1
|
Continisio S, Montonati C, Angelini F, Bocchino PP, Carbonaro C, Giacobbe F, Dusi V, De Filippo O, Ielasi A, Giannino G, Boldi E, Fabris T, D'Ascenzo F, De Ferrari GM, Tarantini G. Single versus dual antiplatelet therapy following percutaneous left atrial appendage closure-A systematic review and meta-analysis. Eur J Clin Invest 2024; 54:e14209. [PMID: 38597271 DOI: 10.1111/eci.14209] [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: 01/02/2024] [Revised: 03/08/2024] [Accepted: 03/16/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND In the last few years, percutaneous LAA occlusion (LAAO) has become a plausible alternative in atrial fibrillation (AF) patients with contraindications to anticoagulation therapy. Nevertheless, the optimal antiplatelet strategy following percutaneous LAAO remains to be defined. METHODS Studies comparing single antiplatelet therapy (SAPT) versus dual antiplatelet therapy (DAPT) following LAAO were systematically searched and screened. The outcomes of interest were ischemic stroke, device-related thrombus (DRT) and major bleeding. A random-effect meta-analysis was performed comparing outcomes in both groups. The moderator effect of baseline characteristics on outcomes was evaluated by univariate meta-regression analyses. RESULTS Sixteen observational studies with 3255 patients treated with antiplatelet therapy (SAPT, n = 1033; DAPT, n = 2222) after LAAO were included. Mean age was 74.5 ± 8.3 years, mean CHA2DS2-VASc and HAS-BLED scores were 4.3 ± 1.5 and 3.2 ± 1.0, respectively. At a weighted mean follow-up of 12.7 months, the occurrence of stroke (RR 1.33; 95% CI 0.64-2.77; p =.44), DRT (RR 1.52; 95% CI 0.90-2.58; p =.12), and the composite of stroke and DRT (RR 1.26; 95% CI 0.67-2.37; p =.47) did not differ significantly between SAPT and DAPT groups. The rate of major bleedings was also not different between groups (RR 1.41; 95% CI 0.64-3.12; p =.39). CONCLUSIONS Among AF patients at high bleeding risk undergoing percutaneous LAAO, a post-procedural minimalistic antiplatelet strategy with SAPT did not significantly differ from DAPT regimens regarding the rate of stroke, DRT and major bleeding.
Collapse
Affiliation(s)
- Saverio Continisio
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Carolina Montonati
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | - Filippo Angelini
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Pier Paolo Bocchino
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Carla Carbonaro
- Department of Medical Sciences, University of Turin, Turin, Italy
| | | | - Veronica Dusi
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
| | - Alfonso Ielasi
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, Milan, Italy
| | | | - Emiliano Boldi
- Division of Cardiology, Clinica S. Rocco di Franciacorta, Brescia, Italy
| | - Tommaso Fabris
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, 'Città della Salute e della Scienza' Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| |
Collapse
|
2
|
Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024:ehae398. [PMID: 39027946 DOI: 10.1093/eurheartj/ehae398] [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: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
Collapse
Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
| |
Collapse
|
3
|
Galea R, Bini T, Krsnik JP, Touray M, Temperli FG, Kassar M, Papadis A, Gloeckler S, Brugger N, Madhkour R, Seiffge DJ, Roten L, Siontis GCM, Heg D, Windecker S, Räber L. Pericardial Effusion After Left Atrial Appendage Closure: Timing, Predictors, and Clinical Impact. JACC Cardiovasc Interv 2024; 17:1295-1307. [PMID: 38795087 DOI: 10.1016/j.jcin.2024.01.310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/29/2024] [Accepted: 01/31/2024] [Indexed: 05/27/2024]
Abstract
BACKGROUND Pericardial effusion (PE) is the most common serious left atrial appendage closure (LAAC) complication, but its mechanisms, time course, and prognostic impact are poorly understood. OBJECTIVES This study sought to assess the frequency, timing, predictors and clinical impact of PE after LAAC. METHODS Data on consecutive patients undergoing percutaneous LAAC between 2009 and 2022 were prospectively collected including the 1-year follow-up. Both single (Watchman 2.5/FLX, Boston Scientific) and double (Amplatzer Cardiac Plug or Amulet, St. Jude Medical/Abbott) LAAC devices were used. An imaging core laboratory adjudicated the PEs and categorized them as early (≤7 days) and late (8-365 days). Logistic regression analysis was used to identify predictors of early and overall PE. RESULTS Of 1,023 attempted LAAC procedures, PE was observed in 44 (4.3%) patients; PE was categorized as early in 34 (3.3%) and late in 10 (0.9%) patients. The majority of PEs occurred within 6 hours after LAAC (n = 25, 56.8%) and were clinically relevant (n = 28, 63.6%). Independent predictors of early PE were double-closure left atrial appendage devices (adjusted OR: 8.20; 95% CI: 1.09-61.69), female sex (adjusted OR: 3.41; 95% CI: 1.50-7.73), the use of oral anticoagulation (OAC) at baseline (adjusted OR: 2.60; 95% CI: 1.11-6.09), and advanced age (adjusted OR: 1.07; 95% CI: 1.01-1.23), whereas female sex and OAC at baseline remained independent predictors of overall PE. CONCLUSIONS In this large LAAC registry, PE was observed in <1 in 20 patients and usually occurred within 6 hours after procedure. The majority of early PEs were clinically relevant and occurred in the Amplatzer Cardiac Plug/Amulet procedures. Independent predictors included the use of double-closure devices, female sex, OAC at baseline, and advanced age. (LAAC-registry: Clinical Outcome After Echocardiography-guided LAA-closure; NCT04628078).
Collapse
Affiliation(s)
- Roberto Galea
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Tommaso Bini
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Juan Perich Krsnik
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mariama Touray
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabrice Gil Temperli
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohammad Kassar
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasios Papadis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steffen Gloeckler
- Department of Cardiology, Klinikum Hochrhei, Waldshut-Tiengen, Germany
| | - Nicolas Brugger
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Raouf Madhkour
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David Julian Seiffge
- Department of Neurology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurent Roten
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - George C M Siontis
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dierik Heg
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
4
|
Wang Z, Chu H, Chen X, Tao L, Yuan Y, Ru L, Wang J, Fan Y, Hu H, Wang C, Chen M, Huang W, Zhou D, Liu X, Liang M, Liu J, Han Y. Percutaneous left atrial appendage closure with SeaLA device in non-valvular atrial fibrillation. Catheter Cardiovasc Interv 2024. [PMID: 38841867 DOI: 10.1002/ccd.31056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 04/03/2024] [Accepted: 04/09/2024] [Indexed: 06/07/2024]
Abstract
OBJECTIVES The clinical efficacy and safety of a novel left atrial appendage (LAA) occluder of the SeaLA closure system in patients with nonvalvular atrial fibrillation (NVAF) were reported. BACKGROUND Patients with NVAF are at a higher risk of stroke compared to healthy individuals. Left atrial appendage closure (LAAC) has emerged as a prominent strategy for reducing the risk of thrombosis in individuals with NVAF. METHODS A prospective, multicenter study was conducted in NVAF patients with a high risk of stroke. RESULTS The LAAC was successfully performed in 163 patients. The mean age was 66.93 ± 7.92 years, with a mean preoperative CHA2DS2-VASc score of 4.17 ± 1.48. One patient with residual flow >3 mm was observed at the 6-month follow-up, confirmed by TEE. During the follow-up, 2 severe pericardiac effusions were noted, and 2 ischemic strokes were observed. Four device-related thromboses were resolved after anticoagulation treatment. There was no device embolism. CONCLUSIONS The LAAC with the SeaLA device demonstrates encouraging feasibility, safety, and efficacy outcomes.
Collapse
Affiliation(s)
- Zulu Wang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Huimin Chu
- Arrhythmia Center, Ningbo First Hospital, The First Affiliated Hospital of Ningbo University, Ningbo, China
| | - Xinjing Chen
- Department of Cardiology, Fujian Provincial Hospital, Fujian Medical University, Fuzhou, China
| | - Ling Tao
- Department of Cardiology, Xijing Hospital, Air Force Military Medical University, Xi'an, China
| | - Yiqiang Yuan
- Department of Cardiology, The 7th People's Hospital of Zhengzhou, Henan Cardiovascular Hospital Affiliated to Southern Medical University, Zhengzhou, China
- Department of Cardiology, Henan Provincial Chest Hospital, Zhengzhou, China
| | - Leisheng Ru
- Department of Cardiology, 980 Hospital of PLA Joint Logistics Support Forces (Bethune International Peace Hospital), Shijiazhuang, China
| | - Jianan Wang
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Youqi Fan
- Department of Cardiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hongde Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, China
| | - Changqian Wang
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Weijian Huang
- Department of Cardiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Daxin Zhou
- Department of Cardiology, Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xingpeng Liu
- Department of Cardiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Ming Liang
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Jing Liu
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Yaling Han
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| |
Collapse
|
5
|
Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [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: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
Collapse
Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
| |
Collapse
|
6
|
Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [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: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
Collapse
Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
| | | |
Collapse
|
7
|
Kramer A, Korsholm K, Nielsen-Kudsk JE. Single antiplatelet therapy following Amplatzer left atrial appendage occlusion. EUROINTERVENTION 2024; 20:e301-e311. [PMID: 38436367 PMCID: PMC10905198 DOI: 10.4244/eij-d-23-00684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 12/04/2023] [Indexed: 03/05/2024]
Abstract
BACKGROUND The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) remains debated. Ideally, this therapy should effectively prevent device-related thrombosis (DRT) while minimising the associated bleeding risk. AIMS We aimed to evaluate the long-term safety and efficacy of a postprocedural single antiplatelet therapy (SAPT) strategy following Amplatzer LAAO in a large consecutive cohort. METHODS This retrospective, single-centre, observational study included all patients discharged on SAPT after LAAO with the Amplatzer Cardiac Plug (ACP) or Amplatzer Amulet between March 2010 and December 2021 at Aarhus University Hospital, Denmark. Baseline, procedural, and imaging data were obtained locally, while clinical outcomes and medication data were extracted from the Danish national health registries. RESULTS A total of 553 patients underwent Amplatzer LAAO during the specified time frame. Of these, 431 (77.9%) high bleeding risk patients were discharged on SAPT with either acetylsalicylic acid (n=403, 72.9%) or clopidogrel (n=28, 5.1%). At 6 months, 173 (41.7%) patients were not on any antithrombotic therapy. The mean CHA2DS2-VASc and HAS-BLED scores were 3.9±1.5 and 3.4±1.1, respectively. DRT was detected in 6 (1.5%) patients on 8-week follow-up imaging using cardiac computed tomography (n=386, 89.6%) or transoesophageal echocardiography (n=27, 6.3%). The 1-year ischaemic stroke rate was 2.2% (95% confidence interval [CI]: 1.1-4.2). One-year rates for major bleeding and cardiovascular death were 5.9% (95% CI: 4.0-8.9) and 2.9% (95% CI: 1.6-5.1), respectively. CONCLUSIONS SAPT following Amplatzer LAAO displayed rates of DRT and stroke comparable to those reported with more intensive antithrombotic regimens. Meanwhile, we observed low rates of major bleeding.
Collapse
Affiliation(s)
- Anders Kramer
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| |
Collapse
|
8
|
Yasmin F, Ali E, Moeed A, Zaidi F, Umar M, Virwani V. Safety and efficacy of percutaneous Watchman 2.5 device versus Amplatzer Amulet for left atrial appendage closure in patients with non-valvular atrial fibrillation: A systematic review and study-level meta-analysis. PLoS One 2024; 19:e0295804. [PMID: 38354181 PMCID: PMC10866506 DOI: 10.1371/journal.pone.0295804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 02/16/2024] Open
Abstract
INTRODUCTION In patients with non-valvular atrial fibrillation (NVAF), mechanical occlusion of the left atrial appendage (LAA) using a permanently implanted device may be an effective alternative to oral anti-coagulants (OAC). To facilitate left atrial appendage closure (LAAC), multiple percutaneous devices have been proposed. Watchman Generation 2.5 and Amplatzer Amulet are the two most popular used devices for preventing stroke in patients with NVAF. We sought to compare safety and efficacy outcomes between Watchman 2.5 and Amplatzer Amulet in patients undergoing LAAC procedure. METHODS We carried out a comprehensive and systematic search of the databases PubMed and Scopus, for all studies that compared the safety and efficacy of Watchman 2.5 and Amplatzer Amulet devices, from inception, till June 2023. We performed the statistical analysis using Review Manager (V.5.4.1 Cochrane Collaboration, London, United Kingdom). The safety outcomes of interest included device success, device-related thrombus, device embolization perioperatively and at follow-up, perioperative pericardial perfusion events, and perioperative cardiac tamponade events. Efficacy outcomes were all-cause mortality perioperatively and at follow-up, cardiovascular (CV) mortality at follow-up, stroke, major and minor bleeding events at follow-up, transient ischemic attack (TIA) in follow-up period, thromboembolic events in follow-up period, and peri-device leakage in perioperative period. All data was analysed using a random-effects model, and presented as risk ratios (RRs) with 95% confidence intervals (95%CIs). RESULTS Regarding safety outcomes, device success was non-significantly reduced in Watchman group when compared with Amulet (RR 0.99, p = 0.57; I2 = 34%). In contrast, device-related thrombus was non-significantly increased in Watchman 2.5 group in comparison to Amulet (RR 1.44, p = 0.11; I2 = 0%). There was no significant difference between the devices in terms of device embolization in the perioperative (RR 0.36, p = 0.38; I2 = 22%) and follow-up (RR 2.24, p = 0.13; I2 = 0%) periods. Likewise, there was no significant difference in the risks of pericardial effusion (RR 0.98, p = 0.98; I2 = 0%), and cardiac tamponade (RR 0.65, p = 0.76; I2 = 62%) perioperatively. Regarding efficacy outcomes, no significant difference was observed in all-cause mortality between devices perioperatively (RR 0.51, p = 0.32; I2 = 0%) and at follow-up (RR 1.08, p = 0.56; I2 = 0%). CV-mortality was non-significantly reduced in Watchman group when compared with Amulet (RR 0.57, p = 0.20; I2 = 0%). The Amulet device was not superior to the Watchman device in terms of stroke at follow-up (RR 1.13, p = 0.63; I2 = 0%). Sub-group analysis showed comparable ischaemic and haemorrhagic stroke events between two devices. Furthermore, at follow-up, there was no significant difference in major (RR 1.06, p = 0.63; I2 = 0%) and minor bleeding events (RR 1.81, p = 0.17; I2 = 0%) between the two devices. No difference was observed for trans-ischemic attack (RR 1.89, p = 0.24; I2 = 0%) and thromboembolic events (RR 0.96, p = 0.96; I2 = 0%) at follow-up. No significant difference was observed between devices for peri-device leakage in perioperative period (RR 2.16, p = 0.05; I2 = 0%). CONCLUSION The data suggested that LAAC is safe and efficacious procedure irrespective of device used, with generally low complication rates. Watchman generation 2.5 remains non-superior to Amplatzer Amulet in terms of safety and efficacy outcomes.
Collapse
Affiliation(s)
- Farah Yasmin
- Yale University School of Medicine, New Haven, CT, United States of America
| | - Eman Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Abdul Moeed
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Farwa Zaidi
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Muhammad Umar
- IU Health Ball Memorial Hospital, Muncie, IN, United States of America
| | | |
Collapse
|
9
|
Samaras A, Papazoglou AS, Balomenakis C, Bekiaridou A, Moysidis DV, Patsiou V, Orfanidis A, Giannakoulas G, Kassimis G, Fragakis N, Saw J, Landmesser U, Alkhouli MA, Tzikas A. Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis. Eur Heart J 2024; 45:214-229. [PMID: 38088437 DOI: 10.1093/eurheartj/ehad828] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/02/2023] [Accepted: 10/19/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND AND AIMS Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion. METHODS A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks. RESULTS Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively). CONCLUSIONS Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.
Collapse
Affiliation(s)
- Athanasios Samaras
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Andreas S Papazoglou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Balomenakis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Dimitrios V Moysidis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Orfanidis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | | | - Apostolos Tzikas
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- European Interbalkan Medical Center, Department of Cardiology, Asklipiou 10, Pylaia, Thessaloniki 57001, Greece
| |
Collapse
|
10
|
Fastner C, Müller C, Brachmann J, Lewalter T, Akin I, Sievert H, Käunicke M, Zeymer U, Hochadel M, Schneider S, Senges J, Erkapic D, Weiß C. Is spontaneous echo contrast associated with device-related thrombus or embolic events after left atrial appendage occlusion? - Insights from the multicenter German LAARGE registry. J Interv Card Electrophysiol 2024; 67:119-128. [PMID: 37261553 PMCID: PMC10770218 DOI: 10.1007/s10840-023-01567-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/12/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Interventional left atrial appendage occlusion (LAAO) provides an alternative to oral anticoagulation (OAC) for prophylaxis of thromboembolic events (TEs) in nonvalvular atrial fibrillation patients, predominantly in those with high bleeding risk and contraindications for long-term OAC. Although spontaneous echo contrast (SEC) is a well-known risk factor for atrial thrombus formation, little is known about whether this means an increased risk of device-related thrombus (DRT) or TEs following LAAO. METHODS This substudy of the prospective, multicenter German LAARGE registry assessed two groups according to absence (SEC -) or presence of SEC (SEC +) in preprocedural cardiac imaging. Clinical and echocardiographic parameters were registered up to 1 year after LAAO. RESULTS Five hundred eighty-eight patients (SEC - 85.5 vs. SEC + 14.5%) were included. More SEC + patients were implanted for OAC non-compliance (11.8 vs. 4.6%, p = 0.008) and a higher proportion received only antiplatelet therapy without OAC at hospital discharge (96.5 vs. 86.0%, p = 0.007). The SEC + patients had larger LA diameters (50 (47; 54) vs. 47 (43; 51) mm, p < 0.001), wider LAA ostia (21 (19; 23) vs. 20 (17; 22) mm at 45°, p = 0.011), and lower left ventricular ejection fraction (50 (45; 60) vs. 60 (50; 60) %, p < 0.001) on admission. Procedural success was very high in both groups (98.1%, p = 1.00). Periprocedural major adverse cardiac and cerebrovascular events and other major complications were rare in both groups (3.8 vs. 4.7%, p = 0.76). At follow-up, DRT was only detected in the SEC - group (3.8 vs. 0%, p = 1.00). The rates of TEs (SEC - 1.2 vs. SEC + 0%, p = 1.00) after hospital discharge and 1-year mortality (SEC - 12.0 vs. SEC + 11.8%, p = 0.96) were not significantly different between the two groups. CONCLUSIONS Presence of SEC at baseline was not associated with an increased rate of DRT or TEs at 1-year follow-up after LAAO in LAARGE.
Collapse
Affiliation(s)
- Christian Fastner
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Claus Müller
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
| | - Johannes Brachmann
- REGIOMED-Kliniken, Coburg, Germany and University of Split, School of Medicine, Split, Croatia
| | - Thorsten Lewalter
- Department of Medicine, Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Ibrahim Akin
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, European Center for AngioScience (ECAS), and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Matthias Käunicke
- Department of Cardiology, University of Witten/Herdecke, Katholisches Klinikum Essen, Essen, Germany
| | - Uwe Zeymer
- Department of Cardiology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | | | | | - Jochen Senges
- Stiftung Institut Für Herzinfarktforschung, Ludwigshafen, Germany
| | - Damir Erkapic
- Department of Cardiology, Rhythmology and Angiology, Diakonie Klinikum Siegen, Siegen, Germany and Department of Cardiology and Angiology, University Hospital Giessen, Giessen, Germany
| | - Christian Weiß
- Department of Cardiology, Städtisches Klinikum Lüneburg gGmbH, Lüneburg, Germany
| |
Collapse
|
11
|
Kikuchi T, Kono Y, Nakagawa K, Okada H, Miyamoto M, Takaya Y, Hirata S, Inoo S, Kuraoka S, Okanoue S, Matsueda K, Satomi T, Hamada K, Iwamuro M, Kawano S, Kawahara Y. Clinical significance of gastrointestinal bleeding history in patients who undergo left atrial appendage closure. JGH Open 2024; 8:e13009. [PMID: 38268955 PMCID: PMC10805487 DOI: 10.1002/jgh3.13009] [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: 06/12/2023] [Revised: 10/06/2023] [Accepted: 11/12/2023] [Indexed: 01/26/2024]
Abstract
Background and Aim Anticoagulant users with nonvalvular atrial fibrillation (NVAF) sometimes suffer from gastrointestinal bleeding (GIB) and have difficulty continuing the medication. Left atrial appendage closure (LAAC) has been developed for such situations. We aimed to clarify the clinical significance of a history of GIB in comparison to other factors in patients who had undergone LAAC. Methods From October 2019 to September 2023, patients with NVAF who underwent LAAC at our hospital were enrolled. We investigated the percentage of patients with a history of GIB who underwent LAAC and compared the incidence of post-LAAC bleeding in these patients compared to those with other factors. Results A total of 45 patients were included. There were 19 patients (42%) with a history of GIB who underwent LAAC. In a Kaplan-Meier analysis, the cumulative incidence of bleeding complications after LAAC was significantly higher in patients with a history of GIB in comparison to patients with other factors. There were eight cases of post-LAAC bleeding in total, and seven cases had GIB. Conclusions We need to recognize that GIB is a significant complication in patients who undergo LAAC. The management of GIB by gastroenterologists is essential to the success of LAAC.
Collapse
Affiliation(s)
- Tatsuya Kikuchi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoshiyasu Kono
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Koji Nakagawa
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Hiroyuki Okada
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
- Department of Internal MedicineHimeji Red Cross HospitalHimejiJapan
| | - Masakazu Miyamoto
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoichi Takaya
- Department of Cardiovascular Medicine, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shoichiro Hirata
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shoko Inoo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Sakiko Kuraoka
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Shotaro Okanoue
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Katsunori Matsueda
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Takuya Satomi
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Kenta Hamada
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Masaya Iwamuro
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Seiji Kawano
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| | - Yoshiro Kawahara
- Department of Practical Gastrointestinal Endoscopy, Faculty of Medicine, Dentistry and Pharmaceutical SciencesOkayama UniversityOkayamaJapan
| |
Collapse
|
12
|
Streb W, Lasek-Bal A, Mitręga K, Kowalczyk J, Podolecki T, Kowalska W, Olma A, Sobczyk A, Kalarus Z. Rationale and design of a randomized clinical trial evaluating the efficacy of mechanical neuroprotection in reducing the risk of silent brain infarcts associated with percutaneous left atrial appendage closure: study protocol for a LAAC-SBI trial. Trials 2023; 24:749. [PMID: 37996955 PMCID: PMC10666419 DOI: 10.1186/s13063-023-07766-3] [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: 08/18/2023] [Accepted: 10/31/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Left atrial appendage closure (LAAC) procedures prevent cardioembolic stroke in patients with atrial fibrillation who have contraindications to oral anticoagulant medications. However, these procedures carry certain risks of peri-procedural complications. One such complication is silent brain infarcts (SBI), which can lead to cognitive impairment and mood disturbances. The implementation of mechanical neuroprotection systems during LAAC procedures may reduce the risk of SBI and associated cognitive and mood disorders. METHODS The LAAC-SBI trial is a prospective, multicenter, randomized, and double-blind interventional study. The study aims to enroll a total of 240 patients, with 120 patients allocated to each group. The study group will evaluate the use of the Sentinel CPS during LAAC, while the control group will undergo LAAC procedures without the Sentinel CPS. The primary endpoint of the study is the number of new SBIs or stroke foci detected by diffusion-weighted magnetic resonance imaging (DW MRI). Secondary endpoints include deterioration of cognitive function, development of dementia syndrome, and occurrence of depressive disorders. These endpoints will be assessed using questionnaire tools such as the Montreal Cognitive Assessment (MoCA), Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), and Hospital Anxiety and Depression Scale (HADS). The observational period for patients in the study is 2 years. DISCUSSION If the study demonstrates a favorable outcome with reduced incidence of SBI and improved cognitive and mood outcomes in patients receiving cerebral protection devices during LAAC, it will have significant implications for clinical management standards. This would support the use of neuroprotection devices not only for LAAC but also in procedures such as atrial fibrillation ablation or transcatheter mitral valve interventions, where the risk of embolic events and subsequent brain injury may also be present. TRIAL REGISTRATION ClinicalTrials.gov NCT05369195. Registration on 11.05.2022.
Collapse
Affiliation(s)
- Witold Streb
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland.
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland.
| | - Anetta Lasek-Bal
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Mitręga
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Jacek Kowalczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Tomasz Podolecki
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Wiktoria Kowalska
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Anna Olma
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Agata Sobczyk
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Silesian Centre for Heart Diseases in Zabrze, Curie-Skłodowskiej 9, Zabrze, 41‒800, Poland
| |
Collapse
|
13
|
Carvalho PEP, Gewehr DM, Miyawaki IA, Nogueira A, Felix N, Garot P, Darmon A, Mazzone P, Preda A, Nascimento BR, Kubrusly LF, Cardoso R. Network Meta-Analysis of Initial Antithrombotic Regimens After Left Atrial Appendage Occlusion. J Am Coll Cardiol 2023; 82:1765-1773. [PMID: 37611779 DOI: 10.1016/j.jacc.2023.08.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/14/2023] [Accepted: 08/15/2023] [Indexed: 08/25/2023]
Abstract
BACKGROUND The optimal antithrombotic therapy following left atrial appendage occlusion (LAAO) in patients with nonvalvular atrial fibrillation (AF) remains uncertain. OBJECTIVES In this study, the authors sought to compare the efficacy and safety of various antithrombotic strategies after LAAO. METHODS We searched the Medline, Cochrane, EMBASE, LILACS, and ClinicalTrials.gov databases for studies reporting outcomes after LAAO, stratified by antithrombotic therapy prescribed at postprocedural discharge. Direct oral anticoagulants (DOACs), vitamin K antagonists (VKAs), single antiplatelet therapy (SAPT), dual antiplatelet therapy (DAPT), DOAC plus SAPT, VKA plus SAPT, and no antithrombotic therapy were analyzed. We performed a frequentist random effects model network meta-analysis to estimate the OR and 95% CI for each comparison. P-scores provided a ranking of treatments. RESULTS Forty-one studies comprising 12,451 patients with nonvalvular AF were included. DAPT, DOAC, DOAC plus SAPT, and VKA were significantly superior to no therapy to prevent device-related thrombosis. DOAC was associated with lower all-cause mortality than VKA (OR: 0.39; 95% CI: 0.17-0.89; P = 0.03). Compared with SAPT, DAPT was associated with fewer thromboembolic events (OR: 0.50; 95% CI: 0.29-0.88; P = 0.02), without a difference in major bleeding. In the analysis of P-scores, DOAC monotherapy was the strategy most likely to have lower thromboembolic events and major bleeding. CONCLUSIONS In this network meta-analysis comparing initial antithrombotic therapies after LAAO, monotherapy with DOAC had the highest likelihood of lower thromboembolic events and major bleeding. DAPT was associated with a lower incidence of thromboembolic events compared with SAPT and may be a preferred option in patients unable to tolerate anticoagulation.
Collapse
Affiliation(s)
- Pedro E P Carvalho
- Department of Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | - Alleh Nogueira
- Department of Medicine, Medical and Public Health School of Bahia, Salvador, Brazil
| | - Nicole Felix
- Department of Medicine, Federal University of Campina Grande, Campina Grande, Brazil
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud, Hôpital Jacques Cartier, Ramsay-Santé, Massy, France
| | | | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Bruno R Nascimento
- Department of Internal Medicine, Federal University of Minas Gerais, Belo Horizonte, Brazil; Interventional Cardiology Department, Hospital Madre Teresa, Belo Horizonte, Brazil
| | | | - Rhanderson Cardoso
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
14
|
Halperin JL, Rothman KJ. Initial Antithrombotic Therapy After Percutaneous Left Atrial Appendage Occlusion: Shifting Approaches to a Moving Target. J Am Coll Cardiol 2023; 82:1774-1776. [PMID: 37879781 DOI: 10.1016/j.jacc.2023.08.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 10/27/2023]
Affiliation(s)
- Jonathan L Halperin
- The Cardiovascular Institute, Mount Sinai Medical Center, New York, New York, USA.
| | - Kenneth J Rothman
- Research Triangle Institute, Research Triangle Park, North Carolina, USA
| |
Collapse
|
15
|
Blanco-Fernández F, Antúnez-Muiños PJ, Núñez-García JC, López-Tejero S, Barreira-de Sousa GJ, García-Monsalvo M, Antúnez-Ballesteros M, Maree A, González-Calle D, Rodríguez-Collado J, Barreiro-Pérez M, Díaz-Peláez E, Pérez del Villar-Moro MC, Sánchez-Fernández PL, Cruz-González I. Effectiveness and Safety of an Outpatient Program for Percutaneous Left Atrial Appendage Occlusion. J Clin Med 2023; 12:6728. [PMID: 37959194 PMCID: PMC10648316 DOI: 10.3390/jcm12216728] [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: 09/12/2023] [Revised: 10/07/2023] [Accepted: 10/08/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a safe and effective alternative to oral anticoagulation for thromboprophylaxis in patients with nonvalvular atrial fibrillation. Technological development in devices and imaging techniques, as well as accumulated experience, have increased procedural success rates and decreased complications. Same-day discharge protocols have been proposed in the field of structural heart disease, but this approach has not been studied in detail for the LAAO procedure. AIM The aim of this study is to assess the safety and efficacy of an outpatient program for LAAO when compared to the conventional treatment approach. METHODS We present a retrospective, non-randomized single-center study of 262 consecutive patients undergoing LAAO. Patients were divided into two groups, the first (n = 131) followed a conventional protocol (CP), and the second (n = 131) an outpatient protocol (OP). The primary composite endpoint comprised MACCE (death, stroke, and bleeding), cardiac tamponade, vascular complication, or attendance in the emergency department after hospital discharge at 30 days. RESULTS The overall success rate was 99.6%, with a periprocedural complication rate of 2.29%. With regards to the CP versus OP group, there were no differences between incidences of the primary composite endpoint (6.1% PC vs. 3.0% PA, p = 0.24), or after an analysis, with propensity score matching. No differences were observed in the individual endpoints. There was a decrease in hospital length of stay in the same-day discharge group (p < 0.01). CONCLUSIONS A same-day discharge LAAO program is safe, effective, and feasible when compared to the conventional strategy. Moreover, it reduces hospital length of stay, which might have clinical and economic benefits.
Collapse
Affiliation(s)
- Fabián Blanco-Fernández
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Pablo J. Antúnez-Muiños
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - Sergio López-Tejero
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Gilles J. Barreira-de Sousa
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Mónica García-Monsalvo
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Milena Antúnez-Ballesteros
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - David González-Calle
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Javier Rodríguez-Collado
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | | | - Elena Díaz-Peláez
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - María C. Pérez del Villar-Moro
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Pedro L. Sánchez-Fernández
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| | - Ignacio Cruz-González
- Department of Cardiology, Hospital Universitario de Salamanca, 37007 Salamanca, Spain (G.J.B.-d.S.)
- Instituto de Investigación Biomédica de Salamanca, 37007 Salamanca, Spain
- Centro de Ivestigación Biomédica en Red—Enfermedades Cardiovasculares (CIBER-CV), 37007 Salamanca, Spain
| |
Collapse
|
16
|
Thevathasan T, Degbeon S, Paul J, Wendelburg DK, Füreder L, Gaul AL, Scheitz JF, Stadler G, Rroku A, Lech S, Buspavanich P, Huemer M, Attanasio P, Nagel P, Reinthaler M, Landmesser U, Skurk C. Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis. J Clin Med 2023; 12:4573. [PMID: 37510689 PMCID: PMC10380523 DOI: 10.3390/jcm12144573] [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: 05/28/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0-0.24] (p = 0.003), while a trend to lower numbers of other peri-procedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78-0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41-0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41-6.39]) and SE (OR 5.0 [95% CI 1.28-43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.
Collapse
Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Sêhnou Degbeon
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Julia Paul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Darius-Konstantin Wendelburg
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Anna Leonie Gaul
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Jan F Scheitz
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Gertraud Stadler
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Andi Rroku
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Sonia Lech
- Institute for Medical Sociology and Rehabilitation Science, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Department of Psychiatry and Neurosciences, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Pichit Buspavanich
- Research Unit Gender in Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
- Institute for Sexology and Sexual Medicine, Charité-Universitätsmedizin Berlin, Campus Mitte, Charitéplatz 1, 10117 Berlin, Germany
| | - Martin Huemer
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Philipp Attanasio
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Patrick Nagel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Markus Reinthaler
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité (DHZC), Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung e.V., Potsdamer Str. 58, 10785 Berlin, Germany
| |
Collapse
|
17
|
Margonato D, Rizza V, Ingallina G, Preda A, Ancona F, Belli M, Godino C, Agricola E, Della Bella P, Grasso C, Contarini M, Mazzone P. Left atrial appendage occlusion in the absence of intraprocedural product specialist monitoring: is it time to proceed alone? Results from a multicenter real-world experience. Front Cardiovasc Med 2023; 10:1172005. [PMID: 37383696 PMCID: PMC10293837 DOI: 10.3389/fcvm.2023.1172005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/31/2023] [Indexed: 06/30/2023] Open
Abstract
Background Percutaneous left atrial appendage occlusion (LAAO) presents many technical complex features, and it is often performed under the intraprocedural surveillance of a product specialist (PS). Our aim is to assess whether LAAO is equally safe and effective when performed in high-volume centers without PS support. Methods Intraprocedural results and long-term outcome were retrospectively assessed in 247 patients who underwent LAAO without intraprocedural PS monitoring between January 2013 and January 2022 at three different hospitals. This cohort was then matched to a population who underwent LAAO with PS surveillance. The primary end point was all-cause mortality at 1 year. The secondary end point was a composite of cardiovascular mortality plus nonfatal ischemic stroke occurrence at 1 year. Results Of the 247 study patients, procedural success was achieved in 243 patients (98.4%), with only 1 (0.4%) intraprocedural death. After matching, we did not identify any significant difference between the two groups in terms of procedural time (70 ± 19 min vs. 81 ± 30 min, p = 0.106), procedural success (98.4% vs. 96.7%, p = 0.242), and procedure-related ischemic stroke (0.8% vs. 1.2%, p = 0.653). Compared to the matched cohort, a significant higher dosage of contrast was used during procedures without specialist supervision (98 ± 19 vs. 43 ± 21, p < 0.001), but this was not associated with a higher postprocedural acute kidney injury occurrence (0.8% vs. 0.4%, p = 0.56). At 1 year, the primary and the secondary endpoints occurred in 21 (9%) and 11 (4%) of our cohort, respectively. Kaplan-Meier curves showed no significant difference in both primary (p = 0.85) and secondary (p = 0.74) endpoint occurrence according to intraprocedural PS monitoring. Conclusions Our results show that LAAO, despite the absence of intraprocedural PS monitoring, remains a long-term safe and effective procedure, when performed in high-volume centers.
Collapse
Affiliation(s)
- Davide Margonato
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Vincenzo Rizza
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Giacomo Ingallina
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Alberto Preda
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Francesco Ancona
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Martina Belli
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Cosmo Godino
- Department of Clinical Cardiology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Eustachio Agricola
- Department of Cardiovascular Imaging, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Paolo Della Bella
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Carmelo Grasso
- Department of Cardiology, C.A.S.T., Azienda Ospedaliero Universitaria Policlinico “G. Rodolico-San Marco”, University of Catania, Catania, Italy
| | - Marco Contarini
- Department of Interventional Cardiology, Umberto I Hospital, Syracuse, Italy
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| |
Collapse
|
18
|
Nestelberger T, Alfadhel M, McAlister C, Saw J. Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long? Card Electrophysiol Clin 2023; 15:157-168. [PMID: 37076228 DOI: 10.1016/j.ccep.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures.
Collapse
Affiliation(s)
- Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Vancouver General Hospital, Basel, British Columbia, Canada; University of British Columbia, 2775 Laurel Street, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
| |
Collapse
|
19
|
Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
Collapse
Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
| | | |
Collapse
|
20
|
Guarracini F, Bonvicini E, Preda A, Martin M, Muraglia S, Casagranda G, Mochen M, Coser A, Quintarelli S, Branzoli S, Bonmassari R, Marini M, Mazzone P. Appropriate Use Criteria of Left Atrial Appendage Closure Devices: Latest Evidences. Expert Rev Med Devices 2023; 20:493-503. [PMID: 37128658 DOI: 10.1080/17434440.2023.2208748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Atrial fibrillation is the most common arrythmia and it is linked to an increased risk of stroke. Even if anticoagulation therapy reduces the rate of stroke the benefits of this therapy have to been balanced with the increased risk of hemorrhagic event. Left atrial appendage closure is a valid alternative to long term anticoagulation in patients with atrial fibrillation and high hemorrhagic risk. Actually new devices with different features have been tested and introduced progressively in the clinical practice. Improvements preprocedural imaging evaluation and the learning curve of the operators led to percutaneous left atrial appendage closure a safe and effective procedure. A good knowledge of different devices and the technique of implant is necessary for optimization percutaneous left atrial appendage closure and the reduction of complications during the acute phase and follow up.
Collapse
Affiliation(s)
| | | | - Alberto Preda
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, Milano, Italy
| | - Marta Martin
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | | | | | - Alessio Coser
- Department of Cardiology, S. Chiara Hospital, Trento, Italy
| | | | | | | | | | - Patrizio Mazzone
- Cardiothoracovascular Department, Electrophysiology Unit, Niguarda Hospital, Milano, Italy
| |
Collapse
|
21
|
Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, Hoang Trinh K, O'Hara G, Rodés-Cabau J. Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives. Circ Cardiovasc Interv 2023; 16:e012812. [PMID: 37192309 DOI: 10.1161/circinterventions.122.012812] [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] [Indexed: 05/18/2023]
Abstract
Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.
Collapse
Affiliation(s)
- Jules Mesnier
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Pedro Cepas-Guillén
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Xavier Freixa
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Eduardo Flores-Umanzor
- Cardiovascular Department, Cardiovascular Institute, Clínic Barcelona, Spain (P.C.-G., X.F., E.F.-U.)
| | - Kim Hoang Trinh
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Gilles O'Hara
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Québec City, Canada (J.M., K.H.T., G.O., J.R.-C.)
| |
Collapse
|
22
|
Patti G, Ghiglieno C. Indications, evidence, and controversy in the closure of the left atrial appendage. Eur Heart J Suppl 2023; 25:B126-B130. [PMID: 37091645 PMCID: PMC10120968 DOI: 10.1093/eurheartjsupp/suad091] [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] [Indexed: 04/25/2023]
Abstract
Closure of the left atrial appendage (LAAO) represents a valid option for the prevention of cardio-embolic stroke in patients with atrial fibrillation (AF) at high bleeding risk. Previous studies had shown that the atrial appendage represents the site of atrial thrombus formation in about 90% of cases in the presence of non-valvular AF. In all patients with AF and higher thromboembolic risk (in particular with CHA2DS2VASc score ≥2 in women and ≥1 in men) there is an indication for thromboembolic prophylaxis with AOC (oral anti-coagulants). The main guidelines and international consensus documents place the indication for the LAAO in patients with the need for thromboembolic prophylaxis who have contraindications to oral anticoagulant therapy (class of recommendation IIb).
Collapse
|
23
|
Gallo F, Ronco F, D'Amico G, Della Rocca DG, Mazzone P, Bordignon S, Casu G, Giannini F, Berti S, Horton RP, D'Angelo G, Urbanek L, Merella P, Ruggiero R, Romeo MR, Bosica F, Schmidt B, Atzori E, Barbierato M, Natale A, Themistoclakis S. Clinical outcomes of left atrial appendage occlusion in patients with previous intracranial or gastrointestinal bleeding: Insights from the LOGIC (Left atrial appendage Occlusion in patients with Gastrointestinal or IntraCranial bleeding) International Multicenter Registry. Catheter Cardiovasc Interv 2023; 101:1144-1153. [PMID: 36924020 DOI: 10.1002/ccd.30629] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 01/30/2023] [Accepted: 03/03/2023] [Indexed: 03/18/2023]
Abstract
AIMS To compare outcomes of patients who underwent left atrial appendage occlusion (LAAO) for nonvalvular atrial fibrillation (NVAF) and contraindication to anticoagulants due to history of either gastrointestinal (GI) or intracranial (IC) bleeding. METHODS Patients with NVAF that underwent LAAO for GI or IC bleeding from seven centers were included in this observational study. Baseline characteristics, procedural features, and follow-up data were collected, and compared between the two groups. The primary outcomes were incidence of ischemic and hemorrhagic events at 12-month. RESULTS Six hundred twenty-eight patients were included, 57% with previous GI-bleeding, and 43% with previous IC-bleeding. Median CHA 2 DS 2-VASc score was 4 (interquartile range [IQRs]: 3-5) for both GI-bleeding and IC-bleeding patients, while GI-bleeding patients had a higher HAS-BLED score (4 [IQRs: 3-4] vs. 3 [IQRs]: 2-3]; p = 0.001). At 12-month follow-up, relative risk reduction for stroke was similar between the two groups. The GI-bleeding group had more hemorrhagic events compared to IC-bleeding group (any bleeding 8.4% vs. 3.2%; p = 0.012; major bleeding BARC 3-5: 4.3% vs. 1.8; p = 0.010). At multivariate analysis history of GI bleeding was an independent predictor of hemorrhagic events (adjusted HR: 2.39, 95% confidence interval: 1.02-5.63; p = 0.047). CONCLUSIONS Outcomes after LAAO may be affected by the different indications for the procedure. In our study, GI-bleeding and IC-bleeding as indication to LAAO differ in their baseline characteristics. LAAO confirms its efficacy in ischemic risk reduction in both groups, while GI bleeding seems to be an independent predictor of bleeding recurrence at 12 months behind the antithrombotic regimen.
Collapse
Affiliation(s)
- Francesco Gallo
- Department of Cardiology, Ospedale dell'Angelo, Venezia, Italy
| | - Federico Ronco
- Department of Cardiology, Ospedale dell'Angelo, Venezia, Italy
| | | | | | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Stefano Bordignon
- Cardioangiologisches Centrum, Bethanien-Markus Krankenhaus, Frankfurt, Germany
| | - Gavino Casu
- Clinical and Interventional Cardiology, Sassari, Italy
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Sergio Berti
- Fondazione Toscana G. Monasterio, Ospedale Del Cuore, Massa, Italy
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | - Giuseppe D'Angelo
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Lukas Urbanek
- Cardioangiologisches Centrum, Bethanien-Markus Krankenhaus, Frankfurt, Germany
| | | | - Rossella Ruggiero
- Interventional Cardiology Unit, GVM Care & Research Maria Cecilia Hospital, Cotignola, Italy
| | - Maria Rita Romeo
- Fondazione Toscana G. Monasterio, Ospedale Del Cuore, Massa, Italy
| | - Francesco Bosica
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Boris Schmidt
- Cardioangiologisches Centrum, Bethanien-Markus Krankenhaus, Frankfurt, Germany
| | - Enrico Atzori
- Clinical and Interventional Cardiology, Sassari, Italy
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA.,Interventional Electrophysiology, Scripps Clinic, La Jolla, California, USA.,Department of Cardiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | | |
Collapse
|
24
|
Hana D, Miller T, Chaker Z, Chobufo MD, Khan A, Patel B, Ghobrial J, Kawsara A, Thompson J, Raybuck B, Badhwar V, Daggubatti R, Mills J, Hamirani YS. Evaluating Gender-based Differences in Clinical Outcomes for Patients Undergoing Left Atrial Appendage Occlusion: A Single Centre Experience. Curr Probl Cardiol 2023; 48:101532. [PMID: 36509198 DOI: 10.1016/j.cpcardiol.2022.101532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/13/2022]
Abstract
There is emerging recent data that has shown women to be more prone to in-hospital major adverse events after trans catheter left atrial appendage occlusion. Institutional LAAO registry at West Virginia University (WVU) was reviewed from January 2016 to October 2021 to identify 271 women and 293 men who underwent successful LAAO device implantation. Patients were evaluated for gender-based differences in baseline characteristics, CHA₂DS₂-VASc Score, HAS-BLED score, procedural data, in-hospital, and follow-up outcomes. Compared to men, women had lower baseline comorbidities including coronary artery disease (135 (49.6%) vs 172 (58.7%), P = 0.03), myocardial infarction (MI) (56 (20.5%) vs 85 (29%), P = 0.02) and coronary artery bypass surgery (10 (3.6%) vs 27 (9.2%), P = 0.008). Women were noted to have a higher CHA₂DS₂-VASc Score (5.3 ± 1.4 vs 4.4 ± 1.4, P < 0.001), and left ventricular ejection fraction (57.9 ± 7.7 vs 52.7 ± 12.4, P < 0.001). Women were noted to have a significantly higher rate of in-hospital composite adverse events (74 (27.2%) vs 58 (19.8%), P = 0.03); bleeding events (38 (10.2%) vs 19 (6.4%), P = 0.003) and associated blood transfusion (6 vs 0, P = 0.001) compared with men. No statistically significant differences were noted between both genders regarding the follow-up outcome. Our single center study shows women to have higher in-hospital composite adverse events as well as higher bleeding events during the index hospital admission.
Collapse
Affiliation(s)
- David Hana
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Tyler Miller
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Zakeih Chaker
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - Muchi D Chobufo
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - Arsalan Khan
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Bansari Patel
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Jonathan Ghobrial
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Akram Kawsara
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - Jesse Thompson
- Department of Medicine, West Virginia University School of Medicine, Morgantown, WV
| | - Bryan Raybuck
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV
| | - Ramesh Daggubatti
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - James Mills
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV
| | - Yasmin S Hamirani
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, WV.
| |
Collapse
|
25
|
Holmes DR, Korsholm K, Rodés-Cabau J, Saw J, Berti S, Alkhouli MA. Left atrial appendage occlusion. EUROINTERVENTION 2023; 18:e1038-e1065. [PMID: 36760206 PMCID: PMC9909459 DOI: 10.4244/eij-d-22-00627] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 11/03/2022] [Indexed: 02/08/2023]
Abstract
Prevention of stroke represents a goal of primary importance in health systems due to its associated morbidity and mortality. As several patient groups with increased stroke rates have been identified, multiple approaches have been developed and implemented: oral anticoagulation (OAC) for patients with atrial fibrillation, surgical and percutaneous revascularisation in patients with carotid disease, device closure for patients with patent foramen ovale, and now, left atrial appendage occlusion (LAAO) for selected patients with non-valvular atrial fibrillation (NVAF). The latter group of patients are the focus of this review which evaluates the pathophysiology, selection of patients, procedural performance, outcomes of treatment both during and post-procedure, adjunctive therapy, complications, and longer-term outcomes.
Collapse
Affiliation(s)
- David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Josep Rodés-Cabau
- Quebec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Jacqueline Saw
- Division of Interventional Cardiology, Vancouver General Hospital and the University of British Columbia, Vancouver, BC, Canada
| | - Sergio Berti
- Cardiology Unit, Fondazione Toscana Gabriele Monasterio, Massa, Italy
| | - Mohamad A Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, MN, USA
| |
Collapse
|
26
|
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.
Collapse
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
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Berti S, De Caterina AR, Grasso C, Casu G, Giacchi G, Pagnotta P, Maremmani M, Mazzone P, Limite L, Tomassini F, Greco F, Romeo MR, Caramanno G, Fassini G, Geraci S, Chiarito M, Tondo C, Tamburino C, Contarini M. Periprocedural outcome in patients undergoing left atrial appendage occlusion with the Watchman FLX device: The ITALIAN-FLX registry. Front Cardiovasc Med 2023; 10:1115811. [PMID: 37180775 PMCID: PMC10172664 DOI: 10.3389/fcvm.2023.1115811] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction The Watchman FLX is a novel device for transcatheter left atrial appendage occlusion (LAAO) specifically designed to improve procedural performance in more complex anatomies with a better safety profile. Recently, small prospective non-randomized studies have shown good procedural success and safety compared with previous experiences. Results from large multicenter registries are needed to confirm the safety and efficacy of the Watchman FLX device in a real-world setting. Methods Italian FLX registry is a retrospective, non-randomized, multicentric study across 25 investigational centers in Italy including consecutive patients undergoing LAAO with the Watchman FLX between March 2019 and September 2021 (N = 772). The primary efficacy outcome was the technical success of the LAAO procedure (peri-device flow ≤ 5 mm) as assessed by intra-procedural imaging. The peri-procedural safety outcome was defined as the occurrence of one of the following events within 7 days after the procedure or by hospital discharge: death, stroke, transient ischemic attack, major extracranial bleeding (BARC type 3 or 5), pericardial effusion with tamponade or device embolization. Results A total of 772 patients were enrolled. The mean age was 76 ± 8 with a mean CHA2DS2-VASc score of 4.1 ± 1.4 and a mean HAS-BLED score of 3.7 ± 1.1. Technical success was achieved in 772 (100%) patients with the first device implanted in 760 (98.4%) patients. A peri-procedural safety outcome event occurred in 21 patients (2.7%) with major extracranial bleeding being the most common (1.7%). No device embolization occurred. At discharge 459 patients (59.4%) were treated with dual antiplatelet therapy (DAPT). Conclusions The Italian FLX registry represents the largest multicenter retrospective real-world study reporting periprocedural outcome of LAAO with the Watchman FLX device, resulting in a procedural success rate of 100% and a low incidence of peri-procedural major adverse events (2.7%).
Collapse
Affiliation(s)
- Sergio Berti
- Fondazione Toscana G. Monasterio, Ospedale del Cuore G. Pasquinucci, Massa, Italy
- Correspondence: Sergio Berti
| | | | - Carmelo Grasso
- Cardiac-Thoracic-Vascular Department, Ferrarotto Hospital and University of Catania, Catania, Italy
| | - Gavino Casu
- Cardiology Unit, Ospedale San Francesco, Nuoro, Italy
| | | | - Paolo Pagnotta
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Michele Maremmani
- Fondazione Toscana G. Monasterio, Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | - Patrizio Mazzone
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Luca Limite
- Department of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital and Vita-Salute University, Milan, Italy
| | - Francesco Tomassini
- Unità interaziendale di emodinamica-Ospedale degli Infermi, Rivoli(To)-Ospedale San Luigi Gonzaga, Turin, Italy
| | | | - Maria Rita Romeo
- Fondazione Toscana G. Monasterio, Ospedale del Cuore G. Pasquinucci, Massa, Italy
| | | | - Gaetano Fassini
- Department of Clinical Electrophysiology & Cardiac Pacing Heart Rhythm Center at Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Salvatore Geraci
- Interventional Cardiology Unit, Umberto I Hospital, Syracuse, Italy
| | - Mauro Chiarito
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Cardio Center, Humanitas Research Hospital IRCCS, Rozzano, Milan, Italy
| | - Claudio Tondo
- Department of Clinical Electrophysiology & Cardiac Pacing Heart Rhythm Center at Monzino Cardiac Center, IRCCS, Milan, Italy
| | - Corrado Tamburino
- Cardiac-Thoracic-Vascular Department, Ferrarotto Hospital and University of Catania, Catania, Italy
| | | |
Collapse
|
28
|
Afzal S, Zeus T, Hofsähs T, Kuballa M, Veulemans V, Piayda K, Heidari H, Polzin A, Horn P, Westenfeld R, Kelm M, Hellhammer K. Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study. Eur Heart J Cardiovasc Imaging 2022; 24:68-77. [PMID: 34977935 DOI: 10.1093/ehjci/jeab280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 12/14/2021] [Indexed: 12/24/2022] Open
Abstract
AIMS The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions and to identify potential risk factors. METHODS AND RESULTS We retrospectively analysed 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. A follow-up was conducted up to 3 months after the intervention. TOE-related AEs were observed in 5.3% of the patients (n = 48). The highest rate of AEs was observed in the percutaneous mitral valve repair (PMVR) group with 8.2% (n = 32), whereas 4.8% (n = 11) of the patients in the left atrial appendage group and 1.8% (n = 5) in the patent foramen ovale/atrial septal defect group developed a TOE-related AE (P = 0.001). The most frequent AE was pneumonia with an incidence of 2.6% (n = 26) in the total cohort. Bleeding events occurred in 1.8% (n = 16) of the patients, mostly in the PMVR group with 2.1% (n = 8). In the multivariate regression analysis, we found a lower haemoglobin {odds ratio (OR) [95% confidence interval (CI)]: 8.82 (0.68-0.98) P = 0.025} and an obstructive sleep apnoea syndrome (OSAS) [OR (95% CI): 2.51 (1.08-5.84) P = 0.033] to be associated with AE. Furthermore, AEs were related to procedural time [OR (95% CI): 1.01 (1.0-1.01) P = 0.056] and oral anticoagulation [OR (95% CI): 1.97 (0.9-4.3) P = 0.076] with borderline significance in the multivariate regression analysis. No persistent damages were observed. CONCLUSION TOE-related AEs during SHD interventions are clinically relevant. It was highest in patients undergoing PMVR. A lower baseline haemoglobin level and an OSAS were found to be associated with the occurrence of a TOE-related AE.
Collapse
Affiliation(s)
- Shazia Afzal
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Tobias Zeus
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Timo Hofsähs
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Matti Kuballa
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Verena Veulemans
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Kerstin Piayda
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Houtan Heidari
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Amin Polzin
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Patrick Horn
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany.,CARID (Cardiovascular Research Institute Düsseldorf), Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany
| | - Katharina Hellhammer
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich Heine University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225 Düsseldorf, Germany
| |
Collapse
|
29
|
Zieliński K, Pracoń R, Konka M, Kruk M, Kępka C, Trochimiuk P, Dębski M, Kaczmarska E, Przyłuski J, Kowalik I, Dzielińska Z, Kurowski A, Witkowski A, Demkow M. Incidence and Predictors of Clinically Significant Bleedings after Transcatheter Left Atrial Appendage Closure. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13802. [PMID: 36360682 PMCID: PMC9658798 DOI: 10.3390/ijerph192113802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/15/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC. METHODS Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014-11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure. RESULTS Among 195 patients (age 74 (68-80), 43.1% females, HAS-BLED score 2.0 (2.0-3.0)), during median follow-up of 370 (IQR, 358-392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16-60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81-210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37-84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32-25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20-17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01-11.08, p = 0.048) predicted post-LAAC CSB. CONCLUSIONS Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.
Collapse
Affiliation(s)
- Kamil Zieliński
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Radosław Pracoń
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marek Konka
- Department of Congenital Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Kruk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Cezary Kępka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Piotr Trochimiuk
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Mariusz Dębski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Edyta Kaczmarska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Jakub Przyłuski
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Ilona Kowalik
- Clinical Research Support Center, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Zofia Dzielińska
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Andrzej Kurowski
- Department of Anesthesiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| | - Marcin Demkow
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, Alpejska 42, 04-628 Warsaw, Poland
| |
Collapse
|
30
|
Chew DS, Zhou K, Pokorney SD, Matchar DB, Vemulapalli S, Allen LA, Jackson KP, Samad Z, Patel MR, Freeman JV, Piccini JP. Left Atrial Appendage Occlusion Versus Oral Anticoagulation in Atrial Fibrillation : A Decision Analysis. Ann Intern Med 2022; 175:1230-1239. [PMID: 35969865 DOI: 10.7326/m21-4653] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Left atrial appendage occlusion (LAAO) is a potential alternative to oral anticoagulants in selected patients with atrial fibrillation (AF). Compared with anticoagulants, LAAO decreases major bleeding risk, but there is uncertainty regarding the risk for ischemic stroke compared with anticoagulation. OBJECTIVE To determine the optimal strategy for stroke prevention conditional on a patient's individual risks for ischemic stroke and bleeding. DESIGN Decision analysis with a Markov model. DATA SOURCES Evidence from the published literature informed model inputs. TARGET POPULATION Women and men with nonvalvular AF and without prior stroke. TIME HORIZON Lifetime. PERSPECTIVE Clinical. INTERVENTION LAAO versus warfarin or direct oral anticoagulants (DOACs). OUTCOME MEASURES The primary end point was clinical benefit measured in quality-adjusted life-years. RESULTS OF BASE-CASE ANALYSIS The baseline risks for stroke and bleeding determined whether LAAO was preferred over anticoagulants in patients with AF. The combined risks favored LAAO for higher bleeding risk, but that benefit became less certain at higher stroke risks. For example, at a HAS-BLED score of 5, LAAO was favored in more than 80% of model simulations for CHA2DS2-VASc scores between 2 and 5. The probability of LAAO benefit in QALYs (>80%) at lower bleeding risks (HAS-BLED score of 0 to 1) was limited to patients with lower stroke risks (CHA2DS2-VASc score of 2). Because DOACs carry lower bleeding risks than warfarin, the net benefit of LAAO is less certain than that of DOACs. RESULTS OF SENSITIVITY ANALYSIS Results were consistent using the ORBIT bleeding score instead of the HAS-BLED score, as well as alternative sources for LAAO clinical effectiveness data. LIMITATION Clinical effectiveness data were drawn primarily from studies on the Watchman device. CONCLUSION Although LAAO could be an alternative to anticoagulants for stroke prevention in patients with AF and high bleeding risk, the overall benefit from LAAO depends on the combination of stroke and bleeding risks in individual patients. These results suggest the need for a sufficiently low stroke risk for LAAO to be beneficial. The authors believe that these results could improve shared decision making when selecting patients for LAAO. PRIMARY FUNDING SOURCE None.
Collapse
Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, and Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada (D.S.C.)
| | - Ke Zhou
- Duke-National University of Singapore Medical School, Singapore (K.Z.)
| | - Sean D Pokorney
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - David B Matchar
- Duke-National University of Singapore Medical School, Singapore, and Division of General Internal Medicine, Duke University Medical Center, Durham, North Carolina (D.B.M.)
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - Larry A Allen
- University of Colorado School of Medicine, Aurora, Colorado (L.A.A.)
| | - Kevin P Jackson
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina (K.P.J.)
| | - Zainab Samad
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, and Department of Medicine, Aga Khan University, Karachi, Pakistan (Z.S.)
| | - Manesh R Patel
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| | - James V Freeman
- Yale University School of Medicine, New Haven, Connecticut (J.V.F.)
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Duke University, and Division of Cardiology, Duke University Medical Center, Durham, North Carolina (S.D.P., S.V., M.R.P., J.P.P.)
| |
Collapse
|
31
|
Incidence and Predictors of Early Death in Patients Undergoing Percutaneous Left Atrial Appendage Closure. JACC Clin Electrophysiol 2022; 8:1093-1102. [DOI: 10.1016/j.jacep.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/25/2022] [Accepted: 06/09/2022] [Indexed: 11/17/2022]
|
32
|
Kewcharoen J, Shah K, Bhardwaj R, Contractor T, Turagam M, Mandapati R, Lakkireddy D, Garg J. Left atrial appendage occlusion in patients with blood cell dyscrasia. Pacing Clin Electrophysiol 2022; 45:1316-1319. [PMID: 35696197 DOI: 10.1111/pace.14550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/31/2022] [Accepted: 06/10/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Jakrin Kewcharoen
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Kuldeep Shah
- Department of Cardiovascular Medicine, Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan, USA
| | - Rahul Bhardwaj
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Tahmeed Contractor
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Mohit Turagam
- Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ravi Mandapati
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas, USA
| | - Jalaj Garg
- Division of Cardiology, Cardiac Arrhythmia Service, Loma Linda University Health, Loma Linda, California, USA
| |
Collapse
|
33
|
Price MJ, Slotwiner D, Du C, Freeman JV, Turi Z, Rammohan C, Kusumoto FM, Kavinsky C, Akar J, Varosy PD, Koutras C, Curtis JP, Masoudi FA. Clinical Outcomes at 1 Year Following Transcatheter Left Atrial Appendage Occlusion in the United States. JACC Cardiovasc Interv 2022; 15:741-750. [PMID: 35393108 DOI: 10.1016/j.jcin.2022.02.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The aim of this study was to report 1-year clinical outcomes following commercial transcatheter left atrial appendage occlusion (LAAO) in the United States. BACKGROUND The National Cardiovascular Data Registry LAAO Registry was initiated to meet a condition of Medicare coverage and allow the assessment of clinical outcomes. The 1-year rates of thromboembolic events after transcatheter LAAO in such a large cohort of "real-world" patients have not been previously reported. METHODS Patients entered into the National Cardiovascular Data Registry LAAO Registry for a Watchman procedure between January 1, 2016, and December 31, 2018, were included. The primary endpoint was ischemic stroke. Key secondary endpoints included the rate of ischemic stroke or systemic embolism, mortality, and major bleeding. Major bleeding was defined as any bleeding requiring hospitalization, and/or causing a decrease in hemoglobin level > 2g/dL, and/or requiring blood transfusion that was not hemorrhagic stroke. The Kaplan-Meier method was used for 1-year estimates of cumulative event rates. RESULTS The study population consisted of 36,681 patients. The mean age was 76.0 ± 8.1 years, the mean CHA2DS2-VASc score was 4.8 ± 1.5, and the mean HAS-BLED score was 3.0 ± 1.1. Prior stroke was present in 25.5%, clinically relevant bleeding in 69.5%, and intracranial bleeding in 11.9%. Median follow-up was 374 days (IQR: 212-425 days). The Kaplan-Meier-estimated 1-year rate of ischemic stroke was 1.53% (95% CI: 1.39%-1.69%), the rate of ischemic stroke or systemic embolism was 2.19% (95% CI: 2.01%-2.38%), and the rate of mortality was 8.52% (95% CI: 8.19%-8.87%). The 1-year estimated rate of major bleeding was 6.93% (95% CI: 6.65%-7.21%). Most bleeding events occurred between discharge and 45 days following the procedure. CONCLUSIONS This study characterizes important outcomes in a national cohort of patients undergoing transcatheter LAAO in the United States. Clinicians and patients can integrate these data in shared decision making when considering this therapy.
Collapse
Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA.
| | - David Slotwiner
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA
| | - Chengan Du
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | - James V Freeman
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Zoltan Turi
- Center for Structural and Congenital Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Chidambaram Rammohan
- Division of Cardiovascular Medicine, Palo Alto Medical Foundation, El Camino Hospital, Mountain View, California
| | - Fred M Kusumoto
- Department of Cardiovascular Disease, Mayo Clinic, Jacksonville, Florida, USA
| | - Clifford Kavinsky
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Joseph Akar
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA; Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Paul D Varosy
- VA Eastern Colorado Health Care System and University of Colorado, Aurora, Colorado, USA
| | - Christina Koutras
- American College of Cardiology Foundation, Washington, District of Columbia, USA
| | - Jeptha P Curtis
- Division of Cardiology, New York Presbyterian Queens, Weill Cornell Medical College, New York, New York, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
| | | |
Collapse
|
34
|
Nestelberger T, Alfadhel M, McAlister C, Saw J. Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long? Interv Cardiol Clin 2022; 11:159-170. [PMID: 35361461 DOI: 10.1016/j.iccl.2021.11.008] [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] [Indexed: 06/14/2023]
Abstract
Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures.
Collapse
Affiliation(s)
- Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Vancouver General Hospital, Basel, British Columbia, Canada; University of British Columbia, 2775 Laurel Street, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
| |
Collapse
|
35
|
Galloo X, Carmeliet T, Prihadi EA, Lochy S, Scott B, Verheye S, Schoors D, Vermeersch P. Left atrial appendage occlusion in recurrent ischaemic stroke, a multicentre experience. Acta Clin Belg 2022; 77:255-260. [PMID: 32951514 DOI: 10.1080/17843286.2020.1821494] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Oral anticoagulation therapy (OAC) remains the gold standard for ischaemic stroke prevention in patients with non-valvular atrial fibrillation (NVAF) and elevated stroke risk. Percutaneous left atrial appendage occlusion (LAAO) has emerged as a potential alternative for stroke prevention in patients who cannot tolerate OAC. Although no randomized data is available, recurrent stroke in NVAF-patients, while on adequate OAC, is regarded as a treatment failure and therefore is considered as a potential indication for LAAO, based upon expert opinion. METHODS/OBJECTIVES A multicentre retrospective cohort study evaluating efficacy, safety and mortality of LAAO in NVAF-patients presenting with recurrent ischaemic stroke, after excluding other plausible causes. RESULTS Fifteen LAAO have been performed in NVAF-patients with recurrent stroke despite ongoing OAC, after exclusion of other plausible causes. Mean age was 78.1 ± 5.8 years, mean CHA2DS2-VASc-score = 6 ± 1.2 and mean HAS-BLED-score = 5 ± 1.2. Successful implantation was achieved in all patients (73% Amplatzer device and 27% Watchman device), without any access-related complications and only one procedure/device-related complication (device embolization) was reported. In all but four patients, OAC was continued at long term after LAAO. No haemorrhagic strokes and only two ischaemic strokes were observed. During follow-up three patients died, all due to non-atrial fibrillation or non-device-related causes. CONCLUSIONS In NVAF-patients at high risk for stroke presenting with recurrent stroke despite adequate OAC, LAAO may be considered an adjunctive, but not alternative treatment to OAC with high feasibility and safety. Abbreviations: AF: atrial fibrillation; ESC: European Society of Cardiology; INR: international normalized ratio; LAA: left atrial appendage; LAAO: left atrial appendage occlusion; NOAC: non-vitamin K oral anticoagulants; NVAF: non-valvular atrial fibrillation; OAC: oral anticoagulation; RS: recurrent (ischaemic) stroke; SD: standard deviation; TIA: transient ischaemic attack; TOE: transoesophageal echocardiography; TTE: transthoracic echocardiography; VKA: vitamin K antagonists.
Collapse
Affiliation(s)
- X. Galloo
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - T. Carmeliet
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - EA. Prihadi
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
| | - S. Lochy
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - B. Scott
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
| | - S. Verheye
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - D. Schoors
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| | - P. Vermeersch
- Cardiology Department, ZNA Hartcentrum - ZNA Middelheim, Antwerp, Belgium
- Cardiology Department, Centrum Voor Hart- En Vaatziekten - UZ Brussel, Brussels, Belgium
| |
Collapse
|
36
|
Badescu MC, Badulescu OV, Butnariu LI, Floria M, Ciocoiu M, Costache II, Popescu D, Bratoiu I, Buliga-Finis ON, Rezus C. Current Therapeutic Approach to Atrial Fibrillation in Patients with Congenital Hemophilia. J Pers Med 2022; 12:519. [PMID: 35455634 PMCID: PMC9029474 DOI: 10.3390/jpm12040519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/18/2022] [Accepted: 03/21/2022] [Indexed: 11/21/2022] Open
Abstract
Cardiovascular disease in hemophiliacs has an increasing prevalence due to the aging of this population. Hemophiliacs are perceived as having a high bleeding risk due to the coagulation factor VIII/IX deficiency, but it is currently acknowledged that they also have an important ischemic risk. The treatment of atrial fibrillation (AF) is particularly challenging since it usually requires anticoagulant treatment. The CHA2DS2-VASc score is used to estimate the risk of stroke and peripheral embolism, and along with the severity of hemophilia, guide the therapeutic strategy. Our work provides the most complete, structured, and updated analysis of the current therapeutic approach of AF in hemophiliacs, emphasizing that there is a growing interest in therapeutic strategies that allow for short-term anticoagulant therapy. Catheter ablation and left atrial appendage occlusion have proven to be efficient and safe procedures in hemophiliacs, if appropriate replacement therapy can be provided.
Collapse
Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Oana Viola Badulescu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
- Hematology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Lacramioara Ionela Butnariu
- Department of Mother and Child Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mariana Floria
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Internal Medicine Clinic, “Dr. Iacob Czihac” Emergency Military Clinical Hospital Iasi, 700483 Iasi, Romania
| | - Manuela Ciocoiu
- Department of Pathophysiology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (O.V.B.); (M.C.)
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Diana Popescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (M.C.B.); (I.-I.C.); (D.P.); (O.N.B.-F.); (C.R.)
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| |
Collapse
|
37
|
Pracoń R, Zieliński K, Bangalore S, Konka M, Kruk M, Kępka C, Trochimiuk P, Dębski M, Przyłuski J, Kaczmarska E, Dzielińska Z, Kurowski A, Witkowski A, Demkow M. Residual stroke risk after left atrial appendage closure in patients with prior oral anticoagulation failure. Int J Cardiol 2022; 354:17-21. [PMID: 35219744 DOI: 10.1016/j.ijcard.2022.02.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 01/19/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and oral anticoagulation (OAC) failure may benefit from left atrial appendage closure (LAAC), however, the evidence is scarce. We report outcomes of LAAC in patients with OAC failure compared to those with classic indications of OAC contraindications. METHODS Prospective registry of LAAC with Amplatzer or WATCHMAN device followed by dual antiplatelet therapy (DAPT) was analyzed (05.2014-11.2019). The study group included patients with OAC failure defined as stroke/TIA/PE/LAA thrombus (n = 39) during OAC, whereas the control group consisted of patients with OAC contraindications (n = 156). Structured follow-up at 3, 6, and 12 months was done. RESULTS The study group compared to controls was younger [73 (IQR, 62-77) vs 74 (IQR, 68-81) years, P = 0.046], with higher CHA2DS2-VASc [5.0 (IQR, 3.0-6.0) vs 4.0 (IQR, 3.0-5.0), P = 0.001)], lower HAS-BLED [2.0 (IQR, 1.0-3.0) vs 3.0 (IQR, 2.0-3.0), P = 0.006] and similar proportion of WATCHMAN implantations (43.6% vs 44.2%, P = 1.000). The reduction from CHA2DS2-VASc predicted to observed annual stroke/TIA/PE rate was markedly smaller in the study vs control group (14% vs 77%) with 10.3% vs 1.9% stroke/TIA/PE respectively (P = 0.031). The reduction from HAS-BLED predicted to observed annual major nonprocedural bleeding rate was higher (100% vs 7.4%) with 0.0% vs 5.1% major bleedings respectively (P = 0.361). The device-related thrombosis remained similar (13.2% vs 11.3%, P = 0.778). CONCLUSIONS Patients after LAAC for OAC failure and unremarkable prior bleeding history presented with high residual stroke and low bleeding risks. Therefore concomitant long-term OAC or prolonged DAPT should strongly be considered in this population.
Collapse
Affiliation(s)
- Radosław Pracoń
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Kamil Zieliński
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland.
| | | | - Marek Konka
- Congenital Cardiac Defects Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Kruk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Cezary Kępka
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Trochimiuk
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Mariusz Dębski
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Jakub Przyłuski
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Edyta Kaczmarska
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Zofia Dzielińska
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| | - Andrzej Kurowski
- Anesthesiology Department, National Institute of Cardiology, Warsaw, Poland
| | - Adam Witkowski
- Interventional Cardiology and Angiology Department, National Institute of Cardiology, Warsaw, Poland
| | - Marcin Demkow
- Coronary and Structural Heart Diseases Department, National Institute of Cardiology, Warsaw, Poland
| |
Collapse
|
38
|
Paitazoglou C, Meincke F, Bergmann MW, Eitel I, Fink T, Vireca E, Wohlmuth P, Veliqi E, Willems S, Markiewicz A, Grygier M. The ALSTER-FLX Registry: 3-month outcomes following left atrial appendage occlusion employing a next-generation device, a matched-pair-analysis to EWOLUTION. Heart Rhythm 2022; 19:917-926. [PMID: 35181483 DOI: 10.1016/j.hrthm.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/09/2022] [Accepted: 02/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The new generation WATCHMAN FLX device for left atrial appendage occlusion has been modified in various aspects to improve procedural results. No comparison of the WATCHMAN FLX to the previous WATCHMAN device is available. OBJECTIVES We aimed to compare procedural results with WATCHMAN FLX in patients on dual antiplatelet therapy at around three months to data with WATCHMAN (EWOLUTION registry). METHODS 164 consecutive patients receiving the WATCHMAN FLX device in four European centers were included in the retrospective ALSTER FLX registry. As a control-group for a matched-pair-analysis, 1020 patients treated with the WATCHMAN device and data up to first follow-up (around three months) from the EWOLUTION registry were used. RESULTS Implantation was successful in all ALSTER FLX patients (100%) and similar to results in EWOLUTION (99%, p=0.2). We observed no stroke or device embolization in ALSTER FLX, similar to EWOLUTION (stroke 0.5%, device embolization 0.4%) at three months. Numerically less ALSTER FLX patients (2.4%) developed a device associated thrombus (DAT) compared to 3.7% EWOLUTION patients, yet without reaching statistical significance after matching (DAT pairwise event-difference median, 95% confidence interval 2(0/6), p=0.1). WATCHMAN FLX implantation was associated with a significant higher sealing rate compared to EWOLUTION at three months (ALSTER FLX 90% vs. EWOLUTION 79.4%, p=0.039 after matching). Major non-procedural bleeding events and mortality were similar after matching (event difference for bleeding 0(-3/3), p=0.6; death (1(-2/4), p=0.3). CONCLUSIONS Periprocedural, early 3-months outcomes with WATCHMAN FLX demonstrate a similar safety profile and an improved sealing rate compared to the WATCHMAN device.
Collapse
Affiliation(s)
- Christina Paitazoglou
- Interventional Cardiology, Cardiologicum Hamburg, Hamburg, Germany; University Heart Center Lübeck, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH).
| | - Felix Meincke
- Asklepios Klinik St. Georg, Hamburg, Germany; Asklepios Klinik Altona, Hamburg, Germany
| | - Martin W Bergmann
- Interventional Cardiology, Cardiologicum Hamburg, Hamburg, Germany; Asklepios Klinik Altona, Hamburg, Germany.
| | - Ingo Eitel
- University Heart Center Lübeck, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH)
| | - Thomas Fink
- University Heart Center Lübeck, Medical Clinic II (Cardiology, Angiology, Intensive Care Medicine), University Schleswig-Holstein (UKSH)
| | | | | | | | | | - Agata Markiewicz
- Department of Cardiology, Poznan University of Medical Sciences, Poznan/POLAND
| | - Marek Grygier
- Department of Cardiology, Poznan University of Medical Sciences, Poznan/POLAND
| |
Collapse
|
39
|
Miller T, Hana D, Patibandla S, Guzman DB, Avalon JC, Zeb I, Kadiyala M, Mills J, Balla S, Kim C, Lisle M, Kawsara M, Raybuck B, Daggubati R, Sengupta PP, Hamirani YS. Cardiac computed tomography angiography for device related thrombus assessment after WATCHMAN FLX™ occluder device implantation: A single-center retrospective observational study. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 41:35-46. [DOI: 10.1016/j.carrev.2022.01.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/03/2022]
|
40
|
Kondo Y, Kobayashi Y. Antithrombotic regimes in patients with prior gastrointestinal bleeding undergoing left atrial appendage closure. Pacing Clin Electrophysiol 2022; 45:439. [PMID: 35077578 DOI: 10.1111/pace.14457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Yusuke Kondo
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Yoshio Kobayashi
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan
| |
Collapse
|
41
|
Ben H, Changsheng M, Shulin W. 2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:535-555. [PMID: 35032332 PMCID: PMC9314806 DOI: 10.1111/pace.14448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).
Collapse
Affiliation(s)
- He Ben
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ma Changsheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wu Shulin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
42
|
Latest outcomes of transcatheter left atrial appendage closure devices and direct oral anticoagulant therapy in patients with atrial fibrillation over the past 5 years: a systematic review and meta-analysis. Cardiovasc Interv Ther 2022; 37:725-738. [PMID: 35098478 PMCID: PMC9474363 DOI: 10.1007/s12928-022-00839-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 01/12/2022] [Indexed: 01/17/2023]
Abstract
Left atrial appendage closure (LAAC) are emerging treatment for patients with atrial fibrillation (AF). However, data on the safety, efficacy, and medications for LAAC devices in patients with AF are lacking. We aimed to investigate the incidence of all-cause mortality, stroke, and major bleeding in AF patients with LAAC devices and DOACs. Moreover, we aimed to investigate the incidence rate of device-related thrombus (DRT) and the medications used in the management of AF patients with LAAC devices to gain insights into achieving better outcome. Based on a literature search using PubMed, EMBASE, Cochrane Library, and Web of Science databases between January 2015 and December 2020, eight LAAC device studies that used WATCHMAN and Amulet, and three DOAC studies that used rivaroxaban, with a total of 24,055 AF patients (LAAC devices, n = 2855; DOAC, n = 21,200), were included. A random-effects model was used to incorporate heterogeneity among studies. The pooled incidence of events per person-years were as follows: all-cause mortality, 0.06 (95% confidence interval [CI] 0.02-0.10) for WATCHMAN, 0.04 (95% CI 0.00-0.14) for Amulet, and 0.03 (95% CI 0.01-0.04) for rivaroxaban; stroke; 0.02 (95% CI 0.00-0.04) for WATCHMAN, 0 for Amulet, and 0.01 (95% CI 0.01-0.02) for rivaroxaban; major bleeding, 0.04 (95% CI 0.02-0.06) for WATCHMAN, 0.02 (95% CI 0.00-0.06) for Amulet, and 0.02 (95% CI 0.01-0.03) for rivaroxaban. The incidence rate of DRT was 2.3%, and complications were reported in 9%. The incidence of all-cause mortality, stroke, and major bleeding were similar between LAAC devices and DOACs. The rate of complications was acceptable, and those of DRT were lower than the average incidence reported in previous studies. However, further follow-up is needed. Concomitant anticoagulant and antiplatelet therapies should be further evaluated to find the optimal regimen for AF patients with LAAC devices.
Collapse
|
43
|
Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures. Medicina (B Aires) 2021; 58:medicina58010045. [PMID: 35056353 PMCID: PMC8778528 DOI: 10.3390/medicina58010045] [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: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.
Collapse
|
44
|
[Atrial fibrillation and the limits of oral anticoagulation: for whom are left atrial appendage occluders suitable?]. Internist (Berl) 2021; 63:230-237. [PMID: 34762155 DOI: 10.1007/s00108-021-01206-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with atrial fibrillation are at a significantly increased risk of thromboembolic events, especially ischemic strokes. Oral anticoagulation reduces this risk, but cannot be used in some patients for various reasons and is associated with a relevantly increased risk of bleeding. As an alternative for prophylaxis of thromboembolic events in patients with atrial fibrillation, there are different options of left atrial appendage closure. AIM This article explains the possibilities of interventional atrial occlusion as well as the suitable patient clientele using an overview of the currently available systems for atrial occlusion, a guideline for patient selection and a summary of the current scientific data. CONCLUSION AND AVAILABLE SCIENTIFIC DATA In carefully selected patients suffering from atrial fibrillation with relative or absolute contraindications for oral anticoagulation, interventional closure of the atrial appendage is a safe alternative for prophylaxis against thromboembolic events. The currently available scientific evidence from randomized controlled trials is sparse. Nevertheless, extensive amounts of registry study data suggest a benefit, while the results of several large randomized controlled trials are expected in the coming years.
Collapse
|
45
|
Lakkireddy D, Thaler D, Ellis CR, Swarup V, Sondergaard L, Carroll J, Gold MR, Hermiller J, Diener HC, Schmidt B, MacDonald L, Mansour M, Maini B, O'Brien L, Windecker S. Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial. Circulation 2021; 144:1543-1552. [PMID: 34459659 PMCID: PMC8570346 DOI: 10.1161/circulationaha.121.057063] [Citation(s) in RCA: 190] [Impact Index Per Article: 63.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Supplemental Digital Content is available in the text. Percutaneous closure of the left atrial appendage (LAA) is an alternative to chronic oral anticoagulation to reduce stroke risk in patients with nonvalvular atrial fibrillation. The Amulet IDE trial (Amplatzer Amulet Left Atrial Appendage Occluder IDE Trial) was designed to evaluate the safety and effectiveness of the dual-seal mechanism of the Amulet LAA occluder compared with the Watchman device.
Collapse
Affiliation(s)
| | | | | | | | | | - John Carroll
- University of Colorado Hospital, Anschultz Medical Campus, Aurora (J.C.)
| | - Michael R Gold
- Medical University of South Carolina, Charleston (M.R.G.)
| | | | | | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Frankfurt, Germany (B.S.)
| | - Lee MacDonald
- South Denver Cardiology Associates P.C., Littleton, CO (L.M.)
| | | | | | | | | |
Collapse
|
46
|
Saad M, Risha O, Sano M, Fink T, Heeger CH, Vogler J, Sciacca V, Eitel C, Stiermaier T, Joost A, Keelani A, Fuernau G, Meyer-Saraei R, Kuck KH, Eitel I, Richard Tilz R. Comparison between Amulet and Watchman left atrial appendage closure devices: A real-world, single center experience. IJC HEART & VASCULATURE 2021; 37:100893. [PMID: 34712772 PMCID: PMC8529070 DOI: 10.1016/j.ijcha.2021.100893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/13/2021] [Indexed: 11/20/2022]
Abstract
Background Data reporting a head-to-head comparison between Amulet and Watchman devices are scarce. The aim of this study was to compare the Watchman™ versus Amulet™ left atrial appendage closure (LAAC) devices in a consecutive, industry-independent registry. Methods Patients who underwent LAAC using Watchman or Amulet devices from January 2014 to December 2019 at the University Heart Center Lübeck, Lübeck, Germany were included in the present analysis. Primary endpoints included periprocedural complications (in-hospital death, pericardial tamponade, device embolization, stroke, major bleeding and vascular access complications), and complications during long-term follow-up (ischemic stroke, hemorrhagic stroke, thromboembolism, device thrombus, bleeding and death). Results After matching the patients for age (±5 years), gender, CHA2DS2Vasc score (±1) and HASBLED score (±1), each of the Watchman and the Amulet groups included 113 patients. Patients in the Amulet group had significantly more periprocedural complications (2.7% vs 10.6%, p = 0.029; respectively) and more major bleeding complications (0% vs 5.3%, p = 0.029; respectively). During long-term follow-up, the rate of events was comparable between the Watchman and Amulet groups (18.3% versus 20.8%, p = 0.729; respectively). Conclusion Amulet LAAC device was associated with increased periprocedural complications as compared to Watchman LAAC device. On long-term follow-up, both devices showed comparable efficacy and safety.
Collapse
Affiliation(s)
- Mohammed Saad
- Medical Clinic III, University Hospital Schleswig-Holstein, Kiel, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Osama Risha
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Makoto Sano
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Thomas Fink
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Christian-Hendrik Heeger
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Julia Vogler
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Vanessa Sciacca
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Charlotte Eitel
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Thomas Stiermaier
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Alexander Joost
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ahmad Keelani
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Georg Fuernau
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Roza Meyer-Saraei
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Karl-Heinz Kuck
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ingo Eitel
- Medical Clinic II, University Heart Center Lübeck, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Roland Richard Tilz
- Medical Clinic II, University Heart Center Lübeck, Division of Electrophysiology, Lübeck, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Lübeck, Germany
| |
Collapse
|
47
|
Cepas-Guillen PL, Flores-Umanzor E, Regueiro A, Brugaletta S, Ibañez C, Sanchis L, Sitges M, Rodés-Cabau J, Sabaté M, Freixa X. Low Dose of Direct Oral Anticoagulants after Left Atrial Appendage Occlusion. J Cardiovasc Dev Dis 2021; 8:jcdd8110142. [PMID: 34821695 PMCID: PMC8623304 DOI: 10.3390/jcdd8110142] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 12/13/2022] Open
Abstract
The optimal antithrombotic strategy following left atrial appendage occlusion (LAAO) is not yet clearly established. Low-dose non-vitamin K antagonist oral anticoagulants (NOAC) might represent a valid alternative, but data regarding their usage is scarce. The aim of this study was to examine the efficacy and safety of low-dose NOAC compared to single (SAPT) or dual antiplatelet therapies (DAPT) after LAAO. We included consecutive patients with non-valvular atrial fibrillation who underwent LAAO and received low-dose apixaban, SAPT, or DAPT at discharge. The primary objective of this study included an efficacy endpoint (thromboembolic events and device related thrombosis (DRT)) and a safety endpoint (incidence of major bleeding) within the first three months after LAAO. A total of 139 patients were included. This group involved SAPT in 26 (18%), DAPT in 73 (53%), and apixaban in 40 (29%) patients. Follow-up at three-months showed no significant differences in the primary efficacy endpoint (2 (8%) SAPT, 3 (4%) DAPT and 0 (0%) apixaban; p value = 0.25). In contrast, the primary safety endpoint occurred more frequently in DAPT patients (7 (10%) DAPT, 0 (0%), SAPT and 0 with apixaban; p value = 0.03). Combining both efficacy and safety outcomes, low dose apixaban had a lower rate of events (2 (8%) with SAPT, 9 (12%) with DAPT and 0 (0%) with apixaban; p = 0.046). Low-dose apixaban after LAAO may be a valid alternative to DAPT and SAPT as depicted by the reduction in the occurrence of major bleedings and combined DRT/major bleedings respectively. Randomized data will be necessary to validate this strategy.
Collapse
Affiliation(s)
- Pedro Luis Cepas-Guillen
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Eduardo Flores-Umanzor
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Ander Regueiro
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Salvatore Brugaletta
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Cristina Ibañez
- Anesthesiology Department, Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Laura Sanchis
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Marta Sitges
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Josep Rodés-Cabau
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Quebec Heart and Lung Institute, Quebec City, QC G1V 4G5, Canada
| | - Manel Sabaté
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
| | - Xavier Freixa
- Cardiology Department, Cardiovascular Institute (ICCV), Hospital Clinic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain; (P.L.C.-G.); (E.F.-U.); (A.R.); (S.B.); (L.S.); (M.S.); (J.R.-C.); (M.S.)
- Correspondence: ; Tel.: +34-932275519
| |
Collapse
|
48
|
Ledwoch J, Staubach S, Akin I, Ince H, Zeymer U, Pleger S, Sievert H, Hochadel M, Senges J, Lewalter T, Brachmann J, Mudra H. Anticoagulation versus antiplatelet therapy after percutaneous left atrial appendage closure-subanalysis from the multicenter LAARGE registry. J Interv Card Electrophysiol 2021; 64:489-496. [PMID: 34686928 DOI: 10.1007/s10840-021-01080-1] [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: 06/04/2021] [Accepted: 10/11/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Data regarding post-procedural antithrombotic therapy following percutaneous left atrial appendage (LAA) in real-world populations using various occluder systems is limited. In the present analysis, anticoagulation (AC) was compared against antiplatelet therapy (APT) using data from the real-world multi-center LAARGE study. METHODS Patients following LAA closure enrolled in the LAARGE study were assigned to two groups depending on initial post-implantation antithrombotic regime consisting of either AC or APT. Selection of antithrombotic medication was at the discretion of the treating center and/or physician. RESULTS From July 2014 until January 2016, a total of 627 patients at 38 centers were included. A total of 75 patients (12%) received AC and 552 patients (88%) received APT, respectively. No significant differences were found between the groups regarding the composite of death, stroke and systemic embolism 1 year after LAA closure (Kaplan-Meier estimated rate 9.4% for AC vs. 12.8% for APT; p log rank = 0.45). With respect to bleeding events also, no differences were observed 1 year after the procedure (major bleeding 4.0% vs. 2.0%, p = 0.23; moderate bleeding 4.0% vs. 4.9%, p = 1.00; any bleeding 8.0% vs. 6.9%, p = 0.73). CONCLUSIONS Postprocedural antithrombotic treatment with AC and APT showed comparable results regarding the composite of death, stroke, and systemic embolism as well as regarding bleeding complications after LAA closure in a real-world all-comers population.
Collapse
Affiliation(s)
- Jakob Ledwoch
- Klinik Für Kardiologie, Pneumologie Und Intern. Intensivmed., Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, München, Germany.
| | - Stephan Staubach
- Klinik Für Kardiologie, Pneumologie Und Intern. Intensivmed., Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, München, Germany
| | - Ibrahim Akin
- I. Medizinische Klinik, Universitätsmedizin, Mannheim, Germany
| | | | - Uwe Zeymer
- I. Medizinische Klinik B, Klinikum Der Stadt Ludwigshafen, Ludwigshafen, Germany
| | - Sven Pleger
- Innere Medizin III, Universitätsklinikum, Heidelberg, Germany
| | | | - Matthias Hochadel
- Stiftung Institut Für Herzinfarktforschung (IHF), Ludwigshafen, Germany
| | - Jochen Senges
- Stiftung Institut Für Herzinfarktforschung (IHF), Ludwigshafen, Germany
| | | | | | - Harald Mudra
- Klinik Für Kardiologie, Pneumologie Und Intern. Intensivmed., Klinikum Neuperlach, Oskar-Maria-Graf-Ring 51, 81737, München, Germany
| |
Collapse
|
49
|
Impact of HAS-BLED Score on outcome after percutaneous left atrial appendage closure: insights from the German Left Atrial Appendage Occluder Registry LAARGE. Clin Res Cardiol 2021; 111:541-547. [PMID: 34455462 DOI: 10.1007/s00392-021-01911-1] [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: 10/09/2020] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
AIM Percutaneous left atrial appendage (LAA) closure has been established as alternative stroke prophylaxis in patients with non-valvular atrial fibrillation (AF) and high bleeding risk. However, little is known regarding the outcome after LAA closure depending on the HAS-BLED score. METHODS A sub-analysis of the prospective, multicenter, Left-Atrium-Appendage Occluder Register-GErmany (LAARGE) registry was performed assessing three different groups with respect to the HAS-BLED score (0-2 [group 1] vs. 3-4 [group 2] vs. 5-7 [group 3]). RESULTS A total of 633 patients at 38 centers were enrolled. Of them, 9% (n = 59) were in group 1, 63% (n = 400) in group 2 and 28% (n = 174) in group 3. The Kaplan-Meier estimated 1-year composite of death, stroke and systemic embolism was 3.4% in group 1 vs. 10.4% in group 2 vs. 20.1% in group 3, respectively (p log-rank < 0.001). The difference was driven by death since stroke and systemic embolism did not show a significant difference between the groups. The rate of major bleeding at 1 year was 0% vs. 0% vs. 2.4%, respectively (p = 0.016). CONCLUSION The present data show that patients had similarly low rates of ischemic complications 1 year after LAA closure irrespective of the baseline bleeding risk. Higher HAS-BLED scores were associated with increased mortality due to higher age and more severe comorbidity of these patients.
Collapse
|
50
|
Labori F, Bonander C, Persson J, Svensson M. Clinical follow-up of left atrial appendage occlusion in patients with atrial fibrillation ineligible of oral anticoagulation treatment-a systematic review and meta-analysis. J Interv Card Electrophysiol 2021; 61:215-225. [PMID: 33580847 PMCID: PMC8324592 DOI: 10.1007/s10840-021-00953-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/01/2021] [Indexed: 10/26/2022]
Abstract
PURPOSE The recommended stroke prevention for patients with atrial fibrillation (AF) and increased risk of ischemic stroke is oral anticoagulation (OAC). Parts of the patient population are not eligible due to contraindication, and percutaneous left atrial occlusion (LAAO) can then be a preventive treatment option. The aim of this systematic review and meta-analysis is to estimate the long-term clinical effectiveness of LAAO as stroke prevention in patients with AF, increased risk of ischemic stroke, and contraindication to OAC. METHODS We performed a systematic review and meta-analysis, using Poisson random effect models, to estimate the incidence rate (events per 100 patient-years) of ischemic stroke, transient ischemic attack, major bleeding, and all-cause death after LAAO treatment. We also calculated the risk reduction of ischemic stroke with LAAO compared with no stroke prevention estimated through a predicted risk in an untreated population (5.5 per 100 patient-years). RESULTS We included 29 observational studies in our meta-analysis, including 7 951 individuals and 12 211 patient-years. The mean CHA2DS2-VASc score among the patients in the included studies is 4.32. The pooled incidence rate of ischemic stroke is 1.38 per 100 patient-years (95% CI 1.08; 1.77). According to a meta-regression model, the estimated incidence rate of ischemic stroke at CHA2DS2-VASc 4 is 1.39 per 100 patient-years. This implies a risk reduction of 74.7% with LAAO compared to predicated risk with no stroke prevention. CONCLUSIONS Our results suggest that LAAO is effective as stroke prevention for patients with AF, increased risk of stroke, and contraindication to oral anticoagulation.
Collapse
Affiliation(s)
- Frida Labori
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden.
| | - Carl Bonander
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Josefine Persson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| | - Mikael Svensson
- Health Economics and Policy, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Box 463, 405 30, Gothenburg, Sweden
| |
Collapse
|