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Ates AH, Kivrak A, Karakulak UN, Coteli C, Yorgun H, Sahiner ML, Barıs Kaya E, Aytemir K. Should left atrial appendage closure be considered in resistant left atrial appendage thrombus cases? 'Former Foe, New Ally'. Pacing Clin Electrophysiol 2024; 47:583-590. [PMID: 38477017 DOI: 10.1111/pace.14969] [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: 11/18/2023] [Revised: 02/15/2024] [Accepted: 02/29/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND The study explores left atrial appendage closure (LAAC) as a safe and effective alternative to anticoagulation for atrial fibrillation (AF) patients at high bleeding risk. Complications, such as cardioembolic events due to left atrial appendage thrombus (LAAT), highlight the need for alternative stroke prevention strategies. AIMS This research assesses LAAC's safety and efficacy in patients with LAAT, aiming to offer valuable insights into its potential as a viable option for stroke prevention in such cases. METHODS The study included 205 patients who underwent LAAC using specific devices between September 2015 and February 2023. Among them, 32 patients had persistent LAAT. Baseline characteristics, antithrombotic medications, risk scores, and LAAC indications were documented. Patients were followed to monitor significant clinical events like stroke, cardiovascular mortality, and all-cause mortality. RESULTS The mean age was 71.9 and mostly female. Indications for LAAC were ischemic cerebrovascular events (CVE) despite anticoagulation (25%), bleeding complications (major/minor, 37.5% each), or both. Successful LAA closure was achieved in all cases, with minimal pericardial effusion in one. One-month follow-up showed no major events or device-related issues. Median follow-up of 16.5 months saw 21.9% non-cardiac deaths. The study underscores LAAC's efficacy for stroke prevention in patients with persistent LAAT. CONCLUSIONS The LAAC in cases of LAAT, whether pursued initially or as a deferred approach, demonstrates feasibility and safety, exhibiting notable procedural success and minimal incidence of periprocedural complications.
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Affiliation(s)
- Ahmet Hakan Ates
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Kivrak
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Nadir Karakulak
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Cem Coteli
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hikmet Yorgun
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Ergun Barıs Kaya
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Kudret Aytemir
- Department of Cardiology, Hacettepe University Faculty of Medicine, Ankara, Turkey
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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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Margonato D, Rizza V, Ingallina G, Preda A, Ancona F, Belli M, Godino C, Agricola E, Della Bella P, Grasso C, Contarini M, Mazzone P. Left atrial appendage occlusion in the absence of intraprocedural product specialist monitoring: is it time to proceed alone? Results from a multicenter real-world experience. Front Cardiovasc Med 2023; 10:1172005. [PMID: 37383696 PMCID: PMC10293837 DOI: 10.3389/fcvm.2023.1172005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
Background Percutaneous left atrial appendage occlusion (LAAO) presents many technical complex features, and it is often performed under the intraprocedural surveillance of a product specialist (PS). Our aim is to assess whether LAAO is equally safe and effective when performed in high-volume centers without PS support. Methods Intraprocedural results and long-term outcome were retrospectively assessed in 247 patients who underwent LAAO without intraprocedural PS monitoring between January 2013 and January 2022 at three different hospitals. This cohort was then matched to a population who underwent LAAO with PS surveillance. The primary end point was all-cause mortality at 1 year. The secondary end point was a composite of cardiovascular mortality plus nonfatal ischemic stroke occurrence at 1 year. Results Of the 247 study patients, procedural success was achieved in 243 patients (98.4%), with only 1 (0.4%) intraprocedural death. After matching, we did not identify any significant difference between the two groups in terms of procedural time (70 ± 19 min vs. 81 ± 30 min, p = 0.106), procedural success (98.4% vs. 96.7%, p = 0.242), and procedure-related ischemic stroke (0.8% vs. 1.2%, p = 0.653). Compared to the matched cohort, a significant higher dosage of contrast was used during procedures without specialist supervision (98 ± 19 vs. 43 ± 21, p < 0.001), but this was not associated with a higher postprocedural acute kidney injury occurrence (0.8% vs. 0.4%, p = 0.56). At 1 year, the primary and the secondary endpoints occurred in 21 (9%) and 11 (4%) of our cohort, respectively. Kaplan-Meier curves showed no significant difference in both primary (p = 0.85) and secondary (p = 0.74) endpoint occurrence according to intraprocedural PS monitoring. Conclusions Our results show that LAAO, despite the absence of intraprocedural PS monitoring, remains a long-term safe and effective procedure, when performed in high-volume centers.
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Affiliation(s)
- Davide Margonato
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Vincenzo Rizza
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Giacomo Ingallina
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Francesco Ancona
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Martina Belli
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Cosmo Godino
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Eustachio Agricola
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Carmelo Grasso
- Department of Cardiology, C.A.S.T., Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Marco Contarini
- Department of Interventional Cardiology, Umberto I Hospital, Syracuse, Italy
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
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Margonato D, Preda A, Ingallina G, Rizza V, Fierro N, Radinovic A, Ancona F, Patti G, Agricola E, Bella PD, Mazzone P. Left atrial appendage occlusion after thromboembolic events or left atrial appendage sludge during anticoagulation therapy: Is two better than one? Real-world experience from a tertiary care hospital. J Arrhythm 2023; 39:395-404. [PMID: 37324751 PMCID: PMC10264741 DOI: 10.1002/joa3.12838] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/21/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients. METHODS Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC. This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all-cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding. RESULTS Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow-up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89-14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11-0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19). CONCLUSIONS In this high-ischemic risk cohort, LAAO + OAC seem a long-term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.
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Affiliation(s)
- Davide Margonato
- Department of Cardiovascular ImagingIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Alberto Preda
- Department of Cardiac Electrophysiology and ArrhythmologyIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Giacomo Ingallina
- Department of Cardiovascular ImagingIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Vincenzo Rizza
- Department of Cardiovascular ImagingIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Nicolai Fierro
- Department of Cardiac Electrophysiology and ArrhythmologyIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
- Department of Thoracic, Heart and Vascular DiseasesMaggiore della Carità HospitalNovaraItaly
| | - Andrea Radinovic
- Department of Cardiac Electrophysiology and ArrhythmologyIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Francesco Ancona
- Department of Cardiovascular ImagingIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Giuseppe Patti
- Department of Thoracic, Heart and Vascular DiseasesMaggiore della Carità HospitalNovaraItaly
| | - Eustachio Agricola
- Department of Cardiovascular ImagingIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and ArrhythmologyIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and ArrhythmologyIRCCS San Raffaele Hospital and Vita‐Salute UniversityMilanItaly
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A Referral Center Experience with Cerebral Protection Devices: Challenging Cardiac Thrombus in the EP Lab. J Clin Med 2023; 12:jcm12041549. [PMID: 36836084 PMCID: PMC9967427 DOI: 10.3390/jcm12041549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 01/30/2023] [Accepted: 02/13/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Cerebral protection devices (CPD) are designed to prevent cardioembolic stroke and most evidence that exists relates to TAVR procedures. There are missing data on the benefits of CPD in patients that are considered high risk for stroke undergoing cardiac procedures like left atrial appendage (LAA) closure or catheter ablation of ventricular tachycardia (VT) when cardiac thrombus is present. PURPOSE This work aimed to examine the feasibility and safety of the routine use of CPD in patients with cardiac thrombus undergoing interventions in the electrophysiology (EP) lab of a large referral center. METHODS The CPD was placed under fluoroscopic guidance in all procedures in the beginning of the intervention. Two different CPDs were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed over a 6F sheath from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over an 8F femoral sheath. Retrospective periprocedural and safety data were obtained from procedural reports and discharge letters. Long-term safety data were obtained by clinical follow-up in our institution and telephone consultations. RESULTS We identified 30 consecutive patients in our EP lab who underwent interventions (21 LAA closure, 9 VT ablation) with placement of a CPD due to cardiac thrombus. Mean age was 70 ± 10 years and 73% were male, while mean LVEF was 40 ± 14%. The location of the cardiac thrombus was the LAA in all 21 patients (100%) undergoing LAA-closure, whereas, in the 9 patients undergoing VT ablation, thrombus was present in the LAA in 5 cases (56%), left ventricle (n = 3, 33%) and aortic arch (n = 1, 11%). The capture device was used in 19 out of 30 (63%) and the deflection device in 11 out of 30 cases (37%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CPD-related complications comprised the vascular access and were as follows: two cases of pseudoaneurysm of the femoral artery not requiring surgery (7%), 1 hematoma at the arterial puncture site (3%) and 1 venous thrombosis (3%) resolved by warfarin. At long-term follow-up, 1 TIA and 2 non-cardiovascular deaths occurred, with a mean follow-up time of 660 days. CONCLUSIONS Placement of a cerebral protection device prior to LAA closure or VT ablation in patients with cardiac thrombus proved feasible, but possible vascular complications needed to be taken into account. A benefit in periprocedural stroke prevention for these interventions seemed plausible but has yet to be proven in larger and randomized trials.
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Zachariah D, Limite LR, Mazzone P, Marzi A, Radinovic A, Baratto F, Italia L, Ancona F, Paglino G, Della Bella P. Use of Cerebral Protection Device in Patients Undergoing Ventricular Tachycardia Catheter Ablation. JACC Clin Electrophysiol 2022; 8:528-530. [PMID: 35450609 DOI: 10.1016/j.jacep.2022.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 12/31/2021] [Accepted: 01/01/2022] [Indexed: 10/19/2022]
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