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Katic J, Borovac JA. Treatment of Persistent Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation on Adequate Oral Anticoagulation: Pathways of Care for All-comers and Heart Failure Patients. Card Fail Rev 2023; 9:e05. [PMID: 37397240 PMCID: PMC10311400 DOI: 10.15420/cfr.2022.28] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/27/2023] [Indexed: 07/04/2023] Open
Abstract
In patients with AF, the presence of left atrial/left atrial appendage (LA/LAA) thrombus is related to an increased risk of thromboembolic events. Anticoagulation therapy, either with vitamin K antagonists or novel oral anticoagulants (NOACs) is therefore mandatory in AF with LA/LAA thrombus in order to lower the risk of stroke or other systemic embolic events. Despite the efficacy of these treatments, some patients will have persistent LAA thrombus remaining or may have contraindications to oral anticoagulation. Currently, little is known about the occurrence, risk factors and resolution rate of LA/LAA thrombus in patients who are already under optimal chronic oral anticoagulation, including vitamin K antagonists or NOACs. The common action in clinical practice in this scenario is switching from one to another anticoagulant drug exhibiting a different mechanism of action. Repeated cardiac imaging is then advised within several weeks to visually verify thrombus dissolution. Finally, there is a substantial scarcity of data on the role and optimal use of NOACs after LAA occlusion. The aim of this review is to critically evaluate data and provide up-to-date information on the best antithrombotic strategies in this challenging clinical scenario.
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Affiliation(s)
- Josip Katic
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
| | - Josip Andelo Borovac
- Cardiovascular Diseases Department, University Hospital of Split Split, Croatia
- Department of Pathophysiology, University of Split School of Medicine Split, Croatia
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Zhang X, Tian B, Cong X, Hao SW, Huan Q, Jin C, Zhu L, Ning ZP. Prediction model based on machine learning for short- and long-term adverse events in left atrial appendage closure. J Thorac Dis 2022; 14:2147-2157. [PMID: 35813710 PMCID: PMC9264065 DOI: 10.21037/jtd-22-499] [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: 03/22/2022] [Accepted: 06/01/2022] [Indexed: 11/21/2022]
Abstract
Background At present, the prediction of adverse events (AE) had practical significance in clinic and the accuracy of AE prediction model after left atrial appendage closure (LAAC) needed to be improved. To identify a good prediction model based on machine learning for short- and long-term AE after LAAC. Methods In this study, 869 patients were included from the Department of Cardiovascular Medicine of Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital during 2017 and 2021. Univariate and multivariate analyses were conducted for short-term AE after LAAC to determine possible risk factors related with AE. We compared 8 machine learning algorithms for prediction short-term AE, and XGBoost was found to have the best performance. In addition, Cox-regression was used for long-term AE to find out the risk factors and establish a prediction model. Results In univariate and multivariate analysis, body mass index (BMI) [odds ratio (OR) =0.91], congestive heart failure, hypertension, age ≥75 years, diabetes, stroke2 attack (CHADS2) score (OR =0.49) and bleeding history or predisposition, labile international normalized ratio (INR), elderly, drug/alcohol usage (BLED) score (OR =1.71) were shown to be significant risk factors for short-term AE. The XGbosst algorithm was used to predict short-term AE based on 15 possible risk factors. For long-term AE, Cox regression was used for the prediction. The CHADS2 score [hazard ratio (HR) =1.43], hypertension (HR =2.18), age more than 75 (HR =0.49), diabetes (HR =0.57), BLED score (HR=0.28), stroke (HR =19.8), hepatopathy (HR =3.97), nephropathy (HR =2.93), INR instability (HR =4.18), drinking (HR =2.67), and drugs (HR =2.36) were significant risk factors for long-term AE. The XGBoost had a good receiver operating characteristic (ROC) curve and area under the curve (AUC) was 0.85. The accuracy of the XGBoost model stayed at nearly 0.95. Conclusions In short- and long-term AE, CHADS2 score and BLED score were the most obvious risk factors. Several other risk factors also played roles in AE of LAAC. The incidence of long-term AE is under 15% and LAAC is effective and safe. The XGBoost model had good prediction accuracy and ROC curve.
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Affiliation(s)
- Xiaogang Zhang
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Bei Tian
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Xinpeng Cong
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Shu-Wen Hao
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Qiang Huan
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Can Jin
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Luoning Zhu
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Zhong-Ping Ning
- Cardiovascular Department, Shanghai University of Medicine and Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
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Suwa Y, Miyasaka Y, Taniguchi N, Harada S, Nakai E, Shiojima I. Atrial fibrillation and stroke: importance of left atrium as assessed by echocardiography. J Echocardiogr 2022; 20:69-76. [DOI: 10.1007/s12574-021-00561-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/04/2021] [Accepted: 12/10/2021] [Indexed: 10/19/2022]
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Anselmino M, Frea S, Gili S, Rovera C, Morello M, Jorfida M, Teodori J, Perversi J, Salvetti I, Grosso Marra W, Faletti R, Righi D, Gaita F, DE Ferrari GM. Left atrial appendage morphology at transesophageal echocardiography: how to improve reproducibility? Minerva Cardiol Angiol 2020; 69:178-184. [PMID: 32657552 DOI: 10.23736/s2724-5683.20.05215-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) morphology, investigated by computed tomography and magnetic resonance imaging, has proved to relate to the risk of cerebrovascular events in patients with atrial fibrillation (AF). The aim of the present study was to assess reproducibility of transesophageal echocardiography (TEE) imaging in describing LAA morphology. METHODS Two-hundred consecutive patients referred for TEE were enrolled. In the first group of 47 (23.5%) patients LAA morphology was analyzed by conventional TEE and described as ChickenWing, Windsock, Cactus or Cauliflower. In the second group of 153 (76.5%) patients, instead, a 3D-Xplane diagnostic algorithm was performed to stratify LAA morphology as linear (ChickenWing) or complex (Windsock/Cactus and Cauliflower). Interobserver variability within three independent readers was assessed in both groups of patients and stratified by operator's experience and training. In a subgroup of 19 (12.4%) patients, the agreement of LAA morphology description by 3D-Xplane diagnostic algorithm was compared to cardiac magnetic resonance. RESULTS By conventional TEE the agreement among operators on LAA morphology classification was poor (ρ<0.13). The 3D-XPlane diagnostic algorithm, significantly increased interobserver agreement up to ρ=0.32 within all readers and up to ρ=0.82 among the experienced and specifically trained operators. LAA morphology description in this latter group provided strong agreement with cardiac magnetic resonance (up to ρ=0.77). CONCLUSIONS LAA morphology assessment is challenging by conventional TEE. To improve reproducibility, the use of the 3D-Xplane technique combined with a specific diagnostic algorithm and training of the operators is fundamental.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Sebastiano Gili
- Interventional Cardiology Unit 3, IRCCS Monzino Cardiac Center, Milan, Italy
| | - Chiara Rovera
- Division of Cardiology, Hospital of Chivasso, Chivasso, Turin, Italy -
| | - Mara Morello
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Marcella Jorfida
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Julien Teodori
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Jacopo Perversi
- Division of Cardiology, Cardinal Massaia Hospital, Asti, Italy
| | - Ilaria Salvetti
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | | | - Riccardo Faletti
- Division of Radiology, Department of Diagnostic Imaging and Radiotherapy, University of Turin, Turin, Italy
| | - Dorico Righi
- Division of Radiology, Department of Diagnostic Imaging and Radiotherapy, University of Turin, Turin, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
| | - Gaetano M DE Ferrari
- Division of Cardiology, Department of Medical Sciences, Molinette Hospital, Città della Salute e della Scienza, Turin, Italy
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Zacà V, Breschi M, Mandorli A, Panchetti L, Ricciardi G, Viani S, Notarstefano P. Rationale, study design, and pilot phase of tHE Management of AntiThrOMbotic therApy (HEMATOMA) in patients undergoing electrophysiological device surgery. J Cardiovasc Med (Hagerstown) 2017; 18:897-899. [DOI: 10.2459/jcm.0000000000000534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Patti G, Scipione R, Ussia GP, Rapacciuolo A, Goffredo C, Sedati P. Intradevice misalignment predicts residual leak in patients undergoing left atrial appendage closure. J Cardiovasc Med (Hagerstown) 2017; 18:900-907. [DOI: 10.2459/jcm.0000000000000566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Anselmino M, Garberoglio L, Gili S, Bertaglia E, Stabile G, Marazzi R, Themistoclakis S, Solimene F, Frea S, Grosso Marra W, Morello M, Scaglione M, De Ponti R, Gaita F. Left atrial appendage thrombi relate to easily accessible clinical parameters in patients undergoing atrial fibrillation transcatheter ablation: A multicenter study. Int J Cardiol 2017; 241:218-222. [PMID: 28413114 DOI: 10.1016/j.ijcard.2017.04.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Revised: 02/20/2017] [Accepted: 04/04/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Transesophageal echocardiography (TEE) is routinely performed before atrial fibrillation (AF) transcatheter ablation to exclude the presence of left atrial (LA) or LA appendage (LAA) thrombi. The aim of the study is to evaluate if easily accessible clinical parameters may relate to the presence of LA or LAA thrombi to identify patients who could potentially avoid TEE. METHODS AND RESULTS Between January 2012 and September 2014, data from 1539 consecutive patients undergoing TEE, as a work-up before AF transcatheter ablation, in six large volume centers were collected. Baseline clinical features, CHA2DS2-VASc score, transthoracic echocardiography and presence of thrombi at TEE were recorded. Exclusion criteria were valvular, hypertrophic or dilated cardiomyopathy, previous heart surgery or an ejection fraction ≤35%. Mean age was 59.6±10.4years, 1215 (78.9%) were males; 951 (62.9%) presented in sinus rhythm (SR) on admission, 324 (21.1%) had undergone at least one previous ablation and 900 (58.5%) had CHA2DS2-VASc score 0-1. Thrombi were encountered in 12 patients (0.8%). SR at TEE independently related to the absence of thrombi (OR 5.15, 95% CI 1.38-19.02, p=0.015); in addition to this, no patient with a CHA2DS2-VASc score 0-1 and SR on admission presented thrombi at TEE (specificity 100%, p=0.011). CONCLUSION In a selected population of patients referred for AF ablation, LA/LAA thrombi prevalence is low. No patients in SR with CHA2DS2-VASc score 0-1 presented LAA thrombi at TEE, identifying a significant subset of patients who could potentially safely be spared from pre-procedural TEE.
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Affiliation(s)
- Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
| | - Lucia Garberoglio
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
| | - Sebastiano Gili
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy.
| | - Emanuele Bertaglia
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Raffaella Marazzi
- Department of Heart and Vessels, Ospedale di Circolo e Fondazone Macchi, University of Insubria, Varese, Italy
| | - Sakis Themistoclakis
- Department of Cardiothoracic and Vascular Medicine, Dell'Angelo Hospital, Mestre, Venice, Italy
| | | | - Simone Frea
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
| | - Walter Grosso Marra
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
| | - Mara Morello
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
| | - Marco Scaglione
- Division of Cardiology, Department of Internal Medicine, Cardinal Massaia Hospital, Asti, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo e Fondazone Macchi, University of Insubria, Varese, Italy
| | - Fiorenzo Gaita
- Division of Cardiology, Department of Medical Sciences, "Città della Salute e della Scienza" Hospital, University of Turin, Italy
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