The long-term efficacy and safety of combining ablation and left atrial appendage closure: A systematic review and meta-analysis

Catheter ablation alone versus catheter ablation with combined percutaneous left atrial appendage closure for atrial fibrillation: a systematic review and meta-analysis

BACKGROUND

Combined catheter ablation (CA) with percutaneous left atrial appendage closure (LAAC) may produce comprehensive treatment for atrial fibrillation (AF) whereby rhythm control is achieved and stroke risk is reduced without the need for chronic oral anticoagulation. However, the efficacy and safety of this strategy is still controversial.

METHODS

This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. The risk of bias was assessed using the Modified Newcastle-Ottawa scale and Cochrane risk of bias tool. Eligible studies reported outcomes in patients with AF who underwent combined CA and LAAC vs CA alone. Studies performing CA without pulmonary vein isolation were excluded.

RESULTS

Eight studies comprising 1878 patients were included (2 RCT, 6 observational). When comparing combined CA and LAAC vs CA alone, pooled results showed no difference in arrhythmia recurrence (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.82-1.33), stroke or systemic embolism (RR 0.78; 95% CI 0.27-2.22), or major periprocedural complications (RR 1.28; 95% CI 0.28-5.89). Total procedure time was shorter with CA alone (mean difference 48.45 min; 95% CI 23.06-74.62).

CONCLUSION

Combined CA with LAAC for AF is associated with similar rates of arrhythmia-free survival, stroke, and major periprocedural complications when compared to CA alone. A combined strategy may be as safe and efficacious for patients at moderate to high risk for bleeding events to negate the need for chronic oral anticoagulation.

Association between dietary intake of niacin and stroke in the US residents: evidence from national health and nutrition examination survey (NHANES) 1999-2018

Objective

This study aims to explore the association between niacin intake and stroke within a diverse, multi-ethnic population.

Methods

A stringent set of inclusion and exclusion criteria led to the enrollment of 39,721 participants from the National Health and Nutrition Examination Survey (NHANES). Two interviews were conducted to recall dietary intake, and the USDA's Food and Nutrient Database for Dietary Studies (FNDDS) was utilized to calculate niacin intake based on dietary recall results. Weighted multivariate logistic regression was employed to examine the correlation between niacin and stroke, with a simultaneous exploration of potential nonlinear relationships using restricted cubic spline (RCS) regression.

Results

A comprehensive analysis of baseline data revealed that patients with stroke history had lower niacin intake levels. Both RCS analysis and multivariate logistic regression indicated a negative nonlinear association between niacin intake and stroke. The dose-response relationship exhibited a non-linear pattern within the range of dietary niacin intake. Prior to the inflection point (21.8 mg) in the non-linear correlation between niacin intake and stroke risk, there exists a marked decline in the risk of stroke as niacin intake increases. Following the inflection point, the deceleration in the decreasing trend of stroke risk with increasing niacin intake becomes evident. The inflection points exhibit variations across diverse populations.

Conclusion

This investigation establishes a negative nonlinear association between niacin intake and stroke in the broader American population.

Combining catheter ablation and left atrial appendage occlusion in high-risk patients with atrial fibrillation: a propensity score-matched analysis

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.

Combined Radiofrequency Ablation and Left Atrial Appendage Closure in Atrial Fibrillation and Systolic Heart Failure

BACKGROUND

Managing patients with atrial fibrillation (AF) and comorbid heart failure (HF) with reduced (HFrEF) or mildly reduced ejection fraction (HFmrEF) is of clinical importance but a great challenge. This study aimed to evaluate the clinical benefit of the combined radiofrequency catheter ablation (RFCA) and left atrial appendage closure (LAAC) procedure in AF patients complicated with systolic HF.

METHODS

AF patients with HFrEF or HFmrEF who underwent the combined RFCA and LAAC procedure were prospectively enrolled in the LAACablation registry. The procedural complications and long-term outcomes were evaluated. Another cohort of AF patients with systolic HF who did not undergo either RFCA or LAAC were used for prognosis comparison.

RESULTS

Among 802 AF patients who underwent the combined procedure, 65 patients were comorbid with systolic HF (25 with HFrEF and 40 with HFmrEF). The overall procedural complication rate was 9.2%, which was mainly attributed to acute decompensated HF (6.2%). Accompanied with markedly reduced AF burden (from median [25th, 75th percentile]: 100 [100, 100] to 0 [0, 1.2]%, p < 0.001), upward trajectories of cardiac function were observed in 51 (78.4%) patients, showing improvement in New York Heart Classification (p < 0.01), natriuretic peptide levels (from 1492 [809, 3259] to 413 [163, 880] pg/mL, p < 0.001) and left ventricular EF (from 42.6 ± 5.3 to 53.8 ± 8.2%, p < 0.001). During the 27-month follow-up period, death, thromboembolism, major bleeding, and HF rehospitalization were observed in three, one, one, and four patients, respectively. The observed event rates showed a significant reduction compared with the non-procedure AF-HF cohort (n = 138; for composite endpoint: hazard ratio: 2.509, 95% confidence interval: 1.415-4.449, p = 0.002) and with the respective rates predicted by risk scores.

CONCLUSIONS

Combining RFCA and LAAC achieves acceptable safety and credible long-term efficacy in AF patients with systolic HF. Further randomized studies are warranted in a larger patient cohort.

Efficacy of Left Atrial Appendage Closure and Oral Anticoagulation After Atrial Fibrillation Catheter Ablation

Left atrial appendage closure (LAAC) proved to be noninferior to oral anticoagulation (OAC) in nonablated patients with atrial fibrillation (AF). This study aimed to compare the efficacy and safety of LAAC with those of OAC therapy in patients after AF ablation. This study included patients who underwent catheter ablation (CA) of AF between January 2016 and December 2020. The cohort was divided into CA + LAAC and CA + OAC, where propensity score matching was used to select controls, and each group contained 682 subjects. The enrolled patients' mean age was 70.34 ± 8.32 years, and 47.3% were female; their CHA2DS2-VASc score was 3.48 ± 1.17. Baseline characteristics were similar between groups. After a 3-year mean follow-up, the incidence of thromboembolic events was 1.25 and 1.10 and that of major bleeding events was 0.65 and 1.72 per 100 patient-years in the CA + LAAC, and CA + OAC groups, respectively. The rate of thromboembolisms and major adverse cardiovascular events was similar between the 2 groups (hazard ratio [HR] 1.162, 95% confidence interval [CI] 0.665 to 2.030, p = 0.598, HR 0.711, 95% CI 0.502 to 1.005, p = 0.053); however, that of major bleeding and all-cause death was significantly reduced with LAAC (HR 0.401, 95% CI 0.216 to 0.746, p = 0.004, HR 0.528, 95% CI 0.281 to 0.989, p = 0.046). There was no significant difference in periprocedural complications (p >0.05) and the rate of AF recurrence (OAC vs LAAC: 39.44% vs 40.62%, p = 0.658). LAAC is a reasonable and safer alternative to OAC therapy in high-risk patients after AF ablation.

Effects of rhythm control on left atrial structure remodeling in atrial fibrillation and heart failure with preserved ejection fraction

Background

The benefits of rhythm control for atrial fibrillation (AF) in heart failure with preserved ejection fraction (HFpEF) have not been conclusively determined. We assessed the effects of rhythm control on left atrial (LA) structure remodeling and prognosis in patients with AF and HFpEF.

Methods

This was a retrospective, real-world, observational study involving patients diagnosed with AF and HFpEF. The cohort was divided into rhythm-control and rate-control groups depending on their treatment strategies. The primary outcomes were all-cause mortality, rehospitalization for any cause, HF-related rehospitalization, and stroke. Differences in follow-up LA structure parameters were also analyzed.

Results

Compared to the rate-control group, patients in the rhythm-control group had a lower risk of HF-related rehospitalization even after adjusting for potential confounders (adjusted HR 0.605, 95% CI 0.413-0.887, p = 0.010). Moreover, rhythm-control therapy led to marked reductions in LA echocardiographic indicators and a higher proportion of LA reverse remodeling (LARR).

Conclusions

Rhythm-control therapy reverses LA structure remodeling and is associated with improved clinical outcomes; therefore, it is an optimal treatment approach for AF in HFpEF patients.

Sex Differences in the Combined Ablation and Left Atrial Appendage Closure: Results From LAACablation Registry

Background

More than 40% of left atrial appendage closure (LAAC) procedures were combined with atrial fibrillation (AF) ablation in China.

Objectives

This study aimed to assess the sex differences in the combined radiofrequency catheter ablation and LAAC procedures.

Methods

Data from the LAACablation (Left Atrial Appendage Closure in Combination With Catheter Ablation) registry, which enrolled AF patients who underwent the combined procedure between 2018 and 2021, were analyzed. Procedural complications, long-term outcomes, and quality of life (QoL) were compared between sexes.

Results

Of 931 patients, 402 (43.2%) were women. Compared with men, women were older (age 71.3 ± 7.4 years vs 68.7 ± 8.1 years; P < 0.001), presented more often with paroxysmal AF (52.5% vs 42.7%; P < 0.003), and had higher CHA₂DS₂-VASc scores (4.1 ± 1.5 vs 3.1 ± 1.5; P < 0.001), but received less often linear ablation and had shorter total procedural times and radiofrequency catheter ablation times. Women had similar rates of total and major procedural complications but presented with a higher incidence of minor complications than men (3.7% vs 1.3%; P = 0.027). Follow-up over 1,812 patient-years revealed similar adverse events between women and men, including all-cause death (HR: 0.89; 95% CI: 0.43-1.85; P = 0.754), thromboembolic events (HR: 1.17; 95% CI: 0.54-2.52; P = 0.697), major bleeding (HR: 0.96; 95% CI: 0.38-2.44; P = 0.935), and their composite (HR: 0.85; 95% CI: 0.56-1.28; P = 0.434). The recurrence rates of atrial tachyarrhythmia were also comparable between sexes presenting either paroxysmal or persistent AF. Women were seen with greater QoL impairment at baseline, but the sex gap narrowed at 1-year follow-up.

Conclusions

In AF patients who underwent the combined procedure, women had similar procedural safety and long-term efficacy to men and presented greater QoL improvement. (Left Atrial Appendage Closure in Combination With Catheter Ablation [LAACablation]; NCT03788941).

Long-term outcome of combined catheter ablation and left atrial appendage closure in atrial fibrillation patients

BACKGROUND

The combined procedure of catheter ablation and left atrial appendage closure (LAAC) aims to simultaneously control the heart rhythm and reduce the risk of strokes in patients with atrial fibrillation (AF). The study aims to evaluate the procedural safety and long-term outcome of the combined procedure in a large patient cohort.

METHODS

Clinical data of AF patients who underwent the combined procedure was retrospectively analyzed. Procedural and imaging follow-up parameters were compared between the transesophageal echocardiography-guided standard process and fluoroscopy-guided modified process, and between the single-seal WATCHMAN and dual-seal LACBES devices. Long-term outcomes included all-cause mortality, thromboembolic events, major bleeding, and recurrence of atrial tachyarrhythmias.

RESULTS

A total of 1114 patients were included. The rates of procedure-related major complications were comparable between the standard and modified processes (3.7% vs. 2.2%, p = 0.219), except for a higher incidence of respiratory depression in standard process group (0.9% vs 0%, p = 0.037), and between WATCHMAN and LACBES devices (2.4% vs. 3.3%, p = 0.535). The follow-up imaging evaluation revealed a high rate of satisfactory seals (99.7%) and a low rate of device related thrombus (1.9%), which were similar between two process groups and devices. The follow-up of over 1960 patient-years revealed low rates of mortality, thromboembolism, and nonprocedural major bleeding (1.8, 3.2, and 0.9 per 100 patient-years, respectively). Recurrent atrial tachyarrhythmias was observed in 23.9% patients.

CONCLUSIONS

The results supported the safety and long-term efficacy of the combined procedure of catheter ablation and LAAC. Fluoroscopy-guided LAAC device implantation may be considered in experienced centers.

Identifying Atrial Fibrillation Mechanisms for Personalized Medicine

Atrial fibrillation (AF) is a major cause of heart failure and stroke. The early maintenance of sinus rhythm has been shown to reduce major cardiovascular endpoints, yet is difficult to achieve. For instance, it is unclear how discoveries at the genetic and cellular level can be used to tailor pharmacotherapy. For non-pharmacologic therapy, pulmonary vein isolation (PVI) remains the cornerstone of rhythm control, yet has suboptimal success. Improving these therapies will likely require a multifaceted approach that personalizes therapy based on mechanisms measured in individuals across biological scales. We review AF mechanisms from cell-to-organ-to-patient from this perspective of personalized medicine, linking them to potential clinical indices and biomarkers, and discuss how these data could influence therapy. We conclude by describing approaches to improve ablation, including the emergence of several mapping systems that are in use today.