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Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024; 45:2914-2932. [PMID: 39027946 PMCID: PMC11335376 DOI: 10.1093/eurheartj/ehae398] [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: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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Guedeney P, Rodés-Cabau J, Ten Berg JM, Windecker S, Angiolillo DJ, Montalescot G, Collet JP. Antithrombotic therapy for transcatheter structural heart intervention. EUROINTERVENTION 2024; 20:972-986. [PMID: 39155752 PMCID: PMC11317833 DOI: 10.4244/eij-d-23-01084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/22/2024] [Indexed: 08/20/2024]
Abstract
Percutaneous transcatheter structural heart interventions have considerably expanded within the last two decades, improving clinical outcomes and quality of life versus guideline-directed medical therapy for patients frequently ineligible for surgical treatment. Transcatheter structural heart interventions comprise valve implantation or repair and also occlusions of the patent foramen ovale, atrial septal defects and left atrial appendage. These procedures expose structural devices to arterial or venous blood flow with various rheological conditions leading to potential thrombotic complications and embolisation. Furthermore, these procedures may concern comorbid patients at high risk of both ischaemic and bleeding complications. This state-of-the-art review provides a description of the device-related thrombotic risk associated with these transcatheter structural heart interventions and of the current evidence-based guidelines regarding antithrombotic treatments. Gaps in evidence for each of the studied transcatheter interventions and the main ongoing trials are also summarised.
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Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jurriën M Ten Berg
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital (Inselspital), University of Bern, Bern, Switzerland
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
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3
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Mesnier J, Cruz-González I, Guedeney P, Arzamendi D, Freixa X, Nombela-Franco L, Peral V, Caneiro-Queija B, Mangieri A, Trejo-Velasco B, Asmarats L, Cepas-Guillén P, Salinas P, Siquier-Padilla J, Estevez-Loureiro R, Laricchia A, O'Hara G, Montalescot G, Rodés-Cabau J. Early Nonprocedural Bleeding After Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2024; 17:1765-1776. [PMID: 39023452 DOI: 10.1016/j.jcin.2024.05.032] [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: 02/19/2024] [Revised: 05/07/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Patients treated with left atrial appendage occlusion (LAAO) are at high bleeding risk. Intensive antithrombotic treatment is recommended after the procedure to prevent device-related thrombosis. OBJECTIVES This study sought to evaluate the incidence, consequences, and predictors of early nonprocedural bleeding after LAAO. METHODS This was a multicenter study including 1,649 patients undergoing LAAO in 9 centers. Early nonprocedural bleeding was defined as bleeding unrelated to the procedure occurring within 3 months after device implantation. The severity of bleeding was defined by the Valve Academic Research Consortium-2 classification. A sensitivity analysis was performed at 45 days. RESULTS A total of 121 (7.3%) patients experienced early nonprocedural bleeding events, and 69 (57.0%) were classified as major bleeding (4.2% of patients). Independent predictors of early nonprocedural bleeding were dual antiplatelet therapy (DAPT) at discharge (adjusted HR [aHR]: 1.61; 95% CI: 1.12-2.33; P = 0.01), prior gastrointestinal bleeding (aHR: 2.15; 95% CI: 1.38-3.35; P < 0.001), and multiple locations of prior bleeding (aHR: 2.33; 95% CI: 1.34-4.05; P < 0.001). DAPT at discharge was predictive of both all and major nonprocedural bleeding at 3 months and 45 days. After a median follow-up of 2.3 years (Q1-Q3: 1.1-4.1 years), early nonprocedural bleeding was independently associated with an increased risk of all-cause death (aHR: 1.53; 95% CI: 1.15-2.06; P < 0.001). This heightened mortality risk was similar at 45 days. CONCLUSIONS Early nonprocedural bleeding after LAAO occurred in ∼7% of patients within 3 months, with more than one-half being classified as major bleeding. Regardless of severity, early nonprocedural bleeding was associated with increased mortality. DAPT at discharge determined an increased risk of early nonprocedural bleeding after LAAO. These results emphasize the importance of bleeding risk for determining antithrombotic strategies after LAAO.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Paul Guedeney
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | | | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | | | - Vicente Peral
- Servicio de Cardiología, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Palma, Balearic Islands, Spain
| | | | - Antonio Mangieri
- Cardiocenter, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | | | | | - Pedro Cepas-Guillén
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Pablo Salinas
- Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Joan Siquier-Padilla
- Servicio de Cardiología, Hospital Universitari Son Espases, Institut d'Investigació Sanitària Illes Balears, Palma, Balearic Islands, Spain
| | | | - Alessandra Laricchia
- GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy; ASST Fatebenefratelli Sacco, Milan, Italy
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Gilles Montalescot
- Sorbonne Université, ACTION Study Group, INSERM UMRS 1166, Institut de Cardiologie (AP-HP), Paris, France
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Institut Clínic Cardiovascular, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain.
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Saw J, Vij V, Galea R, Piayda K, Nelles D, Vogt L, Gloekler S, Fürholz M, Meier B, Räber L, O'Hara G, Arzamendi D, Agudelo V, Asmarats L, Freixa X, Flores-Umanzor E, De Backer O, Sondergaard L, Nombela-Franco L, Salinas P, Korsholm K, Nielsen-Kudsk JE, Zeus T, Operhalski F, Schmidt B, Montalescot G, Guedeney P, Iriart X, Miton N, Gilhofer T, Fauchier L, Veliqi E, Meincke F, Petri N, Nordbeck P, Gonzalez-Ferreiro R, Cruz-González I, Bhatt DL, Laricchia A, Mangieri A, Omran H, Schrickel JW, Beiert T, Rodes-Cabau J, Nickenig G, Sievert H, Sedaghat A, Afzal S. Impact of gender in patients with device-related thrombosis after left atrial appendage closure - A sub-analysis from the multicenter EUROC-DRT-registry. Echocardiography 2024; 41:e15888. [PMID: 39042643 DOI: 10.1111/echo.15888] [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: 04/21/2024] [Revised: 06/21/2024] [Accepted: 06/29/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Device-related thrombosis (DRT) is a common finding after left atrial appendage closure (LAAC) and is associated with worse outcomes. As women are underrepresented in clinical studies, further understanding of sex differences in DRT patients is warranted. METHODS AND RESULTS This sub-analysis from the EUROC-DRT-registry compromises 176 patients with diagnosis of DRT after LAAC. Women, who accounted for 34.7% (61/176) of patients, were older (78.0 ± 6.7 vs. 74.9 ± 9.1 years, p = .06) with lower rates of comorbidities. While DRT was detected significantly later in women (173 ± 267 vs. 127 ± 192 days, p = .01), anticoagulation therapy was escalated similarly, mainly with initiation of novel oral anticoagulant (NOAC), vitamin K antagonist (VKA) or heparin. DRT resolution was achieved in 67.5% (27/40) of women and in 75.0% (54/72) of men (p = .40). In the remaining cases, an intensification/switch of anticoagulation was conducted in 50.% (9/18) of men and in 41.7% (5/12) of women. Final resolution was achieved in 72.5% (29/40) cases in women, and in 81.9% (59/72) cases in men (p = .24). Women were followed-up for a similar time as men (779 ± 520 vs. 908 ± 687 days, p = .51). Kaplan-Meier analysis revealed no difference in mortality rates in women (Hazard Ratio [HR]: 1.73, 95%-Confidence interval [95%-CI]: .68-4.37, p = .25) and no differences in stroke (HR: .83, 95%-CI: .30-2.32, p = .72) within 2 years after LAAC. CONCLUSION Evaluation of risk factors and outcome revealed no differences between men and women, with DRT in women being diagnosed significantly later. Women should be monitored closely to assess for DRT formation/resolution. Treatment strategies appear to be equally effective.
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Affiliation(s)
| | - Vivian Vij
- Heart Center, University Hospital Bonn, Bonn, Germany
| | - Roberto Galea
- Department of Cardiology, Inselspital, Bern, Switzerland
| | | | | | - Lara Vogt
- Heart Center, University Hospital Bonn, Bonn, Germany
| | | | - Monika Fürholz
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Bernhard Meier
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Gilles O'Hara
- Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | | | | | - Lluis Asmarats
- Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | | | | | | | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Tobias Zeus
- Klinik für Kardiologie, Angiologie und Pneumologie, University Hospital Düsseldorf, Germany
| | | | - Boris Schmidt
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany
| | - Gilles Montalescot
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Paul Guedeney
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Xavier Iriart
- Paediatric and Congenital Cardiology Department, Bordeaux University Hospital, Bordeaux, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Noelie Miton
- Paediatric and Congenital Cardiology Department, Bordeaux University Hospital, Bordeaux, France
- IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Pessac, France
| | - Thomas Gilhofer
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Laurent Fauchier
- Department of Cardiology, University Hospital Tours, Tours, France
| | | | | | - Nils Petri
- Heart Center, University Hospital Würzburg, Würzburg, Germany
| | - Peter Nordbeck
- Heart Center, University Hospital Würzburg, Würzburg, Germany
| | | | | | - Deepak L Bhatt
- Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Alessandra Laricchia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy and Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Heyder Omran
- Department of Cardiology, Marienkrankenhaus, Bonn, Germany
| | | | - Thomas Beiert
- Heart Center, University Hospital Bonn, Bonn, Germany
| | - Josep Rodes-Cabau
- Quebec Heart & Lung Institute, Laval University, Quebec City, Canada
| | | | | | | | - Shazia Afzal
- Heart Center, Krankenhaus der Barmherzigen Brüder, Trier, Germany
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Lee WC, Chang WT, Shih JY, Wu PJ, Fang CY, Chen HC, Fang YN, Fang HY. Impact of chronic kidney disease on left atrial appendage occlusion: A meta-analysis of procedural outcomes and complications. Medicine (Baltimore) 2024; 103:e38935. [PMID: 39029071 DOI: 10.1097/md.0000000000038935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) experience atrial fibrillation more frequently. The balance of medical management for stroke prevention and bleeding events presents a challenging issue in CKD population. Left atrial appendage occlusion (LAAO) may be an effective solution for stroke prevention in patients who experience frequent bleeding with oral anticoagulants. However, the specific impact of CKD on the procedural success, complications, and outcomes of LAAO implantations remains underexplored. METHODS We conducted a search of various databases for articles published before October 31, 2023. This search yielded 7 studies, comparing outcomes between CKD and non-CKD cohorts undergoing LAAO implantation. Our analysis focused on CHA2DS2-VASc scores, average eGFR, use of oral anticoagulants, procedural success rates, procedural complications, and associated outcomes. RESULTS The meta-analysis included data from 2576 patients, with 1131 identified as having CKD. The CKD group also had higher CHA2DS2-VASc scores (4.7 ± 1.4 vs 4.0 ± 1.5; P < .001) and HAS-BLED scores (3.8 ± 1.1 vs 3.1 ± 1.0; P < .001) than the non-CKD group. CKD patients showed a nonreduction in procedural success rates and a nonsignificant increase in total complications. The risks of stroke and transient ischemic attack, major bleeding, and cardiovascular mortality were not significantly different between the 2 groups. However, a significantly lower rate of total mortality was observed in the non-CKD group (odds ratio: 0.43; 95% confidence interval, 0.32-0.60). CONCLUSION While CKD is associated with a nonsignificant decrease in procedural success and a nonsignificant increase in complication risks, the outcomes of LAAO implantation are comparably favorable between CKD and non-CKD groups. Despite similar procedural outcomes, the CKD group exhibited a higher rate of all-cause mortality.
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Affiliation(s)
- Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Wei-Ting Chang
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Jhih-Yuan Shih
- Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Po-Jui Wu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Yuan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Huang-Chung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yen-Nan Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Hsiu-Yu Fang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Division of Cardiology, Department of Internal Medicine, Jen-Ai Hospital, Taichung, Taiwan
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Tanaka T, Kawai K, Ellis CR, Srivastava M, Kawakami R, Konishi T, Shiraki T, Sekimoto T, Virmani R, Finn AV. Challenges and advances in device-related thrombus in left atrial appendage occlusion. Future Cardiol 2024:1-16. [PMID: 38948932 DOI: 10.1080/14796678.2024.2363063] [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: 01/03/2024] [Accepted: 05/29/2024] [Indexed: 07/02/2024] Open
Abstract
Oral anticoagulation therapy (OAC) is a mainstay for mitigating stroke and other embolic events in patients with atrial fibrillation (AF). Despite the demonstrated efficacy of OAC in reducing events, many patients are unable to tolerate OAC due to bleeding risks. Left atrial appendage occlusion (LAAO) devices were developed as implantable technologies to moderate stroke risk in patients with intolerance to OAC. Despite clinical data supporting near-comparable protection against thromboembolic events with OAC, device-related thrombus formation has emerged as a critical complication following LAAO that remains a potential limitation to the safety and efficacy of LAAO. Improved biocompatibility of LAAO devices with fluoropolymers, a well-established stent-coating technology used to reduce thrombus formation and promote endothelialization, may optimize outcomes after LAAO.
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Affiliation(s)
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD 20878, USA
| | | | - Mukta Srivastava
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
| | | | | | | | | | | | - Aloke V Finn
- CVPath Institute, Gaithersburg, MD 20878, USA
- University of Maryland, School of Medicine, Baltimore, MD 21201, USA
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Nakashima M, Yamamoto M, Sago M, Tanaka S, Chatani R, Asami M, Hachinohe D, Naganuma T, Ohno Y, Tani T, Okamatsu H, Mizutani K, Watanabe Y, Izumo M, Saji M, Mizuno S, Ueno H, Kubo S, Shirai S, Hayashida K. Comparative Data of Procedural and Midterm Outcomes in Patients Who Underwent Percutaneous Left Atrial Appendage Closure Between the WATCHMAN FLX and WATCHMAN 2.5 Devices - Insight From the OCEAN-LAAC Registry. Circ J 2024; 88:1187-1197. [PMID: 38763735 DOI: 10.1253/circj.cj-24-0062] [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] [Indexed: 05/21/2024]
Abstract
BACKGROUND Limited data are available regarding clinical outcomes after percutaneous left atrial appendage closure using WATCHMAN FLX (WM-FLX) and WATCHMAN-2.5 (WM2.5) devices in Asian patients. METHODS AND RESULTS Data of 1,464 consecutive patients (WM-FLX, n=909; WM2.5, n=555) were extracted from a Japanese multicenter registry, and clinical data were compared between the 2 groups. No in-hospital deaths, periprocedural stroke, or device embolization occurred. Procedural success was significantly higher in the WM-FLX than WM2.5 group (95.8% vs. 91.9%; P=0.002) owing to the lower incidence of periprocedural pericardial effusion (0.55% vs. 1.8%; P=0.021). No significant differences in all-cause death, postprocedural stroke, and device-related thrombus were observed between the 2 groups. However, the cumulative bleeding rate at 1 year was substantially lower in the WM-FLX group (7.8% vs. 16.4%; P<0.001). Landmark analysis of bleeding events highlighted lower bleeding rates in the WM-FLX than WM2.5 group within the first 6 months (6.4% vs. 14.8%; P<0.001), with comparable bleeding rates over the 6- to 12-month period (1.5% vs. 3.2%, respectively; P=0.065). CONCLUSIONS This study demonstrated higher early safety and lower 1-year bleeding rates in the WM-FLX than WM2.5 group. The lower bleeding events with WM-FLX are likely due to multiple factors other than purely difference in devices, such as postprocedural drug regimen.
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Affiliation(s)
| | - Masanori Yamamoto
- Department of Cardiology, Toyohashi Heart Center
- Department of Cardiology, Nagoya Heart Center
- Department of Cardiology, Gifu Heart Center
| | - Mitsuru Sago
- Department of Cardiology, Toyohashi Heart Center
| | - Shuhei Tanaka
- Department of Cardiology, Toyama University Hospital
| | - Ryuki Chatani
- Department of Cardiology, Kurashiki Central Hospital
| | | | - Daisuke Hachinohe
- Department of Cardiology, Sapporo Heart Center, Sapporo Cardio Vascular Clinic
| | - Toru Naganuma
- Department of Cardiology, New Tokyo Hospital
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University
| | - Yohei Ohno
- Department of Cardiology, Tokai University School of Medicine
| | - Tomoyuki Tani
- Department of Cardiology, Sapporo East Tokushukai Hospital
| | | | - Kazuki Mizutani
- Division of Cardiology, Department of Medicine, Kindai University Faculty of Medicine
| | - Yusuke Watanabe
- Department of Cardiology, Teikyo University School of Medicine
| | - Masaki Izumo
- Department of Cardiology, St. Marianna University School of Medicine
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute
| | - Shingo Mizuno
- Department of Cardiology, Shonan Kamakura General Hospital
| | - Hiroshi Ueno
- Department of Cardiology, Toyama University Hospital
| | - Shunsuke Kubo
- Department of Cardiology, Kurashiki Central Hospital
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Chen T, Lu X, Wang X, Chen Q, Zhao R, Zhang W, Song T, Guo J, Chen Y. Peri-device leakage and delayed endothelialization of the Watchman device: a computed tomography study. Eur Radiol 2024:10.1007/s00330-024-10778-5. [PMID: 38780765 DOI: 10.1007/s00330-024-10778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 03/13/2024] [Accepted: 03/19/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES This study aimed to explore the endothelialization process and assess the potential association between endothelialization and peri-device leak (PDL) following Watchman implantation via a quantitative method. METHODS This is a single-center retrospective study of consecutive patients undergoing LAAO between December 2015 and November 2021. Device endothelialization, compared between PDL and non-PDL group, were quantitatively analyzed based on hypoattenuated thickening in cardiac computed tomography angiography (CCTA). Advancement in endothelialization over time were explored using the Cochran-Armitage test and generalized estimating equation approach. Potential risk factors of delayed endothelialization were analyzed using the Cox proportional-hazards model. RESULTS A total of 172 patients (mean age, 68 years ± 10 [standard deviation], 114 men) were finally included. The average endothelialization ratio of the study population was 89.8 ± 7.2 percent. In the follow-up period of postprocedural 3 months to more than 12 months, an incremental trend of endothelialization over time was observed with the ratio of 85.8 ± 8.0, 89.6 ± 7.6, 92.2 ± 4.5, 94.3 ± 2.9 percent, respectively (p < 0.0001). Notably, patients without PDL exhibited a swifter advancement in endothelialization compared to those with PDL, irrespective of device size. The multivariable Cox regression model showed that PDL (HR = 2.113, 95%CI: 1.300-3.435, p = 0.003), DSP (HR = 1.717, 95%CI: 1.113-2.647, p = 0.014) were independent risk factors of delayed endothelialization. CONCLUSION CCTA holds promise as an effective means of quantitatively assessing device endothelialization. Endothelialization advanced gradually over time, with PDL potentially impeding device endothelialization. CLINICAL RELEVANCE STATEMENT A comprehensive understanding of the correlation between endothelialization ratio, time, and residual shunt can establish a more dependable foundation for determining the appropriate anticoagulation treatment following left atrial appendage closure. KEY POINTS Current recommendations for postleft atrial appendage occlusion anti-platelet and anticoagulation therapy are based on animal studies. Cardiac computed tomography angiography (CCTA) combined with the UNet neural network model enables the quantitative assessment of device endothelialization. This technique will allow for additional studies to better understand device endothelialization to optimize treatments in this population.
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Affiliation(s)
- Tao Chen
- 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
- Outpatient Department, The 44th Sanatorium of Retired Cadres in Haidian District, 19 Dahuisi Road, Haidian District, Beijing, 100086, China
| | - Xinyan Wang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Qi Chen
- Department of Health Statistics, Naval Medical University, 800 Xiangyin Road, Yangpu District, Shanghai, 200433, China
| | - Runtao Zhao
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Wei Zhang
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Tingting Song
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
| | - Jun Guo
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China.
| | - Yundai Chen
- Senior Department of Cardiology, The Sixth Medical Center of PLA General Hospital, 6 Fucheng Road, Haidian District, Beijing, 100048, China
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9
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Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
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Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
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10
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MENG XS, WANG QS, WANG XY, LU X, MU Y, WANG J, SONG TT, CHEN YD, CHEN T, GUO J. Minimalistic approach to left atrial appendage occlusion guided by cardiac computed tomography angiography. J Geriatr Cardiol 2024; 21:431-442. [PMID: 38800546 PMCID: PMC11112155 DOI: 10.26599/1671-5411.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2024] Open
Abstract
OBJECTIVE To assess the feasibility and safety of the minimalistic approach to left atrial appendage occlusion (LAAO) guided by cardiac computed tomography angiography (CCTA). METHODS Ninety consecutive patients who underwent LAAO, with or without CCTA-guided, were matched (1:2). Each step of the LAAO procedure in the computed tomography (CT) guidance group (CT group) was directed by preprocedural CT planning. In the control group, LAAO was performed using the standard method. All patients were followed up for 12 months, and device surveillance was conducted using CCTA. RESULTS A total of 90 patients were included in the analysis, with 30 patients in the CT group and 60 matched patients in the control group. All patients were successfully implanted with Watchman devices. The mean ages for the CT group and the control group were 70.0 ± 9.4 years and 68.4 ± 11.9 years (P = 0.52), respectively. The procedure duration (45.6 ± 10.7 min vs. 58.8 ± 13.0 min, P < 0.001) and hospital stay (7.5 ± 2.4 day vs. 9.6 ± 2.8 day, P = 0.001) in the CT group was significantly shorter compared to the control group. However, the total radiation dose was higher in the CT group compared to the control group (904.9 ± 348.0 mGy vs. 711.9 ± 211.2 mGy, P = 0.002). There were no significant differences in periprocedural pericardial effusion (3.3% vs. 6.3%, P = 0.8) between the two groups. The rate of postprocedural adverse events (13.3% vs. 18.3%, P = 0.55) were comparable between both groups at 12 months follow-up. CONCLUSIONS CCTA is capable of detailed LAAO procedure planning. Minimalistic LAAO with preprocedural CCTA planning was feasible and safe, with shortened procedure time and acceptable increased radiation and contras consumption. For patients with contraindications to general anesthesia and/or transesophageal echocardiography, this promising method may be an alternative to conventional LAAO.
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Affiliation(s)
- Xian-Sai MENG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Qing-Song WANG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Xin-Yan WANG
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Xu LU
- Graduate School of Chinese PLA Medical College, Beijing, China
| | - Yang MU
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jing WANG
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Ting-Ting SONG
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Yun-Dai CHEN
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Tao CHEN
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jun GUO
- Senior Department of Cardiology, the Sixth Medical Center, Chinese PLA General Hospital, Beijing, China
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11
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Narayanan CA, Al Taii H, Sabayon MD. Optical Coherence Tomography to Visualize Endothelialization in Left Atrial Appendage Closure: Optical Reality or Illusion? J Am Heart Assoc 2024; 13:e032974. [PMID: 38156595 PMCID: PMC10863796 DOI: 10.1161/jaha.123.032974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 12/30/2023]
Affiliation(s)
| | - Haider Al Taii
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
| | - Muhie Dean Sabayon
- Division of Cardiology, Department of Internal MedicineUniversity of Texas Medical BranchGalvestonTXUSA
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12
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Chen J, Chiu F, Chang S, Cheng H, Huang P, Wu C, Wang Y, Hwang J, Tsai C. Pattern of Endothelialization in Left Atrial Appendage Occluder by Optic Coherence Tomography: A Pilot Study. J Am Heart Assoc 2024; 13:e030080. [PMID: 38156658 PMCID: PMC10863799 DOI: 10.1161/jaha.123.030080] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/03/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Implantation of the left atrial appendage occluder (LAAO) has been proven to prevent stroke effectively in patients with atrial fibrillation who cannot tolerate anticoagulants. Incomplete endothelization of LAAO may cause device-related thrombus, and currently no good image modality exists to clearly see LAAO endothelialization. We aimed to use coronary optic coherence tomography (OCT) to visualize LAAO endothelialization. METHODS AND RESULTS We enrolled 14 patients (72.8±9.4 years old) undergoing pulmonary vein isolation with a preexisting LAAO implanted more than 1 year ago (5 Watchman and 9 Amulet). After pulmonary vein isolation, we did OCT via steerable sheath and coronary guiding catheter to adjust OCT probe location and injected contrast medium to visualize the LAAO surface. In vitro testing was also performed to see the bare occluder. In vitro OCT showed the surface of the bare device as an interrupted granule pattern, which included the Watchman surface polytetrafluoroethylene membrane string, Amulet disc metal strut, and inner polytetrafluoroethylene membrane string. In the implanted Watchman, OCT showed endothelialization as a smooth surface layer with noninterrupted coarser granules. In the implanted Amulet, OCT showed endothelialization as thin (early) or thick (late) endothelialization layer covering struts with OCT shadows. Among patients with Watchman, 2 showed no, 2 early, and 1 complete endothelialization. Among patients with Amulet, 2 showed no, 3 early, and 4 late endothelialization. CONCLUSIONS We demonstrated the feasibility of OCT to visualize LAAO endothelization with high resolution. Further studies are needed to determine antithrombotic regimens if incomplete endothelization is detected. A new OCT catheter may be designed specifically for LAAO.
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Affiliation(s)
- Jien‐Jiun Chen
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Fu‐Chun Chiu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Sheng‐Nan Chang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Hsiao‐Liang Cheng
- Department of AnesthesiaNational Taiwan University HospitalTaipeiTaiwan
| | - Pang‐Shuo Huang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Yun‐Ling BranchDou‐Liu CityTaiwan
| | - Cho‐Kai Wu
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Yi‐Chih Wang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Juey‐Jen Hwang
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
| | - Chia‐Ti Tsai
- Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan
- Graduate Institute of Clinical MedicineNational Taiwan University College of Medicine, Cardiovascular Center, National Taiwan University HospitalTaipeiTaiwan
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13
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Fastner C, Müller C, Brachmann J, Lewalter T, Akin I, Sievert H, Käunicke M, Zeymer U, Hochadel M, Schneider S, Senges J, Erkapic D, Weiß C. Is spontaneous echo contrast associated with device-related thrombus or embolic events after left atrial appendage occlusion? - Insights from the multicenter German LAARGE registry. J Interv Card Electrophysiol 2024; 67:119-128. [PMID: 37261553 PMCID: PMC10770218 DOI: 10.1007/s10840-023-01567-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Interventional left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for prophylaxis of thromboembolic events (TEs) in nonvalvular atrial fibrillation patients, predominantly in those with high bleeding risk and contraindications for long-term OAC. Although spontaneous echo contrast (SEC) is a well-known risk factor for atrial thrombus formation, little is known about whether this means an increased risk of device-related thrombus (DRT) or TEs following LAAO. METHODS This substudy of the prospective, multicenter German LAARGE registry assessed two groups according to absence (SEC -) or presence of SEC (SEC +) in preprocedural cardiac imaging. Clinical and echocardiographic parameters were registered up to 1 year after LAAO. RESULTS Five hundred eighty-eight patients (SEC - 85.5 vs. SEC + 14.5%) were included. More SEC + patients were implanted for OAC non-compliance (11.8 vs. 4.6%, p = 0.008) and a higher proportion received only antiplatelet therapy without OAC at hospital discharge (96.5 vs. 86.0%, p = 0.007). The SEC + patients had larger LA diameters (50 (47; 54) vs. 47 (43; 51) mm, p < 0.001), wider LAA ostia (21 (19; 23) vs. 20 (17; 22) mm at 45°, p = 0.011), and lower left ventricular ejection fraction (50 (45; 60) vs. 60 (50; 60) %, p < 0.001) on admission. Procedural success was very high in both groups (98.1%, p = 1.00). Periprocedural major adverse cardiac and cerebrovascular events and other major complications were rare in both groups (3.8 vs. 4.7%, p = 0.76). At follow-up, DRT was only detected in the SEC - group (3.8 vs. 0%, p = 1.00). The rates of TEs (SEC - 1.2 vs. SEC + 0%, p = 1.00) after hospital discharge and 1-year mortality (SEC - 12.0 vs. SEC + 11.8%, p = 0.96) were not significantly different between the two groups. CONCLUSIONS Presence of SEC at baseline was not associated with an increased rate of DRT or TEs at 1-year follow-up after LAAO in LAARGE.
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Affiliation(s)
- Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Claus Müller
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
| | - Johannes Brachmann
- REGIOMED-Kliniken, Coburg, Germany and University of Split, School of Medicine, Split, Croatia
| | - Thorsten Lewalter
- Department of Medicine, Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Matthias Käunicke
- Department of Cardiology, University of Witten/Herdecke, Katholisches Klinikum Essen, Essen, Germany
| | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | | | | | - Jochen Senges
- Stiftung Institut Für Herzinfarktforschung, Ludwigshafen, Germany
| | - Damir Erkapic
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Siegen, Siegen, Germany and Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Christian Weiß
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
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14
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Jiang X, Xiong Q, Yin Y, Ling Z. Left atrial appendage closure for stroke prevention in atrial fibrillation patients: A promise that came true. Pacing Clin Electrophysiol 2023; 46:1576-1585. [PMID: 37987556 DOI: 10.1111/pace.14877] [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: 09/27/2023] [Revised: 11/01/2023] [Accepted: 11/05/2023] [Indexed: 11/22/2023]
Abstract
Anticoagulation therapy plays a crucial role in the management of atrial fibrillation (AF), considering the high morbidity and mortality of AF-related ischemic strokes. With the plausible hypothesis that left atrial appendage is the main source of thrombus in AF patients, left atrial appendage closure (LAAC) has been regarded as a potential substitute to oral anticoagulation in order to meet the unmet needs for stroke prevention, particularly in patients with high bleeding risk. Notable advancements in safety, efficacy, and device innovation have been made in recent years, albeit concerns still remain regarding the insufficient efficacy data, device-related complications, and the need for procedural optimization. We aim to review current knowledge about LAAC and provide potential future directions for the remaining key issues.
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Affiliation(s)
- Xi Jiang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qingsong Xiong
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyu Ling
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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15
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Vij V, Cruz-González I, Galea R, Piayda K, Nelles D, Vogt L, Gloekler S, Fürholz M, Meier B, Räber L, O'Hara G, Arzamendi D, Agudelo V, Asmarats L, Freixa X, Flores-Umanzor E, De Backer O, Sondergaard L, Nombela-Franco L, McInerney A, Salinas P, Korsholm K, Nielsen-Kudsk JE, Afzal S, Zeus T, Operhalski F, Schmidt B, Montalescot G, Guedeney P, Iriart X, Miton N, Saw J, Gilhofer T, Fauchier L, Veliqi E, Meincke F, Petri N, Nordbeck P, Gonzalez-Ferreiro R, Bhatt DL, Laricchia A, Mangieri A, Omran H, Schrickel JW, Rodes-Cabau J, Nickenig G, Sievert H, Sedaghat A. Symptomatic vs. non-symptomatic device-related thrombus after LAAC: a sub-analysis from the multicenter EUROC-DRT registry. Clin Res Cardiol 2023; 112:1790-1799. [PMID: 37294311 PMCID: PMC10697873 DOI: 10.1007/s00392-023-02237-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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/23/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) after left atrial appendage closure (LAAC) is associated with adverse outcomes, i.e. ischemic stroke or systemic embolism (SE). Data on predictors of stroke/SE in the context of DRT are limited. AIMS This study aimed to identify predisposing factors for stroke/SE in DRT patients. In addition, the temporal connection of stroke/SE to DRT diagnosis was analyzed. METHODS The EUROC-DRT registry included 176 patients, in whom DRT after LAAC were diagnosed. Patients with symptomatic DRT, defined as stroke/SE in the context of DRT diagnosis, were compared against patients with non-symptomatic DRT. Baseline characteristics, anti-thrombotic regimens, device position, and timing of stroke/SE were compared. RESULTS Stroke/SE occurred in 25/176 (14.2%) patients diagnosed with DRT (symptomatic DRT). Stroke/SE occurred after a median of 198 days (IQR 37-558) after LAAC. In 45.8% stroke/SE occurred within one month before/after DRT diagnosis (DRT-related stroke). Patients with symptomatic DRT had lower left ventricular ejection fractions (50.0 ± 9.1% vs. 54.2 ± 11.0%, p = 0.03) and higher rates of non-paroxysmal atrial fibrillation (84.0% vs. 64.9%, p = 0.06). Other baseline parameters and device positions were not different. Most ischemic events occurred among patients with single antiplatelet therapy (50%), however, stroke/SE was also observed under dual antiplatelet therapy (25%) or oral anticoagulation (20%). CONCLUSION Stroke/SE are documented in 14.2% and occur both in close temporal relation to the DRT finding and chronologically independently therefrom. Identification of risk factors remains cumbersome, putting all DRT patients at substantial risk for stroke/SE. Further studies are necessary to minimize the risk of DRT and ischemic events.
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Affiliation(s)
- Vivian Vij
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | | | | | - Dominik Nelles
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Lara Vogt
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | | | | | | | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | | | | | - Lluis Asmarats
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Ole De Backer
- Rigshospitalet, University Hospital Copenhagen, Copenhagen, Denmark
| | - Lars Sondergaard
- Rigshospitalet, University Hospital Copenhagen, Copenhagen, Denmark
| | | | | | | | | | | | - Shazia Afzal
- University Hospital Düsseldorf, Düsseldorf, Germany
| | - Tobias Zeus
- University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Boris Schmidt
- Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany
| | - Gilles Montalescot
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | - Paul Guedeney
- ACTION Study Group, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne University, Paris, France
| | | | | | | | | | | | | | | | - Nils Petri
- University Hospital Würzburg, Würzburg, Germany
| | | | | | | | - Alessandra Laricchia
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Antonio Mangieri
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | | | - Jan Wilko Schrickel
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Josep Rodes-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Georg Nickenig
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | | - Alexander Sedaghat
- Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Rhein-Ahr-Cardio, Bad Neuenahr-Ahrweiler, Germany.
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16
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Moussa I. Predicting Behavior of Device-Related Thrombus After Left Atrial Appendage Occlusion: The Heisenberg's Uncertainty Principle Applies. JACC Cardiovasc Interv 2023; 16:2733-2735. [PMID: 38030359 DOI: 10.1016/j.jcin.2023.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Issam Moussa
- University of Illinois Urbana-Champaign, Urban, Illinois, USA.
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17
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Alkhouli M, Alarouri H, Kramer A, Korsholm K, Collins J, De Backer O, Hatoum H, Nielsen-Kudsk JE. Device-Related Thrombus After Left Atrial Appendage Occlusion: Clinical Impact, Predictors, Classification, and Management. JACC Cardiovasc Interv 2023; 16:2695-2707. [PMID: 38030357 DOI: 10.1016/j.jcin.2023.10.046] [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: 08/28/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 12/01/2023]
Abstract
Despite the unprecedented advances in the left atrial appendage occlusion field, device-related thrombus (DRT) remains an unresolved issue with the therapy. This paper aims to provide a state-of-the-art review of the literature on the incidence, clinical impact, predictors and management of DRT and propose a novel classification of DRT and hypoattenuated thickening.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Hasan Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Anders Kramer
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeremy Collins
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA; Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, Michigan, USA
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18
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Mesnier J, Simard T, Jung RG, Lehenbauer KR, Piayda K, Pracon R, Jackson GG, Flores-Umanzor E, Faroux L, Korsholm K, Chun JKR, Chen S, Maarse M, Montrella K, Chaker Z, Spoon JN, Pastormerlo LE, Meincke F, Sawant AC, Moldovan CM, Qintar M, Aktas MK, Branca L, Radinovic A, Ram P, El-Zein RS, Flautt T, Ding WY, Sayegh B, Benito-González T, Lee OH, Badejoko SO, Paitazoglou C, Karim N, Zaghloul AM, Agarwal H, Kaplan RM, Alli O, Ahmed A, Suradi HS, Knight BP, Alla VM, Panaich SS, Wong T, Bergmann MW, Chothia R, Kim JS, Pérez de Prado A, Bazaz R, Gupta D, Valderrábano M, Sanchez CE, El Chami MF, Mazzone P, Adamo M, Ling F, Wang DD, O'Neill W, Wojakowski W, Pershad A, Berti S, Spoon DB, Kawsara A, Jabbour G, Boersma LVA, Schmidt B, Nielsen-Kudsk JE, Freixa X, Ellis CR, Fauchier L, Demkow M, Sievert H, Main ML, Hibbert B, Holmes DR, Alkhouli M, Rodés-Cabau J. Persistent and Recurrent Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes. JACC Cardiovasc Interv 2023; 16:2722-2732. [PMID: 38030358 DOI: 10.1016/j.jcin.2023.09.017] [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: 06/14/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Scarce data exist on the evolution of device-related thrombus (DRT) after left atrial appendage closure (LAAC). OBJECTIVES This study sought to assess the incidence, predictors, and clinical impact of persistent and recurrent DRT in LAAC recipients. METHODS Data were obtained from an international multicenter registry including 237 patients diagnosed with DRT after LAAC. Of these, 214 patients with a subsequent imaging examination after the initial diagnosis of DRT were included. Unfavorable evolution of DRT was defined as either persisting or recurrent DRT. RESULTS DRT resolved in 153 (71.5%) cases and persisted in 61 (28.5%) cases. Larger DRT size (OR per 1-mm increase: 1.08; 95% CI: 1.02-1.15; P = 0.009) and female (OR: 2.44; 95% CI: 1.12-5.26; P = 0.02) were independently associated with persistent DRT. After DRT resolution, 82 (53.6%) of 153 patients had repeated device imaging, with 14 (17.1%) cases diagnosed with recurrent DRT. Overall, 75 (35.0%) patients had unfavorable evolution of DRT, and the sole predictor was average thrombus size at initial diagnosis (OR per 1-mm increase: 1.09; 95% CI: 1.03-1.16; P = 0.003), with an optimal cutoff size of 7 mm (OR: 2.51; 95% CI: 1.39-4.52; P = 0.002). Unfavorable evolution of DRT was associated with a higher rate of thromboembolic events compared with resolved DRT (26.7% vs 15.1%; HR: 2.13; 95% CI: 1.15-3.94; P = 0.02). CONCLUSIONS About one-third of DRT events had an unfavorable evolution (either persisting or recurring), with a larger initial thrombus size (particularly >7 mm) portending an increased risk. Unfavorable evolution of DRT was associated with a 2-fold higher risk of thromboembolic events compared with resolved DRT.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Trevor Simard
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Richard G Jung
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kyle R Lehenbauer
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Kerstin Piayda
- CardioVascular Center Frankfurt, Frankfurt, Germany; Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Gießen, Germany
| | - Radoslaw Pracon
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | | | - Eduardo Flores-Umanzor
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | - Laurent Faroux
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Julian K R Chun
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | - Moniek Maarse
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Kristi Montrella
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Zakeih Chaker
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - Jocelyn N Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Luigi E Pastormerlo
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Carmen M Moldovan
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Mohammed Qintar
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA; Department of Cardiology, Sparrow Hospital, Michigan State University, Lansing, Michigan
| | - Mehmet K Aktas
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Luca Branca
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Radinovic
- Arrhythmology Department, San Raffaele University Hospital, Milan, Italy
| | - Pradhum Ram
- Emory University Hospital, Atlanta, Georgia, USA
| | - Rayan S El-Zein
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Wern Yew Ding
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Bassel Sayegh
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | | | - Oh-Hyun Lee
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Solomon O Badejoko
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | | | - Nabeela Karim
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Ahmed M Zaghloul
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | | | - Rachel M Kaplan
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Oluseun Alli
- Division of Cardiology, Novant Health Heart and Vascular Institute, Charlotte, North Carolina, USA
| | - Aamir Ahmed
- Rush University Medical Center, Chicago, Illinois, USA
| | | | - Bradley P Knight
- Bluhm Cardiovascular Institute, Northwestern University, Chicago, Illinois, USA
| | - Venkata M Alla
- Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Sidakpal S Panaich
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tom Wong
- Royal Brompton and Harefield Hospitals, Part of Guys' and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | | | - Rashaad Chothia
- Division of Internal Medicine, St Joseph's Medical Center (Dignity Health), Stockton, California, USA
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | | | - Raveen Bazaz
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Dhiraj Gupta
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | | | - Carlos E Sanchez
- Division of Cardiology, OhioHealth Doctors Hospital/OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | - Patrizio Mazzone
- Electrophysiology Unit, Cardio-Thoraco-Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Fred Ling
- Division of Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Dee Dee Wang
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - William O'Neill
- Division of Cardiology, Henry Ford Health System, Detroit, Michigan, USA
| | - Wojtek Wojakowski
- Division of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Ashish Pershad
- Chandler Regional Medical Center, Chandler, Arizona, USA
| | - Sergio Berti
- Fondazione Toscana Gabriele Monasterio Massa, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Daniel B Spoon
- International Heart Institute of Montana, Missoula, Montana, USA
| | - Akram Kawsara
- Division of Cardiology, West Virginia School of Medicine, Morgantown, West Virginia, USA
| | - George Jabbour
- Heart and Vascular Institute, University of Pittsburgh Medical Center, University of Pittsburgh, Altoona, Pennsylvania, USA
| | - Lucas V A Boersma
- Cardiology, St Antonius Hospital, Nieuwegein, the Netherlands; LB Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Medizinische Klinik III, Markuskrankenhaus, Frankfurt, Germany
| | | | - Xavier Freixa
- Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain
| | | | - Laurent Fauchier
- Service de Cardiologie, Centre Hospitalier Universitaire Trousseau Faculté de Médecine, Université François Rabelais, Tours, France
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Horst Sievert
- Heart, Lung and Vascular Institute, Excela Health, Independence Health System, Pittsburgh, Pennsylvania, USA
| | - Michael L Main
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Benjamin Hibbert
- Capital Research Group, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada; Department of Cardiology, Hospital Clínic of Barcelona, August Pi i Sunyer Biomedical Research Institute, University of Barcelona, Barcelona, Spain.
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19
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Chen JJ, Chiu FC, Chang SN, Cheng HL, Huang PS, Wu CK, Wang YC, Hwang JJ, Tsai CT. Optical coherence tomography to visualise the endothelialisation of left atrial appendage occluders. EUROINTERVENTION 2023; 19:703-704. [PMID: 37358363 PMCID: PMC10587842 DOI: 10.4244/eij-d-23-00348] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine, Yun-Lin, Taiwan and Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine, Yun-Lin, Taiwan and Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Sheng-Nan Chang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine, Yun-Lin, Taiwan and Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Hsiao-Liang Cheng
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine, Yun-Lin, Taiwan and Hospital Yun-Lin Branch, Dou-Liu City, Taiwan
| | - Cho-Kai Wu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
- Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
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20
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Cepas-Guillén P, Flores-Umanzor E, Leduc N, Bajoras V, Perrin N, Farjat-Pasos J, McInerney A, Lafond A, Millán X, Zendjebil S, O'Hara G, Ibrahim R, de Backer O, Cruz-González I, Arzamendi D, Sanchis L, Garot P, Nielsen-Kudsk JE, Nombela-Franco L, Aminian A, Rodés-Cabau J, Freixa X. Impact of Device Implant Depth After Left Atrial Appendage Occlusion. JACC Cardiovasc Interv 2023; 16:2139-2149. [PMID: 37565966 DOI: 10.1016/j.jcin.2023.05.045] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) remains one of the main concerns after left atrial appendage occlusion (LAAO). Several risk factors have been proposed, but most cannot be modulated. A modifiable factor such as device implantation depth is a potential target to adjust the risk for DRT. OBJECTIVES The aim of this study was to assess the impact of LAAO device implantation depth as a predisposing factor for DRT. METHODS The study included patients who underwent successful LAAO at 9 centers in Europe and Canada. Patients were classified into 2 groups: proximal device implantation (covered pulmonary ridge [PR] in the lobe and disc cohort or <5 mm from the PR in the single-lobe cohort) and distal device implantation (uncovered PR in the disc and lobe cohort and ≥5 mm in the single-lobe cohort). RESULTS A total of 1,317 patients were included. Among these, proximal and distal device implantation was achieved in 732 (55%) and 585 (45%) patients, respectively. No differences in procedural outcomes were observed between the groups. At follow-up, patients with proximal implantation had a lower incidence of DRT (2.3%) than those with distal implantation (12.2%) (P < 0.001). Deeper device implantation and a larger uncovered left atrial appendage area were associated with a higher incidence of DRT (P < 0.001), regardless of device type. In multivariable analysis, distal implant (HR: 5.92; 95% CI: 3.39-10.36) and no or single antiplatelet therapy (HR: 1.62; 95% CI: 0.99-2.62) emerged as independent predictors of DRT. CONCLUSIONS LAAO device implantation depth is an independent risk factor for DRT. Deeper device implantation and larger uncovered left atrial appendage areas were associated with a higher incidence of DRT.
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Affiliation(s)
- Pedro Cepas-Guillén
- Institut Clinic Cardiovascular, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
| | | | - Nina Leduc
- Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Vilhemas Bajoras
- Rigshospitalet, Copenhagen, Denmark; Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania; Department of Interventional Cardiology, Division of Cardiology and Vascular Diseases, Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania
| | - Nils Perrin
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | - Julio Farjat-Pasos
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | | | - Ana Lafond
- Hospital Universitario de Salamanca, Salamanca, Spain
| | - Xavi Millán
- Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Sandra Zendjebil
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Reda Ibrahim
- Montreal Heart Institute, Université de Montréal, Montréal, Québec, Canada
| | | | | | | | - Laura Sanchis
- Institut Clinic Cardiovascular, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
| | | | | | - Adel Aminian
- Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | - Josep Rodés-Cabau
- Institut Clinic Cardiovascular, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain; Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Xavier Freixa
- Institut Clinic Cardiovascular, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain.
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21
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Iriart X, Blanc G, Bouteiller XP, Legghe B, Bouyer B, Sridi-Cheniti S, Bustin A, Vasile C, Thambo JB, Elbaz M, Cochet H. Clinical Implications of CT-detected Hypoattenuation Thickening on Left Atrial Appendage Occlusion Devices. Radiology 2023; 308:e230462. [PMID: 37668517 DOI: 10.1148/radiol.230462] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
Background At follow-up CT after left atrial appendage occlusion (LAAO), hypoattenuation thickening (HAT) on the atrial aspect of the device is a common finding but the clinical implications require further study. Purpose To assess the association of HAT grade at follow-up CT with clinical characteristics and outcomes in patients who underwent LAAO. Materials and Methods This prospective study included consecutive participants with atrial fibrillation and who were at high risk for stroke (CHA2DS2-VASc score ≥4) who underwent LAAO and were administered pacifier or nonpacifier devices at two French medical centers between January 2012 and November 2020. Postprocedure CT images were evaluated by two radiologists in consensus and device-specific interpretation algorithms were applied to classify HAT as low grade (low suspicion of thrombosis) or high grade (high suspicion of thrombosis). The association between HAT grade and clinical characteristics was assessed using multinomial logistic regression, and variables associated with risk of stroke were assessed using a Cox proportional hazard model. Results This study included 412 participants (mean age, 76 years ± 8 [SD]; 284 male participants) who underwent follow-up CT at a mean of 4.2 months ± 1.7 after LAAO. Low-grade and high-grade HAT were depicted in 98 of 412 (23.8%) and 21 of 412 (5.1%) participants, respectively. High-grade HAT was associated with higher odds of antithrombotic drug discontinuation during follow-up (odds ratio, 9.5; 95% CI: 3.1, 29.1; P < .001), whereas low-grade HAT was associated with lower odds of persisting left atrial appendage patency (odds ratio, 0.46; 95% CI: 0.27, 0.79; P = .005). During a median follow-up of 17 months (IQR, 11-41 months), stroke occurred in 24 of 412 (5.8%) participants. High-grade HAT was associated with stroke (hazard ratio, 4.6; 95% CI: 1.5, 14.0; P = .008) and low-grade HAT (P = .62) was not. Conclusion Low-grade HAT was a more common finding at CT performed after LAAO CT (24%) than was high-grade HAT (5%), but it was associated with more favorable outcomes than high-grade HAT, which was associated with higher stroke risk. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Choe in this issue.
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Affiliation(s)
- Xavier Iriart
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Gregoire Blanc
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Xavier Paul Bouteiller
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Benoit Legghe
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Benjamin Bouyer
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Soumaya Sridi-Cheniti
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Aurélien Bustin
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Corina Vasile
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Jean-Benoit Thambo
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Meyer Elbaz
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
| | - Hubert Cochet
- From the IHU Liryc, CHU/Univ Bordeaux/Inserm 1045, IHU Liryc, Electrophysiology and Heart Modelling Institute, Bordeaux University Foundation, Inserm U1045, Avenue de Magellan, 33604 Pessac, France (X.I., X.P.B., A.B., J.B.T., H.C.); Department of Cardiac Imaging, CHU Bordeaux, Pessac, France (B.L., S.S.C., H.C.); Department of Pediatric and Adult Congenital Heart Disease, M3C National Reference Centre, Bordeaux University Hospital, Bordeaux-Pessac, France (X.I., B.B., C.V., J.B.T.); and Department of Cardiology, CHU de Toulouse, Toulouse, France (G.B., M.E.)
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Anduaga I, Affronti A, Cepas-Guillén P, Alcocer J, Flores-Umanzor E, Regueiro A, Brugaletta S, Quintana E, Sanchis L, Sabaté M, Freixa X. Non-Pharmacological Stroke Prevention in Atrial Fibrillation. J Clin Med 2023; 12:5524. [PMID: 37685589 PMCID: PMC10488500 DOI: 10.3390/jcm12175524] [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: 07/21/2023] [Revised: 08/11/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. It is associated with increased mortality and morbidity, especially due to the increased risk of ischemic stroke and systemic embolism in these patients. For this reason, thromboembolism prevention is the cornerstone of managing AF, and oral anticoagulation is nowadays the first-line treatment. However, since most thrombi form in the left atrial appendage and anticoagulant therapy may have side effects and be contraindicated in some patients, surgical and percutaneous left atrial appendage occlusion (LAAO) have emerged as a non-pharmacological alternative. This review summarizes all existing evidence on surgical and percutaneous LAAO.
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Affiliation(s)
- Iñigo Anduaga
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Alessandro Affronti
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Pedro Cepas-Guillén
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Jorge Alcocer
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduardo Flores-Umanzor
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Ander Regueiro
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Salvatore Brugaletta
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Eduard Quintana
- Cardiovascular Surgery, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, 08007 Barcelona, Spain
| | - Laura Sanchis
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Manel Sabaté
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
| | - Xavier Freixa
- Cardiology Department, Institut Clínic Cardiovascular, Hospital Clínic de Barcelona, 08036 Barcelona, Spain
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Saliba WI, Kawai K, Sato Y, Kopesky E, Cheng Q, Ghosh SKB, Herbst TJ, Kawakami R, Konishi T, Virmani R, Jaber WA, Gibson DN, Shah M, Natale A, Gibson M, Holmes DR, Finn AV. Enhanced Thromboresistance and Endothelialization of a Novel Fluoropolymer-Coated Left Atrial Appendage Closure Device. JACC Clin Electrophysiol 2023; 9:1555-1567. [PMID: 37204356 DOI: 10.1016/j.jacep.2023.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 04/18/2023] [Accepted: 04/19/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) after left atrial appendage closure (LAAC) procedures is a rare but potentially serious event. Thrombogenicity and delayed endothelialization play a role in the development of DRT. Fluorinated polymers are known to have thromboresistant properties that may favorably modulate the healing response to an LAAC device. OBJECTIVES The goal of this study was to compare the thrombogenicity and endothelial coverage (EC) after LAAC between the conventional uncoated WATCHMAN FLX (WM) and a novel fluoropolymer-coated WATCHMAN FLX (FP-WM). METHODS Canines were randomized for implantation with WM or FP-WM devices and given no postimplant antithrombotic/antiplatelet agents. The presence of DRT was monitored by using transesophageal echocardiography and verified histologically. The biochemical mechanisms associated with coating were assessed by using flow loop experiments to quantify albumin adsorption, platelet adhesion, and porcine implants to quantify EC and the expression of markers of endothelial maturation (ie, vascular endothelial-cadherin/p120-catenin). RESULTS Canines implanted with FP-WM exhibited significantly less DRT at 45 days than those implanted with WM (0% vs 50%; P < 0.05). In vitro experiments showed significantly greater albumin adsorption (52.8 [IQR: 41.0-58.3] mm2 vs 20.6 [IQR: 17.2-26.6] mm2; P = 0.03) and significantly less platelet adhesion (44.7% [IQR: 27.2%-60.2%] vs 60.9% [IQR: 39.9%-70.1%]; P < 0.01) on FP-WM. Porcine implants showed significantly greater EC by scanning electron microscopy (87.7% [IQR: 83.4%-92.3%] vs 68.2% [IQR: 47.6%-72.8%]; P = 0.03), and higher vascular endothelial-cadherin/p120-catenin expression after 3 months on FP-WM compared with WM. CONCLUSIONS The FP-WM device showed significantly less thrombus and reduced inflammation in a challenging canine model. Mechanistic studies indicated that the fluoropolymer-coated device binds more albumin, leading to reduced platelet binding, less inflammation, and greater EC.
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Affiliation(s)
- Walid I Saliba
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, Maryland, USA
| | - Yu Sato
- CVPath Institute, Gaithersburg, Maryland, USA
| | - Edward Kopesky
- Boston Scientific Corporation, Maple Grove, Minnesota, USA
| | - Qi Cheng
- CVPath Institute, Gaithersburg, Maryland, USA
| | | | | | | | | | | | - Wael A Jaber
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Douglas N Gibson
- Prebys Cardiovascular Institute, Scripps Clinic, San Diego, California, USA
| | - Manish Shah
- Department of Medicine, MedStar Georgetown Washington Hospital Center, Washington, DC
| | - Andrea Natale
- Department of Electrophysiology, Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA; Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Michael Gibson
- Department of Medicine, Beth Israel Medical Center, Boston, Massachusetts, USA
| | - David R Holmes
- Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aloke V Finn
- CVPath Institute, Gaithersburg, Maryland, USA; University of Maryland, School of Medicine, Baltimore, Maryland, USA.
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Agasthi P, Pujari SH. Peri- and Post-procedural Anticoagulation with Left Atrial Appendage Occlusion Devices. Heart Int 2023; 17:54-59. [PMID: 37456348 PMCID: PMC10339453 DOI: 10.17925/hi.2023.17.1.54] [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: 10/24/2022] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
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25
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Zhong Z, Gao Y, Kovács S, Vij V, Nelles D, Spano L, Nickenig G, Sonntag S, De Backer O, Søndergaard L, Sedaghat A, Mela P. Impact of left atrial appendage occlusion device position on potential determinants of device-related thrombus: a patient-specific in silico study. Clin Res Cardiol 2023:10.1007/s00392-023-02228-x. [PMID: 37291248 DOI: 10.1007/s00392-023-02228-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 05/08/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) is potentially linked to adverse events. Although clinical reports suggest an effect of the device type and position on the DRT risk, in-depth studies of its mechanistic basis are needed. This in silico study aimed to assess the impact of the position of non-pacifier (Watchman) and pacifier (Amulet) LAAO devices on surrogate markers of DRT risk. METHODS The LAAO devices were modeled with precise geometry and virtually implanted in different positions into a patient-specific left atrium. Using computational fluid dynamics, the following values were quantified: residual blood, wall shear stress (WSS) and endothelial cell activation potential (ECAP). RESULTS In comparison to an ostium-fitted device position, deep implantation led to more residual blood, lower average WSS and higher ECAP surrounding the device, especially on the device's atrial surface and the surrounding tissue, suggesting increased risk for potential thrombus. For the non-pacifier device, an off-axis device orientation resulted in even more residual blood, higher ECAP and similar average WSS as compared to an ostium-fitted device position. Overall, the pacifier device showed less residual blood, higher average WSS and lower ECAP, compared to the non-pacifier device. CONCLUSIONS In this in silico study, both LAAO device type and implant position showed an impact on potential markers of DRT in terms of blood stasis, platelet adhesion and endothelial dysfunction. Our results present a mechanistic basis for clinically observed risk factors of DRT and the proposed in silico model may aid in the optimization of device development and procedural aspects.
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Affiliation(s)
- Zhaoyang Zhong
- Chair of Medical Materials and Implants, TUM School of Engineering and Design and Munich Institute of Biomedical Engineering, Technical University of Munich, Garching, Germany
| | - Yiting Gao
- Chair of Medical Materials and Implants, TUM School of Engineering and Design and Munich Institute of Biomedical Engineering, Technical University of Munich, Garching, Germany
| | - Soma Kovács
- Chair of Medical Materials and Implants, TUM School of Engineering and Design and Munich Institute of Biomedical Engineering, Technical University of Munich, Garching, Germany
| | - Vivian Vij
- Department of Cardiology, University Hospital Bonn, Bonn, Germany
| | - Dominik Nelles
- Department of Cardiology, University Hospital Bonn, Bonn, Germany
| | - Lukas Spano
- Chair of Medical Materials and Implants, TUM School of Engineering and Design and Munich Institute of Biomedical Engineering, Technical University of Munich, Garching, Germany
| | - Georg Nickenig
- Department of Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Søndergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Alexander Sedaghat
- Department of Cardiology, University Hospital Bonn, Bonn, Germany.
- RheinAhrCardio, Praxis für Kardiologie, Bad Neuenahr-Ahrweiler, Germany.
| | - Petra Mela
- Chair of Medical Materials and Implants, TUM School of Engineering and Design and Munich Institute of Biomedical Engineering, Technical University of Munich, Garching, Germany.
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Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, Hoang Trinh K, O'Hara G, Rodés-Cabau J. Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives. Circ Cardiovasc Interv 2023; 16:e012812. [PMID: 37192309 DOI: 10.1161/circinterventions.122.012812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.
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Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Pedro Cepas-Guillén
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Xavier Freixa
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Eduardo Flores-Umanzor
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
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Holmes DR, Korsholm K, Rodés-Cabau J, Saw J, Berti S, Alkhouli MA. Left atrial appendage occlusion. EUROINTERVENTION 2023; 18:e1038-e1065. [PMID: 36760206 PMCID: PMC9909459 DOI: 10.4244/eij-d-22-00627] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/03/2022] [Indexed: 02/08/2023]
Abstract
Prevention of stroke represents a goal of primary importance in health systems due to its associated morbidity and mortality. As several patient groups with increased stroke rates have been identified, multiple approaches have been developed and implemented: oral anticoagulation (OAC) for patients with atrial fibrillation, surgical and percutaneous revascularisation in patients with carotid disease, device closure for patients with patent foramen ovale, and now, left atrial appendage occlusion (LAAO) for selected patients with non-valvular atrial fibrillation (NVAF). The latter group of patients are the focus of this review which evaluates the pathophysiology, selection of patients, procedural performance, outcomes of treatment both during and post-procedure, adjunctive therapy, complications, and longer-term outcomes.
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Affiliation(s)
- David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jacqueline Saw
- Division of Interventional Cardiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Sergio Berti
- Cardiology Unit, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Mohamad A Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
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De Backer O, Iriart X, Kefer J, Nielsen-Kudsk JE, Aminian A, Rosseel L, Kofoed KF, Odenstedt J, Berti S, Saw J, Søndergaard L, Garot P. Impact of Computational Modeling on Transcatheter Left Atrial Appendage Closure Efficiency and Outcomes. JACC Cardiovasc Interv 2023; 16:655-666. [PMID: 36990554 DOI: 10.1016/j.jcin.2023.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/22/2022] [Accepted: 01/03/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND When performing transcatheter left atrial appendage (LAA) closure, peridevice leaks and device-related thrombus (DRT) have been associated with worse clinical outcomes-hence, their risk should be mitigated. OBJECTIVES The authors sought to assess whether use of preprocedural computational modeling impacts procedural efficiency and outcomes of transcatheter LAA closure. METHODS The PREDICT-LAA trial (NCT04180605) is a prospective, multicenter, randomized trial in which 200 patients were 1:1 randomized to standard planning vs cardiac computed tomography (CT) simulation-based planning of LAA closure with Amplatzer Amulet. The artificial intelligence-enabled CT-based anatomical analyses and computer simulations were provided by FEops (Belgium). RESULTS All patients had a preprocedural cardiac CT, 197 patients underwent LAA closure, and 181 of these patients had a postprocedural CT scan (standard, n = 91; CT + simulation, n = 90). The composite primary endpoint, defined as contrast leakage distal of the Amulet lobe and/or presence of DRT, was observed in 41.8% in the standard group vs 28.9% in the CT + simulation group (relative risk [RR]: 0.69; 95% CI: 0.46-1.04; P = 0.08). Complete LAA closure with no residual leak and no disc retraction into the LAA was observed in 44.0% vs 61.1%, respectively (RR: 1.44; 95% CI: 1.05-1.98; P = 0.03). In addition, use of computer simulations resulted in improved procedural efficiency with use of fewer Amulet devices (103 vs 118; P < 0.001) and fewer device repositionings (104 vs 195; P < 0.001) in the CT + simulation group. CONCLUSIONS The PREDICT-LAA trial demonstrates the possible added value of artificial intelligence-enabled, CT-based computational modeling when planning for transcatheter LAA closure, leading to improved procedural efficiency and a trend toward better procedural outcomes.
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Affiliation(s)
- Ole De Backer
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
| | - Xavier Iriart
- Bordeaux University Hospital, Fondation Bordeaux Université, Bordeaux, France
| | - Joelle Kefer
- Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | | | - Adel Aminian
- Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | | | | | | | - Jacqueline Saw
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Lars Søndergaard
- Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Philippe Garot
- Hôpital Jacques Cartier, Institut Cardiovasculaire Paris Sud, Ramsay-Santé, Massy, France
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Chen C, Chen Y, Qu L, Su X, Chen Y. 3-Year outcomes after left atrial appendage closure in patients with nonvalvular atrial fibrillation: cardiomyopathy related with increased death and stroke rate. BMC Cardiovasc Disord 2023; 23:27. [PMID: 36650429 PMCID: PMC9844026 DOI: 10.1186/s12872-023-03054-9] [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: 07/30/2022] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Left atrial appendage closure (LAAC) is a novel treatment for stroke prevention in high-risk patients with non-valvular atrial fibrillation (NVAF). However, the long-term outcomes after LAAC in Chinese NVAF patients are still lacking. METHODS This was a single-center, bidirectional, nonrandomized registered study. Patients who underwent LAAC implantation from May 2014 to April 2021 in a large Chinese center were enrolled. The primary endpoint was combined all-cause death and stroke. RESULTS From May 2014 to April 2021, a total of 673 NVAF patients were enrolled. The overall successful implantation rate was 97.62% (657 of 673). The rate of perioperative adverse events was 1.19% (8 of 673), including 3 cardiac tamponades, 2 ischemic strokes, one device-related thrombus (DRT) and 2 device dislocations. 604 (92.24%) patients completed the follow-up, the median follow-up period was 36.9 months (IQR 24.8-56.5 months). 16 stroke events occurred in 15 patients (one patient suffered from both hemorrhagic and ischemic strokes). 13 patients (2.15%) had ischemic stroke, and the fatal rate was 0.33% (2 of 604). 3 patients (0.15%) suffered from hemorrhagic stroke, and the fatal rate was 0.17% (1 of 604). The overall stroke rate was 0.74% per-year. The combined death and stroke rate was 1.93% per-year. In the multivariate Cox regression analysis, age ≥ 75 (hazard ratio 2.264, 95% CI 1.074-4.772, P = 0.032) and ventricular cardiomyopathy (hazard ratio 2.738, 95% CI 1.060-7.071, P = 0.037) were independent predictors of combined mortality and stroke. CONCLUSION The overall successful implantation rate of LAAC was 97.62% and the rate of perioperative adverse events was 1.19% in this study, and the stroke rate was 0.74% per year during the long-term follow-up. Age ≥ 75 years and ventricular cardiomyopathy were independent predictors of the primary endpoint. Trial registration This study was retrospectively registered.
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Affiliation(s)
- Chunyu Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China ,grid.413247.70000 0004 1808 0969Department of Cardiology, The Second Affiliated Hospital of Wuhan University, Zhongnan Hospital, Wuhan, 430060 China
| | - Yuyi Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Lulu Qu
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Xi Su
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
| | - Yanhong Chen
- grid.417273.4Department of Cardiology, Wuhan Asia Heart Hospital, 753Rd Jinghan Road, Wuhan, 430022 Hubei China
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Looking for optimal antithrombotic strategy after transcatheter left atrial appendage occlusion: a real-world comparison of different antiplatelet regimens. Int J Cardiol 2023; 371:92-99. [PMID: 36181948 DOI: 10.1016/j.ijcard.2022.09.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transcatheter left atrial appendage occlusion (LAAO) has emerged as an effective procedure for the prevention of thromboembolic events in non-valvular atrial fibrillation (AF) patients with contraindications to oral anticoagulation. After the procedure, different antithrombotic regimens have been used, in order to prevent device-related thrombus and trying to minimize bleedings. The search for the optimal antithrombotic strategy is still ongoing. We sought to assess efficacy and safety of different antiplatelet therapy (APT) regimens. METHODS We enrolled non-randomized consecutive patients who underwent LAAO at the University Hospital of Parma between 2010 and 2021. Three study groups were identified according to post-procedural APT: long (>1, ≤12 months)-dual APT (DAPT), short (≤ 1 month)-DAPT, lifelong single APT (SAPT). The choice of the APT was left to multidisciplinary team evaluation. The incidence of the primary outcome, a composite of any ischemic or hemorrhagic event, was assessed at follow-up. RESULTS We enrolled a total of 130 patients. Technical success was achieved in 123 (94.6%) patients. After LAAO, 39 [31.7%] patients were discharged on short-DAPT, 35 [28.5%] on long-DAPT and 49 [39.8%] on SAPT. After a median follow-up of 32 months, short-DAPT group had a significantly lower occurrence of the primary outcome (3 [7.7%] vs. 7 [20.0%] in long-DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of the bleeding endpoint (0 vs. 4 [11.4%] in long-DAPT vs. 9 [18.4%] in SAPT, p = 0.020). Finally, comparison of the Kaplan-Meier curves showed that short-DAPT group had a higher primary endpoint-free survival [p = 0.015] compared to the other groups. CONCLUSION Post-procedural short-DAPT strategy was associated with better outcomes, mainly driven by reduction of major bleedings.
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Branca L, Tomasoni D, Cimino G, Cersosimo A, Lombardi CM, Chizzola G, Metra M, Adamo M. Impact and predictors of device-related thrombus after percutaneous left atrial appendage closure. J Cardiovasc Med (Hagerstown) 2023; 24:12-19. [PMID: 36440764 DOI: 10.2459/jcm.0000000000001394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Device-related thrombus (DRT) is a known complication occurring in up to 7% of patients undergoing percutaneous left atrial appendage closure (LAAC). Since the target population of LAAC is generally ineligible for oral anticoagulant therapies, DRT raises important concerns. The aim of this review will be to summarize available evidence on DRT after LAAC focusing on its possible impact on outcomes. Recent findings showed a tighter association between DRT and neurological ischemic events. Antithrombotic regimen adopted after LAAC may have a protective effect against DRT. Many patient-related and procedural factors have been identified as possible predictors of DRT. A tailored approach, which takes into account DRT, is needed in the patient selection for LAAC and in the postprocedural follow-up.
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Affiliation(s)
- Luca Branca
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Zhang S, Xiong SH, Guan YG, Zhao XX, Qin YW, Guo ZF, Bai Y. An updated meta-analysis of device related thrombus following left atrial appendage closure in patients with atrial fibrillation. Front Cardiovasc Med 2022; 9:1088782. [PMID: 36620640 PMCID: PMC9816128 DOI: 10.3389/fcvm.2022.1088782] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022] Open
Abstract
Aims Device related thrombus (DRT) is a known complication of left atrial appendage closure (LAAC). However, the relation between DRT and elevated risk of ischemic events remains controversial. This study is sought to reassessed the incidence of DRT following LAAC and the relation between DRT and elevated risk of ischemic stroke and systemic embolism (SE) with latest clinical trials included. Methods The PubMed, Embase, and Cochrane Library databases were systematically searched from their inception until April 2022 for studies that reported the incidence of DRT and compared the incidence of both stroke and SE between DRT patients and non-DRT patients. Results In 59 eligible studies, the incidence of DRT was 366/12,845 (2.8%, ranging from 0 to 11%, I 2 = 64%). The incidence of DRT was not statistically different between single-seal device (SS) and dual-seal device (DS) in subgroup analysis [171/6,190 (2.8%) vs. 78/3,023 (3.6%); p = 0.93]. The pooled incidence of stroke (26 studies, 7,827 patients) in patients with and without DRT was 11.5% in DRT patients and 2.9% among non-DRT patients (OR: 5.08; 95% CI = 3.47-7.44). In the sensitivity analysis, DRT was associated with higher rate of stroke (12.1 vs. 3.2%; OR: 4.14; 95% CI = 2.69-6.38) and SE (16.0 vs. 3.8%; OR: 4.48; 95% CI = 3.04-6.62). Conclusion The incidence of DRT was low and similar between SS and DS devices. DRT was associated with increased rates of ischemic events. The occurrence rate of ischemic events associated DRT was comparable between two occlusion mechanism devices. Systematic review registration [https://www.crd.york.ac.uk/], identifier [CRD42022326179].
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Urbanek L, Chen S, Bordignon S, Tohoku S, Bologna F, Schulte-Hahn B, Chun KJ, Schmidt B. Unexpected large device related thrombus at 12 months follow-up after left atrial appendage closure. Pacing Clin Electrophysiol 2022; 45:1383-1384. [PMID: 35821363 DOI: 10.1111/pace.14562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/19/2022] [Accepted: 07/01/2022] [Indexed: 01/20/2023]
Abstract
An 89-year-old woman underwent left atrial appendage (LAA) closure (LAAC) in our hospital because of recurrent gastrointestinal bleedings. The first transesophageal echocardiography (TEE) follow-up at six weeks revealed a complete sealing of the LAA and no device related thrombus. In a TEE follow-up at one year after the LAA closure, a large device related thrombus (6 × 3 cm) was found. Treated with oral anticoagulation (apixaban) the thrombus showed a partial resolution one year later.
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Affiliation(s)
- Lukas Urbanek
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | | | - Shota Tohoku
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | | | | | - Kr Julian Chun
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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Alkhouli M, Ellis CR, Daniels M, Coylewright M, Nielsen-Kudsk JE, Holmes DR. Left Atrial Appendage Occlusion: Current Advances and Remaining Challenges. JACC. ADVANCES 2022; 1:100136. [PMID: 38939465 PMCID: PMC11198318 DOI: 10.1016/j.jacadv.2022.100136] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/12/2022] [Accepted: 09/21/2022] [Indexed: 06/29/2024]
Abstract
The field of left atrial appendage occlusion is rapidly evolving. However, several issues remain including the limited randomized efficacy data, peri-device leak, device-related thrombus, and the ongoing refinement of procedural techniques. In this article, we provide a contemporary overview of left atrial appendage occlusion focusing on 4 key remaining challenges: efficacy data, peri-device leak, device-related thrombus, and procedural optimization.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Christopher R. Ellis
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Matthew Daniels
- Institute of Cardiovascular Sciences, Core Technology Facility, University of Manchester, Manchester, United Kingdom
| | - Megan Coylewright
- Department of Cardiovascular Medicine, The Erlanger Heart and Lung Institute, Chattanooga, Tennessee, USA
| | | | - David R. Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Omran H, Büllesfeld L, Heinrich J. Der interventionelle Vorhofohrverschluss: eine Alternative zur oralen Antikoagulation. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1953-0255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ZusammenfassungDie orale Antikoagulation ist der Standard zur Prävention von Embolien bei Patienten mit Vorhofflimmern. Der interventionelle Vorhofohrverschluss ist eine Alternative zur oralen
Antikoagulation bei Patienten mit Vorhofflimmern und Kontraindikationen oder Unverträglichkeiten einer oralen Antikoagulation, insbesondere bei klinisch relevanten Blutungen. Die Sicherheit
des Verfahrens hat in den letzten Jahren erheblich zugenommen. Mehrere große randomisierte Studien vergleichen aktuell die Effektivität und Sicherheit der oralen Antikoagulation und des
interventionellen Vorhofohrverschlusses.
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Affiliation(s)
- Heyder Omran
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
| | - Lutz Büllesfeld
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
| | - Jaroslaw Heinrich
- Innere Medizin/Kardiologie, GFO Kliniken Bonn Betriebsstätte St. Marien, Bonn, Deutschland
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Kramer AD, Korsholm K, Jensen JM, Nørgaard BL, Peelukhana S, Herbst T, Horton R, Kar S, Saw J, Alkhouli M, Nielsen-Kudsk JE. Cardiac computed tomography following Watchman FLX implantation: device-related thrombus or device healing? Eur Heart J Cardiovasc Imaging 2022; 24:250-259. [PMID: 36336848 PMCID: PMC9867931 DOI: 10.1093/ehjci/jeac222] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
AIMS Cardiac computed tomography (CT) is increasingly utilized during follow-up after left atrial appendage closure (LAAC). Hypoattenuated thickening (HAT) is a common finding and might represent either benign device healing or device-related thrombosis (DRT). The appearance and characteristics of HAT associated with the Watchman FLX have not been previously described. Therefore, we sought to investigate cardiac CT findings during follow-up after Watchman FLX implantation with a focus on HAT and DRT. METHODS AND RESULTS Retrospective single-centre, observational study including all patients with successful Watchman FLX implantation and follow-up cardiac CT between March 2019 and September 2021 (n = 244). Blinded analysis of CT images was performed describing the localization, extent, and morphology of HAT and correlated to imaging and histology findings in a canine model. Relevant clinical and preclinical ethical approvals were obtained.Overall, HAT was present in 156 cases (64%) and could be classified as either subfabric hypoattenuation (n = 59), flat sessile HAT (n = 78), protruding sessile HAT (n = 16), or pedunculated HAT (n = 3). All cases of pedunculated HAT and five cases of protruding sessile HAT were considered as high-grade HAT (n = 7). Subfabric hypoattenuation and flat sessile HAT correlated with device healing and endothelialization in histological analysis of explanted devices. CONCLUSION Subfabric hypoattenuation and flat sessile HAT are frequent CT findings for Watchman FLX, likely representing benign device healing and endothelialization. Pedunculated HAT and protruding HAT are infrequent CT findings that might represent DRT.
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Affiliation(s)
- Anders Dahl Kramer
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Jesper Møller Jensen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | - Bjarne Linde Nørgaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark
| | | | - Thomas Herbst
- Research and Development, Boston Scientific, Maple Grove, MN, USA
| | - Rodney Horton
- Research and Development, Boston Scientific, Maple Grove, MN, USA,Texas Cardiac Arrhythmia Institute, Austin, TX, USA
| | - Saibal Kar
- Research and Development, Boston Scientific, Maple Grove, MN, USA,Los Robles Regional Medical Center, Thousand Oaks, CA, USA
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, British Columbia, Canada
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, MN, USA
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Mendez K, Kennedy DG, Wang DD, O’Neill B, Roche ET. Left Atrial Appendage Occlusion: Current Stroke Prevention Strategies and a Shift Toward Data-Driven, Patient-Specific Approaches. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2022; 1:100405. [PMID: 39131471 PMCID: PMC11308563 DOI: 10.1016/j.jscai.2022.100405] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 06/08/2022] [Accepted: 06/14/2022] [Indexed: 08/13/2024]
Abstract
The left atrial appendage (LAA) is a complex structure with unknown physiologic function protruding from the main body of the left atrium. In patients with atrial fibrillation, the left atrium does not contract effectively. Insufficient atrial and LAA contractility predisposes the LAA morphology to hemostasis and thrombus formation, leading to an increased risk of cardioembolic events. Oral anticoagulation therapies are the mainstay of stroke prevention options for patients; however, not all patients are candidates for long-term oral anticoagulation. Percutaneous occlusion devices are an attractive alternative to long-term anticoagulation therapy, although they are not without limitations, such as peri-implant leakage and device-related thrombosis. Although efforts have been made to reduce these risks, significant interpatient heterogeneity inevitably yields some degree of device-anatomy mismatch that is difficult to resolve using current devices and can ultimately lead to insufficient occlusion and poor patient outcomes. In this state-of-the-art review, we evaluated the anatomy of the LAA as well as the current pathophysiologic understanding and stroke prevention strategies used in the management of the risk of stroke associated with atrial fibrillation. We highlighted recent advances in computed tomography imaging, preprocedural planning, computational modeling, and novel additive manufacturing techniques, which represent the tools needed for a paradigm shift toward patient-centric LAA occlusion. Together, we envisage that these techniques will facilitate a pipeline from the imaging of patient anatomy to patient-specific computational and bench-top models that enable customized, data-driven approaches for LAA occlusion that are engineered specifically to meet each patient's unique needs.
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Affiliation(s)
- Keegan Mendez
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Darragh G. Kennedy
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Biomedical Engineering, Columbia University, New York, New York
| | | | | | - Ellen T. Roche
- Harvard/MIT Health Sciences and Technology Program, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, Massachusetts
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Antúnez-Muiños P, Vicente-Palacios V, Pérez-Sánchez P, Sampedro-Gómez J, Sánchez-Puente A, Dorado-Díaz PI, Nombela-Franco L, Salinas P, Gutiérrez-García H, Amat-Santos I, Peral V, Morcuende A, Asmarats L, Freixa X, Regueiro A, Caneiro-Queija B, Estevez-Loureiro R, Rodés-Cabau J, Sánchez PL, Cruz-González I. Predictive Power for Thrombus Detection after Atrial Appendage Closure: Machine Learning vs. Classical Methods. J Pers Med 2022; 12:jpm12091413. [PMID: 36143197 PMCID: PMC9503612 DOI: 10.3390/jpm12091413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/12/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022] Open
Abstract
Device-related thrombus (DRT) after left atrial appendage (LAA) closure is infrequent but correlates with an increased risk of thromboembolism. Therefore, the search for DRT predictors is a topic of interest. In the literature, multivariable methods have been used achieving non-consistent results, and to the best of our knowledge, machine learning techniques have not been used yet for thrombus detection after LAA occlusion. Our aim is to compare both methodologies with respect to predictive power and the search for predictors of DRT. To this end, a multicenter study including 1150 patients who underwent LAA closure was analyzed. Two lines of experiments were performed: with and without resampling. Multivariate and machine learning methodologies were applied to both lines. Predictive power and the extracted predictors for all experiments were gathered. ROC curves of 0.5446 and 0.7974 were obtained for multivariate analysis and machine learning without resampling, respectively. However, the resampling experiment showed no significant difference between them (0.52 vs. 0.53 ROC AUC). A difference between the predictors selected was observed, with the multivariable methodology being more stable. These results question the validity of predictors reported in previous studies and demonstrate their disparity. Furthermore, none of the techniques analyzed is superior to the other for these data.
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Affiliation(s)
- Pablo Antúnez-Muiños
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
- Correspondence: ; Tel.: +34-923291100
| | | | - Pablo Pérez-Sánchez
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | | | | | - Pedro Ignacio Dorado-Díaz
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Luis Nombela-Franco
- Instituto Cardiovascular, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Pablo Salinas
- Instituto Cardiovascular, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain
| | - Hipólito Gutiérrez-García
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Ignacio Amat-Santos
- CIBERCV, Instituto de Ciencias del Corazón (ICICOR), Hospital Clínico Universitario de Valladolid, 47003 Valladolid, Spain
| | - Vicente Peral
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07120 Palma, Spain
| | - Antonio Morcuende
- Department of Cardiology, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07120 Palma, Spain
| | - Lluis Asmarats
- Quebec Heart and Kung Institute, Laval University, Quebec City, QC G1V 0A6, Canada
| | - Xavier Freixa
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | - Ander Regueiro
- Institut Clínic Cardiovascular, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), 08036 Barcelona, Spain
| | | | | | - Josep Rodés-Cabau
- Quebec Heart and Kung Institute, Laval University, Quebec City, QC G1V 0A6, Canada
| | - Pedro Luis Sánchez
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
| | - Ignacio Cruz-González
- CIBERCV, University Hospital of Salamanca, 37007 Salamanca, Spain
- Biomedical Research Institute of Salamanca (IBSAL), 37007 Salamanca, Spain
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Clinical and echocardiographic risk factors for device-related thrombus after left atrial appendage closure: an analysis from the multicenter EUROC-DRT registry. Clin Res Cardiol 2022; 111:1276-1285. [PMID: 35849156 DOI: 10.1007/s00392-022-02065-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 07/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry. METHODS We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics. RESULTS Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 ± 18.5 vs. 42.4 ± 18.0 cm/s, p = 0.02). Occluders implanted in DRT patients were larger (25.5 ± 3.8 vs. 24.6 ± 3.5 mm, p = 0.03) and implanted deeper in the LAA (mean depth: 7.6 ± 4.7 vs. 5.7 ± 4.7 mm, p < 0.01). Coverage of the appendage ostium was achieved less often in DRT patients (69.5% vs. 81.5%, p < 0.01), while DRT patients were less frequently on oral anticoagulation (7.1% vs. 16.7%, p < 0.01). Multivariate analysis identified age, prior stroke/TIA and SEC as independent risk factors for DRT. After PSM, implantation depth was found to be predictive. Rates of stroke/TIA were higher in DRT patients (13.5% vs. 3.8%, Hazard Ratio: 4.21 [95%-confidence interval: 1.88-9.49], p < 0.01). CONCLUSIONS DRT after LAAC is associated with adverse outcome and appears to be of multifactorial origin, depending on patient characteristics, anticoagulation regimen and device position.
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Simard TJ, Hibbert B, Alkhouli MA, Abraham NS, Holmes DR. Device-related thrombus following left atrial appendage occlusion. EUROINTERVENTION 2022; 18:224-232. [PMID: 35440430 DOI: 10.4244/eij-d-21-01010] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Thrombus formation on intracardiac devices remains a subject of importance, with rates in the 2-5% range. Device-related thrombus (DRT) following left atrial appendage occlusion is an area of particular concern considering its association with embolic events. DRT continues to present numerous questions, including the optimal definition, incidence, risk factors, monitoring, therapy, and clinical outcomes - all subjects of ongoing assessment. Herein, we discuss these considerations, building upon the relevant historical context and pathophysiologic insights while discussing the future considerations in this rapidly evolving field.
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Affiliation(s)
- Trevor J Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Benjamin Hibbert
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - Neena S Abraham
- Department of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
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Korsholm K, Jensen JM, Nørgaard BL, Nielsen-Kudsk JE. Temporal changes and clinical significance of peridevice leak following left atrial appendage occlusion with Amplatzer devices. Catheter Cardiovasc Interv 2022; 99:2071-2079. [PMID: 35582829 PMCID: PMC9541112 DOI: 10.1002/ccd.30178] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 12/05/2022]
Abstract
Background The natural history of peridevice leak (PDL) following left atrial appendage occlusion (LAAO) is unknown. This study sought to investigate changes of PDL from 2 until 12 months after LAAO, using cardiac computed tomography (CT), and to assess the potential association between persistent PDL and clinical outcomes Methods Single‐center observational study of Amplatzer LAAO implants between 2010 and 2017 (n = 206). Patients with 2 and 12 months cardiac CT were included in the study (n = 153). Images were blindly analyzed. PDL was characterized by frequency and size at the device disc, lobe, and left atrial appendage contrast patency. Patients were followed for the composite outcome of ischemic stroke, transient ischemic attack, systemic embolism, or all‐cause death. Median follow up from LAAO was 3.1 (2.3–4.3) years. Results Contrast patency was present in 101 (66%) and 72 (47%) (p < 0.001) at 2 and 12 months, respectively. PDL was identified at the disc in 103 (67%) patients at 2 months versus 93 (61%) at 12 months (p = 0.08), and at the lobe in 29 (19%) at both time points. PDL area at the disc did not change significantly over time, ∆ area: −8.95 mm (95% confidence interval [CI]: −18.9; 1.01) p = 0.08. Permanent atrial fibrillation was independently associated with persistent PDL. Persistent versus no PDL was associated with a 62% worse clinical outcome, however not statistically significant, hazard ratio (HR): 1.62 (95% CI: 0.9–2.93), p = 0.11. Conclusion Persistent PDL was frequently observed following LAAO with Amplatzer devices. The PDL frequency and size appeared unchanged between 2 and 12 months. Persistent PDL was not significantly associated with worse clinical outcomes, yet this needs further delineation in future studies.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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Hussain KM, Jain A, Ahmad NT, Hussain KA, Aldergash S. Transient Ischemic Attack Secondary to Device-Related Thrombus After Left Atrial Appendage Closure. Cureus 2022; 14:e24073. [PMID: 35573559 PMCID: PMC9097762 DOI: 10.7759/cureus.24073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/18/2022] Open
Abstract
The patient is an 84-year-old female with a significant past medical history of traumatic subarachnoid hemorrhage, bleeding peptic ulcer disease, permanent atrial fibrillation status post percutaneous left atrial appendage closure (LAAC) initially admitted to the hospital secondary to expressive aphasia. The patient was found to have a transient ischemic attack (TIA). A transesophageal echocardiogram (TEE) showed a thrombus on the watchman device (WD). The patient was treated with unfractionated heparin infusion and later transitioned to apixaban without any further TIA or stroke over 30 days period. Device-related thrombosis (DRT) with systemic thromboembolism occurred almost after 480 days of putting the WD which is very rare.
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43
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Computed tomography measurement for left atrial appendage closure. Cardiovasc Interv Ther 2022; 37:440-449. [DOI: 10.1007/s12928-022-00852-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/07/2022] [Indexed: 11/02/2022]
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44
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Galea R, Mahmoudi K, Gräni C, Elhadad S, Huber AT, Heg D, Siontis GCM, Brugger N, Sebag F, Windecker S, Valgimigli M, Landolff Q, Roten L, Amabile N, Räber L. Watchman FLX vs. Watchman 2.5 in a Dual-Center Left Atrial Appendage Closure Cohort: the WATCH-DUAL study. Europace 2022; 24:1441-1450. [PMID: 35253840 DOI: 10.1093/europace/euac021] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/09/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS No studies have compared Watchman 2.5 (W2.5) with Watchman FLX (FLX) devices to date. We aimed at comparing the FLX with W2.5 devices with respect to clinical outcomes, left atrial appendage (LAA) sealing properties and device-related thrombus (DRT). METHODS AND RESULTS All consecutive left atrial appendage closure (LAAC) procedures performed at two European centres between November 2017 and February 2021 were included. Procedure-related complications and net adverse cardiovascular events (NACE) at 6 months after LAAC were recorded. At 45-day computed tomography (CT) follow-up, intra- (IDL) and peri- (PDL) device leak, residual patent neck area (RPNA), and DRT were assessed by a Corelab. Out of 144 LAAC consecutive procedures, 71 and 73 interventions were performed using W2.5 and FLX devices, respectively. There were no differences in terms of procedure-related complications (4.2% vs. 2.7%, P = 0.626). At 45-day CT, the FLX was associated with lower frequency of IDL [21.3% vs. 40.0%; P = 0.032; odds ratio (OR): 0.375; 95% confidence interval (CI): 0.160-0.876; P = 0.024], similar rate of PDL (29.5% vs. 42.0%; P = 0.170), and smaller RPNA [6 (0-36) vs. 40 (6-115) mm2; P = 0.001; OR: 0.240; 95% CI: 0.100-0.577; P = 0.001] compared with the W2.5 group. At 45 days, rate of DRT as detected by CT and/or transoesophageal echocardiography (TOE), was higher with W2.5 (6.0% vs. 0%, P = 0.045). At 6-month follow-up, NACE did not differ between groups. CONCLUSIONS In this cohort of consecutive LAACs, FLX as compared to W2.5, was associated with similar procedure-related complications and 6-month NACE, but with improved LAA neck coverage, and lower IDL and DRT.
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Affiliation(s)
- Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Khalil Mahmoudi
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Simon Elhadad
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France.,Cardiology Department, Jossigny, France
| | - Adrian T Huber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Dik Heg
- Clinical Trials Unit, University of Bern, Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Nicolas Brugger
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Frederic Sebag
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Stephan Windecker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland.,Cardiocentro Ticino, Institute and Università della Svizzera Italiana (USI), Lugano, Switzerland
| | - Quentin Landolff
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Laurent Roten
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
| | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern CH-3010, Switzerland
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45
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Chao T, Joung B, Takahashi Y, Lim TW, Choi E, Chan Y, Guo Y, Sriratanasathavorn C, Oh S, Okumura K, Lip GYH. 2021 Focused update of the 2017 consensus guidelines of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation. J Arrhythm 2021; 37:1389-1426. [PMID: 34887945 PMCID: PMC8637102 DOI: 10.1002/joa3.12652] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/22/2021] [Indexed: 12/19/2022] Open
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the "coronavirus disease 2019" (COVID-19) pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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Affiliation(s)
- Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Boyoung Joung
- Division of CardiologyDepartment of Internal MedicineYonsei University College of MedicineSeoulRepublic of Korea
| | - Yoshihide Takahashi
- The Department of Advanced Arrhythmia ResearchTokyo Medical and Dental UniversityTokyoJapan
| | - Toon Wei Lim
- National University Heart CentreNational University HospitalSingaporeSingapore
| | - Eue‐Keun Choi
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Yi‐Hsin Chan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkouTaoyuanTaiwan
| | - Yutao Guo
- Pulmonary Vessel and Thrombotic DiseaseChinese PLA General HospitalBeijingChina
| | | | - Seil Oh
- Department of Internal MedicineSeoul National University HospitalSeoulRepublic of Korea
| | - Ken Okumura
- Division of CardiologySaiseikai Kumamoto HospitalKumamotoJapan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular ScienceUniversity of Liverpool & Liverpool Heart and Chest HospitalLiverpoolUK
- Aalborg Thrombosis Research UnitDepartment of Clinical MedicineAalborg UniversityAalborgDenmark
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46
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Alfadhel M, Nestelberger T, Samuel R, McAlister C, Saw J. Left atrial appendage closure - Current status and future directions. Prog Cardiovasc Dis 2021; 69:101-109. [PMID: 34843811 DOI: 10.1016/j.pcad.2021.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 11/22/2021] [Indexed: 10/19/2022]
Abstract
Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular atrial fibrillation (AF). LAAC aims to reduce the risk of thromboembolism without increasing the risk of bleeding, a crucial strategy for patients at high risk for bleeding. Over the last few decades, the safety and long-term efficacy of the procedure in specific populations have grown, and more patients are being treated with these devices. Current and future studies focus on expanding the target population as well as the iteration of current technology. This article reviews recent, present, and future LAAC studies on the two most common devices, the Watchman device (Boston Scientific Corporation) and the Amplatzer cardiac plug (ACP) (St. Jude Medical, Minneapolis, MN), and their subsequent next generations, the Watchman FLX, and the Amulet, respectively.
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Affiliation(s)
- Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada; Cardiovascular Research Institute Basel (CRIB), Department of Cardiology, University Hospital Basel, University of Basel, Switzerland
| | - Rohit Samuel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Canada.
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47
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2021 Focused Update Consensus Guidelines of the Asia Pacific Heart Rhythm Society on Stroke Prevention in Atrial Fibrillation: Executive Summary. Thromb Haemost 2021; 122:20-47. [PMID: 34773920 PMCID: PMC8763451 DOI: 10.1055/s-0041-1739411] [Citation(s) in RCA: 221] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in the Asia-Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The practice guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of the AF Better Care pathway, the advantages of non-vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian AF patients with single one stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” pandemic, etc. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician's decision remains the most important factor in the management of AF.
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48
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Schmidt B, Chun KRJ. Preliminary or Premature?: The Dilemma of Early Data Reporting Leaving Questions Unanswered. JACC Cardiovasc Interv 2021; 14:2375-2376. [PMID: 34736736 DOI: 10.1016/j.jcin.2021.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 08/30/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Boris Schmidt
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Frankfurt, Germany.
| | - K R Julian Chun
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Frankfurt, Germany
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49
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Nielsen-Kudsk JE. Prevention of Left Atrial Appendage Device-Related Thrombosis: Is Reduced-Dose Direct Oral Anticoagulation the Way Forward? JACC Cardiovasc Interv 2021; 14:2365-2367. [PMID: 34656491 DOI: 10.1016/j.jcin.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 08/03/2021] [Indexed: 11/29/2022]
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