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Shimohama S, Katsumata M, Azami S, Kitagawa S, Tsuruta H, Inohara T, Nakahara J, Izawa Y. Warfarin Therapy and Percutaneous Left Atrial Appendage Closure for a Patient with Atrial Fibrillation and Antithrombin-III Deficiency. Keio J Med 2024; 73:27-30. [PMID: 38987205 DOI: 10.2302/kjm.2023-0017-cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024]
Abstract
Some patients develop ischemic stroke despite taking direct oral anticoagulants because of the presence of other risk factors such as coagulopathies. A 65-year-old male patient with non-valvular atrial fibrillation (NVAF) taking rivaroxaban was diagnosed as having embolic stroke and antithrombin-III (AT-III) deficiency. Echocardiography revealed a thrombus in the left atrial appendage (LAA). He was prescribed warfarin, and after resolution of the thrombus, we successfully performed percutaneous LAA closure (LAAC), with no subsequent recurrence or device-related thrombosis. Warfarin and LAAC may be feasible for NVAF patients with AT-III deficiency.
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Affiliation(s)
- Sho Shimohama
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Masahiro Katsumata
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Shumpei Azami
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Kitagawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Hikaru Tsuruta
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Taku Inohara
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Jin Nakahara
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshikane Izawa
- Department of Neurology, Keio University School of Medicine, Tokyo, Japan
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Preda A, Margonato D, Gaspardone C, Rizza V, Vella C, Rampa L, Marzi A, Guarracini F, Della Bella P, Agricola E, Gaspardone A, Montorfano M, Mazzone P. Left Atrial Appendage Closure in Patients With a Mechanical Mitral Valve Prosthesis: A Multicentre Italian Pilot Study. Can J Cardiol 2024; 40:1635-1642. [PMID: 38492735 DOI: 10.1016/j.cjca.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/15/2024] [Accepted: 01/31/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND In patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy and therapeutic international normalized ratio (INR) range, the incidence of cardiac thromboembolism is not negligible, and the subgroup of patients who have a mechanical prosthetic mitral valve (PMV) has the highest risk. We aimed to assess the long-term effects of left atrial appendage closure (LAAC) in AF patients with a mechanical PMV who experienced a failure of VKA therapy. METHODS In this retrospective, multicentre study, patients underwent LAAC because of thrombotic events including transient ischemic attack and/or stroke, systemic embolism, and evidence of left atrial appendage thrombosis and/or sludge, despite VKA therapy, were enrolled. Patients with a mechanical PMV were included and compared with those affected by nonvalvular AF. The primary endpoint was the composite of all-cause death, major cardiovascular events, and major bleedings at follow-up. The feasibility and safety of LAAC also were assessed. RESULTS A total of 55 patients (42% female; mean age, 70 ± 9 years), including 12 with a mechanical PMV, were enrolled. The most-frequent indication to LAAC (71%) was LAA thrombosis or sludge. Procedural success was achieved in 96% of overall cases, and in 100% of patients with a PMV. In 35 patients, a cerebral protection device was used. During a median follow-up of 6.1 ± 4.3 years, 4 patients with a PMV, and 20 patients without a PMV, reported adverse events (hazard ratio 0.73 [95% confidence interval 0.25-2.16, P = 0.564]). CONCLUSIONS LAAC seems to be a valuable alternative in patients with AF who have a mechanical PMV, with failure of VKA therapy. This off-label, real-world clinical practice indication deserves validation in further studies.
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Affiliation(s)
- Alberto Preda
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Davide Margonato
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Gaspardone
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Vincenzo Rizza
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Ciro Vella
- Interventional Cardiology Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Rampa
- Department of Cardiac Electrophysiology and Arrhythmology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Milan, Italy
| | - Alessandra Marzi
- Department of Cardiac Electrophysiology and Arrhythmology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Milan, Italy
| | - Fabrizio Guarracini
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, San Raffaele Scientific Institute, Milan, Italy
| | | | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy; School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
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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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Ge L, Xu Y, Li J, Li Y, Xi Y, Wang X, Wang J, Mu Y, Wang H, Lu X, Guo J, Chen Z, Chen T, Chen Y. The impact of contrast retention on thrombus formation risks in patients with atrial fibrillation: A numerical study. Heliyon 2024; 10:e26792. [PMID: 38434273 PMCID: PMC10907767 DOI: 10.1016/j.heliyon.2024.e26792] [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: 01/25/2024] [Accepted: 02/20/2024] [Indexed: 03/05/2024] Open
Abstract
Background Contrast retention (CR) is an important predictor of left atrial appendage thrombus (LAAT) and stroke in patients with non-valvular atrial fibrillation (AF). We sought to explore the underlying mechanisms of CR using computational fluid dynamic (CFD) simulations. Methods A total of 12 patients with AF who underwent both cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) before left atrial appendage occlusion (LAAO) were included in the study. The patients were allocated into the CR group or non-CR group based on left atrial appendage (LAA) angiography. Patient-specific models were reconstructed to evaluate time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP). Additionally, the incidence of thrombosis was predicted using residence time (RT) at different time-points. Results TAWSS was lower [median (Interquartile Range) 0.27 (0.19-0.47) vs 1.35 (0.92-1.79), p < 0.001] in LAA compared to left atrium. In contrast, RRT [1438 (409.70-13869) vs 2.23 (1.81-3.14), p < 0.001] and ECAP [122.70 (30.01-625.70) vs 0.19 (0.16-0.27), p < 0.001)] was higher in the LAA. The patients in the CR group had significantly higher RRT [(mean ± SD) 16274 ± 11797 vs 639.70 ± 595.20, p = 0.009] and ECAP [610.80 ± 365.30 vs 54.26 ± 54.38, p = 0.004] in the LAA compared to the non-CR group. Additionally, patients with CR had a wider range of thrombus-prone regions [0.44(0.27-0.66)% vs 0.05(0.03-0.27)%, p = 0.009] at the end of the 15th cardiac cycle. Conclusions These findings suggest that CR might be an indicator of high-risk thrombus formation in the LAA. And CT-based CFD simulation may be a feasible substitute for the evaluation of LAA thrombotic risk in patients with AF, especially in patients with CR.
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Affiliation(s)
- Lan Ge
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yawei Xu
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Jun Li
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yuan Li
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Yifeng Xi
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Xinyan Wang
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Jing Wang
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yang Mu
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Hongsen Wang
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Xu Lu
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Jun Guo
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Zengsheng Chen
- Key Laboratory of Biomechanics and Mechanobiology (Beihang University), Ministry of Education, Beijing Advanced Innovation Center for Biomedical Engineering, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100083, China
| | - Tao Chen
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
| | - Yundai Chen
- Medical School of Chinese PLA, 28 Fuxing Road, Haidian District, Beijing 100853, China
- Senior Department of Cardiology, the Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing 100048, China
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Anic A, Bakovic D, Jurisic Z, Farkowski M, Lisica L, Breskovic T, Nielsen-Kudsk JE, Perrotta L, de Asmundis C, Boveda S, Chun J. Diagnostic and therapeutic pathways for the malignant left atrial appendage: European Heart Rhythm Association physician survey. Europace 2023; 25:euad204. [PMID: 37440757 PMCID: PMC10359107 DOI: 10.1093/europace/euad204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/29/2023] [Indexed: 07/15/2023] Open
Abstract
AIMS Patients with atrial fibrillation who despite taking oral anti-coagulant therapy (OAT) suffer a stroke or systemic embolism (SSE) without vascular cause or who develop left atrial appendage (LAA) thrombus (LAAT) should be considered as having malignant LAA. The optimal treatment strategy to reduce SSE risk in such patients is unknown. The aim of the study is to investigate the diagnostic and therapeutic pathways for malignant LAA practiced in European cardiac centres. METHODS AND RESULTS An 18-item online questionnaire on malignant LAA was disseminated by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee. A total of 196 physicians participated in the survey. There seems to be high confidence in transoesophageal echocardiography (TEE) imaging, considering LAAT diagnosis. Switching to another direct oral anti-coagulant (DOAC) is the preferred initial step for the treatment of malignant LAA followed by a switch to vitamin K antagonist (VKA), low-molecular-weight heparin, or continued/optimized DOAC dosage, whereas LAA closure is the last option. Left atrial appendage closure is a viable option in patients with embolic stroke despite OAT and no evidence of thrombus at TEE (empty LAA) after comprehensive diagnostic measures to exclude other sources of embolism. CONCLUSION This EHRA survey provides a snapshot of the contemporary management of patients diagnosed with malignant LAA. Currently, the majority of patients are treated on an outpatient basis with either shifting from VKA to DOAC or from one DOAC to another. Left atrial appendage closure in this population seems to be reserved for patients with higher bleeding risk or complications of malignant LAA, such as stroke.
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Affiliation(s)
- Ante Anic
- Department for Cardiovascular Diseases, University Hospital Centre Split, Soltanska 1, 21000 Split, Croatia
| | - Darija Bakovic
- Department for Cardiovascular Diseases, University Hospital Centre Split, Soltanska 1, 21000 Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Zrinka Jurisic
- Department for Cardiovascular Diseases, University Hospital Centre Split, Soltanska 1, 21000 Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | - Michal Farkowski
- Department of Cardiology, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
- II Department of Heart Arrhythmia, National Institute of Cardiology, Warsaw, Poland
| | - Lucija Lisica
- Department for Cardiovascular Diseases, University Hospital Centre Split, Soltanska 1, 21000 Split, Croatia
| | - Toni Breskovic
- Department for Cardiovascular Diseases, University Hospital Centre Split, Soltanska 1, 21000 Split, Croatia
- School of Medicine, University of Split, Split, Croatia
| | | | | | - Carlo de Asmundis
- Heart Rhythm Management Centre, University Hospital (UZ) Brussels, Brussels, Belgium
| | - Serge Boveda
- Cardiology-Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
| | - Julian Chun
- CCB, Cardiology, Med. Klinik III, Markus Krankenhaus, Frankfurt, Germany
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS Expert Consensus Statement on Transcatheter Left Atrial Appendage Closure. JACC Cardiovasc Interv 2023; 16:1384-1400. [PMID: 36990858 DOI: 10.1016/j.jcin.2023.01.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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Preda A, Baroni M, Varrenti M, Vargiu S, Carbonaro M, Giordano F, Gigli L, Mazzone P. Left Atrial Appendage Occlusion in Patients with Failure of Antithrombotic Therapy: Good Vibes from Early Studies. J Clin Med 2023; 12:3859. [PMID: 37298059 PMCID: PMC10253996 DOI: 10.3390/jcm12113859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/17/2023] [Indexed: 06/12/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes patients to an increased risk of cardioembolic events (CE), such as ischemic stroke, TIA, or systemic embolism [...].
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Affiliation(s)
- Alberto Preda
- Cardio-Thoraco-Vascular Department, Electrophysiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 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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10
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS Expert Consensus Statement on Transcatheter Left Atrial Appendage Closure. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:100577. [PMID: 39130704 PMCID: PMC11307869 DOI: 10.1016/j.jscai.2022.100577] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L. Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V. Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M. Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D. Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M. Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J. Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G. Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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11
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Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure. Heart Rhythm 2023; 20:e1-e16. [PMID: 36990925 DOI: 10.1016/j.hrthm.2023.01.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.
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Affiliation(s)
- Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - João L Cavalcante
- Department of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University, New Haven, Connecticut
| | - Andrew M Goldsweig
- Division of Cardiovascular Medicine, The University of Nebraska Medical Center, Omaha, Nebraska
| | | | - Issam D Moussa
- Carle Heart and Vascular Institute, Carle Illinois College of Medicine, Urbana, Illinois
| | - Thomas M Munger
- Department of Cardiovascular Medicine, Mayo Clinic Health System Rochester, Rochester, Minnesota
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Green Hospital, La Jolla, California
| | - Mark Reisman
- Division of Cardiology, Weill Cornell Medical Center, New York, New York
| | | | - Zoltan G Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey
| | - Dee Dee Wang
- Center for Structural Heart Disease, Henry Ford Health System, Detroit, Michigan
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12
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Guérios EE, Chamié F. Percutaneous left atrial appendage closure: beyond the classic indications. ASIAINTERVENTION 2023; 9:70-77. [PMID: 36936101 PMCID: PMC10015488 DOI: 10.4244/aij-d-22-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/29/2022] [Indexed: 03/16/2023]
Abstract
Percutaneous left atrial appendage closure (LAAC) has proven to be an effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). International guidelines traditionally recommend LAAC for NVAF patients at high thromboembolic risk and contraindication to or at high risk for OAC. However, there are many other clinical situations in which this procedure may also be beneficial. This paper discusses the potential role of LAAC in specific haemorrhagic diseases (cerebral amyloid angiopathy, age-related macular degeneration, hereditary haemorrhagic telangiectasia, and Moyamoya disease), after left atrial appendage (LAA) electrical isolation, in cases of persistent thrombus inside the LAA, in end-stage renal disease and in special groups of patients for whom low compliance and persistence to OAC may be anticipated.
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Affiliation(s)
- Enio E Guérios
- Department of Interventional Cardiology, Pilar Hospital, Curitiba, Brazil
| | - Francisco Chamié
- Department of Interventional Cardiology, Hospital dos Servidores do Estado, Rio de Janeiro, Brazil
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13
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Left atrial appendage thrombus formation, potential of resolution and association with prognosis in a large real-world cohort. Sci Rep 2023; 13:889. [PMID: 36650206 PMCID: PMC9845308 DOI: 10.1038/s41598-023-27622-3] [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: 05/05/2022] [Accepted: 01/04/2023] [Indexed: 01/19/2023] Open
Abstract
Comprehensive data on factors influencing left atrial appendage (LAA) thrombus formation, resolution and impact on survival are limited. In this single-center, retrospective study 7759 (2010-2015) patients with symptomatic ongoing atrial fibrillation (AF) on admission were screened for LAA thrombi. 450 patients had LAA thrombi. 481 patients without LAA thrombi were randomly selected as controls. We assessed clinical, echocardiographic, laboratory parameters and long-term survival of both groups. Patients with LAA thrombi compared to controls were older, had more strokes, higher CHA2DS2 -VASc scores, worse renal function, less controlled diabetes, advanced heart failure, lower LAA emptying velocities, higher levels of cardiac and inflammatory markers (all p < 0.001). 56.3% of followed-up patients (304) dissolved their LAA thrombi. Chances of thrombus resolution increased with rising LAA flow velocities (OR 1.061, p = 0.022), whereas advanced age (OR 0.950, p < 0.001) and presence of permanent AF (OR 0.354, p < 0.001) decreased chances of thrombus resolution. Presence of LAA thrombi was associated with a markedly reduced 10-year survival probability (31% versus 69%). LAA thrombus formation is promoted by advanced structural heart disease, inflammation, diabetes and impaired renal function. Younger age, non-permanent AF and higher LAA flow velocities were predictors of thrombus resolution. Thrombus formation was associated with poor prognosis.
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14
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Jin LS, Ke JY, Lin YN, Li L, Fu JY, Chen YL, Qiu YX, Li XW, Pan YQ, Li YC. Percutaneous left atrial appendage closure using the LAmbre device in patients with atrial fibrillation and left atrial appendage thrombus. Front Cardiovasc Med 2022; 9:1071119. [PMID: 36505354 PMCID: PMC9729287 DOI: 10.3389/fcvm.2022.1071119] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022] Open
Abstract
Background Left atrial appendage closure (LAAC) is considered a valid alternative for the prevention of thromboembolic stroke in patients with persistent left atrial appendage thrombus (LAAT) despite adequate anticoagulation. However, the data on LAAC using the LAmbre device for patients with LAAT is limited. This study was performed to explore efficacy and safety as well as to share the experience of the modified LAAC procedure with the LAmbre device. Materials and methods A total of 7 patients with persistent LAAT despite adequate anticoagulation underwent modified LAAC with the LAmbre device between November 2019 and April 2022. Transesophageal echocardiography was performed 3 months postoperatively to detect device-related thrombosis and peridevice leak. The patients' clinical events were evaluated during the perioperative and follow-up periods. Results The median age, CHA2DS2-VASc score, and HAS-BLED score of all patients were 71 [53-73], 3 [2-4], and 2 [2-3], respectively. In the procedure, a cerebral protection system was used in two patients. LAAC with the LAmbre device was successfully performed in all patients without perioperative events. During the median follow-up of 383 [325-865] days, postoperative transesophageal echocardiography was performed in six (85.7%) patients. Device-related thrombosis was detected in one (16.7%) patient, and no significant peridevice leak was observed. No thromboembolic event or bleeding event occurred in any patients. Conclusion LAAC with the LAmbre device is effective and safe when performed by experienced operators in highly selected patients with LAAT after adequate anticoagulation.
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15
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Amiloidosis cardiaca y cierre de aurícula izquierda. Estudio CAMYLAAC. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2022.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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16
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Amat-Santos IJ, Delgado-Arana JR, Cruz-González I, Gutiérrez H, García-Bolao I, Millán X, Tirado-Conte G, Ruiz-Nodar JM, Mohandes M, Palazuelos J, Torres Saura F, Del Valle R, Valero Picher E, Núñez García JC, Gómez I, Albarrán Rincón R, Arzamendi D, Nombela-Franco L, Korniiko L, Barrero A, Santos-Martínez S, Serrador A, San Román JA. Cardiac amyloidosis and left atrial appendage closure. The CAMYLAAC Study. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022:S1885-5857(22)00208-0. [PMID: 35934294 DOI: 10.1016/j.rec.2022.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION AND OBJECTIVES Transthyretin cardiac amyloidosis (ATTR-CA) patients often have atrial fibrillation and increased bleeding/thrombogenic risks. We aimed to evaluate outcomes of left atrial appendage closure (LAAC) compared with patients without a known diagnosis of CA. METHODS Comparison at long-term of patients diagnosed with ATTR-CA who underwent LAAC between 2009 and 2020 and those without a known diagnosis of CA. RESULTS We studied a total of 1159 patients. Forty patients (3.5%) were diagnosed with ATTR-CA; these patients were older and had more comorbidities, higher HAS-BLED and CHA2DS2-VASc scores, and lower left ventricular function. Successful LAAC was achieved in 1137 patients (98.1%) with no differences between groups. Regarding in-hospital and follow-up complications, there were no differences between the groups in ischemic stroke (5% vs 2.5% in those without a known diagnosis of CA; P=.283), hemorrhagic stroke (2.5% and 0.8% in the control group; P=.284), major or minor bleeding. At the 2-year follow-up, there were no significant differences in mortality (ATTR-CA: 20% vs those without known CA: 13.6%, 0.248); however, the at 5-year follow-up, ATTR-CA patients had higher mortality (40% vs 19.2%; P <.001) but this difference was unrelated to hemorrhagic complications or ischemic stroke. CONCLUSIONS LAAC could reduce the risk of bleeding complications and ischemic cerebrovascular events without increasing the rate of early or mid-term complications. Although long-term survival was impaired in ATTR-CA patients, it was comparable to that of patients without a known diagnosis of CA at the 2-year follow-up, suggesting that LAAC for patients with ATTR-CA might not be futile.
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Affiliation(s)
- Ignacio J Amat-Santos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.
| | - José R Delgado-Arana
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Ignacio Cruz-González
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complejo Asistencial Universitario de Salamanca, Spain
| | - Hipólito Gutiérrez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ignacio García-Bolao
- Servicio de Cardiología, Clínica Universitaria de Navarra, Pamplona, Navarra, Spain
| | - Xavier Millán
- Servicio de Cardiología, Hospital Universitario Sant Pau, Barcelona, Spain
| | | | - Juan Miguel Ruiz-Nodar
- Servicio de Cardiología, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Alicante, Spain
| | - Mohsen Mohandes
- Servicio de Cardiología, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Jorge Palazuelos
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Central de la Defensa Gómez Ulla, Madrid, Spain; Servicio de Cardiología, Hospital La luz, Madrid, Spain
| | | | - Raquel Del Valle
- Servicio de Cardiología, Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Ernesto Valero Picher
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | - Itziar Gómez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Dabit Arzamendi
- Servicio de Cardiología, Hospital Universitario Sant Pau, Barcelona, Spain
| | | | - Liza Korniiko
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Alejandro Barrero
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Sandra Santos-Martínez
- Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ana Serrador
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J Alberto San Román
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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