Left atrial appendage closure - Current status and future directions

Atrial appendage closure is associated with increased risk for postoperative atrial fibrillation

OBJECTIVES

This study aims to examine the relationship between left atrial appendage closure (LAAC) and post-operative atrial fibrillation (POAF) in cardiac surgery patients with no pre-operative atrial fibrillation (AF).

METHODS

We analyzed a cohort of 2059 adult patients in our Society of Thoracic Surgery (STS) database who underwent at least one of the following procedures between 2018 and 2021: coronary artery bypass grafting (CABG), aortic valve replacement, or mitral valve replacement. All patients had no pre-operative AF, and 169 (8.2%) of them received a left atrial appendage closure (LAAC). Primary outcome was new-onset POAF and secondary outcomes included 1-year mortality, 30-day readmission, 1-year incident stroke, and post-operative hospital length of stay (LOS). Patients without an LAAC were matched to patients with LAAC using a 1:1 nearest neighbor propensity score method to reduce the bias due to potential confounding. Associations between LAAC and postoperative adverse outcomes were assessed using appropriate statistical tests for matched analyses.

RESULTS

The matched cohort included 162 pairs. LAAC was associated with elevated risk of new-onset POAF (41.4% vs. 25.3%, p = 0.003), and postoperative hospital LOS (142.1 vs. 120.5 h, p = 0.001). The LAAC did not significantly impact all-cause 1-year mortality, 30-day readmission, and 1-year incident stroke.

CONCLUSIONS

In cardiac surgery patients with no pre-operative history AF, LAAC was associated with substantially higher rates of new-onset POAF, without a corresponding impact on risk of 1-year incident stroke, 30-day readmission, or 1-year mortality.

Correlations Between Plasma BNP Level and Risk of Thrombotic-Hemorrhagic Events After Left Atrial Appendage Closure

Background: Percutaneous left atrial appendage closure (LAAC) reduces the incidence of stroke/bleeding events in patients with non-valvular atrial fibrillation, high risk of stroke, and contraindication in continuing anticoagulation therapy. Of them, patients with heart failure may remain at high risk of these events after LAAC. Method: Patients who underwent LAAC and were listed for the multi-center, prospectively collected OCEAN-LAAC registry, were eligible. Of them, individuals without baseline plasma B-type natriuretic peptide (BNP) levels and those dependent on hemodialysis were excluded. The prognostic impact of baseline plasma BNP levels on the incidence of death or stroke/bleeding events after LAAC was evaluated. Results: A total of 937 patients (median 78 years, 596 men) were included. The LAAC device was successfully implanted in 934 (98%) patients. Over the 366 (251, 436) days after the LAAC, 148 patients encountered a primary outcome. The common logarithm of baseline plasma BNP was independently associated with the primary outcome with an adjusted hazard ratio of 1.46 (95% confidence interval 1.06-2.18, p = 0.043). A calculated cutoff of 2.12 (equivalent to 133 pg/mL of plasma BNP level) significantly stratified the cumulative incidence of the primary outcome (29% vs. 21% for 2 years, p = 0.004). Conclusions: Using prospectively collected large-scale multi-center Japanese registry data, we demonstrated that a baseline higher plasma BNP level was independently associated with a higher incidence of stroke/bleeding events and mortality after LAAC. Further studies are warranted to understand the optimal therapeutic strategy for LAAC candidates with elevated baseline plasma BNP levels.

Left Atrial Appendage Closure Devices May Demonstrate Significant 18 F-FDG Uptake in the Absence of Infection

ABSTRACT

A 79-year-old man found to have a pulmonary nodule and pleural effusion on CT went on to have an 18 F-FDG PET/CT scan. The lung abnormality did not show FDG uptake and appeared benign. However, PET/CT detected moderately increased FDG uptake associated with a left atrial appendage closure device inserted 11 months prior to the PET/CT. Infection of a left atrial closure device has previously been demonstrated with FDG PET/CT. This case, in the absence of infection, with normal serum inflammatory markers, highlights that left atrial closure devices, in common with other foreign bodies/devices, may demonstrate significant, incidental FDG uptake.

Infective endocarditis associated with left atrial appendage occlusion device: a contemporary systematic review

BACKGROUND

Data are limited regarding infective endocarditis (IE) complicating left atrial appendage occlusion (LAAO) device procedures. This systematic review examines the etiology, diagnosis, and management of infective endocarditis (IE) following LAAO.

METHODS

A comprehensive search of six databases was performed between 2007 and 2022. In selecting studies, articles were included if they provided information about IE complicating LAAO, with relevant clinical and imaging details. Articles were excluded if they were editorials, study protocols, letters, or abstracts.

RESULTS

We identified seven cases of IE complicating LAAO published between 2007 and 2022, from the United States and Europe, highlighting the exceedingly rare reported incidence of the condition. Staphylococcus aureus is the predominant organism implicated in LAAO infections. Echocardiography is a key imaging modality for diagnosing LAAO IE. Both antibiotic therapy and surgical intervention in appropriate patients are important for managing LAAO device-related IE.

CONCLUSIONS

The limited data in the current literature regarding LAAO IE underscores the need for prospective clinical trials to establish evidence-based guidelines for infection prophylaxis, diagnosis, and management. Our findings emphasize the importance of vigilance for device-related infections, especially as the use of LAAO devices continues to grow worldwide.

Predictive nomogram models for atrial fibrillation in COPD patients: A comprehensive analysis of risk factors and prognosis

The aim of the present study was to identify the independent risk factors and prognostic indicators for atrial fibrillation (AF) in patients with chronic obstructive pulmonary disease (COPD) and to develop predictive nomogram models. This retrospective study included a total of 286 patients with COPD who were admitted to the Second Affiliated Hospital of Guilin Medical College between January 2020 and May 2022. The average age of the patients was 77.11±8.67 years. Based on the presence or absence of AF, the patients were divided into two groups: The AF group (n=87) and the non-AF group (n=199). Logistic regression analysis was conducted to identify variables with significant differences between the two groups. Nomogram models were constructed to predict the occurrence of AF in COPD patients and to assess prognosis. Survival analysis was performed using the Kaplan-Meier method. The follow-up period for the present study extended until April 31, 2023. Survival time was defined as the duration from the date of the interview to the date the participant succumbed or the end of the follow-up period. In the present study, age, uric acid (UA) and left atrial diameter (LAD) were found to be independent risk factors for the development of AF in patients diagnosed with COPD. The stepwise logistic regression analysis revealed that age had an odds ratio (OR) of 1.072 [95% confidence interval (CI): 1.019-1.128; P=0.007], UA had an OR of 1.004 (95% CI: 1.001-1.008; P=0.010) and LAD had an OR of 1.195 (95% CI: 1.098-1.301; P<0.001). Univariate and multivariate Cox regression analysis revealed that LAD and UA were independent prognostic factors for long-term mortality in COPD patients with AF. LAD had a hazard ratio (HR) of 1.104 (95% CI: 1.046-1.165; P<0.001) and UA had an HR of 1.004 (95% CI: 1.000-1.008; P=0.042). Based on these findings, predictive nomogram models were developed for AF in COPD patients, which demonstrated good discrimination ability with an area under the curve of 0.886. The prognostic nomogram for COPD patients with AF also showed good predictive accuracy with a concordance index of 0.886 (95% CI: 0.842-0.930). These models can provide valuable information for risk assessment and prognosis evaluation in clinical practice. Age, UA and LAD are independent risk factors for AF in COPD patients. The developed nomogram models provide a reliable tool for predicting AF in COPD patients and for prognosis assessment.

Cost-effectiveness of left atrial appendage closure for stroke prevention in atrial fibrillation: a systematic review appraising the methodological quality

BACKGROUND

The increasing global prevalence of atrial fibrillation (AF) has led to a growing demand for stroke prevention strategies, resulting in higher healthcare costs. High-quality economic evaluations of stroke prevention strategies can play a crucial role in maximising efficient allocation of resources. In this systematic review, we assessed the methodological quality of such economic evaluations.

METHODS

We searched electronic databases of PubMed, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and Econ Lit to identify model-based economic evaluations comparing the left atrial appendage closure procedure (LAAC) and oral anticoagulants published in English since 2000. Data on study characteristics, model-based details, and analyses were collected. The methodological quality was evaluated using the modified Economic Evaluations Bias (ECOBIAS) checklist. For each of the 22 biases listed in this checklist, studies were categorised into one of four groups: low risk, partial risk, high risk due to inadequate reporting, or high risk. To gauge the overall quality of each study, we computed a composite score by assigning + 2, 0, - 1 and - 2 to each risk category, respectively.

RESULTS

In our analysis of 12 studies, majority adopted a healthcare provider or payer perspective and employed Markov Models with the number of health states varying from 6 to 16. Cost-effectiveness results varied across studies. LAAC displayed a probability exceeding 50% of being the cost-effective option in six out of nine evaluations compared to warfarin, six out of eight evaluations when compared to dabigatran, in three out of five evaluations against apixaban, and in two out of three studies compared to rivaroxaban. The methodological quality scores for individual studies ranged from 10 to - 12 out of a possible 24. Most high-risk ratings were due to inadequate reporting, which was prevalent across various biases, including those related to data identification, baseline data, treatment effects, and data incorporation. Cost measurement omission bias and inefficient comparator bias were also common.

CONCLUSIONS

While most studies concluded LAAC to be the cost-effective strategy for stroke prevention in AF, shortcomings in methodological quality raise concerns about reliability and validity of results. Future evaluations, free of these shortcomings, can yield stronger policy evidence.

Non-Pharmacological Stroke Prevention in Atrial Fibrillation

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.

Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography

Transcatheter therapies for structural heart disease continue to grow at a rapid pace, and echocardiography is the primary imaging modality used to support such procedures. Transesophageal echocardiographic guidance of structural heart disease procedures must be performed by highly skilled echocardiographers who can provide rapid, accurate, and high-quality image acquisition and interpretation in real time. Training standards are needed to ensure that interventional echocardiographers have the necessary expertise to perform this complex task. This document provides guidance on all critical aspects of training for cardiology and anesthesiology trainees and postgraduate echocardiographers who plan to specialize in interventional echocardiography. Core competencies common to all transcatheter therapies are reviewed in addition to competencies for each specific transcatheter procedure. A core principle is that the length of interventional echocardiography training or achieved procedure volumes are less important than the demonstration of procedure-specific competencies within the milestone domains of knowledge, skill, and communication.

Improved left atrial appendage closure procedural efficiency using radiofrequency transseptal wire system

OBJECTIVE

The radiofrequency (RF) needle has been shown to improve transseptal puncture efficiency and safety compared to mechanical needles. This study aimed to investigate the use of VersaCross RF transseptal wire system (Baylis Medical) to improve procedural efficiency of left atrial appendage closure (LAAC) compared to the standard RF needle-based workflow.

METHODS

Eighty-one LAAC procedures using WATCHMAN FLX were retrospectively analyzed comparing the standard RF needle-based workflow to a RF wire-based workflow. Study primary endpoint was time to WATCHMAN device release, and secondary endpoints were transseptal puncture time, LAAC success, fluoroscopy use, and procedural complications.

RESULTS

Twenty-five cases using standard RF needle-based workflow were compared to 56 cases using the RF wire-based workflow. Baseline patient characteristics were similar between both groups. LAAC was successful in all patients with no differences in intraprocedural complication rates (p = 0.40). Transseptal puncture time was 1.3 min faster using the RF wire-based workflow compared to the standard RF needle-based workflow (6.5 ± 2.3  vs. 7.8 ± 2.3 min, p = 0.02). Overall, time to final WATCHMAN device release was 4.5 min faster with the RF wire-based workflow compared to the RF needle-based workflow (24.6 ± 5.6 vs. 29.1 ± 9.6 min, p = 0.01). Fluoroscopy time was 21% lower using the RF wire-based workflow (7.6 ± 2.8 vs. 9.6 ± 4.4 min; p = 0.05) and fluoroscopy dose was 67% lower (47.1 ± 35.3 vs. 144.9 ± 156.9 mGy, p = 0.04) and more consistent (F-test, p ˂ 0.0001).

CONCLUSIONS

The RF wire-based workflow streamlines LAAC procedures, improving LAAC efficiency and safety by reducing fluoroscopy, device exchanges, and delivery sheath manipulation.

Infective endocarditis of a left atrial appendage closure device: a case report and literature review

Background

Due to advances in interventional cardiology in recent years, more and more patients are currently receiving cardiac devices, with a subsequent increase in the number of patients with device-associated endocarditis. Device-associated endocarditis is a life-threatening disease with special diagnostic and therapeutic challenges. Interventional devices for left atrial appendage (LAA) closure have been available for several years. However, there have been very few case reports of LAA closure device–associated endocarditis.

Case summary

An 83-year-old woman presented with fever and fatigue. She had a history of permanent atrial fibrillation and recurrent bleeding on oral anticoagulation. Consequently, the patient underwent interventional LAA closure ∼20 months earlier. Blood cultures grew Staphylococcus aureus. Transoesophageal echocardiography revealed an LAA closure device–associated mobile, echo-dense mass that was consistent with infectious vegetation in this clinical context. Intravenous antibiotic therapy was started, and our heart team recommended complete removal of the device, which the patient refused. The patient subsequently died as a result of progressive endocarditis and multiple pre-existing co-morbidities.

Discussion

Left atrial appendage occlusion device–associated endocarditis has rarely been reported. Due to the increase in LAA closure device implantation, device-associated endocarditis is expected to increase in the future. Transoesophageal echocardiography is required for correct diagnosis. Our case report suggests that an infection can occur long after implantation.

Protecting the Brain, From the Heart: Safely Mitigating the Consequences of Thrombosis in Intracerebral Hemorrhage Survivors With Atrial Fibrillation

Optimal antithrombotic management after intracerebral hemorrhage remains one of the central unresolved issues for patients who survive, especially for those patients with atrial fibrillation. Given the observational nature of the studies regarding anticoagulation resumption after intracerebral hemorrhage, there is uncertainty regarding resumption of oral anticoagulation therapy and its timing. There is limited high-quality evidence to guide clinical practice, leading to significant practice variation and uncertainty for patients and providers. Here, we aim to provide the key elements to guide clinicians in their individual decision: whether or not to start or resume anticoagulation in patients with a history of intracerebral hemorrhage.