Outcomes of Elderly Patients Undergoing Left Atrial Appendage Closure

Next-Day Discharge After Transcatheter Aortic Valve Implantation With the ACURATE neo/neo2 Self-Expanding Aortic Bioprosthesis

Previous studies have shown the safety of early discharge pathways in selected patients and using selected transcatheter heart valves. Hence, we sought to evaluate the safety of next-day discharge (NDD) in patients who underwent transfemoral transcatheter aortic valve implantation (TF-TAVI) with the ACURATE neo/neo2 (Boston Scientific, Marlborough, Massachusetts) self-expanding aortic bioprosthesis. Patients who underwent TF-TAVI between January 2018 and April 2023 were prospectively included. Patients were stratified into 3 groups according to discharge times within 24 hours (NDD), between 24 and 48 hours, and those discharged >48 hours after TAVI. The primary outcome was the first unplanned readmission at 30 days after TAVI. Log-rank test was used to assess the differences in the outcome of interest between the groups. A total of 368 all-comers were included in this study. According to discharge times, 204 patients followed NDD, 69 patients 24 to 48 hours discharge, and 95 patients >48 hours discharge after TAVI. The mean age was 84 ± 6.3 years and 61% were women, without differences between the groups. The mean Society of Thoracic Surgeons score was lower in those with NDD versus 24 to 48 hours and >48 hours (2.9 ± 1.0, 3.2 ± 1.2, and 3.4 ± 1.4, respectively, p = 0.014). There were no differences between the groups in terms of preprocedural right bundle branch block or pacemaker. The need for new permanent pacemaker implantation was the leading postprocedural complication; it occurred more frequently in the >48 hours group than the 24 to 48 hours, and <24 hours groups (24% vs 8.6% and 2.2%, p <0.001). There were 5 strokes (1.4%) and all of them occurred in the >48 hours group (p = 0.005). At 30 days after discharge, there were no deaths and no differences in all-cause readmissions (9.3% in <24 hours, 8.6% in 24 to 48 hours, and 19% in >48 hours, log-rank p = 0.087). The readmission rates for new permanent pacemaker implantation requirement were 3.3% (n = 6) in NDD, 0% in 24 to 48 hours, and 1.6% (n = 5) in the >48 hours groups (p = 0.27). In conclusion, in unselected patients who underwent TF-TAVI with the ACURATE neo/neo2 self-expanding bioprosthesis, the NDD pathway is feasible and appears to be safe, without an increased risk of death or all-cause rehospitalization through 30 days after hospital discharge.

Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives

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.

The left atrial appendage: An enigmatic friend or foe and implications of closure

The left atrial appendage (LAA) is often thought of as a vestigial organ serving as a nidus for clot formation in those with atrial fibrillation (A-fib). The LAA, however, has unique anatomy which allows it to serve special functions in the human body. Closing the LAA has been shown to decrease the risk of thromboembolic events in patients who cannot tolerate anticoagulation. Several methods of closure exist including percutaneous endocardial closure, epicardial closure, and surgical clipping. In addition to decreasing stroke risk, there appears to be physiologic changes that occur after LAA closure. This comprehensive review aims to describe the functions of the LAA, compare the different methods of closure, and propose a new method for identifying which patients may benefit from LAA closure versus anticoagulation based on each patients' individual comorbidities rather than their contraindications.

Cardiogeriatrics: the current state of the art

It is estimated that by 2050, 17% of the world's population will be greater than 85 years old, which, combined with cardiovascular disease (CVD) being the leading cause of death and disability, sets an unprecedented burden on our health and care systems. This perfect storm will be accompanied by a rise in the prevalence of CVD due to increased survival of patients with pre-existing CVD and the incidence of CVD that is associated with the process of ageing. In this review, we will focus on the diagnosis and management of common CVD conditions in old age, namely: heart failure (HF), coronary artery disease (CAD), atrial fibrillation (AF) and valvular heart disease (VHD). Despite limited evidence, clinical guidelines are increasingly considering the complexity of management of these conditions in the older person, which often coexist, for example, AF and HF or CAD and VHD. Furthermore, they, in turn, need specific consideration in the context of comorbidities, polypharmacy, frailty and impaired cognition found in this age group. Hence, the emerging role of the geriatric cardiologist is therefore vital in performing comprehensive geriatric assessment, attending multidisciplinary team meetings and ultimately considering the patient and the sum of their diseases in their totality. There have been recent advances in CVD management but how we apply these to deliver integrated care to the elderly population is key. This review article aims to bring together emerging studies and guidelines on assessment and management of CVD in the elderly, summarising latest definitions, diagnostics, therapeutics and future challenges.

In-hospital safety outcomes of left atrial appendage occlusion in octogenarians and nonagenarians

AIMS

Data on safety outcomes of left atrial appendage occlusion (LAAO) in elderly patients are limited. This study aimed to compare the outcomes of LAAO between octogenarians (age 80-89) and nonagenarians (age ≥90) vs. younger patients (age ≤79).

METHODS AND RESULTS

We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients hospitalized for LAAO from 2016 to 2020 and to compare in-hospital safety outcomes in octogenarians and nonagenarians vs. younger patients. The primary outcome was a composite of in-hospital all-cause mortality or stroke. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. Outcomes were determined using logistic regression models. Among 84 140 patients hospitalized for LAAO, 32.9% were octogenarians, 2.8% were nonagenarians, and 64.3% were ≤79 years of age. Over the study period, the volume of LAAO increased in all age groups (all Ptrend < 0.01). After adjustment for clinical and demographic factors, octogenarians and nonagenarians had similar odds of in-hospital all-cause mortality or stroke [adjusted odds ratio (aOR) 1.41, 95% confidence interval (CI) 0.93-2.13 for octogenarians; aOR 1.69, 95% CI 0.67-3.92 for nonagenarians], cardiac tamponade, acute kidney injury, major bleeding, and blood transfusion, in addition to similar LOS and total costs compared with younger patients (all P > 0.05). However, octogenarians and nonagenarians had higher odds of vascular complications compared with younger patients (aOR 1.47, 95% CI 1.08-1.99 for octogenarians; aOR 1.60, 95% CI 1.18-2.97 for nonagenarians).

CONCLUSION

Octogenarians and nonagenarians undergoing LAAO have a similar safety profile compared with clinically similar younger patients except for higher odds of vascular complications.

Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis

Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.

Balancing the risk of stroke and bleeding in atrial fibrillation patients with a history of falls

INTRODUCTION

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and can lead to serious consequences such as ischemic stroke and systemic thromboembolism. The risk of thromboembolism can be reduced by anticoagulation, however many patients with high falls risk do not receive oral anticoagulation.

AREAS COVERED

In this narrative literature review, performed with searches of the PubMed database, we discuss the factors predisposing AF patients to falls, ways to optimize bleeding risk with individualized assessment, and clarify misconceptions around falls risk and anticoagulation therapy.

EXPERT OPINION

In general, the advantages of stroke prevention with oral anticoagulation outweigh the risk of bleeding resulting from falls, especially with the increasing use of non-vitamin K oral anticoagulants, which are associated with fewer intracranial hemorrhages and thromboembolic complications than vitamin K anticoagulants. Most studies in this field are observational and randomized controlled studies would be beneficial.

Short-Term Outcomes Following Left Atrial Appendage Closure in the Very Elderly: A Population-Based Analysis

Background Data on percutaneous left atrial appendage closure (LAAC) outcomes in the very elderly with atrial fibrillation are limited. We aimed to investigate the clinical characteristics and short-term outcomes of patients 80 years or older following percutaneous LAAC in a large nationwide database. Methods and Results Using the Nationwide Readmissions Database, we identified patients who underwent percutaneous LAAC between January 2016 and December 2018. Patients were categorized based on age (≥80 and <80 years old). The primary outcome was in-hospital mortality. Secondary outcomes were in-hospital end points including periprocedural complications, 30-day outcomes, and all-cause 30-day readmissions. A propensity score-matched model (1:1) was used to adjust for baseline characteristics among the study groups. A total of 13 208 patients were included in this study (43% women, median age in years [interquartile range] 79.5 [73-84]) and matched one-to-one (6604 and 6604 patients were ≥80 and <80 years old, respectively). In-hospital mortality was not statistically different between the study groups and occurred in 21 patients ≥80 years old (0.32%) and in 14 patients <80 years old (0.21%); P=0.236. Rates of in-hospital stroke/transient ischemic attack were higher in patients ≥80 years old compared with those <80 years old (1.22% versus 0.77%; P=0.009). In-hospital bleeding requiring transfusion, vascular complications, systemic embolization, and pericardial effusion/tamponade requiring pericardiocentesis or surgical intervention occurred more frequently in patients ≥80 years old. Furthermore, the elderly group was more likely to be readmitted within 30 days compared with those <80 years old (9.91% versus 8.4%; P=0.004); however, rates of 30-day complications were not statistically different between the study groups. Conclusions In a large nationwide database, patients ≥80 years old undergoing percutaneous LAAC were found to have similar in-hospital mortality but an increased risk of periprocedural complications and 30-day readmission compared with younger patients. Our data suggest that LAAC should be considered on a case-by-case basis in the very elderly, taking into consideration the risks and benefits of this intervention. Further studies are needed to assess long-term LAAC outcomes in this high-risk population.

Association of advanced age with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: insights from the National Inpatient Sample of 36,065 procedures

Background

Age-stratified analyses of atrial fibrillation (AF) patients undergoing percutaneous left atrial appendage occlusion (LAAO) are limited. The purpose of current study was to compare in-hospital outcomes in elderly AF patients (age > 80 years) to a relatively younger cohort (age £ 80 years) after LAAO.

Methods

Data were extracted from National Inpatient Sample for calendar years 2015–2018. LAAO device implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO.

Results

A total of 36,065 LAAO recipients were included in the final analysis, of which 34.6% (n=12,475) were performed on elderly AF patients. Elderly AF patients had a higher prevalence of major complications (6.7% vs. 5.7%, p < 0.01) and mortality (0.4% vs. 0.1%, p < 0.01) after LAAO device implantation in the crude analysis. After multivariate adjustment of potential confounders, age > 80 years was associated with increased risk of inpatient mortality (adjusted odds ratio [aOR] 4.439, 95% confidence interval [CI] 2.391–8.239) but not major complications (aOR 1.084, 95% CI 0.971–1.211), prolonged length of stay (aOR 0.943, 95% CI 0.88–1.101), or increased hospitalization costs (aOR 0.909, 95% CI 0.865–0.955).

Conclusion

Over 1 in 3 LAAO device implantations occurred in elderly AF patients. After adjusting for potential confounding variables, advanced age was associated with inpatient mortality, but not with other LAAO procedural–related outcomes including major complications, prolonged length of stay, or increased hospitalization costs.

Comparison of the Safety of Left Atrial Appendage Occlusion in Patients Aged <75 Versus Those Aged ≥75 Years (from a Nationwide Cohort Sample)

The mean age in clinical trials of percutaneous left atrial appendage occlusion (LAAO) has been <75 years. We aimed to better understand the safety of LAAO in older patients. National Inpatient Sample and International Classification of Diseases, Tenth Revision codes were used to identify patients with atrial fibrillation who underwent LAAO during the years 2016-2018. Patients were grouped by age <75 and ≥75 years. Baseline characteristics; length of stay; cost; hospital mortality; and other adverse events, including hematoma, vascular complications, perforation/tamponade, and stroke/ transient ischemic attack, were compared for the 2 groups. A total of 6,877 patients were identified, of whom 4,160 (60.4%) were aged ≥75 years. Length of stay and hospitalization costs were similar for the 2 groups. There were 10 deaths in patients aged ≥75 years and 1 death in patients aged <75 years (p = 0.059). The incidence of perforation/tamponade was 1.3% in patients aged ≥75 years versus 0.6% for those <75 years (p = 0.008). This difference persisted on multivariate analysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.01 to 3.07). The risk of perforation/tamponade was also higher in female patients (OR 2.74, 95% CI 1.63 to 4.59). There was a trend toward higher combined procedure-related adverse events (OR 1.46, 95% CI 0.99 to 2.15) in patients ≥75 years. There was no difference in the individual components of hematoma, vascular complication, and stroke/transient ischemic attack between both groups. In conclusion, percutaneous LAAO was associated with a higher risk of perforation and tamponade in older patients, particularly women.

Prediction model based on machine learning for short- and long-term adverse events in left atrial appendage closure

Background

At present, the prediction of adverse events (AE) had practical significance in clinic and the accuracy of AE prediction model after left atrial appendage closure (LAAC) needed to be improved. To identify a good prediction model based on machine learning for short- and long-term AE after LAAC.

Methods

In this study, 869 patients were included from the Department of Cardiovascular Medicine of Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital during 2017 and 2021. Univariate and multivariate analyses were conducted for short-term AE after LAAC to determine possible risk factors related with AE. We compared 8 machine learning algorithms for prediction short-term AE, and XGBoost was found to have the best performance. In addition, Cox-regression was used for long-term AE to find out the risk factors and establish a prediction model.

Results

In univariate and multivariate analysis, body mass index (BMI) [odds ratio (OR) =0.91], congestive heart failure, hypertension, age ≥75 years, diabetes, stroke₂ attack (CHADS₂) score (OR =0.49) and bleeding history or predisposition, labile international normalized ratio (INR), elderly, drug/alcohol usage (BLED) score (OR =1.71) were shown to be significant risk factors for short-term AE. The XGbosst algorithm was used to predict short-term AE based on 15 possible risk factors. For long-term AE, Cox regression was used for the prediction. The CHADS₂ score [hazard ratio (HR) =1.43], hypertension (HR =2.18), age more than 75 (HR =0.49), diabetes (HR =0.57), BLED score (HR=0.28), stroke (HR =19.8), hepatopathy (HR =3.97), nephropathy (HR =2.93), INR instability (HR =4.18), drinking (HR =2.67), and drugs (HR =2.36) were significant risk factors for long-term AE. The XGBoost had a good receiver operating characteristic (ROC) curve and area under the curve (AUC) was 0.85. The accuracy of the XGBoost model stayed at nearly 0.95.

Conclusions

In short- and long-term AE, CHADS₂ score and BLED score were the most obvious risk factors. Several other risk factors also played roles in AE of LAAC. The incidence of long-term AE is under 15% and LAAC is effective and safe. The XGBoost model had good prediction accuracy and ROC curve.