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Fernandes JM, Pinheiro RPS, Serpa F, de Andrade NM, Pereira V, Sbardelotto ÂEE, Gomes WF. Left atrial appendage occlusion devices vs direct oral anticoagulants for atrial fibrillation: An updated systematic review and meta-analysis. Curr Probl Cardiol 2024; 50:102880. [PMID: 39395644 DOI: 10.1016/j.cpcardiol.2024.102880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Accepted: 10/08/2024] [Indexed: 10/14/2024]
Abstract
BACKGROUND Direct Oral Anticoagulants (DOACs) are the first line anticoagulation for patients with non-valvular atrial fibrillation (NVAF). Percutaneous Left Atrial Appendage Occlusion (LAAO) has emerged as a new therapy and its safety and effectiveness compared with DOACs are still controversial. METHODS A systematic review of randomized controlled trials and observational studies was conducted, focusing on patients with NVAF. Outcomes analyzed included: (1) all-cause mortality; (2) cardiovascular (CV) mortality; (3) thromboembolic events; (4) stroke or transient ischemic attack (TIA); (5) bleeding events; and a (6) composite of death, hemorrhagic, and thromboembolic events. We performed a subgroup analysis of major bleeding according to different definitions: (1) Bleeding Academic Research Consortium (BARC); (2) International Society on Thrombosis and Haemostasis (ISTH); and (3) other definitions. RESULTS Ten studies involving 18,507 patients were included, with 42.35 % undergoing LAAO. In pooled analysis, LAAO was associated with lower rates of all-cause mortality (HR 0.63; 95 % CI 0.50-0.80), cardiovascular mortality (HR 0.56; 95 % CI 0.45-0.70), and of the composite outcome (HR 0.73; 95 % CI 0.58-0.92). A trend towards lower stroke/TIA events was observed but not statistically significant. Overall bleeding events did not significantly differ between groups; using the ISTH definition, LAAO showed significantly lower incidence of bleeding events (HR 0.63; 95 % CI 0.43-0.91). No difference was found in thromboembolic events. CONCLUSION LAAO was associated with a significantly lower all-cause mortality and cardiovascular mortality, as well as the composite of death, hemorrhagic or thromboembolic events, as compared with DOACs.
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Affiliation(s)
- Julia M Fernandes
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Rua Comendador Elias Jafet, 755- São Paulo, São Paulo, 05653-000, Brazil.
| | - Rafael P S Pinheiro
- Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255- Rio de Janeiro, Rio de Janeiro, 21941-617, Brazil.
| | - Frans Serpa
- Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, Texas, 75390, USA.
| | - Naieli M de Andrade
- Escola Bahiana de Medicina e Saúde Pública- Bahia, Av. Dom João VI, 275, Salvador, Bahia, 40290-000, Brazil.
| | - Vinicius Pereira
- Facultad Ciencias Biomédicas, Universidad Austral, Av. Juan Domingo Perón, 1500- Pilar, Buenos Aires, B1629, Argentina.
| | - Ângelo E E Sbardelotto
- Universidade Federal do Rio de Janeiro, Rua Professor Rodolpho Paulo Rocco, 255- Rio de Janeiro, Rio de Janeiro, 21941-617, Brazil.
| | - Wilton F Gomes
- INC Hospital, Department of Interventional Cardiology, Universidade Federal do Paraná, Faculdades Pequeno Príncipe, Hospital Santa Casa de Misericórdia de Curitiba, Rua Jeremias Maciel Perretto, 300, Curitiba, Paraná, 81210-310, Brazil.
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2
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D'Anna L, Abu-Rumeileh S, Merlino G, Ornello R, Foschi M, Diana F, Barba L, Mastrangelo V, Romoli M, Lobotesis K, Bax F, Kuris F, Valente M, Otto M, Korompoki E, Sacco S, Gigli GL, Nguyen TN, Banerjee S. Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review. J Am Heart Assoc 2024; 13:e034783. [PMID: 38874062 DOI: 10.1161/jaha.124.034783] [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: 06/15/2024]
Abstract
There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
- Department of Brain Sciences Imperial College London London United Kingdom
| | - Samir Abu-Rumeileh
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | - Giovanni Merlino
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Francesco Diana
- Interventional Neuroradiology Vall d'Hebron University Hospital Barcelona Catalunya Spain
| | - Lorenzo Barba
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | | | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience Bufalini Hospital, Azienda Unità Sanitaria Locale Romagna Cesena Italy
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
| | - Francesco Bax
- Philip Kistler Research Center, Department of Neurology Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Fedra Kuris
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Mariarosaria Valente
- Clinical Neurology Udine University Hospital and Dipartmento di Area Medica, University of Udine Udine Italy
| | - Markus Otto
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | - Eleni Korompoki
- Department of Brain Sciences Imperial College London London United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Gian Luigi Gigli
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Thanh N Nguyen
- Department of Neurology, Radiology Boston Medical Center Boston MA USA
| | - Soma Banerjee
- Department of Stroke and Neuroscience Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
- Department of Brain Sciences Imperial College London London United Kingdom
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Sablić S, Dolić K, Budimir Mršić D, Čičmir-Vestić M, Matana A, Lovrić Kojundžić S, Marinović Guić M. Communicating Arteries and Leptomeningeal Collaterals: A Synergistic but Independent Effect on Patient Outcomes after Stroke. Neurol Int 2024; 16:620-630. [PMID: 38921950 PMCID: PMC11206870 DOI: 10.3390/neurolint16030046] [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: 04/25/2024] [Revised: 05/29/2024] [Accepted: 05/29/2024] [Indexed: 06/27/2024] Open
Abstract
The collateral system is a compensatory mechanism activated in the acute phase of an ischemic stroke. It increases brain perfusion to the hypoperfused area. Arteries of the Willis' circle supply antegrade blood flow, while pial (leptomeningeal) arteries direct blood via retrograde flow. The aim of our retrospective study was to investigate the relationship between both collateral systems, computed tomography perfusion (CTP) values, and functional outcomes in acute stroke patients. Overall, 158 patients with anterior circulation stroke who underwent mechanical thrombectomy were included in the study. We analyzed the presence of communicating arteries and leptomeningeal arteries on computed tomography angiography. Patients were divided into three groups according to their collateral status. The main outcomes were the rate of functional independence 3 months after stroke (modified Rankin scale score, mRS) and mortality rate. Our study suggests that the collateral status, as indicated by the three groups (unfavorable, intermediate, and favorable), is linked to CT perfusion parameters, potential recuperation ratio, and stroke outcomes. Patients with favorable collateral status exhibited smaller core infarct and penumbra volumes, higher mismatch ratios, better potential for recuperation, and improved functional outcomes compared to patients with unfavorable or intermediate collateral status.
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Affiliation(s)
- Sara Sablić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
| | - Krešimir Dolić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Danijela Budimir Mršić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
| | - Mate Čičmir-Vestić
- Department of Neurology, University Hospital of Split, 21000 Split, Croatia;
| | - Antonela Matana
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Sanja Lovrić Kojundžić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
| | - Maja Marinović Guić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital of Split, 21000 Split, Croatia; (S.S.); (K.D.); (D.B.M.); (S.L.K.)
- School of Medicine, University of Split, 21000 Split, Croatia
- University Department of Health Studies, University of Split, 21000 Split, Croatia;
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Zheng W, Tang Y, Lin H, Huang H, Lei H, Lin H, Huang Y, Lin X, Liu N, Du H. Atrial Fibrillation and Clinical Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-Analysis of Adjusted Effect Estimates. J Am Heart Assoc 2023; 12:e031733. [PMID: 38108252 PMCID: PMC10863768 DOI: 10.1161/jaha.123.031733] [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: 07/11/2023] [Accepted: 11/08/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND The impact of atrial fibrillation (AF) on the clinical outcomes in patients with acute ischemic stroke (AIS) who received endovascular thrombectomy remains unclear. We aimed to perform a meta-analysis of adjusted effect estimates to examine the association between the presence of AF and the clinical outcomes in patients with AIS who received endovascular thrombectomy. METHODS AND RESULTS We searched PubMed, Embase, and the Cochrane database between January 1, 2013 and July 10, 2023. Data were meta-analyzed to compare the outcomes among patients with AIS with and without AF who received endovascular thrombectomy. Our primary outcome was 90-day functional independence defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes included excellent independence (90-day modified Rankin Scale score of 0-1), 90-day mortality, symptomatic intracranial hemorrhage, and any intracranial hemorrhage. Eighteen observational studies comprising 16 096 patients with AIS (mean age, 70.1 years; women, 48.2%; 6862 with AF versus 9234 without AF) were included. There were no statistically significant differences for modified Rankin Scale score of 0 to 2 (pooled odds ratio [OR], 1.14 [95% CI, 0.95-1.37]; [95% prediction interval [PI], 0.72-1.80]), mortality (OR, 0.92 [95% CI, 0.79-1.08]; [95% PI, 0.77-1.11]), symptomatic intracranial hemorrhage (OR, 0.97 [95% CI, 0.71-1.32]; [95% PI, 0.43-2.17]), and any intracranial hemorrhage (OR, 1.08 [95% CI, 0.91-1.28]; [95% PI, 0.74-1.58]) among patients with AIS with and without AF. CONCLUSIONS This meta-analysis detected no significant differences in 90-day functional outcomes, mortality, and intracerebral hemorrhage risk after endovascular thrombectomy in patients with AIS with and without AF. REGISTRATION URL: https://www.crd.york.ac.uk/prospero; Unique identifier: CRD 42021293511.
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Affiliation(s)
- Wei Zheng
- Department of NeurologyFujian Provincial Geriatric HospitalFuzhouChina
- Fujian Medical University Teaching HospitalFuzhouChina
| | - Yi Tang
- Department of NeurologyFujian Provincial Geriatric HospitalFuzhouChina
- Fujian Medical University Teaching HospitalFuzhouChina
| | - Huajing Lin
- Department of NeurologyFujian Provincial Geriatric HospitalFuzhouChina
- Fujian Medical University Teaching HospitalFuzhouChina
| | - Huapin Huang
- Stroke Research Center, Department of NeurologyFujian Medical University Union HospitalFuzhouFujianChina
- Institute of Clinical Neurology, Fujian Medical UniversityFuzhouChina
| | - Hanhan Lei
- Stroke Research Center, Department of NeurologyFujian Medical University Union HospitalFuzhouFujianChina
| | - Huiying Lin
- Stroke Research Center, Department of NeurologyFujian Medical University Union HospitalFuzhouFujianChina
| | - Ying Huang
- Department of NeurologyFujian Provincial Geriatric HospitalFuzhouChina
- Fujian Medical University Teaching HospitalFuzhouChina
| | - Xiaojuan Lin
- Department of NeurologyFujian Provincial Geriatric HospitalFuzhouChina
- Fujian Medical University Teaching HospitalFuzhouChina
| | - Nan Liu
- Stroke Research Center, Department of NeurologyFujian Medical University Union HospitalFuzhouFujianChina
- Institute of Clinical Neurology, Fujian Medical UniversityFuzhouChina
- Department of RehabilitationFujian Medical University Union HospitalFuzhouFujianChina
| | - Houwei Du
- Stroke Research Center, Department of NeurologyFujian Medical University Union HospitalFuzhouFujianChina
- Institute of Clinical Neurology, Fujian Medical UniversityFuzhouChina
- Department of RehabilitationFujian Medical University Union HospitalFuzhouFujianChina
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Patel J, Bhaskar SMM. Diagnosis and Management of Atrial Fibrillation in Acute Ischemic Stroke in the Setting of Reperfusion Therapy: Insights and Strategies for Optimized Care. J Cardiovasc Dev Dis 2023; 10:458. [PMID: 37998516 PMCID: PMC10672610 DOI: 10.3390/jcdd10110458] [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: 10/03/2023] [Revised: 10/25/2023] [Accepted: 11/10/2023] [Indexed: 11/25/2023] Open
Abstract
Reperfusion therapy in the form of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) has revolutionised the field of stroke medicine. Atrial fibrillation (AF) patients constitute a major portion of the overall stroke population; however, the prevalence of AF amongst acute ischemic stroke (AIS) patients receiving reperfusion therapy remains unclear. Limitations in our understanding of prevalence in this group of patients are exacerbated by difficulties in appropriately diagnosing AF. Additionally, the benefits of reperfusion therapy are not consistent across all subgroups of AIS patients. More specifically, AIS patients with AF often tend to have poor prognoses despite treatment relative to those without AF. This article aims to present an overview of the diagnostic and therapeutic management of AF and how it mediates outcomes following stroke, most specifically in AIS patients treated with reperfusion therapy. We provide unique insights into AF prevalence and outcomes that could allow healthcare professionals to optimise the treatment and prognosis for AIS patients with AF. Specific indications on acute neurovascular management and secondary stroke prevention in AIS patients with AF are also discussed.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab, Sydney 2150, Australia
- South Western Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney 2170, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney 2150, Australia
- Ingham Institute for Applied Medical Research, Neurovascular Imaging Laboratory, Clinical Sciences Stream, Sydney 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South Western Sydney Local Health District (SWSLHD), Sydney 2170, Australia
- Department of Neurology, National Cerebral and Cardiovascular Center (NCVC), Suita 564-8565, Osaka, Japan
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