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Cimmino G, Loffredo FS, Gallinoro E, Prozzo D, Fabiani D, Cante L, Salerno G, Cappelli Bigazzi M, Golino P. Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:444. [PMID: 34063719 PMCID: PMC8147783 DOI: 10.3390/medicina57050444] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/22/2021] [Accepted: 04/29/2021] [Indexed: 12/31/2022]
Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.
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Affiliation(s)
- Giovanni Cimmino
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Francesco S. Loffredo
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
- Molecular Cardiology, International Centre for Genetic Engineering and Biotechnology, 34149 Trieste, Italy
| | - Emanuele Gallinoro
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Cardiovascular Center Aalst, OLV Clinic, 9300 Aalst, Belgium
| | - Dario Prozzo
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
| | - Dario Fabiani
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Luigi Cante
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | - Gemma Salerno
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
| | | | - Paolo Golino
- Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, 80131 Naples, Italy; (G.C.); (E.G.); (D.P.); (D.F.); (L.C.); (P.G.)
- Vanvitelli Cardiology Unit, Monaldi Hospital, 80131 Naples, Italy; (G.S.); (M.C.B.)
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Gallinoro E, D'Elia S, Prozzo D, Lioncino M, Natale F, Golino P, Cimmino G. Cognitive Function and Atrial Fibrillation: From the Strength of Relationship to the Dark Side of Prevention. Is There a Contribution from Sinus Rhythm Restoration and Maintenance? ACTA ACUST UNITED AC 2019; 55:medicina55090587. [PMID: 31540311 PMCID: PMC6780629 DOI: 10.3390/medicina55090587] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/07/2019] [Accepted: 09/10/2019] [Indexed: 12/12/2022]
Abstract
Atrial fibrillation (AF) is the most common chronic cardiac arrhythmia with an increasing prevalence over time mainly because of population aging. It is well established that the presence of AF increases the risk of stroke, heart failure, sudden death, and cardiovascular morbidity. In the last two decades several reports have shown an association between AF and cognitive function, ranging from impairment to dementia. Ischemic stroke linked to AF is a well-known risk factor and predictor of cognitive decline. In this clinical scenario, the risk of stroke might be reduced by oral anticoagulation. However, recent data suggest that AF may be a predictor of cognitive impairment and dementia also in the absence of stroke. Cerebral hypoperfusion, reduced brain volume, microbleeds, white matter hyperintensity, neuroinflammation, and genetic factors have been considered as potential mechanisms involved in the pathogenesis of AF-related cognitive dysfunction. However, a cause-effect relationship remains still controversial. Consequently, no therapeutic strategies are available to prevent AF-related cognitive decline in stroke-free patients. This review will analyze the potential mechanisms leading to cognitive dysfunction in AF patients and examine the available data on the impact of a sinus rhythm restoration and maintenance strategy in reducing the risk of cognitive decline.
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Affiliation(s)
- Emanuele Gallinoro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Saverio D'Elia
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Dario Prozzo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Michele Lioncino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Francesco Natale
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Paolo Golino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
| | - Giovanni Cimmino
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy.
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Oka H, Kamimura T, Hiramatsu Y, Fukumitsu K, Iwata R, Kondo M, Hirashima Y, Aihara S, Harada A, Tsuruya K. Cholesterol Crystal Embolism Induced by Direct Factor Xa Inhibitor: A First Case Report. Intern Med 2018; 57:71-74. [PMID: 28943551 PMCID: PMC5799060 DOI: 10.2169/internalmedicine.8660-16] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
An 80-year-old man presented at our hospital with renal failure. He had been treated with edoxaban, an oral direct factor Xa inhibitor, for deep vein thrombosis for 10 months prior to admission. Although the pulses in his bilateral pedal arteries were palpable, cyanosis was present in the bilateral toes. Laboratory data indicated azotemia and eosinophilia. A skin biopsy confirmed a diagnosis of cholesterol crystal embolism (CCE). Because no invasive vascular procedure was performed, we assumed that CCE was related to edoxaban. To the best of our knowledge, this is the first case report suggesting CCE induced by an Xa inhibitor.
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Affiliation(s)
- Hideaki Oka
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Taro Kamimura
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Yuki Hiramatsu
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Kento Fukumitsu
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Rei Iwata
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Mika Kondo
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | | | - Seishi Aihara
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Atsumi Harada
- Division of Kidney Center, Matsuyama Red Cross Hospital, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
- Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, Japan
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