessment. Catheter Cardiovasc Interv 2024. [PMID: 38662126 DOI: 10.1002/ccd.31044] [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: 09/26/2023] [Revised: 02/13/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Limited data exists regarding incidence, progression, and predictors of left atrial appendage (LAA) sealing after transcatheter LAA closure. We aimed to evaluate the incidence, progression, and predictive factors associated with LAA sealing after LAA closure. METHODS This study includes patients who underwent successful LAA closure with Watchman FLX device and had both pre- and postprocedural computed tomography (CT). Postprocedural CT was performed 45 days after LAA closure and used to evaluate residual LAA patency. Patient who had residual LAA patency at 45 days underwent 1-year follow-up CT. RESULTS A total of 105 patients (mean age: 75.2 ± 9.6 years; 53.3% female) who underwent successful LAA closure with Watchman FLX device and had pre- and postprocedural CT at 45 days were included. Residual patency was observed in 35 (33.3%) patients: 21 (20.0%) patients showed complete contrast opacification in LAA (complete LAA patency) while 14 (13.3%) patients showed contrast opacification only in the distal LAA (distal LAA patency). Among patients with residual LAA patency at 45 days, the rate of LAA sealing at 1 year was significantly higher in the distal LAA patency group than in the complete LAA patency group (75.0% vs. 16.7%; p = 0.019). Increased depth oversizing was associated with both distal LAA patency and complete LAA patency. CONCLUSION Postprocedural CT at 45 days detected patent LAA in one-third of patients after LAA closure. LAA sealing was more frequently observed at 1 year among the distal LAA patency group than the complete LAA patency group.
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Affiliation(s)
- Sung-Han Yoon
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Medicine, Division of Structural Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Joseph Kofi Amoah
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jason Galo
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mauricio Arruda
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanjay Rajagopalan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven J Filby
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Wang E, Sadleir P, Sourinathan V, Weerasooriya R, Playford D, Joshi P. Thoracoscopic Left Atrial Appendage Occlusion with the AtriClip PRO2: An Experience of 144 Patients. Heart Lung Circ 2024:S1443-9506(24)00128-8. [PMID: 38604885 DOI: 10.1016/j.hlc.2024.02.010] [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: 04/02/2023] [Revised: 12/30/2023] [Accepted: 02/13/2024] [Indexed: 04/13/2024]
Abstract
AIM To report the clinical outcomes of thoracoscopic left atrial appendage occlusion (LAAO) with the AtriClip PRO2 device (Atricure Inc, Mason, OH, USA). Stroke risk reduction with LAAO in patients with atrial fibrillation is now well-established. Many surgical and percutaneous techniques have been used, with varying rates of success. The percutaneous devices have had issues with procedural complications and peridevice flow. Thoracoscopic AtriClip offers an epicardial linear closure of the appendage at its ostium. This study sought to evaluate its safety and efficacy in achieving complete LAA closure. METHOD This is a prospective series of thoracoscopic AtriClip PRO2 as a standalone procedure or a thoracoscopic AtriClip deployed as an adjunct to minimal access cardiac and thoracic surgery. Study ethical approval was granted by the hospital Human Research Ethics Committee. RESULTS In total, 144 thoracoscopic AtriClip procedures were conducted by a single surgeon from 2017 to 2022, 56 standalone and 88 concomitant. There was no mortality or major morbidities. A 100% success in complete LAA closure was observed, with 87% complete follow-up imaging. For patients that underwent standalone AtriClip after cessation of anticoagulation, no thromboembolic phenomena were seen in the 180 patient-years of follow-up. CONCLUSIONS This study demonstrates that thoracoscopic placement of AtriClip is safe and effective in achieving consistent and complete LAAO. Future randomised trials will be useful to compare outcomes with percutaneous devices.
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Affiliation(s)
- Edward Wang
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Paul Sadleir
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia
| | - Vijay Sourinathan
- Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia
| | - Rukshen Weerasooriya
- Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia; Faculty of Medicine, The University of Western Australia, Perth, WA, Australia
| | - David Playford
- School of Medicine, The University of Notre Dame Australia, Perth, WA, Australia
| | - Pragnesh Joshi
- Department of Cardiothoracic Surgery, Sir Charles Gairdner Hospital, Perth, WA, Australia; Heart Rhythm Clinic, Hollywood Private Hospital, Perth, WA, Australia; Faculty of Medicine, The University of Western Australia, Perth, WA, Australia.
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Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
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19
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Hao Z, Liu B, Xie X, Fan Y, Wang J, Shao Q, Jiang L, He B. Combining catheter ablation and left atrial appendage occlusion in high-risk patients with atrial fibrillation: a propensity score-matched analysis. Hellenic J Cardiol 2024:S1109-9666(24)00057-5. [PMID: 38460616 DOI: 10.1016/j.hjc.2024.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Revised: 12/23/2023] [Accepted: 03/03/2024] [Indexed: 03/11/2024] Open
Abstract
BACKGROUND The safety and efficacy of a combined approach of catheter ablation (CA) and left atrial appendage occlusion (LAAO) compared to LAAO alone remain unknown. METHODS Patients with atrial fibrillation (AF) at increased stroke risk who underwent LAAO were divided into either combined (CA and LAAO) procedures or LAAO alone group. Propensity score matching was utilized to balance baseline characteristics. The primary endpoint of the study was a composite of death, thromboembolic events, major bleeding, heart failure (HF) rehospitalization, and major periprocedural complications. RESULTS A total of 707 AF patients who underwent LAAO were included. After 1:1 propensity score matching, 166 patients who underwent LAAO alone (n = 83) or the combined procedure (n = 83) were analyzed. Successful LAAO was achieved in all (100%) patients, with a low incidence of periprocedural complications in both groups (2.4% vs. 4.8%, LAAO vs. combined, p = 0.68). The incidence of peri-device leak post-LAAO was significantly higher in the combined group (25.3% vs. 43.4%, p = 0.01). After a median follow-up of 2 years, there were no significant differences in the rates of the primary composite endpoint between the two strategies (22.2% vs. 14.3%, HR: 1.24 [95% CI: 0.51-2.97], p = 0.63). However, the rate of HF rehospitalization was significantly lower in the combined group (19.6% vs. 3.6%, HR: 4.89 [95% CI: 1.50-15.97], p = 0.024). CONCLUSIONS Combining CA and LAAO in a "one-stop" approach is safe and brings additional benefits in relieving symptoms of heart failure, although peri-device leak was more common compared to LAAO alone.
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Affiliation(s)
- Ziyong Hao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bin Liu
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyi Xie
- Department of Ultrasonography, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiting Fan
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qin Shao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lisheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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20
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Zhang J, Li C, Zhou L, Sang C, Li S, Ma C. Characteristics and outcome of patients with left atrial appendage closure in China: a single-center experience. BMC Cardiovasc Disord 2024; 24:108. [PMID: 38355458 PMCID: PMC10865656 DOI: 10.1186/s12872-023-03651-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/01/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clinical characteristics and long-term data on the safety and efficacy of LAAC in preventing cerebrovascular accident and thromboembolism among Chinese patients with non-valvular AF (NVAF) remain limited. METHODS Data of consecutive NVAF patients who underwent LAAC at Beijing Anzhen Hospital, Capital Medical University, from June 1, 2014, to December 31, 2021, were collected and analyzed retrospectively. The primary effectiveness endpoint was the composite endpoint of stroke/transient ischemic attack, systemic embolism, and death from cardiovascular causes. The primary safety endpoint is the severe bleeding defined by the LAAC Munich consensus. RESULTS Of the 222 patients enrolled, the mean age was 66.90 ± 9.62 years, with a majority being male (77.03%). Many patients are non-paroxysmal AF (71.19%) with a median duration of AF of 4.00 years. The mean CHA2DS2-VASc score was 3.78 ± 1.49, and the mean HAS-BLED score was 1.68 ± 0.86. Thromboembolic events (76.58%) were the most common indication for LAAC. The device, technical, and procedural success rates were 98.65%, 98.65%, and 93.69%, respectively. The anticoagulation continuation rate was 56.36%, 31.25%, and 22.60% at 3-, 6- and 12 months post-procedure, respectively. Throughout a mean 2.81 years of follow-up, the incidence of the primary efficacy endpoint was 4.27 per 100 patient-years, predominantly attributable to stroke/TIA (3.12 per 100 PYs). Five patients experienced major bleeding during the follow-up period. Post-procedure imaging revealed minimal complications, with only one substantial peri-device leak. Device-related thrombus occurred in 2.33% of patients, resolving with anticoagulation. CONCLUSION The study demonstrates that LAAC is a safe and effective alternative option for Chinese patients with AF, with a high success rate, few complications as well as fewer long-term adverse outcome events.
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Affiliation(s)
- Jingrui Zhang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changyi Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Lu Zhou
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
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21
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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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22
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Li X, Feng S, Ren Z, Wu J, Zhou L, Yang H, Zheng Y, Meng W, Zhang J, Su Y, Jiang Y, Xu J, Sun H, Xu Y, Zhao D, Yin X. Long-term outcomes of left atrial appendage closure with or without concomitant pulmonary vein isolation:a propensity score matching analysis based on CLACBAC study. BMC Cardiovasc Disord 2024; 24:85. [PMID: 38310248 PMCID: PMC10837861 DOI: 10.1186/s12872-024-03725-1] [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: 06/25/2023] [Accepted: 01/11/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND The combined procedure of left atrial appendage closure (LAAC) with concomitant pulmonary vein isolation (PVI) has demonstrated its efficacy and safety. However, there is still a lack of comparative investigations regarding the long-term benefits of the combined procedure when compared to LAAC alone. Our study aims to assess the long-term outcomes of combined procedure of LAAC with concomitant PVI in comparison with a propensity matched LAAC alone group. METHODS Propensity score matching (PSM) was employed to rectify covariate imbalances, resulting in the inclusion of 153 comparable patients from the initial cohort of 333 non-valvular atrial fibrillation (AF) patients. Clinical outcomes, encompassing thrombotic events, major cardiocerebrovascular adverse events (MACCE), re-hospitalization due to cardiovascular disease (CVD), and atrial tachycardia (AT), were juxtaposed between the two groups. Bleeding events and peri-device complications, such as residual flow, device-related thrombus, and device replacement, were also compared. Additionally, a patients group underwent PVI alone was included for comparing AF recurrence rates between the PVI alone group and the combined group. RESULTS Following PSM, 153 patients (mean age 70.3 ± 8.9, 62.7% men) were included, with 102 undergoing the combined procedure and 51 undergoing LAAC alone. No significant differences were found in baseline characteristics between the two groups. The mean follow-up time was 37.6 ± 7.9 months, and two patients were lost to follow-up in the combined procedure group. Thrombotic events were observed in 4 (7.8%) patients in the LAAC alone group and 4 (4.0%) in the combined group (Log-rank p = 0.301). The proportion of patients experiencing MACCE, re-hospitalization due to CVD, and AT between the two groups was comparable, as were bleeding events and peri-device complications. Among patients from the combined procedure group without AF recurrence, a significant difference was noted in prior-procedure left ventricular ejection fraction (LVEF) and LVEF at the 12th month after the procedure (57.2% ± 7.1% vs. 60.5% ± 6.5%, p = 0.002). CONCLUSION The concomitant PVI and LAAC procedure did not increase procedure-related complications, nor did it confer significant benefits in preventing thrombotic events or reducing other cardiovascular events. However, the combined procedure improved heart function, suggesting potential long-term benefits.
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Affiliation(s)
- Xiang Li
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China
| | - Shiyu Feng
- Tongji University School of Medicine, Shanghai, 200092, China
| | - Zhongyuan Ren
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jiayu Wu
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- School of Medicine, Anhui University of Science and Technology, Anhui province, Huainan, China
| | - Lili Zhou
- School of Clinical Medicine, Shanghai University of Medicine and Health Sciences, Shanghai, 201318, China
| | - Haotian Yang
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yixing Zheng
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Weilun Meng
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Jun Zhang
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yang Su
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Yan Jiang
- Tongji University School of Medicine, Shanghai, 200092, China
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China
| | - Jun Xu
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
| | - Hui Sun
- Tongji University School of Medicine, Shanghai, 200092, China
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China
- Department of Cardiology, Shanghai Tenth People's Hospital Chongming Branch, Shanghai, 202157, China
| | - Yawei Xu
- Tongji University School of Medicine, Shanghai, 200092, China.
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Dongdong Zhao
- Tongji University School of Medicine, Shanghai, 200092, China.
- Heart Centre, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, 200092, China.
| | - Xiaobing Yin
- Tongji University School of Medicine, Shanghai, 200092, China.
- Department of Nursing, Shanghai Tenth People's Hospital, Tongji University School of Medicine, Shanghai, 200092, China.
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23
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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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24
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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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25
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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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Gurol ME, Wright CB, Janis S, Smith EE, Gokcal E, Reddy VY, Merino JG, Hsu JC. Stroke Prevention in Atrial Fibrillation: Our Current Failures and Required Research. Stroke 2024; 55:214-225. [PMID: 38134262 PMCID: PMC11167726 DOI: 10.1161/strokeaha.123.040447] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Nonvalvular atrial fibrillation is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. These medications also require strict compliance for efficacy, and they have nontrivial failure rates in higher-risk patients. Left atrial appendage closure is a nonpharmacological method to prevent ischemic strokes in atrial fibrillation without the need for lifelong anticoagulant use, but this procedure has the potential for complications and residual embolic events. This workshop of the Roundtable of Academia and Industry for Stroke Prevention discussed future research needed to further decrease the ischemic and hemorrhagic risks among patients with atrial fibrillation. A direct thrombin inhibitor, factor Xa inhibitors, and left atrial appendage closure are FDA-approved approaches whereas factor XIa inhibitors are currently being studied in phase 3 randomized controlled trials for stroke prevention. The benefits, risks, and shortcomings of these treatments and future research required in different high-risk patient populations are reviewed in this consensus statement.
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Affiliation(s)
- M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Clinton B Wright
- Division of Clinical Research, NINDS, Bethesda, MD (C.B.W., S.J.)
| | | | - Eric E Smith
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.)
| | - Elif Gokcal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G., E.G.)
| | - Vivek Y Reddy
- Helmsley Trust Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York (V.Y.R.)
| | - José G Merino
- Department of Neurology, Georgetown University Medical Center (J.G.M.)
| | - Jonathan C Hsu
- Department of Cardiology, University of California, San Diego, La Jolla (J.C.H.)
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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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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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Haertel F, Lustermann P, Hamadanchi A, Gruen K, Bogoviku J, Aftanski P, Westphal J, Baez L, Franz M, Schulze PC, Moebius-Winkler S. Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage. Int J Mol Sci 2023; 24:16802. [PMID: 38069127 PMCID: PMC10705923 DOI: 10.3390/ijms242316802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Echocardiographic detection of residual peri-device leakage (PDL) after percutaneous left atrial appendage occlusion (LAAO) is crucial for managing anticoagulation. Galectin-3, a protein involved in tissue-foreign body interactions, may hold significance in understanding PDL and cardiac tissue remodeling after LAAO. This study aimed to analyze galectin-3 serum levels in relation to PDL using a novel echo-morphological classification. LAAO eligible patients were included in the study. Galectin-3 serum levels were measured before LAAO, at 45 days (45D), and at 6 months (6M) after the procedure. Transesophageal echocardiography was used to assess LAAO success. A new echo-morphological classification categorized the degree of LAAO into three different types (A: homogenous echodensity, indicating completely thrombosed device; B: inhomogeneous echolucencies (<50% of device); and C: partially thrombosed device with echolucencies > 50%). Among 47 patients, complete LAAO was achieved in 60% after 45D and in 74% after 6M. We observed a significant increase and distribution of serum levels of galectin-3 [ng/mL] after 45D among the three types (baseline: 13.1 ± 5.8 ng/mL; 45D: 16.3 ± 7.2 ng/mL (Type A) vs. 19.2 ± 8.6 ng/mL (Type B) vs. 25.8 ± 9.4 ng/mL (Type C); p = 0.031), followed by a drop in galectin-3 for Types A and B after 6M toward and below the baseline levels (6M: 8.9 ± 3.1 ng/mL (Type A) vs. 12.4 ± 5.5 ng/mL (Type B)), whereas Type C persisted in showing elevated galectin-3 levels compared to all other types (6M: 17.5 ± 4.5 ng/mL (Type C); p < 0.01). Increased galectin-3 serum levels after LAAO likely reflect the transition from thrombus formation to fibrotic scar development in the LAA lumen. Successful occlusion is associated with a time-restricted decrease in galectin-3 levels after 6 months, while relevant PDL leads to persistently elevated levels, making galectin-3 a potential predictor of occlusion success.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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31
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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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Mostafa MR, Eid MM, Abuelazm M, Al-Abdouh A, Najim M, Hassan AR, El-Sakka AA, Renjithal SLM, Malik MA, Mohamed S, Balmer-Swain M, Paul TK, Goldsweig AM. Meta-Analysis of the Outcomes of Peri-Device Leak After Left Atrial Appendage Closure. Am J Cardiol 2023; 204:325-332. [PMID: 37572568 DOI: 10.1016/j.amjcard.2023.07.102] [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: 02/21/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/14/2023]
Abstract
Left atrial appendage closure (LAAC) reduces the risk of thromboembolic stroke in atrial fibrillation. Peri-device leak (PDL) after LAAC may affect the subsequent risk of thromboembolism. We conducted a systematic review and meta-analysis to evaluate the effect of PDL after LAAC. We searched PubMed/Medline, Embase, and Google Scholar for studies reporting outcomes of PDL after LAAC from inception through October 2022. The primary outcome was the composite of stroke, transient ischemic attack (TIA), or systemic embolism (SE). Secondary outcomes included all-cause and cardiovascular mortality, ischemic stroke, TIA, and device-related thrombus. Outcomes were pooled using random-effects models. We used I2 statistics to assess statistical heterogeneity; I2 >50% considered significant heterogeneity. This study included 54,279 patients from 11 studies (6 observational, 2 nonrandomized controlled trials [non-RCTs] primary results, 2 RCT post hoc analyses, and 1 analysis combining 2 RCTs data). PDL was associated with a significant increase in the composite outcome of stroke, TIA, or SE (odds ratio 1.63, 95% confidence interval 1.06 to 2.52, p = 0.03, I2 = 43%) as compared with cases with no PDL. There were no significant differences in all-cause or cardiovascular mortality, ischemic stroke, TIA, or device-related thrombus. In conclusion, PDL after LAAC is associated with an increased risk of thromboembolism (composite stroke, TIA, or SE) without impacting mortality.
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Affiliation(s)
- Mostafa Reda Mostafa
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Magdi Eid
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Abuelazm
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mostafa Najim
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Abdul Rhman Hassan
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amro A El-Sakka
- Department of Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Muhammad Ahmed Malik
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Sarah Mohamed
- Department of Medicine, Cairo University School of Medicine, Cairo, Egypt
| | - Mallory Balmer-Swain
- Department Cardiology, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Timir K Paul
- Department of Cardiovascular Medicine, University of Tennessee at Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts.
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Zhang P, Zhao Y, Sun J, Wang Q, Li W, Zhang R, Chen M, Mo B, Yu Y, Feng X, Liu B, Yu Y, Lu Q, Li Y. Safety and efficacy of ablation for atrial fibrillation in combination with left atrial appendage occlusion in octogenarians. Clin Cardiol 2023; 46:1202-1209. [PMID: 37522390 PMCID: PMC10577539 DOI: 10.1002/clc.24099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Catheter ablation (CA) combined with left atrial appendage occlusion (LAAO) is a feasible approach for atrial fibrillation (AF) patients. Its role in octogenarians with AF is unclear. HYPOTHESIS In AF patients over 80 years, CA combined with LAAO is a feasible way in restoring sinus rhythm and preventing stroke. METHODS This is a single-center retrospective study. Patients who underwent CA and LAAO in a single procedure between March 2018 and December 2020 were included. Efficacy endpoints included procedural success rate, AF recurrence rate, and thromboembolic events. Safety endpoints included pericardial effusion/cardiac tamponade, device-related thrombus (DRT), all-cause death, and major bleeding. RESULTS Five hundred and five patients (mean age 69.5 ± 7.7 years; 230 [45.5%] female) were included, with 46 (9.1%) patients aged ≥80 years old (octogenarian group). Prevalence of paroxysmal AF (25 [54.3%] vs. 207 [45.1%], p < 0.001) and CHA2DS2VASc score (4.1 ± 1.3 vs. 3.1 ± 1.4, p < 0.0001) were higher in octogenarian patients. There were six cases (1.2%) of pericardial effusion (all in nonoctogenarian patients). At 3 months postprocedure, 437 patients underwent TEE/CT. Thirty-two (80%) octogenarian patients and 308 (77.6%) nonoctogenarian patients had no peri-device leak. After a mean follow-up of 26.9 ± 9.1 months, AF was documented in 10 (21.7%) patients in octogenarian group and in 103 (22.4%) patients in nonoctogenarian group (p = 0.99). The annual thromboembolic risk was 2.1% and 0.8% in the octogenarian group and nonoctogenarian group, respectively. Death occurred in 16 nonoctogenarian patients. One major bleeding was recorded in the octogenarian group. CONCLUSIONS The combination of CA and LAAO in a single procedure is a feasible treatment option in octogenarians with comparable efficacy and safety profile.
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Affiliation(s)
- Peng‐Pai Zhang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yan Zhao
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Qun‐Shan Wang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Wei Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Rui Zhang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Mu Chen
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Bin‐Feng Mo
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi Yu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Xiang‐Fei Feng
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Bo Liu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi‐Chi Yu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Qiu‐Fen Lu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi‐Gang Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
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Qi YB, Chu HM. Progress in the study and treatment of peri-device leak after left atrial appendage closure. World J Clin Cases 2023; 11:5857-5862. [PMID: 37727474 PMCID: PMC10506037 DOI: 10.12998/wjcc.v11.i25.5857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 05/28/2023] [Accepted: 08/09/2023] [Indexed: 09/01/2023] Open
Abstract
For patients with atrial fibrillation with an increased risk of stroke and contraindications to long-term anticoagulation, percutaneous left atrial appendage closure (LAAC) has become an important alternative to long-term oral anticoagulation. Incomplete closure of the LAAC during the procedure leads to faster blood flow in the interstitial space around the device, resulting in peri-device leak (PDL), which is not uncommon. Studies are still inconclusive in determining the incidence, long-term safety, and management of PDL. Therefore, this article reviewed the progress made in the research and treatment of PDL after LAAC.
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Affiliation(s)
- Ying-Bo Qi
- Department of Cardiology, Health Science Center, Ningbo University, Ningbo 315000, Zhejiang Province, China
| | - Hui-Min Chu
- Department of Cardiology, Arrhythmia Center, Ningbo First Hospital, Ningbo 3153000, Zhejiang Province, China
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35
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Choe YH. Association of Hypoattenuation Thickening at CT after Left Atrial Appendage Occlusion with Stroke. Radiology 2023; 308:e231828. [PMID: 37668525 DOI: 10.1148/radiol.231828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Yeon Hyeon Choe
- From the Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Ilwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea
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Anduaga I, Affronti A, Cepas-Guillén P, Alcocer J, Flores-Umanzor E, Regueiro A, Brugaletta S, Quintana E, Sanchis L, Sabaté M, Freixa X. Non-Pharmacological Stroke Prevention in Atrial Fibrillation. J Clin Med 2023; 12:5524. [PMID: 37685589 PMCID: PMC10488500 DOI: 10.3390/jcm12175524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.
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Affiliation(s)
- Iñigo Anduaga
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Alessandro Affronti
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Pedro Cepas-Guillén
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Jorge Alcocer
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduardo Flores-Umanzor
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Salvatore Brugaletta
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduard Quintana
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08007 Barcelona, Spain
| | - Laura Sanchis
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Manel Sabaté
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Xavier Freixa
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
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Lakkireddy D, Nielsen-Kudsk JE, Windecker S, Thaler D, Price MJ, Gambhir A, Gupta N, Koulogiannis K, Marcoff L, Mediratta A, Anderson JA, Gage R, Ellis CR. Mechanisms, predictors, and evolution of severe peri-device leaks with two different left atrial appendage occluders. Europace 2023; 25:euad237. [PMID: 37584233 PMCID: PMC10427960 DOI: 10.1093/europace/euad237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023] Open
Abstract
AIMS Incomplete left atrial appendage occlusion (LAAO) due to peri-device leak (PDL) is a limitation of the therapy. The Amulet IDE trial is the largest randomized head-to-head trial comparing the Amulet and Watchman 2.5 LAAO devices with fundamentally different designs. The predictors and mechanistic factors impacting differences in PDLs within the Amulet IDE trial are assessed in the current analysis. METHODS AND RESULTS An independent core lab analysed all images for the presence or absence of severe PDL (>5 mm). The incidence, mechanistic factors, predictors using propensity score-matched controls, and evolution of severe PDLs through 18 months were assessed. Of the 1878 patients randomized in the trial, the Amulet occluder had significantly fewer severe PDLs than the Watchman device at 45 days (1.1 vs. 3.2%, P < 0.001) and 12 months (0.1 vs. 1.1%, P < 0.001). Off-axis deployment or missed lobes were leading mechanistic PDL factors in each device group. Larger left atrial appendage (LAA) dimensions including orifice diameter, landing zone diameter, and depth predicted severe PDL with the Watchman device, with no significant anatomical limitations noted with the Amulet occluder. Procedural and device implant predictors were found with the Amulet occluder attributed to the learning curve with the device. A majority of Watchman device severe PDLs did not resolve over time through 18 months. CONCLUSION The dual-occlusive Amplatzer Amulet LAA occluder provided improved LAA closure compared with the Watchman 2.5 device. Predictors and temporal observations of severe PDLs were identified in the Amulet IDE trial. CLINICAL TRIAL REGISTRATION https://clinicaltrials.gov Unique identifier NCT02879448.
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Affiliation(s)
- Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, 5100 W 100th St, Suite-200, Overland Park, KS 66211, USA
| | | | - Stephan Windecker
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | - Alok Gambhir
- Northside Hospital Cardiovascular Institute, Atlanta, GA, USA
| | - Nigel Gupta
- Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Leo Marcoff
- Cardiovascular Core Lab at Morristown Medical Center, Morristown, NJ, USA
| | - Anuj Mediratta
- Cardiovascular Core Lab at Morristown Medical Center, Morristown, NJ, USA
| | | | - Ryan Gage
- Abbott Structural Heart, Plymouth, MN, USA
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Bhuta S, Shaaban A, Binda NC, Antaki J, Augostini RS, Kalbfleisch SJ, Savona SJ, Okabe T, Houmsse M, Afzal MR, Daoud EG, Hummel JD. Direct current cardioversion practices following percutaneous left atrial appendage closure. J Cardiovasc Electrophysiol 2023; 34:1698-1705. [PMID: 37493499 DOI: 10.1111/jce.15999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Among patients with non-valvular atrial fibrillation (AF) and percutaneous left atrial appendage closure (LAAC) undergoing direct current cardioversion (DCCV), the need for and use of LAA imaging and oral anticoagulation (OAC) is unclear. OBJECTIVE The purpose of this study is to evaluate the real-world use of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) before DCCV and use of OAC pre- and post-DCCV in patients with AF status post percutaneous LAAC. METHODS This retrospective single center study included all patients who underwent DCCV after percutaneous LAAC from 2016 to 2022. Key measures were completion of TEE or CCTA pre-DCCV, OAC use pre- and post-DCCV, incidence of left atrial thrombus (LAT) or device-related thrombus (DRT), incidence of peri-device leak (PDL), and DCCV-related complications (stroke, systemic embolism, device embolization, major bleeding, or death) within 30 days. RESULTS A total of 76 patients with AF and LAAC underwent 122 cases of DCCV. LAAC consisted of 47 (62%), 28 (37%), and 1 (1%) case of Watchman 2.5, Watchman FLX, and Lariat, respectively. Among the 122 DCCV cases, 31 (25%) cases were identified as "non-guideline based" due to: (1) no OAC for 3 weeks and no LAA imaging within 48 h before DCCV in 12 (10%) cases, (2) no OAC for 4 weeks following DCCV in 16 (13%) cases, or (3) both in 3 (2%) cases. Among the 70 (57%) cases that underwent TEE or CCTA before DCCV, 16 (23%) cases had a PDL with a mean size of 3.0 ± 1.1 mm, and 4 (6%) cases had a LAT/DRT on TEE resulting in cancellation. There were no DCCV-related complications within 30 days. DISCUSSION There is a widely varied practice pattern of TEE, CCTA, and OAC use with DCCV after LAAC, with a 6% rate of LAT/DRT. LAA imaging before DCCV appears prudent in all cases, especially within 1 year of LAAC, to assess for device position, PDL, and LAT/DRT.
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Affiliation(s)
- Sapan Bhuta
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Adnan Shaaban
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Nkongho C Binda
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James Antaki
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Ralph S Augostini
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Steven J Kalbfleisch
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Salvatore J Savona
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Toshimasa Okabe
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mahmoud Houmsse
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Muhammad R Afzal
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Emile G Daoud
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- Section of Electrophysiology, Division of Cardiovascular Medicine, Ross Heart Hospital, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Segar MW, Zhang A, Paisley RD, Badjatiya A, Lambeth KD, Mullins K, Razavi M, Molina-Razavi JE, Rasekh A, Saeed M. Risk Stratification in Patients Who Underwent Percutaneous Left Atrial Appendage Occlusion. Am J Cardiol 2023; 200:50-56. [PMID: 37295180 DOI: 10.1016/j.amjcard.2023.05.019] [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: 02/13/2023] [Revised: 04/04/2023] [Accepted: 05/13/2023] [Indexed: 06/12/2023]
Abstract
Left atrial appendage occlusion (LAAO) is effective in preventing thromboembolism. Risk stratification tools could help identify patients at risk for early mortality after LAAO. In this study, we validated and recalibrated a clinical risk score (CRS) to predict risk of all-cause mortality after LAAO. This study used data from patients who underwent LAAO in a single-center, tertiary hospital. A previously developed CRS using 5 variables (age, body mass index [BMI], diabetes, heart failure, and estimated glomerular filtration rate) was applied to each patient to assess risk of all-cause mortality at 1 and 2 years. The CRS was recalibrated to the present study cohort and compared with established atrial fibrillation-specific (CHA2DS2-VASc and HAS-BLED) and generalized (Walter index) risk scores. Cox proportional hazard models were used to assess the risk of mortality and discrimination was assessed by Harrel C-index. Among 223 patients, the 1- and 2-year mortality rates were 6.7% and 11.2%, respectively. With the original CRS, only low BMI (<23 kg/m2) was a significant predictor of all-cause mortality (hazard ratio [HR] [95% CI] 2.76 [1.03 to 7.35]; p = 0.04). With recalibration, BMI <29 kg/m2 and estimated glomerular filtration rate <60 ml/min/1.73 m2 were significantly associated with an increased risk of death (HR [95% CI] 3.24 [1.29 to 8.13] and 2.48 [1.07 to 5.74], respectively), with a trend toward significance noted for history of heart failure (HR [95% CI] 2.13 [0.97 to 4.67], p = 0.06). Recalibration improved the discriminative ability of the CRS from 0.65 to 0.70 and significantly outperformed established risk scores (CHA2DS2-VASc = 0.58, HAS-BLED = 0.55, Walter index = 0.62). In this single-center, observational study, the recalibrated CRS accurately risk stratified patients who underwent LAAO and significantly outperformed established atrial fibrillation-specific and generalized risk scores. In conclusion, clinical risk scores should be considered as an adjunct to standard of care when evaluating a patient's candidacy for LAAO.
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Affiliation(s)
- Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas.
| | - Allan Zhang
- School of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Anish Badjatiya
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Kaleb D Lambeth
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Karen Mullins
- Quality CV Service Line, Baylor St. Luke's Medical Center, Houston, Texas
| | - Mehdi Razavi
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | | | - Abdi Rasekh
- Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Mohammad Saeed
- Department of Cardiology, Texas Heart Institute, Houston, Texas
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Paitazoglou C, Eitel I, Stiermaier T, Ince H, Kische S, Pokushalov E, Schmitz T, Schmidt B, Gori T, Meincke F, Vireca E, Wohlmuth P, Lucas B, Bergmann MW. Sex-related differences in outcome after left atrial appendage occlusion: Insights from Europe and the EWOLUTION registry. Catheter Cardiovasc Interv 2023. [PMID: 37393575 DOI: 10.1002/ccd.30759] [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: 12/14/2022] [Revised: 05/18/2023] [Accepted: 06/18/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Women with atrial fibrillation (AF) generally experience worse symptoms, poorer quality of life, and have a higher risk of stroke and death. There is limited availability of sex-related differences regarding left atrial appendage occlusion (LAAO). AIMS The aim of this study was to evaluate the sex-related differences in patients undergoing LAAO in EWOLUTION. METHODS A total of 1025 patients scheduled for elective LAAO therapy employing the WATCHMAN Gen 2.5 prospectively consented for participation; 1005 patients received a successful implant and were followed for 2 years. As we detected sex-related differences in baseline data we performed a propensity score matching. The primary endpoint is a combined endpoint of survival free from mortality, major bleeding, ischemic stroke, transitory ischemic attack (TIA) and systemic embolization (SE) up to 2-year clinical follow-up. Secondary Endpoints were periprocedural data and overall 2-year survival. RESULTS Women were older but had less often vascular disease and hemorrhagic stroke. There was no sex-related significant difference after LAAO at 2 years in the combined endpoint of survival free from mortality, major bleeding, ischemic stroke, TIA, and SE (female vs. male: 79% vs.76%, p = 0.24) or in overall survival (female vs. male: 85% vs. 82%, p = 0.16). Procedural data showed a higher sealing rate after the implantation in women (complete sealing female 94% vs. male 90%, p = 0.033), significantly more pericardial effusions (female 1.2% vs. male 0.2%, p = 0.031) and a similar periprocedural risk profile. CONCLUSIONS Females undergoing LAAO differ in various baseline variables, but after adjustment, we observed similar safety and efficacy of LAAO with no significant difference in long-term outcomes between women and men.
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Affiliation(s)
- Christina Paitazoglou
- Department Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH), University Heart Center Lübeck, Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Lübeck, Germany
| | - Ingo Eitel
- Department Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH), University Heart Center Lübeck, Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Lübeck, Germany
| | - Thomas Stiermaier
- Department Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH), University Heart Center Lübeck, Lübeck, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg-Kiel-Lübeck, Lübeck, Germany
| | - Hueseyin Ince
- Department of Cardiology, Vivantes Klinikum Neukölln and Klinikum Am Urban, Berlin, Germany
- Department of Cardiology, University Rostock, Rostock, Germany
| | - Stephan Kische
- Department of Cardiology, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Evgeny Pokushalov
- Department of Cardiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Thomas Schmitz
- Department of Cardiology, Elisabeth Krankenhaus, Essen, Germany
| | - Boris Schmidt
- Department of Cardiology, Cardioangiologisches Centrum Bethanien, Frankfurt, Germany
| | - Tommaso Gori
- Department of Cardiology, Universitätsmedizin Mainz und DZHK Standort Rhein-Main, Mainz, Germany
| | | | | | | | - Boersma Lucas
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Amsterdam UMV, Amsterdam, The Netherlands
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Kadian M, Kok CY, Ravindran D, Passam F, Pasalic L, Kizana E. Focal Anticoagulation by Somatic Gene Transfer: Towards Preventing Cardioembolic Stroke. Heart Lung Circ 2023:S1443-9506(23)00509-7. [PMID: 37316436 DOI: 10.1016/j.hlc.2023.05.006] [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: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/16/2023]
Abstract
Cardioembolic stroke (CS) has emerged as a leading cause of ischaemic stroke (IS); distinguished by thrombi embolising to the brain from cardiac origins; most often from the left atrial appendage (LAA). Contemporary therapeutic options are largely dependent on systemic anticoagulation as a blanket preventative strategy, yet this does not represent a nuanced or personalised solution. Contraindications to systemic anticoagulation create significant unmedicated and high-risk cohorts, leaving these patients at risk of significant morbidity and mortality. Atrial appendage occlusion devices are increasingly used to mitigate stroke risk from thrombi emerging from the LAA in patients ineligible for oral anticoagulants (OACs). Their use, however, is not without risk or significant cost, and does not address the underlying aetiology of thrombosis and CS. Viral vector-based gene therapy has emerged as a novel strategy to target a spectrum of haemostatic disorders, achieving success through the adeno-associated virus (AAV) based therapy of haemophilia. Yet, thrombotic disorders, such as CS, have had limited exploration within the realm of AAV gene therapy approaches-presenting a gap in the literature and an opportunity for further research. Gene therapy has the potential to directly address the cause of CS by localised targeting of the molecular remodelling that serves to promote thrombosis.
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Affiliation(s)
- Megha Kadian
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, The University of Queensland, St Lucia, Qld, Australia
| | - Cindy Y Kok
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Dhanya Ravindran
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Freda Passam
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Heart Research Institute, Charles Perkins Centre, Sydney, NSW, Australia
| | - Leonardo Pasalic
- Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia; Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Sydney, NSW, Australia
| | - Eddy Kizana
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.
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Lin A. Early and late Watchman device migration and embolization: Insights from the NCDR LAAO registry. J Cardiovasc Electrophysiol 2023; 34:1499-1501. [PMID: 37232433 DOI: 10.1111/jce.15942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023]
Affiliation(s)
- Albert Lin
- Department of Medicine, Northwestern University, Chicago, Illinois, USA
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Korsholm K, Kramer A, Andersen A, Saw J, Nørgaard BL, Jensen JM, Nielsen-Kudsk JE. Left atrial appendage sealing performance of the Amplatzer Amulet and Watchman FLX device. J Interv Card Electrophysiol 2023; 66:391-401. [PMID: 35951214 PMCID: PMC9977851 DOI: 10.1007/s10840-022-01336-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/02/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The left atrial appendage (LAA) sealing properties of the Amplatzer Amulet and Watchman FLX devices were compared using cardiac computed tomography (CT) follow-up. METHODS Single-center cohort study of patients undergoing LAAO between 2017 and 2020. Two consecutive cohorts were enrolled, one treated with the Amplatzer Amulet (n = 150) up till 2019, and a second cohort treated with the Watchman FLX (n = 150) device from 2019. Cardiac CT was performed 2 months postprocedure. The primary outcome was complete LAA occlusion defined as no visible peri-device leak (PDL) and absence of contrast patency in the distal LAA. Secondary outcomes included PDL, contrast patency without visible PDL, PDL area, and periprocedural complications. RESULTS Complete occlusion was achieved in 39 (30.5%) of the Amulet group, compared to 89 (71.8%) of the FLX group, p < 0.001. A PDL at the Amulet disc was present in 65 (50.8%), at the lobe in 16 (12.5%), and at both the disc and lobe in 13 (10.2%). For FLX, a PDL was present in 20 (16.1%). Contrast patency without visible PDL was observed in 24 (18.8%) and 15 (12.1%) of the Amulet and FLX group, respectively. The PDL area at the Amulet mid-lobe was 92 mm2 (59-158) and 32 mm2 (IQR 28-96) for FLX, p = 0.019. Device-related thrombosis occurred in 1 (0.7%) and 2 (1.3%), respectively (p = 0.99), with periprocedural adverse events occurring in 6 (4%) and 8 (5.3%) of the Amulet and FLX group (p = 0.79). CONCLUSION Complete LAA occlusion was achieved in a significantly higher proportion treated with the Watchman FLX compared to the Amulet device. PDL was smaller with the FLX than the Amulet. Conceptual device design differences make interpretation of results complex, and additional studies with clinical outcomes are needed.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jacqueline Saw
- Department of Cardiology, Vancouver General Hospital, Vancouver, Canada
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens, Boulevard 99, 8200, Aarhus, Denmark.
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Sakriss C, Roehl P, Schwenzky A, Hoyme M, Ebelt H. Transition from WATCHMAN V.2.5 to WATCHMAN FLX for closure of the left atrial appendage: echocardiographic and clinical findings. Open Heart 2023; 10:openhrt-2022-002246. [PMID: 36918230 PMCID: PMC10016248 DOI: 10.1136/openhrt-2022-002246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
INTRODUCTION Interventional closure of the left atrial appendage (LAAC) has been established as an alternative treatment for patients with atrial fibrillation (AF) and an elevated risk of stroke. The WATCHMAN FLX (WM FLX) as the newest WATCHMAN LAAC device differs in several technical characteristics from its precursor, the WATCHMAN V.2.5 (WM V.2.5). METHODS The data presented here are derived from a retrospective single-centre study. All patients in which an LAAC was performed between February 2017 and March 2021 with either a WM V.2.5 or WM FLX device were included. RESULTS 169 patients were included in this study, of whom 95 had been treated with WM V.2.5 and 74 with WM FLX, respectively. Directly after implantation, only minor differences regarding membrane thickness and connector protrusion were noted, whereas no relevant differences were found regarding device sizing, device compression or peridevice leakage, respectively. However, at 3-month follow-up, device compression was significantly reduced in WM FLX indicating a continued device expansion which was paralleled by a reduced number of peridevice leakage in comparison to WM V.2.5. Additionally, the combined clinical endpoint of death, stroke/transistoric ischaemic attack, tamponade, device embolisation, device-related thrombosis or peridevice leakage was reduced in WM FLX. CONCLUSION LAAC using the WM FLX device results in a continued device expansion over the first 3 months based on differences in radial force in comparison to WM V.2.5. This is accompanied by a reduction in adverse clinical endpoints.
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Affiliation(s)
- Charlotte Sakriss
- Department of Medicine II, Sankt Johann Nepomuk, Catholic Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Peter Roehl
- Department of Medicine II, Sankt Johann Nepomuk, Catholic Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Andreas Schwenzky
- Department of Medicine II, Sankt Johann Nepomuk, Catholic Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Matthias Hoyme
- Department of Medicine II, Sankt Johann Nepomuk, Catholic Hospital Erfurt, Erfurt, Thüringen, Germany
| | - Henning Ebelt
- Department of Medicine II, Sankt Johann Nepomuk, Catholic Hospital Erfurt, Erfurt, Thüringen, Germany
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Chen JJ, Chiu FC, Chang SN, Cheng HL, Huang PS, Wu CK, Wang YC, Hwang JJ, Tsai CT. Impact of pre-existing left atrial appendage occluder on catheter ablation of atrial fibrillation. HEART (BRITISH CARDIAC SOCIETY) 2023; 109:921-928. [PMID: 36750355 DOI: 10.1136/heartjnl-2022-321934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/09/2023] [Indexed: 02/09/2023]
Abstract
BACKGROUND Patients with drug-refractory atrial fibrillation (AF) and pre-existing left atrial appendage occluder (LAAO) device may need pulmonary vein isolation (PVI). In this pioneer study, we investigated the impact of pre-existing LAAO on AF substrates and outcomes of PVI. METHODS From our AF registry, 65 drug-refractory patients with LAAO (72.1±11.4 years old; CHA2DS2-VASc score 3.7±2.1) were included for PVI. A balanced control group with 124 patients without LAAO receiving PVI (70.9±10.2 years old, CHA2DS2-VASc 3.6±1.9) were included for comparison. RESULTS We found PVI is feasible in patients with AF with pre-existing LAAO without new peridevice leak. Two patients with LAAO and one without LAAO had stroke during the procedure (2/65 vs 1/124, p=0.272). Complete isolation of left-sided PVs might not be achieved if the device covered the ridge joining the left atrial (LA) appendage to the body of LA. Local electrogram could be detected over LAAO and there was propagation of conduction over the occluder either under sinus rhythm or under atrial arrhythmia. LAAO might modulate LA substrate and induce peridevice fibrosis, peridevice LA flutter and complex fractionate atrial electrogram. The AF recurrent rate at 1 year was similar between the two groups (9.2% vs 8.8%). CONCLUSIONS This pioneer study first showed impacts of LAAO on LA substrate and PVI procedure.
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Affiliation(s)
- Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Yunlin County, Taiwan
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Yunlin County, Taiwan
| | - Sheng-Nan Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Yunlin County, Taiwan
| | - Hsiao-Liang Cheng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Dou-Liu, Yunlin County, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan .,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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46
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Holmes DR, Korsholm K, Rodés-Cabau J, Saw J, Berti S, Alkhouli MA. Left atrial appendage occlusion. EUROINTERVENTION 2023; 18:e1038-e1065. [PMID: 36760206 PMCID: PMC9909459 DOI: 10.4244/eij-d-22-00627] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/03/2022] [Indexed: 02/08/2023]
Abstract
Prevention of stroke represents a goal of primary importance in health systems due to its associated morbidity and mortality. As several patient groups with increased stroke rates have been identified, multiple approaches have been developed and implemented: oral anticoagulation (OAC) for patients with atrial fibrillation, surgical and percutaneous revascularisation in patients with carotid disease, device closure for patients with patent foramen ovale, and now, left atrial appendage occlusion (LAAO) for selected patients with non-valvular atrial fibrillation (NVAF). The latter group of patients are the focus of this review which evaluates the pathophysiology, selection of patients, procedural performance, outcomes of treatment both during and post-procedure, adjunctive therapy, complications, and longer-term outcomes.
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Affiliation(s)
- David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jacqueline Saw
- Division of Interventional Cardiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Sergio Berti
- Cardiology Unit, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Mohamad A Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
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47
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Letsas KP, Saplaouras A. Atrial fibrillation ablation combined with left atrial appendage occlusion: Optimal patient selection should be the main focus. Int J Cardiol 2023; 371:130-131. [PMID: 36096274 DOI: 10.1016/j.ijcard.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/06/2022] [Indexed: 12/14/2022]
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48
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Li S, Dong J, Luo J, Wang G, Xie D, Zhou L. Comparison of different quantitative evaluation protocols for peri-device leak detection using cardiac computed tomography angiography after left atrial appendage closure. Int J Cardiovasc Imaging 2023; 39:659-666. [PMID: 36329328 PMCID: PMC9947090 DOI: 10.1007/s10554-022-02748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
This study seeks to propose and compare different quantitative evaluation methods for identifying patients with peri-device leak (PDL) using cardiac computed tomography angiography (CCTA). Patients who had undergone left atrial appendage (LAA) closure and both transesophageal echocardiography (TEE) and CCTA were enrolled. Hounsfield units (HU) were measured in the proximal and distal regions of the left atrial appendage (p-LAA, d-LAA) on the CCTA, and the average of the two was determined (a-LAA). The relative HU ratios of the LAA to the center of the left atrium (LA) were calculated (p-LAA/c-LA, d-LAA/c-LA, a-LAA/c-LA). The area under the curve (AUC) for the LAA HU and the LAA/LA HU ratio were analyzed and compared. Fifty-one patients were included in this study. Pairwise comparisons showed a statistically significant difference (p = 0.029) in diagnostic performance between the d-LAA (AUC = 0.868) and a-LAA (AUC = 0.972). There were no significant differences between the a-LAA and p-LAA (p = 0.549) or between the d-LAA and p-LAA (p = 0.053). At the optimal cutoff for a-LAA of 115.5 HU, the sensitivity was 100%, the specificity was 88%. At the optimal cutoff for p-LAA of 109 HU, the sensitivity was 100%, the specificity was 84%. The LAA/LA HU ratio did not exhibit better diagnostic performance than HU attenuation in the LAA (p > 0.05). The a-LAA > 115.5 is useful in identifying PDL. Due to its convenience and intuitiveness, p-LAA > 109.0 can also be used as an alternative protocol for a-LAA.
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Affiliation(s)
- Shiqi Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Jing Dong
- Department of Echocardiography, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Jie Luo
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Gaofeng Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Dujiang Xie
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
| | - Ling Zhou
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
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49
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Telmesani A, Chang SM, Faza N, Little SH, Shah DJ. Role of Multimodality Imaging in Transcatheter Structural Interventions. Methodist Debakey Cardiovasc J 2023; 19:91-104. [PMID: 37213875 PMCID: PMC10198236 DOI: 10.14797/mdcvj.1209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 04/06/2023] [Indexed: 05/23/2023] Open
Abstract
Cardiac imaging is the backbone for safe and optimal transcatheter structural interventions. Transthoracic echocardiogram is the initial modality to assess valvular disorders, while transesophageal echocardiogram is best to delineate the mechanism of valvular regurgitation, preprocedural assessment for transcatheter edge-to-edge repair, and for intraprocedural guidance. Cardiac computed tomography is the modality of choice for assessing calcifications, maneuvering multiplaner reconstruction of different cardiac structures, preprocedural planning for various transcatheter valve replacement, and assessing for hypoattenuated leaflet thickening and reduced leaflet motion. Cardiac magnetic resonance imaging is best known for most accurate volumetric assessment of valvular regurgitation and chamber size quantification. Cardiac positron emission tomography is the only modality that could assess active infection through using fluorine 18 fluorodeoxyglucose radiotracer.
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Affiliation(s)
- Amr Telmesani
- College of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
| | - Su Min Chang
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
| | - Nadeen Faza
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
| | - Stephen H. Little
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
| | - Dipan J. Shah
- Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas, US
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50
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Wang Y, Wang M, Guo X, Han L, Kassab G. Safety and feasibility of left atrial appendage inversion in swine: A proof-of-concept study for potential therapy to prevent embolic stroke. Front Bioeng Biotechnol 2023; 11:1011121. [PMID: 36873377 PMCID: PMC9978740 DOI: 10.3389/fbioe.2023.1011121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 02/09/2023] [Indexed: 02/18/2023] Open
Abstract
Objective: Left atrial appendage (LAA) occlusion or exclusion has been used in patients with atrial fibrillation to prevent stroke, but the techniques and devices have shortcomings. This study aims to validate the safety and feasibility of a novel LAA inversion procedure. Methods: LAA inversion procedures were done in six pigs. Before the procedure and at 8 weeks postoperatively, heart rate, blood pressure, and electrocardiogram (ECG) were recorded. The serum concentration of atrial natriuretic peptide (ANP) was measured. The LAA was observed and measured by transesophageal echocardiogram (TEE) and intracardiac echocardiogram (ICE). At 8 weeks after LAA inversion, the animal was euthanized. The heart was collected for morphology and histology, including hematoxylin-eosin, Masson trichrome, and immunofluorescence staining. Results: TEE and ICE showed that LAA was inverted, and the inversion was maintained during the 8-week study duration. Food intake, body weight gain, heart rate, blood pressure, ECG, and serum ANP level were comparable before and after the procedure. Morphology and histological staining showed that there was no obvious inflammation or thrombus. Tissue remodeling and fibrosis were observed at the LAA inverted site. Conclusion: The inversion of LAA effectively eliminates the dead space of LAA and thus may reduce the risk of embolic stroke. The novel procedure is safe and feasible, but the efficacy in reducing embolization remains to be demonstrated in future studies.
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Affiliation(s)
- Yanmin Wang
- California Medical Innovations Institute, San Diego, CA, United States
| | | | - Xiaomei Guo
- California Medical Innovations Institute, San Diego, CA, United States.,3DT Holdings, LCC, San Diego, CA, United States
| | - Ling Han
- California Medical Innovations Institute, San Diego, CA, United States
| | - Ghassan Kassab
- California Medical Innovations Institute, San Diego, CA, United States.,3DT Holdings, LCC, San Diego, CA, United States
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