Left Atrial Appendage Closure in Patients with Atrial Fibrillation and Previous Intracerebral Hemorrhage

Single versus dual antiplatelet therapy following percutaneous left atrial appendage closure-A systematic review and meta-analysis

BACKGROUND

In the last few years, percutaneous LAA occlusion (LAAO) has become a plausible alternative in atrial fibrillation (AF) patients with contraindications to anticoagulation therapy. Nevertheless, the optimal antiplatelet strategy following percutaneous LAAO remains to be defined.

METHODS

Studies comparing single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) following LAAO were systematically searched and screened. The outcomes of interest were ischemic stroke, device-related thrombus (DRT) and major bleeding. A random-effect meta-analysis was performed comparing outcomes in both groups. The moderator effect of baseline characteristics on outcomes was evaluated by univariate meta-regression analyses.

RESULTS

Sixteen observational studies with 3255 patients treated with antiplatelet therapy (SAPT, n = 1033; DAPT, n = 2222) after LAAO were included. Mean age was 74.5 ± 8.3 years, mean CHA2DS2-VASc and HAS-BLED scores were 4.3 ± 1.5 and 3.2 ± 1.0, respectively. At a weighted mean follow-up of 12.7 months, the occurrence of stroke (RR 1.33; 95% CI 0.64-2.77; p =.44), DRT (RR 1.52; 95% CI 0.90-2.58; p =.12), and the composite of stroke and DRT (RR 1.26; 95% CI 0.67-2.37; p =.47) did not differ significantly between SAPT and DAPT groups. The rate of major bleedings was also not different between groups (RR 1.41; 95% CI 0.64-3.12; p =.39).

CONCLUSIONS

Among AF patients at high bleeding risk undergoing percutaneous LAAO, a post-procedural minimalistic antiplatelet strategy with SAPT did not significantly differ from DAPT regimens regarding the rate of stroke, DRT and major bleeding.

When Atrial Fibrillation Meets Cerebral Amyloid Angiopathy: Current Evidence and Strategies

Non-valvular atrial fibrillation (AF) and cerebral amyloid angiopathy (CAA) are two common diseases in elderly populations. Despite the effectiveness of oral anticoagulant therapy in cardioembolic stroke prevention, intracranial hemorrhage represents the most serious complication of these therapies. Cerebral amyloid angiopathy is one of the main risk factors for spontaneous intracranial bleeding, and this risk is highly increased by age and concomitant antithrombotic therapies. Cerebral amyloid angiopathy can be silent for years and then manifest with clinical features simulating TIA (TIA-mimics) or stroke in AF patients, pushing clinicians to rapidly start VKAs or DOACs, thus increasing the risk of intracranial bleeding if the diagnosis of CAA was unknown. Because the cerebral amyloid angiopathy is easily diagnosed with non-contrast MRI, suspecting the disease can avoid catastrophic complications. In this review, we will provide physicians managing anticoagulant therapies with key tips to familiarize themselves with cerebral amyloid angiopathy, with a focus on the possible clinical presentations and on the diagnostic criteria.

Stroke prevention in an octogenarian with atrial fibrillation, cerebral amyloid angiopathy and intracerebral hemorrhage

Left-atrial-appendage-closure (LAAC) is suggested as alternative to antiplatelet/anticoagulant therapy (AP/AC) for stroke-prevention in patients with cerebral-amyloid-angiopathy (CAA), intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Disadvantages of LAAC are the need for postinterventional AP and impairment of left atrial function, thus promoting heart-failure. Therefore, in an 83-year-old edoxaban-treated AF-patient with ICH and CAA, only antihypertensive therapy with neither AP/AC nor LAAC was recommended. Twenty-seven months without stroke/ICH support this strategy, which needs confirmation by a randomized-trial.

Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation

Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.

Prediction model based on machine learning for short- and long-term adverse events in left atrial appendage closure

Background

At present, the prediction of adverse events (AE) had practical significance in clinic and the accuracy of AE prediction model after left atrial appendage closure (LAAC) needed to be improved. To identify a good prediction model based on machine learning for short- and long-term AE after LAAC.

Methods

In this study, 869 patients were included from the Department of Cardiovascular Medicine of Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital during 2017 and 2021. Univariate and multivariate analyses were conducted for short-term AE after LAAC to determine possible risk factors related with AE. We compared 8 machine learning algorithms for prediction short-term AE, and XGBoost was found to have the best performance. In addition, Cox-regression was used for long-term AE to find out the risk factors and establish a prediction model.

Results

In univariate and multivariate analysis, body mass index (BMI) [odds ratio (OR) =0.91], congestive heart failure, hypertension, age ≥75 years, diabetes, stroke₂ attack (CHADS₂) score (OR =0.49) and bleeding history or predisposition, labile international normalized ratio (INR), elderly, drug/alcohol usage (BLED) score (OR =1.71) were shown to be significant risk factors for short-term AE. The XGbosst algorithm was used to predict short-term AE based on 15 possible risk factors. For long-term AE, Cox regression was used for the prediction. The CHADS₂ score [hazard ratio (HR) =1.43], hypertension (HR =2.18), age more than 75 (HR =0.49), diabetes (HR =0.57), BLED score (HR=0.28), stroke (HR =19.8), hepatopathy (HR =3.97), nephropathy (HR =2.93), INR instability (HR =4.18), drinking (HR =2.67), and drugs (HR =2.36) were significant risk factors for long-term AE. The XGBoost had a good receiver operating characteristic (ROC) curve and area under the curve (AUC) was 0.85. The accuracy of the XGBoost model stayed at nearly 0.95.

Conclusions

In short- and long-term AE, CHADS₂ score and BLED score were the most obvious risk factors. Several other risk factors also played roles in AE of LAAC. The incidence of long-term AE is under 15% and LAAC is effective and safe. The XGBoost model had good prediction accuracy and ROC curve.

Safety and effectiveness of left atrial appendage closure in patients with non-valvular atrial fibrillation and prior major bleeding

OBJECTIVES

To investigate safety and effectiveness of left atrial appendage closure (LAAC) in atrial fibrillation patients with prior major bleeding.

METHODS

A total of 377 consecutive patients scheduled for LAAC with Watchman device were divided into bleeding group (n = 137) and non-bleeding group (n = 240). Data were compared between groups.

RESULTS

The bleeding group had more patients ≥75 years old (P = 0.044), higher CHA₂DS₂-VASc (P = 0.029) and HAS-BLED scores (P = 0.001) than the non-bleeding group. During the long-term follow-up, except for thromboembolism event (P = 0.031), the incidences of major bleeding  , all-cause death  , co-primary efficacy events  , and the cumulative survival ratio after adjustment of confounding factors    were comparable. The observed thromboembolism rate was reduced by 86.3% (P = 0.0002) and 55.1% (P = 0.0293) and the observed major bleeding rate was decreased by 61.9% (P = 0.0393) and 35.7% (P = 0.2426) compared with expected risks in bleeding and non-bleeding groups, respectively. The risk reduction in thromboembolism and major bleeding were significantly greater in bleeding group versus non-bleeding group (all P < 0.0001).

CONCLUSIONS

Among patients with prior bleeding, LAAC is a safe and effective alternative to anticoagulation therapy and seems to emerge as a higher efficacy in risk reduction of thromboembolism and major bleeding compared to those without prior bleeding.

Management of Intracerebral Hemorrhage: JACC Focus Seminar

Intracerebral hemorrhage (ICH) accounts for a disproportionate amount of stroke-related morbidity and mortality. Although chronic hypertension and cerebral amyloid angiopathy are the underlying cerebral vasculopathies accounting for the majority of ICH, there are a broad range of potential causes, and effective management requires accurate identification and treatment of the underlying mechanism of hemorrhage. Magnetic resonance imaging and vascular imaging techniques play a critical role in identifying disease mechanisms. Modern treatment of ICH focuses on rapid stabilization, often requiring urgent treatment of mass effect, aggressive blood pressure reduction and correction of contributing coagulopathies to achieve hemostasis. We discuss management of patients with ICH who continue to require long-term anticoagulation, the interaction of ICH with neurodegenerative diseases, and our approach to prognostication after ICH. We close this review with a discussion of novel medical and surgical approaches to ICH treatment that are being tested in clinical trials.

Left atrial appendage occlusion in atrial fibrillation patients with previous intracranial bleeding: A national multicenter study

BACKGROUND

Intracranial hemorrhage (ICH) represents the most serious complication of oral anticoagulant therapy (OAT) in patients with atrial fibrillation (AF), and AF patients with previous ICH are a challenge for clinicians. Left atrial appendage (LAA) occlusion has emerged as an alternative option for AF patients not suitable for OAT. Currently, few data are available on long term outcomes after LAA occlusion in this population. We evaluated the safety and efficacy of LAA occlusion in a cohort of patients with AF and previous ICH.

METHODS

This is a multicenter, observational, retrospective study involving 5 LAA occlusion centers in Italy. It includes all consecutive patients (n = 120) with previous ICH who underwent LAA occlusion for nonvalvular AF and high thromboembolic risk. Procedural outcomes, post-procedural therapies and 12-months follow-up data were analyzed.

RESULTS

The device was successfully implanted in 100% of cases, with a 6% of major peri-procedural complications. 59% had a prior ICH during OAT. The sample had a high risk of stroke (5.18%/year) and bleeding (6.62%/year). 30% were discharged on single and 54.2% on dual antiplatelet therapy. The expected annual risk for thromboembolism was 5.1%. Excluding periprocedural ischemic complications, the stroke annual rate was 1.8%. The expected annual risk of bleeding was 6.7%. The observed annual bleeding rate was 5.45%.

CONCLUSIONS

Percutaneous LAA occlusion is an effective option for AF patients and previous intracranial hemorrhage. After LAA occlusion, a single antiplatelet therapy strategy could be considered for patients with the highest risk of recurrent bleeding.

Treatment strategies for patients with atrial fibrillation and anticoagulant-associated intracranial hemorrhage: an overview of the pharmacotherapy

INTRODUCTION

Oral anticoagulants (OAC) reduce stroke/systemic embolism and mortality risks in atrial fibrillation (AF). However, there is an inherent bleeding risk with OAC, where intracranial hemorrhage (ICH) is the most feared, disabling, and lethal complication of this therapy. Therefore, the optimal management of OAC-associated ICH is not well defined despite multiple suggested strategies.

AREAS COVERED

In this review, the authors describe the severity and risk factors for OAC-associated ICH and the associated implications for using DOACs in AF patients. We also provide an overview of the management of OAC-associated ICH and treatment reversal strategies, including specific and nonspecific reversal agents as well as a comprehensive summary of the evidence about the resumption of DOAC and the optimal timing.

EXPERT OPINION

In the setting of an ICH, supportive care/measures are needed, and reversal of anticoagulation with specific agents (including administration of vitamin K, prothrombin complex concentrates, idarucizumab and andexanet alfa) should be considered. Most patients will likely benefit from restarting anticoagulation after an ICH and permanently withdrawn of OAC is associated with worse clinical outcomes. Although the timing of OAC resumption is still under debate, reintroduction after 4-8 weeks of the bleeding event may be possible, after a multidisciplinary approach to decision-making.

Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO).

BACKGROUND

Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated.

METHODS

A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model.

RESULTS

A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices.

CONCLUSIONS

In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.

[Left atrial appendage occlusion in patients with nonvalvular atrial fibrillation : Present evidence, ongoing studies, open questions]

About every fifth ischemic stroke is caused by atrial fibrillation. Oral anticoagulation is highly effective in secondary stroke prevention, but a relevant portion of patients with atrial fibrillation is not (permanently) anticoagulated for a variety of reasons. Based on present evidence, no general recommendation can be given for left atrial appendage occlusion in patients with nonvalvular atrial fibrillation. However, left atrial appendage occlusion is a treatment option after severe anticoagulation-related bleeding, if the cause of bleeding is not treatable. Left atrial appendage occlusion is critical in patients with a relative contraindication for oral anticoagulation or lack of adherence to given medication. It seems to be important that further randomized studies confirm a benefit of left atrial appendage occlusion in selected patients with nonvalvular atrial fibrillation. In addition, it is vital to clarify whether discontinuation of antiplatelets is feasible after catheter-based left atrial appendage occlusion, as antiplatelets are associated with a risk of bleeding. Within this review article, we discuss present evidence, gaps of knowledge and provide an overview on ongoing clinical studies. In addition, we summarize the design of the CLOSURE-AF study. This randomized multicenter study will start recruitment soon and is funded by the German Center for Cardiovascular Research e. V.

Percutaneous left atrial appendage closure in patients with prior intracranial bleeding and thromboembolism

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) is an alternative treatment in atrial fibrillation patients with contraindication to oral anticoagulation. However, patient selection criteria for LAAC are debated.

OBJECTIVE

The purpose of this study was to evaluate the outcome after LAAC in patients with prior intracranial bleeding and thromboembolism.

METHODS

Consecutive patients with atrial fibrillation and prior intracranial bleeding who underwent LAAC from February 2009 to August 2018 at the Turku University Hospital, Finland, were included in a prospective registry. Patients were followed through clinical visits and annual phone calls up to 5 years.

RESULTS

Overall 104 patients (mean age 73 ± 7 years; 30% women; CHA₂DS₂-VASc score 4.7 ± 1.4; HAS-BLED score 3.3 ± 0.9) with atrial fibrillation and prior intracranial bleeding underwent successful LAAC using mainly (n = 102) Amplatzer devices. Median time from intracranial bleeding to LAAC was 7 months, and median follow-up 3.6 years. Antithrombotic treatment was ≤6 months in 71 patients (68%), and 48 patients (46%) received aspirin or clopidogrel alone. The rates of thromboembolism and intracranial bleeding (per 100 patient-years) were 3.4 and 1.9, respectively. In 39 patients with previous thromboembolism, the rate of thromboembolism was 3.6 per 100 patient-years (95% confidence interval 1.5-7.0), yielding a 69% relative risk reduction with respect to predicted risk based on median CHA₂DS₂-VASc score. Overall, rates of thromboembolism and intracranial bleeding were broadly similar in patients with and those without prior thromboembolism.

CONCLUSION

Percutaneous LAAC with minimized antithrombotic treatment was demonstrated to be a valid treatment option in high-risk patients with prior intracranial bleeding and thromboembolism.

Anticoagulation for atrial fibrillation after intracranial hemorrhage: A systematic review

Background

We summarize the existing evidence on the potential benefit of oral anticoagulation (OAC) in intracerebral hemorrhage (ICH) survivors with nonvalvular atrial fibrillation (NVAF).

Methods

Systematic review of the literature to address the following issues: (1) prevalence of NVAF in ICH survivors, (2) current prescription of OAC, (3) factors associated with resumption of OAC, (4) risk of ischemic stroke (IS) and recurrent ICH, and (5) ideal timing for restarting OAC in ICH survivors with NVAF.

Results

After screening 547 articles, 26 were included in the review. Only 3 focused specifically on patients with ICH as primary event, NVAF as indication for OAC, and recurrent ICH and IS as primary endpoints. In addition, 19 letters to the editor/reviews/editorials/experts' surveys/experts' opinion were used for discussion purposes.

Conclusions

NVAF is highly prevalent among ICH survivors. The risks of IS, recurrent ICH, and mortality are heightened in this group. Most published data show a net benefit in terms of IS prevention and mortality when anticoagulation is restarted. However, those studies are observational and mostly retrospective, therefore selection bias may play a major role in the results observed in these cohorts. Only randomized controlled trials, either pragmatic or explanatory, can provide more conclusive answers for this important clinical question.