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Korsholm K, Iriart X, Saw J, Wang DD, Berti S, Galea R, Freixa X, Arzamendi D, De Backer O, Kramer A, Cademartiri F, Cochet H, Odenstedt J, Aminian A, Räber L, Cruz-Gonzalez I, Garot P, Jensen JM, Alkhouli M, Nielsen-Kudsk JE. Position Statement on Cardiac Computed Tomography Following Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2024; 17:1747-1764. [PMID: 39142755 DOI: 10.1016/j.jcin.2024.04.050] [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: 02/16/2024] [Revised: 04/10/2024] [Accepted: 04/26/2024] [Indexed: 08/16/2024]
Abstract
Left atrial appendage occlusion (LAAO) is rapidly growing as valid stroke prevention therapy in atrial fibrillation. Cardiac imaging plays an instrumental role in preprocedural planning, procedural execution, and postprocedural follow-up. Recently, cardiac computed tomography (CCT) has made significant advancements, resulting in increasing use both preprocedurally and in outpatient follow-up. It provides a noninvasive, high-resolution alternative to the current standard, transesophageal echocardiography, and may display advantages in both the detection and characterization of device-specific complications, such as peridevice leak and device-related thrombosis. The implementation of CCT in the follow-up after LAAO has identified new findings such as hypoattenuated thickening on the atrial device surface and left atrial appendage contrast patency, which are not readily assessable on transesophageal echocardiography. Currently, there is a lack of standardization for acquisition and interpretation of images and consensus on definitions of essential findings on CCT in the postprocedural phase. This paper intends to provide a practical and standardized approach to both acquisition and interpretation of CCT after LAAO based on a comprehensive review of the literature and expert consensus among European and North American interventional and imaging specialists.
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Affiliation(s)
| | - Xavier Iriart
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Dee Dee Wang
- Henry Ford Health System, Detroit, Michigan, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Roberto Galea
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Hubert Cochet
- Bordeaux University Hospital, Institut Hospitalo-Universitaire Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université, Bordeaux, France
| | | | - Adel Aminian
- Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium
| | - Lorenz Räber
- Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | | | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
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Chatani R, Kubo S, Tasaka H, Nishiura N, Mushiake K, Ono S, Maruo T, Kadota K. Transition from WATCHMAN generation-2.5 device to WATCHMAN FLX device for percutaneous left atrial appendage closure: Incidence and predictors of device-related thrombosis and short- to mid-term outcomes. Catheter Cardiovasc Interv 2024; 104:318-329. [PMID: 38895767 DOI: 10.1002/ccd.31111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 04/18/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Patients with nonvalvular atrial fibrillation (AF) not suitable for long-term anticoagulant therapy undergo percutaneous left atrial appendage closure (LAAC) using the WATCHMAN device. The safety and efficacy of WATCHMAN-FLX (WM-FLX) compared with WATCHMAN-2.5 (WM-2.5), particularly in Asian populations, is unknown. METHODS We evaluated the background, procedure, and clinical outcomes of 199 patients who underwent LAAC between September 2019 and December 2022 and compared WM-2.5 (72 patients) with WM-FLX (127 patients). RESULTS The mean age was 76 years, with 128 men, and 100 had nonparoxysmal AF (non-PAF). The mean CHA2DS2-VASc, and HAS-BLED were 5.1, and 3.2 points, respectively. WM-FLX group demonstrated a shorter procedure time than WM-2.5 group (50 vs. 42 min, p = 0.001). The WM-FLX group demonstrated no procedural-related acute cardiac tamponade, which was significantly low (5.6% vs. 0%, p = 0.02), and a significantly higher rate of complete seal at 45-day (63% vs. 80%, p = 0.04). WM-FLX group had a significantly higher cumulative 1-year incidence of device-related thrombosis (DRT) than WM-2.5 group (3.4% vs. 7.0%, Log-rank p = 0.01). Univariate analysis identified two DRT risk factors in the WM-FLX group: non-PAF (odds ratio [OR] 7.72; 95% confidence interval [CI] 1.20-48.7; p = 0.04), and 35-mm device (OR 5.13; 95% CI 1.31-19.8; p = 0.02). CONCLUSIONS WM-FLX significantly improved the procedural quality and safety of LAAC. However, DRT remains an important issue even in the novel LAAC device, being a hazard for patients with high DRT risk, such as having non-PAF and using 35-mm devices.
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Affiliation(s)
- Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shunsuke Kubo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiroshi Tasaka
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Naoki Nishiura
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazunori Mushiake
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sachiyo Ono
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeshi Maruo
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazushige Kadota
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
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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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Kramer A, Korsholm K, Nielsen-Kudsk JE. Single antiplatelet therapy following Amplatzer left atrial appendage occlusion. EUROINTERVENTION 2024; 20:e301-e311. [PMID: 38436367 PMCID: PMC10905198 DOI: 10.4244/eij-d-23-00684] [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: 08/16/2023] [Accepted: 12/04/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) remains debated. Ideally, this therapy should effectively prevent device-related thrombosis (DRT) while minimising the associated bleeding risk. AIMS We aimed to evaluate the long-term safety and efficacy of a postprocedural single antiplatelet therapy (SAPT) strategy following Amplatzer LAAO in a large consecutive cohort. METHODS This retrospective, single-centre, observational study included all patients discharged on SAPT after LAAO with the Amplatzer Cardiac Plug (ACP) or Amplatzer Amulet between March 2010 and December 2021 at Aarhus University Hospital, Denmark. Baseline, procedural, and imaging data were obtained locally, while clinical outcomes and medication data were extracted from the Danish national health registries. RESULTS A total of 553 patients underwent Amplatzer LAAO during the specified time frame. Of these, 431 (77.9%) high bleeding risk patients were discharged on SAPT with either acetylsalicylic acid (n=403, 72.9%) or clopidogrel (n=28, 5.1%). At 6 months, 173 (41.7%) patients were not on any antithrombotic therapy. The mean CHA2DS2-VASc and HAS-BLED scores were 3.9±1.5 and 3.4±1.1, respectively. DRT was detected in 6 (1.5%) patients on 8-week follow-up imaging using cardiac computed tomography (n=386, 89.6%) or transoesophageal echocardiography (n=27, 6.3%). The 1-year ischaemic stroke rate was 2.2% (95% confidence interval [CI]: 1.1-4.2). One-year rates for major bleeding and cardiovascular death were 5.9% (95% CI: 4.0-8.9) and 2.9% (95% CI: 1.6-5.1), respectively. CONCLUSIONS SAPT following Amplatzer LAAO displayed rates of DRT and stroke comparable to those reported with more intensive antithrombotic regimens. Meanwhile, we observed low rates of major bleeding.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Kramer A, Patti G, Nielsen-Kudsk JE, Berti S, Korsholm K. Left Atrial Appendage Occlusion and Post-procedural Antithrombotic Management. J Clin Med 2024; 13:803. [PMID: 38337496 PMCID: PMC10856063 DOI: 10.3390/jcm13030803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an established alternative to oral anticoagulation for stroke prevention in atrial fibrillation. Antithrombotic therapy is used in the post-procedural period to prevent device-related thrombosis (DRT). The risk of DRT is considered highest in the first 45-90 days after device implantation, based on animal studies of the device healing process. Clinically applied antithrombotic regimens vary greatly across studies, continents, and centers. This article gives an overview of the evidence behind current antithrombotic regimens, ongoing randomized trials, and future post-procedural management.
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Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, 13100 Vercelli, Italy;
- Department of Thoracic and Cardiovascular Diseases, Maggiore della Carità Hospital, 28100 Novara, Italy
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
| | - Sergio Berti
- Department of Interventional and Diagnostic Cardiology, Fondazione CNR-Regione Toscana G, Monasterio, Ospedale del Cuore, 54100 Massa, Italy;
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark; (A.K.); (J.E.N.-K.)
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De Backer O, Garot P. Residual leaks after transcatheter left atrial appendage closure: why and how to assess it? Eur Heart J 2024; 45:230-232. [PMID: 38105575 DOI: 10.1093/eurheartj/ehad843] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2023] Open
Affiliation(s)
- Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Jacques Cartier, Massy, France
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Flores-Umanzor E, Asghar A, Cepas-Guillén PL, Farrell A, Keshvara R, Alvarez-Rodriguez L, Osten M, Freixa X, Horlick E, Abrahamyan L. Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis. Clin Res Cardiol 2023:10.1007/s00392-023-02359-1. [PMID: 38112741 DOI: 10.1007/s00392-023-02359-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative. OBJECTIVE This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD). METHODS Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies. RESULTS We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade. CONCLUSIONS Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO. Transcatheter Left Atrial Appendage Occlusion (laao) Can Prevent Cardioembolic Events In Chronic Kidney Disease (ckd) Patients. However, Ckd Patients, Particularly Those With End-stage Renal Disease/dialysis (esrd), May Face Increased Odds Of Acute Kidney Injury, In-hospital And Long-term Bleeding, And Mortality. Notably, These Adverse Outcomes In Ckd Patients May Be Linked To Their High Comorbidity Burden, Particularly In Those With Esrd, Rather Than The Laao Procedure Itself. Careful Patient Selection, Management, And Surveillance Involving Multidisciplinary Teams Are Essential For Ckd Patients Undergoing Laao To Ensure Maximum Clinical Benefit Transcatheter left atrial appendage occlusion (LAAO) can prevent cardioembolic events in chronic kidney disease (CKD) patients. However, CKD patients, particularly those with end-stage renal disease/dialysis (ESRD), may face increased odds of acute kidney injury, in-hospital and long-term bleeding, and mortality. Notably, these adverse outcomes in CKD patients may be linked to their high comorbidity burden, particularly in those with ESRD, rather than the LAAO procedure itself. Careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO to ensure maximum clinical benefit.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Areeba Asghar
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Pedro L Cepas-Guillén
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Leyre Alvarez-Rodriguez
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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Alkhouli M, Alarouri H, Kramer A, Korsholm K, Collins J, De Backer O, Hatoum H, Nielsen-Kudsk JE. Device-Related Thrombus After Left Atrial Appendage Occlusion: Clinical Impact, Predictors, Classification, and Management. JACC Cardiovasc Interv 2023; 16:2695-2707. [PMID: 38030357 DOI: 10.1016/j.jcin.2023.10.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
Despite the unprecedented advances in the left atrial appendage occlusion field, device-related thrombus (DRT) remains an unresolved issue with the therapy. This paper aims to provide a state-of-the-art review of the literature on the incidence, clinical impact, predictors and management of DRT and propose a novel classification of DRT and hypoattenuated thickening.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Hasan Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anders Kramer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeremy Collins
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
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Bergmann MW, Meincke F. Improving Left Atrial Appendage Closure: Reducing the Risk of Device-Related Thrombus. JACC Cardiovasc Interv 2023; 16:2150-2152. [PMID: 37565971 DOI: 10.1016/j.jcin.2023.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 06/26/2023] [Indexed: 08/12/2023]
Affiliation(s)
- Martin W Bergmann
- Department of Cardiology, Asklepios Klinik Altona, Hamburg, Germany.
| | - Felix Meincke
- Department of Cardiology, Asklepios Klinik Altona, Hamburg, Germany
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