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Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
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Pastormerlo LE, De Caterina AR, Esposito A, Korsholm K, Berti S. State-of-the-Art of Transcatheter Left Atrial Appendage Occlusion. J Clin Med 2024; 13:939. [PMID: 38398253 PMCID: PMC10889674 DOI: 10.3390/jcm13040939] [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: 01/07/2024] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024] Open
Abstract
Left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in patients with atrial fibrillation, especially in patients with absolute/relative contraindications to these therapies. This review will cover three main aspects of the procedure. In the fist part of the manuscript, we focus on patient selection. We describe three main categories of patients with primary indication to LAAO, namely patients with previous or at a high risk of intracerebral bleeding, patients with a history of major gastrointestinal bleeding and patients with end-stage renal disease and absolute contraindication to novel oral anticoagulants. Some other potential indications are also described. In the second part of the manuscript, we review available devices, trying to highlight different aspects and potential specific advantages. The last section overviews different ways for pre-, intra- and postprocedural imaging, in order to improve procedural safety and efficacy and ameliorate patient outcome. The characteristics of available contemporary devices and the role of imaging in procedural planning, intraprocedural guidance and follow-up are described.
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Affiliation(s)
- Luigi Emilio Pastormerlo
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
| | | | - Augusto Esposito
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, C319, 8200 Aarhus, Denmark
| | - Sergio Berti
- UOC Diagnostica Interventistica Fondazione Toscana Gabriele Monasterio Massa, 54100 Massa, Italy
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Flores-Umanzor E, Asghar A, Cepas-Guillén PL, Farrell A, Keshvara R, Alvarez-Rodriguez L, Osten M, Freixa X, Horlick E, Abrahamyan L. Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis. Clin Res Cardiol 2023:10.1007/s00392-023-02359-1. [PMID: 38112741 DOI: 10.1007/s00392-023-02359-1] [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: 09/14/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative. OBJECTIVE This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD). METHODS Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies. RESULTS We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade. CONCLUSIONS Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO. Transcatheter Left Atrial Appendage Occlusion (laao) Can Prevent Cardioembolic Events In Chronic Kidney Disease (ckd) Patients. However, Ckd Patients, Particularly Those With End-stage Renal Disease/dialysis (esrd), May Face Increased Odds Of Acute Kidney Injury, In-hospital And Long-term Bleeding, And Mortality. Notably, These Adverse Outcomes In Ckd Patients May Be Linked To Their High Comorbidity Burden, Particularly In Those With Esrd, Rather Than The Laao Procedure Itself. Careful Patient Selection, Management, And Surveillance Involving Multidisciplinary Teams Are Essential For Ckd Patients Undergoing Laao To Ensure Maximum Clinical Benefit Transcatheter left atrial appendage occlusion (LAAO) can prevent cardioembolic events in chronic kidney disease (CKD) patients. However, CKD patients, particularly those with end-stage renal disease/dialysis (ESRD), may face increased odds of acute kidney injury, in-hospital and long-term bleeding, and mortality. Notably, these adverse outcomes in CKD patients may be linked to their high comorbidity burden, particularly in those with ESRD, rather than the LAAO procedure itself. Careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO to ensure maximum clinical benefit.
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Affiliation(s)
- Eduardo Flores-Umanzor
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Areeba Asghar
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Pedro L Cepas-Guillén
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Ashley Farrell
- Library and Information Services, University Health Network, Toronto, ON, Canada
| | - Rajesh Keshvara
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Leyre Alvarez-Rodriguez
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Mark Osten
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Eric Horlick
- Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Lusine Abrahamyan
- Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
- Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
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4
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Liu C, Han S, Cui K, Wang F. Efficacy and safety of patients with chronic kidney disease undergoing left atrial appendage closure for atrial fibrillation. PLoS One 2023; 18:e0287928. [PMID: 37883421 PMCID: PMC10602315 DOI: 10.1371/journal.pone.0287928] [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: 10/28/2023] Open
Abstract
BACKGROUND The relative safety and efficacy of left atrial appendage closure (LAAC) for atrial fibrillation (AF) in patients with chronic kidney disease (CKD) have not been well defined. To evaluate the results in this cohort, we conducted a systematic review and meta-analysis of observational studies. METHODS We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to January 2023 for all relevant studies. Our inclusion criteria were met by twelve observational studies that included 61324 patients altogether. RESULTS Compared with no CKD group, in-hospital mortality (OR: 2.84, 95% CI: 2.12-3.81, p<0.01, I2 = 0%), acute kidney injury (AKI) (OR: 4.39,95% CI:4.00-4.83, P<0.01, I2 = 3%), major bleeding events (OR: 1.44, 95% CI: 1.29-1.60, p<0.01 I2 = 0%), and pericardial effusion/tamponade (OR 1.30; 95% CI 1.13-1.51, p < 0.01; I2 = 0%) were more common in the CKD group, especially in patients with end-stage renal disease (ESRD). No significant difference was observed in the occurrence of stroke (OR: 1.24, 95% CI: 0.86-1.78, P = 0.25, I2 = 0%), LAAC success rates (OR: 1.02, 95% CI: 0.33-3.16, p = 0.97, I2 = 58%) and vascular access complications (OR: 1.13, 95% CI: 0.91-1.39, p = 0.28, I2 = 0%) between the two groups. During the follow-up, there was no difference in the risk of stroke between the two groups. CONCLUSIONS CKD patients who receive LAAC have a greater risk of in-hospital mortality, AKI, pericardial effusion/tamponade, and major bleeding events than those without CKD, especially in patients with ESRD. No significant difference in the risk of stroke was found in the long-term follow-up after LAAC between the two groups, demonstrating a similar efficacy of LAAC to prevent stroke in CKD patients.
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Affiliation(s)
- Chaofan Liu
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Shaojie Han
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Fang Wang
- Guang’an Shi Zhongyi Yiyuan: Guang’an Hospital of Traditional Chinese Medicine, Beijing, China
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5
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Guérios EE, Chamié F. Percutaneous left atrial appendage closure: beyond the classic indications. ASIAINTERVENTION 2023; 9:70-77. [PMID: 36936101 PMCID: PMC10015488 DOI: 10.4244/aij-d-22-00040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 08/29/2022] [Indexed: 03/16/2023]
Abstract
Percutaneous left atrial appendage closure (LAAC) has proven to be an effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). International guidelines traditionally recommend LAAC for NVAF patients at high thromboembolic risk and contraindication to or at high risk for OAC. However, there are many other clinical situations in which this procedure may also be beneficial. This paper discusses the potential role of LAAC in specific haemorrhagic diseases (cerebral amyloid angiopathy, age-related macular degeneration, hereditary haemorrhagic telangiectasia, and Moyamoya disease), after left atrial appendage (LAA) electrical isolation, in cases of persistent thrombus inside the LAA, in end-stage renal disease and in special groups of patients for whom low compliance and persistence to OAC may be anticipated.
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Affiliation(s)
- Enio E Guérios
- Department of Interventional Cardiology, Pilar Hospital, Curitiba, Brazil
| | - Francisco Chamié
- Department of Interventional Cardiology, Hospital dos Servidores do Estado, Rio de Janeiro, Brazil
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6
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Mathai SV, Sohal S, Flatow E, Nagaraj S, Hajra A, Chugh Y, Palaiodimos L, Lee HJ, Ansari J, Cohen M, Volgman AS, Faillace R. Sex Differences in Periprocedural and Long-Term Outcomes Following Transcatheter Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 48:23-31. [PMID: 36336589 DOI: 10.1016/j.carrev.2022.10.002] [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: 07/18/2022] [Revised: 10/01/2022] [Accepted: 10/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) is among the most common arrhythmias associated with an increased risk of cardioembolic phenomena, including stroke. Percutaneous left atrial appendage occlusion (LAAO) has proven beneficial in reducing stroke and mortality in patients with atrial fibrillation who have contraindications to anticoagulation. However, the sex differences in outcomes following LAAO have not been studied systematically. METHODS Electronic databases PUBMED, Embase, and Web of Science were systematically searched until March 2022 for studies evaluating patient outcomes following LAAO for AF. The primary outcomes of interest were the risks of periprocedural stroke, major bleeding, pericardial complications, and all-cause mortality. Secondary outcomes included stroke risks, major bleeding, device-related thrombus, cardiovascular and all-cause mortality on long-term follow-up. A random-effects model meta-analysis was conducted, and heterogeneity was assessed using the I-squared test. RESULTS Sixteen studies were included in the final analysis encompassing 111,775 patients, out of which 45,441 (40.7 %) were women. Women had a significantly higher risk of peri-procedural complications including all-cause mortality [relative risk (RR), 95 % confidence intervals (CI); RR 1.94, 95 % CI 1.40-2.69], stroke [RR 1.85, 95 % CI 1.29-2.67], major bleeding [RR 1.63, 95 % CI 1.08-2.44], and pericardial events [RR 1.80, 95 % CI 1.58-2.05]. However, there were no statistically significant differences between sexes in terms of risk of stroke, major bleeding, device-related thrombus, cardiovascular and all-cause mortality on long-term follow-up. CONCLUSION Among patients undergoing LAAO implantation, women were at higher risk of periprocedural complications than men. This risk was not significant on long-term follow-up.
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Affiliation(s)
- Sheetal Vasundara Mathai
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America.
| | - Sumit Sohal
- Division of Cardiology, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112, United States of America
| | - Elie Flatow
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America
| | - Sanjana Nagaraj
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America
| | - Adrija Hajra
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America
| | - Yashasvi Chugh
- Division of Interventional and Structural Cardiology, Department of Medicine, Minneapolis Heart Institute, Minneapolis, MN, United States of America
| | - Leonidas Palaiodimos
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America
| | - Hyon Jae Lee
- Division of Cardiology, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112, United States of America
| | - Julia Ansari
- Division of Cardiology, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112, United States of America
| | - Marc Cohen
- Division of Cardiology, Department of Medicine, RWJ-BH Newark Beth Israel Medical Center, 201 Lyons Ave, Newark, NJ 07112, United States of America
| | - Annabelle Santos Volgman
- Division of Cardiology, Department of Medicine, Rush University Medical Center, 1620 W Harrison St, Chicago, IL 60612, United States of America
| | - Robert Faillace
- Department of Medicine, NYC Health +Hospitals/Jacobi Medical Center, 1400 Pelham Pkwy S, Bronx, NY 10461, United States of America
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Fink T, Paitazoglou C, Bergmann MW, Sano M, Keelani A, Sciacca V, Saad M, Eitel C, Heeger CH, Skurk C, Landmesser U, Thiele H, Stiermaier T, Fuernau G, Reil JC, Frey N, Kuck KH, Tilz RR, Sandri M, Eitel I. Left atrial appendage closure in end-stage renal disease and hemodialysis: Data from a German multicenter registry. Catheter Cardiovasc Interv 2023; 101:610-619. [PMID: 36682074 DOI: 10.1002/ccd.30559] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/02/2022] [Accepted: 12/31/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). OAC treatment has been proven feasible in mild-to-moderate chronic kidney disease (CKD). In contrast, the optimal antithrombotic management of AF patients with end-stage renal disease (ESRD) is unknown and LAAC has not been proven in these patients in prospective randomized clinical trials. OBJECTIVES The objective of this study is to evaluate safety and efficacy of LAAC in patients with ESRD. METHODS Patients undergoing LAAC were collected in a German multicenter real-world observational registry. A composite endpoint consisting of the occurrence of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleeding was assessed. Patients with ESRD were compared with propensity score-matched patients without severe CKD. ESRD was defined as a glomerular filtration rate < 15 ml/min/1.73 m2 or chronic hemodialysis treatment. RESULTS A total of 604 patients were analyzed, including 57 with ESRD and 57 propensity-matched patients. Overall, 596 endocardial and 8 epicardial LAAC procedures were performed. Frequency of major complications was 7.0% (42/604 patients) in the overall cohort, 8.8% (5/57 patients) in patients with ESRD, and 10.5% (6/57 patients) in matched controls (p = 0.75). The estimated event-free survival of the combined endpoint after 500 days was 90.7 ± 4.5% in patients with ESRD and 90.2 ± 5.5% in matched controls (p = 0.33). CONCLUSIONS LAAC had comparable procedural safety and clinical efficacy in patients with ESRD and patients without severe CKD.
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Affiliation(s)
- Thomas Fink
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Christina Paitazoglou
- Interventional Cardiology, Cardiologicum Hamburg, Hamburg, Germany.,Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Lübeck, Germany
| | | | - Makoto Sano
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany
| | - Ahmad Keelani
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany
| | - Vanessa Sciacca
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,Clinic for Electrophysiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Mohammed Saad
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Lübeck, Germany.,Department of Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Charlotte Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Christian-Hendrik Heeger
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité University Medicine, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité University Medicine, Berlin, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Thomas Stiermaier
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Georg Fuernau
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Jan-Christian Reil
- Department of Cardiology, Angiology and Intensive Care Medicine, University Heart Center Lübeck, Lübeck, Germany.,Clinic for General and Interventional Cardiology/Angiology, Herz- und Diabeteszentrum NRW, Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Norbert Frey
- Department of Cardiology, University Hospital Schleswig-Holstein, Kiel, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany.,Department of Cardiology, Angiology and Pneumology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg/Mannheim, Germany
| | - Karl-Heinz Kuck
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany.,LANS Medicum, Hamburg, Germany
| | - Roland R Tilz
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
| | - Marcus Sandri
- Department of Internal Medicine/Cardiology, Heart Center Leipzig, Leipzig, Germany
| | - Ingo Eitel
- Department of Cardiology, Angiology and Intensive Care Medicine-Division of Electrophysiology, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Germany
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8
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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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9
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Chen Y, Zhang Y, Qu L, Chen C, Su X, Chen Y. Sex Differences in Efficacy and Safety After Left Atrial Appendage Closure: A 4.3-Year Follow-Up Analysis. Front Cardiovasc Med 2022; 9:814958. [PMID: 35665257 PMCID: PMC9157540 DOI: 10.3389/fcvm.2022.814958] [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: 11/14/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Women are related to higher stroke risk and poorer outcome after stroke attack in patients with non-valvular atrial fibrillation (NVAF). The sex differences in efficacy and safety after left atrial appendage closure (LAAC) have remained elusive. This retrospective study aimed to investigate the safety, feasibility, and clinical outcomes of LAAC between women and men. Methods From 2014 to 2018, 395 patients who underwent LAAC in our center were enrolled in this retrospective study. Baseline clinical characteristics, procedural parameters, and postoperative follow-up data were collected and compared between women and men. Results The study included 154 women and 241 men. Compared with men, women were older (68.1 ± 7.9 vs. 64.6 ± 8.8, p < 0.01**), with higher CHA2DS2-VASc score (4.0 ± 1.7 vs. 3.0 ± 1.6, p < 0.01**). During the mean follow-up duration of 1,566 days (4.3 years), there were 39 major adverse cardiovascular events (MACE, including 19 cardiovascular or unexplained deaths, 15 ischemic strokes, and 5 major bleedings) recorded in 34 patients. The overall rate of ischemic stroke was 0.9 per 100 patient-years, and the overall rate of MACE was 2.1 per 100 patient-years. The cardiovascular or unexplained death and major bleeding were comparable between women and men. Compared with men, women had lower rates of ischemic stroke, fatal or disabling ischemic stroke, MACE, and fatal or disabling MACE, but none of them reached statistical differences (HR: 0.361, p = 0.099, HR: 0.429, p = 0.276, HR: 0.600, p = 0.170, and HR: 0.621, p = 0.254, respectively). In the adjusted analyses with multivariate Cox regression models, women had a lower fatal or disabling ischemic stroke rate compared with men (HR: 0.100, p = 0.041). Conclusion Left atrial appendage closure was feasible and safe for patients of both genders. The ischemic stroke, cardiovascular or unexplained death, and major bleeding were comparable between women and men. However, women were the independent protective factors against fatal or disabling ischemic stroke after LAAC implantation.
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10
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Nogami A, Kurita T, Kusano K, Goya M, Shoda M, Tada H, Naito S, Yamane T, Kimura M, Shiga T, Soejima K, Noda T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Kohsaka S, Mitamura H. JCS/JHRS 2021 guideline focused update on non‐pharmacotherapy of cardiac arrhythmias. J Arrhythm 2022; 38:1-30. [PMID: 35222748 PMCID: PMC8851582 DOI: 10.1002/joa3.12649] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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11
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Nogami A, Kurita T, Kusano K, Goya M, Shoda M, Tada H, Naito S, Yamane T, Kimura M, Shiga T, Soejima K, Noda T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Kohsaka S, Mitamura H. JCS/JHRS 2021 Guideline Focused Update on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2022; 86:337-363. [PMID: 34987141 DOI: 10.1253/circj.cj-21-0162] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | - Tsuyoshi Shiga
- Department of Clinical Pharmacology and Therapeutics, The Jikei University School of Medicine
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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12
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Vallurupalli S, Sharma T, Al’Aref S, Devabhaktuni SR, Dhar G. Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease. KIDNEY360 2021; 3:396-402. [PMID: 35373133 PMCID: PMC8967650 DOI: 10.34067/kid.0004082021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/06/2021] [Indexed: 01/10/2023]
Abstract
Anticoagulation to reduce thromboembolic stroke risk due to nonvalvular atrial fibrillation in ESKD is associated with increased bleeding. There is an existing debate in ESKD centers around the pros and cons of anticoagulation. We propose percutaneous left atrial appendage occlusion as a third alternative to balance thrombosis and bleeding risks in this high-risk population.
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Affiliation(s)
- Srikanth Vallurupalli
- University of Arkansas for Medical Sciences, Little Rock, Arkansas,Central Arkansas Veterans Healthcare System, Little Rock, Arkansas,Correspondence: Srikanth Vallurupalli, University of Arkansas for Medical Sciences, 4301 West Markham St, slot 532, Little Rock, AR 72205.
| | - Tanya Sharma
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Subhi Al’Aref
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | - Gaurav Dhar
- University of Arkansas for Medical Sciences, Little Rock, Arkansas,Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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13
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Ahuja KR, Ariss RW, Nazir S, Vyas R, Saad AM, Macciocca M, Moukarbel GV. The Association of Chronic Kidney Disease With Outcomes Following Percutaneous Left Atrial Appendage Closure. JACC Cardiovasc Interv 2021; 14:1830-1839. [PMID: 34412801 DOI: 10.1016/j.jcin.2021.06.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 05/17/2021] [Accepted: 06/08/2021] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the associations of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with in-hospital and short-term outcomes using a large national database representative of contemporary clinical practice. BACKGROUND CKD and ESRD are associated with increased risk for stroke and bleeding in patients with atrial fibrillation on oral anticoagulation. Left atrial appendage closure (LAAC) may provide a reasonable alternative for these patients; however, the impact of CKD and ESRD on in-hospital and short-term outcomes following LAAC remain largely unknown. METHODS The Nationwide Readmissions Database was used to identify LAAC procedures from 2016 to 2017 in patients with no CKD, CKD (stages I-V), and ESRD. Multivariable logistic regression models were used to assess in-hospital and short-term outcomes. The primary outcome was in-hospital mortality. RESULTS Of 21,274 patients who underwent LAAC during the study period, 3,954 (18.6%) had CKD and 571 (2.7%) had ESRD. ESRD was associated with increased risk for in-hospital mortality compared with no CKD (3.3% vs 0.4%; adjusted odds ratio: 6.48; 95% confidence interval: 3.35-12.50; P < 0.001) and CKD (3.3% vs 0.5%; adjusted odds ratio: 11.43; 95% confidence interval: 4.77-27.39; P < 0.001). CKD was associated with increased risk for in-hospital acute kidney injury or hemodialysis and stroke or transient ischemic attack. ESRD and CKD were associated with increased readmissions extending to 90 days compared with no CKD, and ESRD was associated with increased readmissions compared with CKD. There was no difference with respect to other in-hospital outcomes. CONCLUSIONS ESRD is associated with higher in-hospital mortality, and CKD is associated with higher rates of stroke or transient ischemic attack in patients undergoing LAAC. Further research is needed to assess the impact of CKD and ESRD on long-term outcomes in these patients.
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Affiliation(s)
- Keerat Rai Ahuja
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - Robert W Ariss
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Salik Nazir
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Rohit Vyas
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA
| | - Anas M Saad
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Michael Macciocca
- Division of Cardiology, Reading Hospital-Tower Health System, West Reading, Pennsylvania, USA
| | - George V Moukarbel
- Division of Cardiovascular Medicine, University of Toledo, Toledo, Ohio, USA.
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14
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Abdul Ghaffar Y, Osman M, Al-Harbi A, Munir MB, Daggubati R. Meta-Analysis of Device Related Thrombosis After Left Atrial Appendage Occlusion in Women Versus Men. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 31:89-90. [PMID: 33781678 DOI: 10.1016/j.carrev.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 11/18/2020] [Indexed: 11/26/2022]
Affiliation(s)
| | - Mohammed Osman
- West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Anas Al-Harbi
- West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
| | - Muhammad Bilal Munir
- West Virginia University Heart & Vascular Institute, Morgantown, WV, USA; Divison of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Ramesh Daggubati
- West Virginia University Heart & Vascular Institute, Morgantown, WV, USA
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15
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Magnocavallo M, Bellasi A, Mariani MV, Fusaro M, Ravera M, Paoletti E, Di Iorio B, Barbera V, Della Rocca DG, Palumbo R, Severino P, Lavalle C, Di Lullo L. Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy. J Clin Med 2020; 10:jcm10010083. [PMID: 33379379 PMCID: PMC7796391 DOI: 10.3390/jcm10010083] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/21/2020] [Accepted: 12/22/2020] [Indexed: 12/17/2022] Open
Abstract
Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.
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Affiliation(s)
- Michele Magnocavallo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Antonio Bellasi
- Department of Research, Innovation and Brand Reputation, ASST-Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Maria Fusaro
- National Council of Research, Institute of Clinical Physiology, 56124 Pisa, Italy;
| | - Maura Ravera
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Ernesto Paoletti
- Nefrologia, Dialisi e Trapianto, Policlinico San Martino, 16132 Genova, Italy; (M.R.); (E.P.)
| | - Biagio Di Iorio
- Department of Nephrology and Dialysis, Moscati Hospital, 83100 Avellino, Italy;
| | - Vincenzo Barbera
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
| | | | - Roberto Palumbo
- Department of Nephrology and Dialysis, Sant’Eugenio Hospital, 00144 Rome, Italy;
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Policlinico Universitario Umberto I, Sapienza University of Rome, 00161 Rome, Italy; (M.M.); (M.V.M.); (P.S.); (C.L.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, Parodi-Delfino Hospital, 00034 Colleferro, Italy;
- Correspondence: ; Fax: +39-06-972233213
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16
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Busu T, Khan SU, Alhajji M, Alqahtani F, Holmes DR, Alkhouli M. Observed versus Expected Ischemic and Bleeding Events Following Left Atrial Appendage Occlusion. Am J Cardiol 2020; 125:1644-1650. [PMID: 32273055 DOI: 10.1016/j.amjcard.2020.02.041] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/22/2020] [Accepted: 02/25/2020] [Indexed: 12/14/2022]
Abstract
Data on the efficacy of left atrial appendage occlusion (LAAO) in clinical practice are limited. We performed a systematic review and meta-analysis of observational studies that reported observed versus expected rates of ischemic strokes and/or major bleeding following LAAO. Our primary end points were the pooled relative risk reduction (RRR) in ischemic stroke and major bleeding with corresponding 95% confidence intervals compared with what was expected by the CHA2DS2-VASc and HASBLED scores, respectively. Twenty-nine studies including 11,071 patients (age 74.0 ± 8.7 years, 60% males) met the inclusion criteria. The mean CHA2DS2-VASc score was 4.22 ± 1.48, and the mean HASBLED score was 3.04 ± 1.16. During 19,567 patient-year follow-up, 290 of 11,071 patients (2.62%) suffered an acute ischemic stroke. This represented a 73.6% (95% confidence interval 68.9-78.2%) RRR in ischemic strokes compared with what was expected based on the CHA2DS2-VASc score. A total of 26 studies reported observed versus expected major bleeding (10,056 patients; age 74.0 ± 8.7, 60% males). During 16,967 patient-year follow-up, 404 of 10,056 patients (4.0%) suffered a major bleeding event. This represented a 55% (95% confidence interval 44.2% to -65.9%) RRR in major bleeding compared with what was expected based on the HASBLED score. These estimates were consistent across subgroups stratified according to age, CHADS2VASc, HASBLED scores and type of LAAO device used. In conclusion, LAAO is associated with a favorable observed/expected ratio with regards to ischemic stroke and major bleeding in clinical practice. Future clinical trials remain essential to further assess the efficacy of LAAO via a direct comparison with oral anticoagulation.
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17
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Black-Maier E, Piccini JP, Granger CB. Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:2968-2976. [PMID: 31520437 DOI: 10.1111/jce.14182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short-term warfarin therapy is noninferior to long-term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life-threatening bleeding compared to OAC. Although direct-acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end-stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device-related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.
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Affiliation(s)
- Eric Black-Maier
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christopher B Granger
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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