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Zhang Z, Zhou J, Lin Q, Wang C, Huang Y, Dai Y, Zuo W, Liu N, Xiao Y, Liu Q. Overcoming barriers for left atrial appendage thrombus: a systematic review of left atrial appendage closure. BMC Cardiovasc Disord 2024; 24:175. [PMID: 38515032 PMCID: PMC10956221 DOI: 10.1186/s12872-024-03843-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Approximately 90% of intracardial thrombi originate from the left atrial appendage in non-valvular atrial fibrillation patients. Even with anticoagulant therapy, left atrial appendage thrombus (LAAT) still occurs in 8% of patients. While left atrial appendage closure (LAAC) could be a promising alternative, the current consensus considers LAAT a contraindication to LAAC. However, the feasibility and safety of LAAC in patients with LAAT have yet to be determined. METHODS This systematic review synthesizes published data to explore the feasibility and safety of LAAC for patients with LAAT. RESULTS This study included a total of 136 patients with LAATs who underwent successful LAAC. The Amulet Amplatzer device was the most frequently utilized device (48.5%). Among these patients, 77 (56.6%) had absolute contraindications to anticoagulation therapy. Cerebral protection devices were utilized by 47 patients (34.6%). Transesophageal echocardiography (TEE) is the primary imaging technique used during the procedure. Warfarin and novel oral anticoagulants were the main anticoagulant medications used prior to the procedure, while dual antiplatelet therapy was primarily used post-procedure. During a mean follow-up period of 13.2 ± 11.5 months, there was 1 case of fatality, 1 case of stroke, 3 major bleeding events, 3 instances of device-related thrombus, and 8 cases of peri-device leakage. CONCLUSIONS This review highlights the preliminary effectiveness and safety of the LAAC procedure in patients with persistent LAAT. Future large-scale RCTs with varied LAAT characteristics and LAAC device types are essential for evidence-based decision-making in clinical practice.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Hunan Province, Changsha, 410011, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China
| | - Yongguo Dai
- Department of Pharmacology, Wuhan University TaiKang Medical School (School of Basic Medical Sciences), Hubei Province, Wuhan, 430071, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Hunan Province, Changsha, 410011, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Hunan Province, Changsha, 410011, People's Republic of China.
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Zhao Y, Cao LY, Zhao YX, Wang F, Xie LL, Xing HY, Wang Q. Medical record data-enabled machine learning can enhance prediction of left atrial appendage thrombosis in nonvalvular atrial fibrillation. Thromb Res 2023; 223:174-183. [PMID: 36764084 DOI: 10.1016/j.thromres.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/16/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND As a major complication of non-valvular atrial fibrillation (NVAF), left atrial appendage (LAA) thrombosis is associated with cerebral ischemic strokes, as well as high morbidity. Due to insufficient incorporation of risk factors, most current scoring methods are limited to the analysis of relationships between clinical characteristics and LAA thrombosis rather than detecting potential risk. Therefore, this study proposes a clinical data-driven machine learning method to predict LAA thrombosis of NVAF. METHODS Patients with NVAF from January 2014 to June 2022 were enrolled from Southwest Hospital. We selected 40 variables for analysis, including demographic data, medical history records, laboratory results, and the structure of LAA. Three machine learning algorithms were adopted to construct classifiers for the prediction of LAA thrombosis risk. The most important variables related to LAA thrombosis and their influences were recognized by SHapley Addictive exPlanations method. In addition, we compared our model with CHADS2 and CHADS2-VASc scoring methods. RESULTS A total of 713 participants were recruited, including 127 patients with LAA thrombosis and 586 patients with no obvious thrombosis. The consensus models based on Random Forest and eXtreme Gradient Boosting LAA thrombosis prediction (RXTP) achieved the best accuracy of 0.865, significantly outperforming CHADS2 score and CHA2DS2-VASc score (0.757 and 0.754, respectively). The SHAP results showed that B-type natriuretic peptide, left atrial appendage width, C-reactive protein, Fibrinogen and estimated glomerular filtration rate are closely related to the risk of LAA thrombosis in nonvalvular atrial fibrillation. CONCLUSIONS The RXTP-NVAF model is the most effective model with the greatest ROC value and recall rate. The summarized risk factors obtained from SHAP enable the optimization of the treatment strategy, thereby preventing thromboembolism events and the occurrence of cardiogenic ischemic stroke.
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Affiliation(s)
- Yue Zhao
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University (Third Military Medical University),Chongqing, China
| | - Li-Ya Cao
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University (Third Military Medical University),Chongqing, China
| | - Ying-Xin Zhao
- Department of Pharmacy, Army Medical Center, Army Medical University (Third Military Medical University),Chongqing, China
| | - Fei Wang
- Medical Big Data and Artificial Intelligence Center, the First Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Lin-Li Xie
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University (Third Military Medical University),Chongqing, China
| | - Hai-Yan Xing
- Department of Pharmacy, Army Medical Center, Army Medical University (Third Military Medical University),Chongqing, China.
| | - Qian Wang
- Department of Pharmacy, the First Affiliated Hospital of Army Medical University (Third Military Medical University),Chongqing, China.
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Sun S, Su B, Lin J, Zhao C, Ma C. A nomogram to predict left atrial appendage thrombus and spontaneous echo contrast in non-valvular atrial fibrillation patients. BMC Cardiovasc Disord 2022; 22:311. [PMID: 35820838 PMCID: PMC9277967 DOI: 10.1186/s12872-022-02737-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Non-valvular atrial fibrillation (NVAF) significantly increases the risk of stroke. Although there is availability of prediction models, their ability to predict the risk of stroke in NVAF patients remains suboptimal. Therefore, there is need to improve prediction of high-risk individuals, which is critical for efficient management of patients with NVAF.
Objective The objective of our paper is to develop a nomogram for predicting the risk of left atrial appendage thrombus (LAAT) and spontaneous echo contrast (SEC), thereby replacing the risk of stroke in NVAF patients. Design This was a retrospective cohort study that analyzed clinical data and echocardiographic indices of 387 patients with NVAF from October 2018 to June 2021. Multivariable logistic regression was used to evaluate independent factors that were used to construct the prediction nomogram. Analysis The discriminative ability and calibration of the nomogram to predict LAAT/SEC were tested using C-statistic and calibration plot. The performance of the nomogram was assessed against the CHA2DS2 score, CHA2DS2-VASc score and ATRIA score using the receiver operating characteristic curve (ROC), decision curve analysis (DCA), integrated discrimination index (IDI) and net reclassification index (NRI). Result Out of the total 387 patients enrolled in this study, 232 had LAAT/SEC. Multivariable analyses demonstrated that N-terminal pro-B-type natriuretic peptide (NT-proBNP), albumin (ALB), LAA ejection fraction (LAAEF) and LAA global peak longitudinal strain (LAA GPLS) were independent predictors of LAAT/SEC. The constructed nomogram had good discriminative (C = 0.886) and calibration (0.876) abilities after bias correction by the C-index. Compared with other models, the decision curve analyses demonstrated that the nomogram had greater net benefits. Besides, the nomogram had significant improvement in predictive performance, sensitivity and reclassification for LAAT/SEC compared with the CHA2DS2 [(c-index: 0.886 vs. 0.576, p < 0.05), (NRI: 0.539, p < 0.05), (IDI: 0.432, p < 0.05)], CHA2DS2-VASc [(c-index: 0.886 vs0.579, p < 0.05), (NRI: 0.513, p < 0.05), (IDI: 0.432, p < 0.05)] or ATRIA [(c-index: 0.886 vs0.583, p < 0.05), (NRI: 0.546, p < 0.05), (IDI: 0.432, p < 0.05)]. Conclusion Taken together, our data demonstrated that the developed nomogram was effective and had potential clinical application in the prediction of LAAT/SEC in patients with NVAF.
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Affiliation(s)
- Shikun Sun
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Bo Su
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Jia Lin
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Caiming Zhao
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
| | - Changsheng Ma
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China.
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Wang L, Fan J, Wang Z, Liao Y, Zhou B, Ma C. Evaluating left atrial appendage function in a subtype of non-valvular atrial fibrillation using transesophageal echocardiography combined with two-dimensional speckle tracking. Quant Imaging Med Surg 2022; 12:2721-2731. [PMID: 35502388 PMCID: PMC9014135 DOI: 10.21037/qims-21-942] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/25/2022] [Indexed: 12/30/2023]
Abstract
BACKGROUND The use of transesophageal echocardiography (TEE) is a clinically feasible method for quantitative analysis of left atrial appendage (LAA) function. LAA dysfunction is closely associated with atrial fibrillation (AF)-related stroke. However, there are few studies on the changes in LAA function in patients with different types of AF. This study aimed to observe changes in LAA systolic motion and function in patients with different types of AF by using speckle-tracking echocardiography (STE). METHODS A retrospective study of 216 patients with non-valvular AF was conducted. The LAA was divided into three parts: the basal segment (B), middle segment (M), and top segment (A). Speck -racking technology was used to measure and record the forward strain values of the basal segment (B), middle segment (M), and top segment (A) of the LAA, and the peak positive strain dispersion of the LAA was calculated. The left atrial appendage mechanical dispersion (LAAMD) was defined as the standard deviation (SD) of the peak positive strain at each segment of the R-R interval. RESULTS Partial speckle-tracking parameters of the LAA showed statistical significance between the two groups. The peak strain on the top segment of the LAA was reduced in the persistent atrial fibrillation (per-AF) group compared to the paroxysmal atrial fibrillation (par-AF) group [11.87 (6.47-20.12) vs. 16.02 (9.76-24.50); 12.66 (6.66-21.22) vs. 20.16 (14.16-30.56); both P<0.01]. In the group with lower LAAMD, the proportion of patients with persistent AF (per-AF) was higher (66.3% vs. 33.7%; P<0.001), the left atrial dilatation was more significant (45.80±5.656 vs. 42.85±4.867; P<0.001), the LAA filling velocity and LAA empty velocity were lower (42.35±20.354 vs. 51.0±20.599; 38.71±24.39 vs. 51.62±21.282; both P<0.001), the LAA ejection fraction was significantly lower (52.16±25.538 vs. 70.85±20.741; P=0.000), and the peak positive strains of the M and A of the LAA were lower than those in the higher LAAMD group. CONCLUSIONS The deformability of the LAA is decreased diffusely in per-AF, especially in the A of the LAA. Compliance with LAA was worse in patients with per-AF than in those with par-AF.
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Affiliation(s)
- Li Wang
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiali Fan
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Zixuan Wang
- Department of Clinical Medicine, Soochow University, Suzhou, China
| | - Yuping Liao
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bingyuan Zhou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Changsheng Ma
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
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Wei Y, Cui M, Liu S, Yu H, Feng J, Gao W, Li L. Increased hemoglobin A1c level associates with low left atrial appendage flow velocity in patients of atrial fibrillation. Nutr Metab Cardiovasc Dis 2021; 31:3176-3183. [PMID: 34629254 DOI: 10.1016/j.numecd.2021.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/15/2021] [Accepted: 07/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS High hemoglobin A1c (HbAlc) level is associated with increased cardiovascular disease risk and thromboembolic events [1]. The study sought to explored the association between HbAlc and left atrial appendage flow velocity (LAAV) among non-valvular atrial fibrillation (AF) patients. METHODS AND RESULTS A total of 249 consecutive non-valvular AF patients who underwent transesophageal echocardiography (TEE) were divided into two subgroups according to the median of LAAV level (<45 cm/s, ≥45 cm/s). Blood samples and other baseline clinical data of all patients were collected and analyzed. The low LAAV group included 126 patients and the high LAAV group included 123 patients. Patients in the low LAAV group were older and had a higher percentage of persistent AF, chronic heart failure, and higher CHA2DS2-VASc score (P < 0.05). HbAlc level in the low LAAV group was significantly higher than the high LAAV group [6.1 (5.7-6.5)% vs 5.9 (5.6-6.2)%, P = 0.010]. The low LAAV group had larger left atrial diameter (LAD), left atrial area (LAA), higher left atrial pressure (LAP), and lower left ventricular ejection fraction (LVEF) (P < 0.05). Spearman rank correlation analysis showed that the HbAlc level was negatively correlated with LAAV (r = -0.211, P = 0.001). Multivariate analysis indicated that female gender (OR = 2.233, 95% CI 1.110-4.492, P = 0.024), persistent AF (OR = 6.610, 95% CI 3.109-14.052, P < 0.001), and HbAlc (OR = 1.903, 95% CI 1.092-3.317, P = 0.023) were independent factors that associated with low LAAV in AF patients. CONCLUSION Increased HbAlc level is associated with decreased LAAV and may reflect a low contractile function of the left atrial appendage.
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Affiliation(s)
- Ying Wei
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Ming Cui
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Shuwang Liu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Haiyi Yu
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Jieli Feng
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Wei Gao
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China
| | - Lei Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, 100191, China; Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Ministry of Health, Beijing, 100191, China; Key Laboratory of Molecular Cardiovascular Science, Ministry of Education, Beijing, 100191, China; Beijing Key Laboratory of Cardiovascular Receptors Research, Beijing, 100191, China.
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