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Benson JM, Keesee J, Smith L, Navarro J, Khouzam RN. The left atrial appendage: An enigmatic friend or foe and implications of closure. Curr Probl Cardiol 2024; 49:102620. [PMID: 38718930 DOI: 10.1016/j.cpcardiol.2024.102620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/05/2024] [Indexed: 05/19/2024]
Abstract
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.
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Affiliation(s)
- John-Michael Benson
- Grand Strand Medical Center, Department of Internal Medicine, Myrtle Beach, SC, United States.
| | - Jacob Keesee
- Grand Strand Medical Center, Department of Internal Medicine, Myrtle Beach, SC, United States
| | - Lincoln Smith
- Grand Strand Medical Center, Department of Internal Medicine, Myrtle Beach, SC, United States
| | - Jayden Navarro
- Edward Via College of Osteopathic Medicine, Spartanburg, SC, United States
| | - Rami N Khouzam
- Grand Strand Medical Center, Department of Internal Medicine, Myrtle Beach, SC, United States; Edward Via College of Osteopathic Medicine, Spartanburg, SC, United States; University of South Carolina (USC) School of Medicine, SC, United States; Mercer School of Medicine, GA, United States; University of Tennessee Health Science Center, TN, United States
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2
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Alarouri HS, Lo Russo GV, Chavez Ponce A, Akkawi AR, Mahayni A, Sularz A, Killu AM, Simard T, Singh G, Miranda WR, Alkhouli M. Association of transcatheter left atrial appendage occlusion with acute changes in left atrial pressure: An invasive hemodynamic study. Heart Rhythm 2024; 21:1024-1031. [PMID: 38365125 DOI: 10.1016/j.hrthm.2024.02.022] [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: 11/15/2023] [Revised: 01/29/2024] [Accepted: 02/11/2024] [Indexed: 02/18/2024]
Abstract
BACKGROUND The hemodynamic effects of transcatheter left atrial appendage occlusion (LAAO) remain unclear. OBJECTIVE We sought to assess the effect of LAAO on invasive hemodynamics and their correlation with clinical outcomes. METHODS We recorded mean left atrial pressure (mLAP) before and after device deployment. We assessed the prevalence and predictors of mLAP increase after deployment, the association between significant mLAP increase after deployment and 45-day peridevice leak (PDL), and the association between mLAP increase and heart failure (HF) hospitalization. A significant mLAP increase was defined as one equal to or greater than the mean percentage increase in mLAP after deployment (≥28%). RESULTS We included 302 patients (36.4% female; mean age, 75.8 ± 9.5 years). After deployment, mLAP increased in 48% of patients, 38% of whom experienced significant mLAP increase. Independent predictors of mLAP increase were baseline mLAP ≤14 mm Hg, nonparoxysmal atrial fibrillation, and age per 5 years (odds ratios: 3.66 [95% CI, 2.21-6.05], 1.81 [95% CI, 1.08-3.02], and 0.85 [95% CI, 0.73-0.99], respectively). Significant mLAP increase was an independent predictor of 45-day PDL (odds ratio, 2.55; 95% CI, 1.04-6.26). There was no association between mLAP increase and HF hospitalization. CONCLUSION After deployment, mLAP acutely rises in 48% of patients, although this is not associated with increased HF hospitalizations. PDL is more likely to develop at 45 days in patients with significant increase in mLAP after deployment, although most leaks were small (<5 mm). These findings suggest that mLAP increase after deployment is not associated with major safety concerns. Additional studies are warranted to explore the long-term hemodynamic effects of LAAO.
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Affiliation(s)
- Hasan S Alarouri
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gerardo V Lo Russo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Abdul-Rahman Akkawi
- Department of Internal Medicine, University of Kansas Medical Center, Wichita, Kansas
| | - Abdulah Mahayni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Agata Sularz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ammar M Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Gurpreet Singh
- Department of Cardiovascular Medicine, Mayo Clinic Health System, Eau Claire, Wisconsin
| | - William R Miranda
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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3
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Maigrot JLA, Weiss AJ, Zhou G, Jenkins HN, Koroukian SM, Dewan KC, Soltesz EG. Outcomes After Left Atrial Appendage Clip Placement During Cardiac Surgery: A Nationwide Analysis. Am J Cardiol 2024; 220:39-46. [PMID: 38583697 DOI: 10.1016/j.amjcard.2024.03.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/05/2024] [Accepted: 03/23/2024] [Indexed: 04/09/2024]
Abstract
This study evaluated the nationwide associations between concomitant left atrial appendage clip (LAAC) placement during cardiac surgery and postoperative outcomes. We identified 1,260,999 patients who underwent coronary artery bypass grafting, valve, and aortic surgeries in the 2016 to 2020 Nationwide Readmissions Database and stratified by concomitant LAAC versus no LAAC placement. Patients who underwent surgical ablation were excluded. Mortality and complications were compared during index admissions and for patients readmitted within 30 and 90 days of the index discharge date for unmatched and propensity score-matched groups. Overall, 6.7% (84,293) of patients underwent cardiac surgery and concomitant LAAC placement without surgical ablation. After propensity score matching, the index admission mortality and overall complications were not different in patients with LAAC versus patients without LAAC. LAAC placement was associated with increased any-cause 30-day readmissions (15% vs 13%, p <0.01). In patients with LAAC, within 30 days, there were no differences in mortality (3.9% vs 3.8%, p = 0.60) or overall complications (64% vs 63%, p = 0.20), whereas stroke was lower (5.3% vs 6.5%, p <0.01) and heart failure was higher (35% vs 30%, p <0.01). For patients readmitted within 90 days, similar findings were observed for any-cause readmissions, mortality, overall complications, stroke, and heart failure. In conclusion, concomitant LAAC placement during cardiac surgery was associated with lower early postdischarge incidence of stroke and a favorable overall risk-benefit profile. Given these short-term findings in a real-world population of all patients who underwent cardiac surgery, longer-term studies with more granular data are needed to evaluate the potential benefit of this practice.
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Affiliation(s)
- Jean-Luc A Maigrot
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron J Weiss
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Guangjin Zhou
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Haley N Jenkins
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Siran M Koroukian
- Department of Population and Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Krish C Dewan
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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4
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Pasierski M, Batko J, Kuźma Ł, Wańha W, Jasiński M, Widenka K, Deja M, Bartuś K, Hirnle T, Wojakowski W, Lorusso R, Tobota Z, Maruszewski BJ, Suwalski P, Kowalewski M. Surgical ablation, left atrial appendage occlusion or both? Nationwide registry analysis of cardiac surgery patients with underlying atrial fibrillation. Eur J Cardiothorac Surg 2024; 65:ezae014. [PMID: 38218721 DOI: 10.1093/ejcts/ezae014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/23/2023] [Accepted: 01/11/2024] [Indexed: 01/15/2024] Open
Abstract
OBJECTIVES The aim of this study was to evaluate in-hospital outcomes and long-term survival of patients undergoing cardiac surgery with preoperative atrial fibrillation (AF). We compared different strategies, including no-AF treatment, left atrial appendage occlusion (LAAO) alone, concomitant surgical ablation (SA) alone or both. METHODS A retrospective analysis using the KROK registry included all patients with preoperative diagnosis of AF who underwent cardiac surgery in Poland between between January 2012 and December 2022. Risk adjustment was performed using regression analysis with inverse probability weighting of propensity scores. We assessed 6-year survival with Cox proportional hazards models. Sensitivity analysis was performed based on index cardiac procedure. RESULTS Initially, 42 510 patients with preoperative AF were identified, and, after exclusion, 33 949 included in the final analysis. A total of 1107 (3.26%) received both SA and LAAO, 1484 (4.37%) received LAAO alone, 3921 (11.55%) SA alone and the remaining 27 437 (80.82%) had no AF-directed treatment. As compared to no treatment, all strategies were associated with survival benefit over 6-year follow-up. A gradient of treatment was observed with the highest benefit associated with SA + LAAO followed by SA alone and LAAO alone (log-rank P < 0.001). Mortality benefits were reflected when stratified by surgery type with the exception of aortic valve surgery where LAAO alone fare worse than no treatment. CONCLUSIONS Among patients with preoperative AF undergoing cardiac surgery, surgical management of AF, particularly SA + LAAO, was associated with lower 6-year mortality. These findings support the benefits of incorporating SA and LAAO in the management of AF during cardiac surgery.
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Affiliation(s)
- Michał Pasierski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Jakub Batko
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- CAROL-Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Marek Jasiński
- Department and Clinic of Cardiac Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Kazimierz Widenka
- Clinical Department of Cardiac Surgery, District Hospital No. 2, Univeristy of Rzeszów, Rzeszów, Poland
| | - Marek Deja
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Tomasz Hirnle
- Department of Cardiosurgery, Medical University of Bialystok, Bialystok, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Centre Maastricht (CARIM), Maastricht, Netherlands
| | - Zdzisław Tobota
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Bohdan J Maruszewski
- Department of Pediatric Cardiothoracic Surgery, The Children's Memorial Health Institute, Warsaw, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Centre Maastricht (CARIM), Maastricht, Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
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5
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Sun J, Zhang R, Yang M, Li W, Zhang PP, Mo BF, Wang QS, Chen M, Li YG. Combined Radiofrequency Ablation and Left Atrial Appendage Closure in Atrial Fibrillation and Systolic Heart Failure. Diagnostics (Basel) 2023; 13:3325. [PMID: 37958221 PMCID: PMC10647617 DOI: 10.3390/diagnostics13213325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Managing patients with atrial fibrillation (AF) and comorbid heart failure (HF) with reduced (HFrEF) or mildly reduced ejection fraction (HFmrEF) is of clinical importance but a great challenge. This study aimed to evaluate the clinical benefit of the combined radiofrequency catheter ablation (RFCA) and left atrial appendage closure (LAAC) procedure in AF patients complicated with systolic HF. METHODS AF patients with HFrEF or HFmrEF who underwent the combined RFCA and LAAC procedure were prospectively enrolled in the LAACablation registry. The procedural complications and long-term outcomes were evaluated. Another cohort of AF patients with systolic HF who did not undergo either RFCA or LAAC were used for prognosis comparison. RESULTS Among 802 AF patients who underwent the combined procedure, 65 patients were comorbid with systolic HF (25 with HFrEF and 40 with HFmrEF). The overall procedural complication rate was 9.2%, which was mainly attributed to acute decompensated HF (6.2%). Accompanied with markedly reduced AF burden (from median [25th, 75th percentile]: 100 [100, 100] to 0 [0, 1.2]%, p < 0.001), upward trajectories of cardiac function were observed in 51 (78.4%) patients, showing improvement in New York Heart Classification (p < 0.01), natriuretic peptide levels (from 1492 [809, 3259] to 413 [163, 880] pg/mL, p < 0.001) and left ventricular EF (from 42.6 ± 5.3 to 53.8 ± 8.2%, p < 0.001). During the 27-month follow-up period, death, thromboembolism, major bleeding, and HF rehospitalization were observed in three, one, one, and four patients, respectively. The observed event rates showed a significant reduction compared with the non-procedure AF-HF cohort (n = 138; for composite endpoint: hazard ratio: 2.509, 95% confidence interval: 1.415-4.449, p = 0.002) and with the respective rates predicted by risk scores. CONCLUSIONS Combining RFCA and LAAC achieves acceptable safety and credible long-term efficacy in AF patients with systolic HF. Further randomized studies are warranted in a larger patient cohort.
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Affiliation(s)
| | | | | | | | | | | | | | - Mu Chen
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
| | - Yi-Gang Li
- Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai 200092, China
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Stöllberger C, Finsterer J, Schneider B. Stroke prevention in an octogenarian with atrial fibrillation, cerebral amyloid angiopathy and intracerebral hemorrhage. Clin Case Rep 2023; 11:e7630. [PMID: 37384229 PMCID: PMC10293576 DOI: 10.1002/ccr3.7630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/31/2023] [Accepted: 06/18/2023] [Indexed: 06/30/2023] Open
Abstract
Left-atrial-appendage-closure (LAAC) is suggested as alternative to antiplatelet/anticoagulant therapy (AP/AC) for stroke-prevention in patients with cerebral-amyloid-angiopathy (CAA), intracerebral hemorrhage (ICH) and atrial fibrillation (AF). Disadvantages of LAAC are the need for postinterventional AP and impairment of left atrial function, thus promoting heart-failure. Therefore, in an 83-year-old edoxaban-treated AF-patient with ICH and CAA, only antihypertensive therapy with neither AP/AC nor LAAC was recommended. Twenty-seven months without stroke/ICH support this strategy, which needs confirmation by a randomized-trial.
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Alkhouli M, Di Biase L, Natale A, Rihal CS, Holmes DR, Asirvatham S, Bartus K, Lakkireddy D, Friedman PA. Nonthrombogenic Roles of the Left Atrial Appendage: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:1063-1075. [PMID: 36922093 DOI: 10.1016/j.jacc.2023.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 01/03/2023] [Accepted: 01/09/2023] [Indexed: 03/18/2023]
Abstract
The atrial appendage (LAA) is a well-established source of cardioembolism in patients with atrial fibrillation. Therefore, research involving the LAA has largely focused on its thrombogenic attribute and the utility of its exclusion in stroke prevention. However, recent studies have highlighted several novel functions of the LAA that may have important therapeutic implications. In this paper, we provide a concise overview of the LAA anatomy and summarize the emerging data on its nonthrombogenic roles.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
| | - Luigi Di Biase
- Montefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Andrea Natale
- St David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Charanjit S Rihal
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Samuel Asirvatham
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Medical College, John Paul Hospital, Jagiellonian University, Krakow, Poland
| | | | - Paul A Friedman
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Ren Z, Zheng Y, Zhang J, Yang H, Wu J, Li H, Guo R, Meng W, Zhang J, Sun H, Xu Y, Zhao D. Patients With Larger Left Atrial Appendage Orifice Presented Worse Prognosis Contributed by Acute Heart Failure After Left Atrial Appendage Closure. J Am Heart Assoc 2022; 11:e026309. [DOI: 10.1161/jaha.122.026309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background
Left atrial appendage (LAA) closure (LAAC) could prevent stroke in patients with atrial fibrillation. However, LAAC may impair the compliance of the left atrium and result in poor prognosis. This study aimed to comparatively evaluate the prognosis of LAAC among patients with different sizes of LAA orifice.
Methods and Results
Three hundred two consecutive patients who underwent successful LAAC were included and divided into 4 groups based on LAA orifice size that was measured using transesophageal echocardiography. Clinical outcomes including thromboembolic events, major cardiocerebrovascular adverse events, and acute heart failure (AHF) were compared among 4 quartile groups and between propensity‐score matched groups of large and small LAAs. Through follow‐up of 39.6±8.4 months, survival of thromboembolic events was similar. Survival of major cardiocerebrovascular adverse events was significantly lower in the group with the largest LAA orifice (log‐rank
P
<0.001), including a higher incidence of AHF with New York Heart Association class III to IV (21.4%, log‐rank
P
=0.009). A large LAA orifice (by cutoff) could predict major cardiocerebrovascular adverse events (hazard ratio, 3.749 [95% CI, 2.074–6.779]) in most patients, except for subgroups of those aged <65 years, with paroxysmal atrial fibrillation, and/or with failed rhythm/rate control. Further compared with a propensity‐score matched small‐LAA group, the large‐LAA orifice group still presented worse survival of AHF with New York Heart Association class III to IV (log‐rank
P
=0.010).
Conclusions
Patients with a larger LAA orifice presented a worse prognosis after LAAC, including a higher incidence of AHF. A large LAA orifice could predict a post‐LAAC AHF event in most patients, except for young patients, patients with paroxysmal atrial fibrillation, and/or with failed rhythm/rate control.
Registration
URL:
clinicaltrials.gov
; Unique identifier: NCT04185142.
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Affiliation(s)
- Zhongyuan Ren
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Yixing Zheng
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Jingying Zhang
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Haotian Yang
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Jiayu Wu
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Hailing Li
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Rong Guo
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Weilun Meng
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Jun Zhang
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Hui Sun
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Yawei Xu
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
| | - Dongdong Zhao
- Heart Center, Shanghai Tenth People’s Hospital, School of Medicine Tongji University Shanghai China
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