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Meier B. Every Patent Foramen Ovale Should Be Closed. J Clin Med 2024; 13:3355. [PMID: 38893065 PMCID: PMC11172438 DOI: 10.3390/jcm13113355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 05/17/2024] [Accepted: 06/05/2024] [Indexed: 06/21/2024] Open
Abstract
At present, the patent foramen ovale (PFO) does not receive the deserved medical attention. The PFO poses a serious threat to health and even the life of mankind. The first respective case report in the medical literature dates back to the 19th century. It led to death. The fact that a PFO is present in roughly 25% of people underscores its overall potential to cause harm. Yet at the same time, the sheer number discourages the medical community from screening for it and from treating it. About 5% of the population have particularly dangerous forms of PFOs. Such PFOs portray a high enough risk for clinical events, the likes of death, stroke, myocardial infarction, or ocular, visceral, and peripheral embolism, to justify screening for them. Highly significant health incidents being at stake, it appears obvious that PFO closure should be used for primary prevention. This is supported by the fact that closing a PFO is the simplest intervention in cardiology, with presumably the highest clinical yield. Being mainly a preventive measure, PFO closure represents a mechanical vaccination. When closing PFOs for one of the rarer therapeutic indications (migraine, platypnea orthodeoxia, etc.), patients automatically profit from the collateral benefit of getting, at the same time, mechanically vaccinated for life against paradoxical embolism. Vice versa, closing a PFO for the prevention of paradoxical embolism betters or cures migraine or exercise dyspnea not infrequently, thereby improving quality of life as a collateral benefit.
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Affiliation(s)
- Bernhard Meier
- Department of Cardiology, University of Bern, 3012 Bern, Switzerland
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2
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Kowalewski M, Święczkowski M, Kuźma Ł, Maesen B, Dąbrowski EJ, Matteucci M, Batko J, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Raffa GM, Malvindi PG, Pannone L, Meani P, Lorusso R, Whitlock R, La Meir M, de Asmundis C, Cox J, Suwalski P. Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke. JTCVS OPEN 2024; 19:131-163. [PMID: 39015454 PMCID: PMC11247209 DOI: 10.1016/j.xjon.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/17/2023] [Accepted: 02/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I 2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I 2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I 2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I 2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I 2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I 2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Łukasz Kuźma
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Jakub Batko
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Meani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | | | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - James Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Thoracic Research Centre
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
- McMaster University, Hamilton, Canada
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
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3
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Teiger E, Eschalier R, Amabile N, Rioufol G, Ducrocq G, Garot P, Lepillier A, Bille J, Elbaz M, Defaye P, Audureau E, Le Corvoisier P. Left atrial appendage closure in very elderly patients in the French National Registry. Heart 2024; 110:245-253. [PMID: 37813560 DOI: 10.1136/heartjnl-2023-322871] [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: 04/23/2023] [Accepted: 08/19/2023] [Indexed: 10/17/2023] Open
Abstract
OBJECTIVE Left atrial appendage closure (LAAC) is recommended to decrease the stroke risk in patients with atrial fibrillation and contraindications to anticoagulation. However, age-stratified data are scarce. The aim of this study was to provide information on the safety and efficacy of LAAC, with emphasis on the oldest patients. METHODS A nationwide, prospective, multicentre, observational registry was established by 53 French cardiology centres in 2018-2021. The composite primary endpoint included ischaemic stroke, systemic embolism, and unexplained or cardiovascular death. Separate analyses were done in the groups <80 years and ≥80 years. RESULTS Among the 1053 patients included, median age was 79.7 (73.6-84.3) years; 512 patients (48.6%) were aged ≥80 years. Procedure-related serious adverse events were non-significantly more common in octogenarians (7.0% vs 4.4% in patients aged <80 years, respectively; p=0.07). Despite a higher mean CHA2DS2-VASc score in octogenarians, the rate of thromboembolic events during the study was similar in both groups (3.0 vs 3.1/100 patient-years; p=0.85). By contrast, all-cause mortality was significantly higher in octogenarians (15.3 vs 10.1/100 patient-years, p<0.015), due to a higher rate of non-cardiovascular deaths (8.2 vs 4.9/100 patient-years, p=0.034). The rate of the primary endpoint was 8.1/100 patient-years overall with no statistically significant difference between age groups (9.4 and 7.0/100 patient-years; p=0.19). CONCLUSION Despite a higher mean CHA2DS2-VASc score in octogenarians, the rate of thromboembolic events after LAAC in this age group was similar to that in patients aged <80 years. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT03434015).
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Affiliation(s)
- Emmanuel Teiger
- Department of Cardiology, APHP, Henri Mondor University Hospital, Créteil, France
- Clinical Investigation Center 1430 and U955-IMRB team 3, Ecole Nationale Vétérinaire d'Alfort, UPEC, INSERM, Créteil, France
| | - Romain Eschalier
- Cardiology Department, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
- CHU Clermont-Ferrand, CNRS, SIGMA Clermont, Institut Pascal, University of Clermont Auvergne, Clermont-Ferrand, France
| | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Gilles Rioufol
- Department of Interventional Cardiology, Lyon Cardiovascular Hospital, Bron Cedex, France
- CARMEN INSERM 1060, INSERM, Bron, France
| | - Gregory Ducrocq
- Department of Cardiology, FACT (French Alliance for Cardiovascular Trials), DHU-FIRE, Bichat-Claude Bernard University Hospital, Paris, France
| | - Philippe Garot
- Institut Cardiovasculaire Paris-Sud (ICPS), Ramsay-Santé, Hôpital Privé Jacques Cartier, Massy, France
| | - Antoine Lepillier
- Department of Cardiology, Centre Cardiologique du Nord, Saint-Denis, France
| | - Jacques Bille
- Cardiology Department, Saint Joseph Hospital, Marseille, France
| | - Meyer Elbaz
- Department of Cardiology, Rangueil University Hospital, Toulouse, France
| | - Pascal Defaye
- Department of Rhythmology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Etienne Audureau
- AP-HP, Department of Public Health, Henri Mondor University Hospital, Creteil, France
- Equipe CEpiA, INSERM, UPEC, U955-IMRB, Créteil, France
| | - Philippe Le Corvoisier
- Clinical Investigation Center 1430, APHP, Groupe Hospitalier Henri Mondor, Creteil, France
- Clinical Investigation Center 1430 and U955-IMRB team 3, INSERM, Créteil, France
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Nelles D, Amli H, Sugiura A, Vij V, Beiert T, Nickenig G, Kütting D, Schrickel JW, Sedaghat A. The CT derived angle between the transseptal puncture site and the left atrial appendage as a predictor for complex interventional occlusion procedures. Echocardiography 2023; 40:1227-1236. [PMID: 37788148 DOI: 10.1111/echo.15699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/13/2023] [Accepted: 09/20/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE To evaluate the role of the CT-derived angle between the intra-atrial septum (IAS) and the left atrial appendage (LAA) on procedural complexity and clinical outcomes in left atrial appendage occlusion (LAAO) procedures. BACKGROUND Given the broad variations in anatomy, LAAO remains one of the most challenging interventional procedures in structural heart disease. In recent years, preprocedural cardiac tomography (CT) has evolved as a valuable tool; however, prediction of procedural complexity remains cumbersome. METHODS We retrospectively analyzed 47 patients that underwent LAAO at our center in whom pre-procedural cardiac CT-scans were available. Among other baseline parameters, we measured the angle between the LAA ostium and the preferred transseptal puncture site at the IAS. We compared patients with an angle above and below the median regarding procedural characteristics and procedural outcome. RESULTS The median angle between the LAA and the IAS was 127.3° (IQR: 120.9-141.3). LAAO took longer in patients with a measured angle below the median (55.0 ± 22.7 min vs. 41.3 ± 17.5 min; p = .04), resulting in longer radiation times (13.0 ± 5.3 min vs. 9.8 ± 5.7 min; p = .04) and more contrast use (61.1 ± 47.5 mL vs. 33.6 ± 24.7 mL; p = .05). Moreover, the necessity for a sheath exchange was significantly higher (30.4% vs. 4.2%, p = .02) and device repositioning or device resizing trended to be more frequent (26.1% vs. 8.3%; p = .1 and 21.7% vs. 8.3%; p = .2). There were no differences in procedural outcome, device-position and peri-device leak (PDL). CONCLUSIONS The angle between the transseptal puncture site and the LAA ostium may serve as a predictor for more demanding LAAO interventions. In our study a steeper angle led to a prolonged procedure resulting in higher doses of contrast and radiation, but was not associated with a worse procedural outcome.
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Affiliation(s)
- Dominik Nelles
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Hazem Amli
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Atsushi Sugiura
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Vivian Vij
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Thomas Beiert
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Georg Nickenig
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Daniel Kütting
- Department of Radiology, University Hospital Bonn, Bonn, Germany
| | - Jan Wilko Schrickel
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
| | - Alexander Sedaghat
- Heart Center, Department of Medicine II, University Hospital Bonn, Bonn, Germany
- RheinAhrCardio - Praxis für Kardiologie, Bad Neuenahr-Ahrweiler, Germany
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5
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Melillo F, Leo G, Parlati ALM, Gaspardone C, Bellini B, Della Bella P, Montorfano M, Mazzone P, Nemola G, Cozzani G, Stella S, Ancona F, Ingallina G, Salerno A, Cera M, Agricola E, Margonato A, Godino C. Direct oral anticoagulants versus percutaneous left atrial appendage occlusion in atrial fibrillation: 5-year outcomes. Int J Cardiol 2023; 389:131188. [PMID: 37453454 DOI: 10.1016/j.ijcard.2023.131188] [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: 03/30/2023] [Revised: 06/23/2023] [Accepted: 07/12/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND LAAO is an emerging option for thromboembolic event prevention in patients with NVAF. We previously reported data on comparison between LAAO and DOAC at two-year follow-up in NVAF patients at HBR (HAS-BLED ≥3). AIMS Limited data are available on long term follow-up. We aimed to evaluate the efficacy and safety of DOACs versus LAAO indication after 5 years. METHODS We enrolled 193 HBR treated with LAAO and 189 HBR patients with DOACs. At baseline, LAAO group had higher HAS-BLED (4.2 vs 3.3, p < 0.001) and lower CHADS-VASc (4.3 vs. 4.7, p = 0.005). After 1:1 PSM, 192 patients were included (LAAO n = 96; DOACs n = 96). RESULTS At 5-year follow-up the rate of the combined safety and effectiveness endpoint (ISTH major bleeding and thromboembolic events) was significantly higher in LAAO group (p = 0.042), driven by a higher number of thromboembolic events (p = 0.047). The rate of ISTH-major bleeding events was similar (p = 0.221). After PSM no significant difference in the primary effectiveness (LAAO 13.3% vs DOACs 9.5%, p = 0.357) and safety endpoint (LAAO 7.5% vs DOACs 7.5%; p = 0.918) were evident. Overall bleeding rate was significantly higher in DOACs group (25.0% vs 13.7%, p = 0.048), while a non-significant higher number of TIA was reported in LAAO group (5.4% vs 1.1%, p = 0.098). All-cause and cardiovascular mortality were higher in LAAO group at both unmatched and matched analysis. CONCLUSION We confirmed safety and effectiveness of both DOAC and LAAO in NVAF patients at HBR, with no significant differences in thromboembolic events or major bleeding were at 5-year follow-up. The observed increased mortality after LAAO warrants further investigations in RCTs.
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Affiliation(s)
- Francesco Melillo
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy; Echo Lab, Clinica Montevergine, GVM Care and Research, Mercogliano (AV), Italy
| | - Giulio Leo
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | | | - Carlo Gaspardone
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Barbara Bellini
- Interventional Cardiology Unit, San Raffaele Hospital, Milan, Italy
| | - Paolo Della Bella
- Arrhythmia and Electrophysiology Unit, San Raffaele Hospital, Milan, Italy
| | | | - Patrizio Mazzone
- Arrhythmia and Electrophysiology Unit, San Raffaele Hospital, Milan, Italy
| | - Giulia Nemola
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Gianmarco Cozzani
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Stefano Stella
- Cardiovascular Imaging Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Francesco Ancona
- Cardiovascular Imaging Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Giacomo Ingallina
- Cardiovascular Imaging Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Anna Salerno
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Michela Cera
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alberto Margonato
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Cosmo Godino
- Cardiology Unit, Heart Valve Center, San Raffaele Hospital, Milan, Italy.
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Kar S, Doshi SK, Alkhouli M, Camm AJ, Coylewright M, Gibson MC, Granger CB, Gurol ME, Huber K, Mansour M, Nair DG, Natale A, Pocock SJ, Reddy VR, Saliba W, Christen T, Allocco DJ, Ellenbogen KA, Leon MB. Rationale and design of a randomized study comparing the Watchman FLX device to DOACs in patients with atrial fibrillation. Am Heart J 2023; 264:123-132. [PMID: 37279840 DOI: 10.1016/j.ahj.2023.05.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 05/25/2023] [Accepted: 05/28/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) closure (LAAC) was developed as a nonpharmacologic alternative to oral anticoagulants (OACs) in patients with atrial fibrillation (AF) who are at an increased risk for stroke or systemic embolism. The Watchman device permanently seals off the LAA to prevent thrombi from escaping into the circulation. Previous randomized trials have established the safety and efficacy of LAAC compared to warfarin. However, direct OACs (DOACs) have become the preferred pharmacologic strategy for stroke prevention in patients with AF, and there is limited data comparing Watchman FLX to DOACs in a broad AF patient population. CHAMPION-AF is designed to prospectively determine whether LAAC with Watchman FLX is a reasonable first-line alternative to DOACs in patients with AF who are indicated for OAC therapy. STUDY DESIGN A total of 3,000 patients with a CHA2DS2-VASc score ≥2 (men) or ≥3 (women) were randomized to Watchman FLX or DOAC in a 1:1 allocation at 142 global clinical sites. Patients in the device arm were to be treated with DOAC and aspirin, DOAC alone, or DAPT for at least 3 months postimplant followed by aspirin or P2Y12 inhibitor for 1-year. Control patients were required to take an approved DOAC for the duration of the trial. Clinical follow-up visits are scheduled at 3- and 12-months, and then annually through 5 years; LAA imaging is required at 4 months in the device group. Two primary end points will be evaluated at 3 years: (1) composite of stroke (ischemic/hemorrhagic), cardiovascular death, and systemic embolism compared for noninferiority, and (2) nonprocedural bleeding (International Society on Thrombosis and Haemostasis [ISTH] major and clinically relevant nonmajor bleeding) tested for superiority in the device arm against DOACs. The third primary noninferiority end point is the composite of ischemic stroke and systemic embolism at 5 years. Secondary end points include 3- and 5-year rates of (1) ISTH-defined major bleeding and (2) the composite of cardiovascular death, all stroke, systemic embolism, and nonprocedural ISTH bleeding. CONCLUSIONS This study will prospectively evaluate whether LAAC with the Watchman FLX device is a reasonable alternative to DOACs in patients with AF. CLINICAL TRIAL REGISTRATION NCT04394546.
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Affiliation(s)
- Saibal Kar
- Los Robles Medical Center, Thousand Oaks, CA.
| | | | | | - A John Camm
- St. Georges University of London, London, United Kingdom
| | | | - Michael C Gibson
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | | | - Mahmut E Gurol
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Kenneth Huber
- St Luke's Mid America Heart Institute, Kansas City, MO
| | | | - Devi G Nair
- St Bernard's Medical Center & Arrhythmia Research Group, Jonesboro, AR
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St David's Medical Center, Austin, TX
| | - Stuart J Pocock
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Vivek R Reddy
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | | | | | - Martin B Leon
- Columbia University Medical Center/NewYork Presbyterian Hospital, New York, NY
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7
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Franchin L, Piroli F, Demola P, Mantovani F, Iannaccone M, Manfredi R, D’Ascenzo F, Fortuni F, Ugo F, Meucci F, Navazio A, Boccuzzi G. Efficacy and safety of left atrial appendage closure compared with oral anticoagulation in atrial fibrillation: a meta-analysis of randomized controlled trials and propensity-matched studies. Front Cardiovasc Med 2023; 10:1212161. [PMID: 37829693 PMCID: PMC10565038 DOI: 10.3389/fcvm.2023.1212161] [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: 04/25/2023] [Accepted: 09/12/2023] [Indexed: 10/14/2023] Open
Abstract
Backgrounds Two recent randomized controlled trials (RCTs), the PROTECT-AF and the PREVAIL, showed that in atrial fibrillation (AF) patients, left atrial appendage closure (LAAC) is comparable to oral anticoagulants (OAC) in the prevention of stroke and could also possibly reduce mortality. Nevertheless, this net clinical benefit was not confirmed in the most recent RCT comparing LAAC vs. OAC, the PRAGUE-17 trial. Aim aim of the present study was to evaluate the efficacy and safety of LAAC compared with OAC among available high-quality studies. Methods A systematic search of electronic databases (Medline, Scopus, Embase and the Cochrane Library) was performed to identify eligible RCTs and observational studies with propensity score matching (PSM) analysis. PRISMA guidelines were used for abstracting data and assessing data quality and validity. Outcomes of interest were the occurrence of cardiovascular death (CVD), all-cause death, all-type stroke, and major bleedings. Results A total of 3 RCTs and 7 PMS studies involving 25,700 patients were identified. 12,961 patients received LAAC while 12,739 received OAC therapy. After a median follow-up of 2.6 years (IQR 2-4.4), patients who received LAAC had lower risk of CVD (RR = 0.62; 95%CI, 0.51-0.74, I2 = 0%), all-cause death (RR = 0.67; 95% CI, 0.57-0.78, I2 68%) and major bleedings (RR = 0.68; 95%CI, 0.48-0.95 I2 = 87%) compared with patients on OAC. No difference was found between the two groups regarding strokes incidence (RR = 0.94; 95% CI, 0.77-1.15, I2 = 0%). Conclusions According to this meta-analysis, LAAC has comparable efficacy in the prevention of stroke compared with OAC and a reduced risk of major bleedings, all-cause death and CVD that may be even larger with longer follow-up. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=269768, identifier CRD42021269768.
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Affiliation(s)
- Luca Franchin
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
- Department of Cardiology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Francesco Piroli
- Cardiology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pierluigi Demola
- Cardiology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Mario Iannaccone
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | - Roberto Manfredi
- Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti”, Ancona, Italy
| | - Fabrizio D’Ascenzo
- Division of Cardiology, Department of Medicine, A.O.U Città Della Salute e Della Scienza, Turin, Italy
| | - Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy
- Department of Cardiology, Leiden University Medical Center, Leiden, Netherlands
| | - Fabrizio Ugo
- Division of Cardiology, Sant’Andrea Hospital, Vercelli, Italy
| | - Francesco Meucci
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Alessandro Navazio
- Cardiology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giacomo Boccuzzi
- Department of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
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8
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Zeitler EP, Kearing S, Coylewright M, Nair D, Hsu JC, Darden D, O'Malley AJ, Russo AM, Al-Khatib SM. Comparative Effectiveness of Left Atrial Appendage Occlusion Versus Oral Anticoagulation by Sex. Circulation 2023; 147:586-596. [PMID: 36780379 DOI: 10.1161/circulationaha.122.062765] [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: 10/06/2022] [Accepted: 01/06/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND The comparative real-world outcomes of older patients with atrial fibrillation (AF) treated with anticoagulation compared with left atrial appendage occlusion (LAAO) may be different from those in clinical trials because of differences in anticoagulation strategies and patient demographics, including a greater proportion of women. We sought to compare real-world outcomes between older patients with AF treated with anticoagulation and those treated with LAAO by sex. METHODS Using Medicare claims data from 2015 to 2019, we identified LAAO-eligible beneficiaries and divided them into sex subgroups. Patients receiving LAAO were matched 1:1 to those receiving anticoagulation alone through propensity score matching. The risks of mortality, stroke or systemic embolism, and bleeding were compared between matched groups with adjustment for potential confounding characteristics in Cox proportional hazards models. RESULTS Among women, 4085 LAAO recipients were matched 1:1 to those receiving anticoagulation; among men, 5378 LAAO recipients were similarly matched. LAAO was associated with a significant reduction in the risk of mortality for women and men (hazard ratio [HR], 0.509 [95% CI, 0.447-0.580]; and HR, 0.541 [95% CI, 0.487-0.601], respectively; P<0.0001), with a similar finding for stroke or systemic embolism (HR, 0.655 [95% CI, 0.555-0.772]; and HR, 0.649 [95% CI, 0.552-0.762], respectively; P<0.0001). Bleeding risk was significantly greater in LAAO recipients early after implantation but lower after the 6-week periprocedural period for women and men (HR, 0.772 [95% CI, 0.676-0.882]; and HR, 0.881 [95% CI, 0.784-0.989], respectively; P<0.05). CONCLUSIONS In a real-world population of older Medicare beneficiaries with AF, compared with anticoagulation, LAAO was associated with a reduction in the risk of death, stroke, and long-term bleeding among women and men. These findings should be incorporated into shared decision-making with patients considering strategies for reduction in AF-related stroke.
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Affiliation(s)
- Emily P Zeitler
- Dartmouth Health (E.P.Z., S.K.), Lebanon, NH
- Dartmouth Institute, Lebanon, NH (E.P.Z., A.J.O.)
| | | | | | - Devi Nair
- St. Bernard's Heart and Vascular Center, Jonesboro, AR (D.N.)
| | | | - Douglas Darden
- Kansas City Heart Rhythm Institute, Overland Park (D.D.)
| | - A James O'Malley
- Dartmouth Institute, Lebanon, NH (E.P.Z., A.J.O.)
- Geisel School of Medicine at Dartmouth College, Hanover, NH (A.J.O.)
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, NJ (A.M.R.)
| | - Sana M Al-Khatib
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.M.A.-K.)
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9
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Madhavan MV, Howard JP, Brener MI, Der Nigoghossian C, Chen S, Makkar R, Osmancik P, Reddy VY, Holmes DR, Stone GW, Leon MB, Ahmad Y. Long-Term Outcomes of Randomized Controlled Trials Comparing Percutaneous Left Atrial Appendage Closure to Oral Anticoagulation for Nonvalvular Atrial Fibrillation: A Meta-Analysis. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100096. [PMID: 37275318 PMCID: PMC10236864 DOI: 10.1016/j.shj.2022.100096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/28/2022] [Accepted: 08/17/2022] [Indexed: 06/07/2023]
Abstract
Background Oral anticoagulation (OAC) has been considered the standard of care for stroke prophylaxis for patients with nonvalvular atrial fibrillation; however, many individuals are unable or unwilling to take long-term OAC. The safety and efficacy of percutaneous left atrial appendage closure (LAAC) have been controversial, and new trial data have recently emerged. We therefore sought to perform an updated meta-analysis of randomized clinical trials (RCTs) comparing OAC to percutaneous LAAC, focusing on individual clinical endpoints. Methods We performed a systematic search of the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials from January 2000 through December 2021 for all RCTs comparing percutaneous LAAC to OAC in patients with nonvalvular atrial fibrillation. Fixed and random effects meta-analyses of hazard ratios (HRs) were performed using the longest follow-up duration available by intention-to-treat. The prespecified primary endpoint was all-cause mortality. Results Three RCTs enrolling 1516 patients were identified. The weighted mean follow-up was 54.7 months. LAAC was associated with a reduced risk of all-cause mortality (HR 0.76; 95% confidence interval [CI], 0.59-0.96; p = 0.023), hemorrhagic stroke (HR 0.24; 95% CI, 0.09-0.61; p = 0.003), and major nonprocedural bleeding (HR 0.52; 95% CI, 0.37-0.74; p < 0.001). There was no significant difference between LAAC and OAC for any other endpoints. Conclusions The available evidence from RCTs suggests LAAC therapy is associated with reduced long-term risk of death compared with OAC. This may be driven by reductions in hemorrhagic stroke and major nonprocedural bleeding. There were no significant differences in the risk of all stroke. Further large-scale clinical trials are needed to validate these findings.
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Affiliation(s)
- Mahesh V. Madhavan
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - James P. Howard
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael I. Brener
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Caroline Der Nigoghossian
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
| | - Shmuel Chen
- Cardiovascular Research Foundation, New York, New York, USA
| | - Raj Makkar
- Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Vivek Y. Reddy
- The Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Gregg W. Stone
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martin B. Leon
- Division of Cardiology, Department of Medicine, NewYork-Presbyterian Hospital and the Columbia University Irving Medical Center, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
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10
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Han S, Jia R, Zhao S, Chan J, Bai Y, Cui K. Left Atrial Appendage Closure for Atrial Fibrillation in the Elderly >75 Years Old: A Meta-Analysis of Observational Studies. Diagnostics (Basel) 2022; 12:diagnostics12123174. [PMID: 36553181 PMCID: PMC9777302 DOI: 10.3390/diagnostics12123174] [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: 11/16/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022] Open
Abstract
Background: Left atrial appendage closure (LAAC) is an established therapy for patients with atrial fibrillation (AF); however, there is a limited understanding of LAAC in elderly patients (≥75 years old). We conducted a meta-analysis to investigate the procedural complications and long-term outcomes after LAAC in the elderly versus the non-elderly. Methods: We screened PubMed, EMBASE, Cochrane Library, and Web of Science. Procedural endpoints of interest included successful implantation LAAC rates, in-hospital mortality, major bleeding events, pericardial effusion/tamponade, stroke, and vascular access complications related to LAAC. Long-term outcomes included all-cause mortality, major bleeding events, and stroke/transient ischemic attack (TIA) during follow-up. Results: Finally, 12 studies were included in the analysis; these included a total of 25,094 people in the elderly group and 36,035 people in the non-elderly group. The successful implantation LAAC rates did not differ between the groups, while the elderly patients experienced more periprocedural mortality (OR 2.62; 95% CI 1.79−3.83, p < 0.01; I2 = 0%), pericardial effusion/tamponade (OR 1.39; 95% CI: 1.06−1.82, p < 0.01; I2 = 0%), major bleeding events (OR 1.32; 95% CI 1.17−1.48, p < 0.01; I2 = 0%), and vascular access complications (OR 1.34; 95% CI 1.16−1.55, p < 0.01; I2 = 0%) than the non-elderly patients. The long-term stroke/TIA rates did not differ between the elderly and the non-elderly at least one year after follow-up. Conclusions: Even though successful implantation LAAC rates are similar, elderly patients have a significantly higher incidence of periprocedural mortality, major bleeding events, vascular access complications, and pericardial effusion/tamponade after LAAC than non-elderly patients. The stroke/TIA rates did not differ between both groups after at least one-year follow-up.
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11
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Zhao M, Hou CR, Bai J, Post F, Walsleben J, Herold N, Yu J, Zhang Z, Yu J. Effect of congestive heart failure on safety and efficacy of left atrial appendage closure in patients with non-valvular atrial fibrillation. Expert Rev Med Devices 2022; 19:805-814. [DOI: 10.1080/17434440.2022.2141112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Mingzhong Zhao
- Heart Center, Zhengzhou Ninth People’s Hospital, Zhengzhou, China
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | - Cody R. Hou
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Jianlin Bai
- Department of Surgery, Zhengzhou Ninth People’s Hospital, Zhengzhou, China
| | - Felix Post
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Germany
| | - Jens Walsleben
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Germany
| | - Nora Herold
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Germany
| | - Juan Yu
- Heart Center, Zhengzhou Ninth People’s Hospital, Zhengzhou, China
| | - Zufeng Zhang
- Heart Center, Zhengzhou Ninth People’s Hospital, Zhengzhou, China
| | - Jiangtao Yu
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Germany
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12
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Iatrogenic atrial septal defects after transseptal puncture for percutaneous left atrial appendage occlusion and their hemodynamic effects. J Geriatr Cardiol 2022; 19:675-684. [PMID: 36284683 PMCID: PMC9548059 DOI: 10.11909/j.issn.1671-5411.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) requires puncture of the interatrial septum. The immediate hemodynamic effects of iatrogenic atrial septal defects (iASD) after LAAO have not been examined so far. We aimed at evaluating these effects through invasive measurements of pressure and oxygen saturation. Moreover, we assessed the incidence of persistent iASD at three months. METHODS Forty-eight patients scheduled for percutaneous LAAO were prospectively included in the study. Pressure and oxygen saturation were measured (1) in the right atrium (RA) before transseptal puncture, (2) in the left atrium (LA) through the transseptal sheath after transseptal puncture, (3) in the LA after removal of introducer sheath, and (4) in the RA after removal of introducer sheath. Transesophageal echocardiography was performed at three months to detect iASD. RESULTS Pressure in the RA increased significantly after removing the introducer sheath (P = 0.034), whereas no difference was found in oxygen saturation in the RA (P = 0.623). Pressure measurement in the LA showed no significant difference after removing the introducer sheath (P = 0.718). Oxygen saturation in the LA also showed no significant difference (P = 0.129). Follow-up transesophageal echocardiogram at 3 months revealed a persistent iASD in 4 patients (8.5 %). CONCLUSIONS Our study suggests that iASD after percutaneous LAAO does not result in significant shunts directly after the procedure, although a significant increase of mean right atrial pressure can be observed. Persistent iASDs after percutaneous LAAO seem to be relatively rare at three months.
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13
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Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:biomedicines10092268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [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: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
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Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
- Correspondence:
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14
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Zhao M, Zhao M, Hou CR, Post F, Herold N, Walsleben J, Meng Z, Yu J. Left Atrial Appendage Closure Yields Favorable Cardio- and Cerebrovascular Outcomes in Patients With Non-valvular Atrial Fibrillation and Prior Stroke. Front Neurol 2022; 12:784557. [PMID: 35082747 PMCID: PMC8784739 DOI: 10.3389/fneur.2021.784557] [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: 09/28/2021] [Accepted: 12/08/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction: Patients with non-valvular atrial fibrillation (NVAF) and previous stroke are at significantly higher risk of stroke recurrence. Data on the efficacy of left atrial appendage closure (LAAC) on these patients is limited. The aim of this study was to investigate the differences of LAAC efficacy on long-term cardio- and cerebrovascular outcomes in NVAF patients with vs. without prior stroke. Methods: Three hundred and seventy consecutive NVAF patients who underwent LAAC were enrolled and divided into stroke and non-stroke groups based on history of previous stroke. Endpoints, such as thromboembolism, major bleeding, and mortality post-LAAC, were followed up among groups. Results: Patients in the stroke group had higher mean CHA2DS2-VASc and HAS-BLED scores compared to the non-stroke group (5.1 vs. 3.6 and 4.1 vs. 3.4, both P < 0.001, respectively). Over a median follow-up of 2.2 years, there were no significant differences in incidence rates of thromboembolism, device-related thrombus (DRT), major bleeding, and combined efficacy endpoints between the two groups. In both stroke and non-stroke groups, LAAC decreased the risk of thromboembolism [relative risk reduction (RRR) 87.5%, P = 0.034, and 74.6%, P = 0.004, respectively] and major bleeding (RRR 68.8%, P = 0.034, and 68.6%, P = 0.007, respectively) compared with predicted risk. The RRR in thromboembolism was greater in patients with vs. without prior stroke (OR 2.45, 95% CI: 1.20–5.12, P = 0.016). The incidence rates of all-cause mortality and non-cardiovascular death were similar between the two groups, but the risks of cardiovascular death post-LAAC both before (1.4% vs. 8.1%, respectively, P = 0.038) and after adjustment for confounding factors (P = 0.048) were significantly decreased in the stroke group. Conclusions: Patients with vs. without prior stroke did not exhibit a worse clinical prognosis after LAAC. LAAC may provide an increased benefit in cardio-cerebrovascular outcomes in patients with previous stroke compared to those without previous stroke. Further research is necessary to evaluate the efficacy of LAAC in this field.
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Affiliation(s)
- Mingzhong Zhao
- Department of Cardiology, Helmut-G-Walther-Klinikum, Lichtenfels, Germany.,Heart Center, Zhengzhou Ninth People's Hospital, Zhengzhou, China
| | - Mengxi Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cody R Hou
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, United States
| | - Felix Post
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Koblenz, Germany
| | - Nora Herold
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Koblenz, Germany
| | - Jens Walsleben
- Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Koblenz, Germany
| | - Zhaohui Meng
- Department of Cardiology, Helmut-G-Walther-Klinikum, Lichtenfels, Germany.,Department of Cardiology, Kunming Medical University, Kunming, China
| | - Jiangtao Yu
- Department of Cardiology, Helmut-G-Walther-Klinikum, Lichtenfels, Germany.,Clinic for General Internal Medicine and Cardiology, Catholic Medical Center Koblenz-Montabaur, Koblenz, Germany
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15
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Clinical benefit of left atrial appendage closure in octogenarians. J Geriatr Cardiol 2021; 18:886-896. [PMID: 34908926 PMCID: PMC8648545 DOI: 10.11909/j.issn.1671-5411.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2021] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVES Whether left atrial appendage closure (LAAC) in octogenarians yield similar net clinical benefit compared to younger patients, was the purpose of the present study. METHODS Two real-world LAAC registries, enrolling 744 consecutive Amplatzer and Watchman patients from 2009 to 2018, were retrospectively analyzed. RESULTS All events are reported per 100 patient-years. Two hundred and sixty one octogenarians and 483 non-octogenarians with a mean follow-up of 1.7 ± 1.3 and 2.3 ± 1.6 years, and a total of 1,502 patient-years were included. Octogenarians had a higher risk for stroke (CHA2DS2-VASc score: 5.2 ± 1.2 vs. 4.3 ± 1.7, P < 0.0001) and bleeding (HAS-BLED score: 3.3 ± 0.8 vs. 3.1 ± 1.1, P = 0.001). The combined safety endpoint of major periprocedural complications and major bleeding events at follow-up was comparable (30/446, 6.7% vs. 47/1056, 4.4%; hazard ratio [HR] = 1.2; 95% confidence interval [CI]: 0.73-1.98;P = 0.48) between the groups. The efficacy endpoint of all-cause stroke, systemic embolism, and cardiovascular/unexplained death occurred more often in octogenarians (61/446, 13.7% vs. 80/1056, 7.6%; HR = 7.0; 95% CI: 4.53-10.93;P < 0.0001). Overall, octogenarians had a lower net clinical benefit, i.e., the composite of all above mentioned hazards, from LAAC compared to younger patients (82/446, 18.4% vs. 116/1056, 11.0%; HR = 4.6; 95% CI: 3.11-7.0;P < 0.0001). Compared to the anticipated stroke rate, the observed rate decreased by 41% in octogenarians and 53% in non-octogenarians. The observed bleeding rate was reduced by 10% octogenarians and 41% non-octogenarians. CONCLUSIONS LAAC can be performed with similar safety in octogenarians as compared to younger patients. On the long-term, it both reduces stroke and bleeding events, although to a lesser extent than in non-octogenarians.
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16
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Osmancik P, Herman D, Neuzil P, Hala P, Taborsky M, Kala P, Poloczek M, Stasek J, Haman L, Branny M, Chovancik J, Cervinka P, Holy J, Kovarnik T, Zemanek D, Havranek S, Vancura V, Peichl P, Tousek P, Lekesova V, Jarkovsky J, Novackova M, Benesova K, Widimsky P, Reddy VY. Left Atrial Appendage Closure versus Non-Warfarin Oral Anticoagulation in Atrial Fibrillation: 4-Year Outcomes of PRAGUE-17. J Am Coll Cardiol 2021; 79:1-14. [PMID: 34748929 DOI: 10.1016/j.jacc.2021.10.023] [Citation(s) in RCA: 111] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/05/2021] [Accepted: 10/14/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND The PRAGUE-17 trial demonstrated that left atrial appendage closure (LAAC) was non-inferior to non-warfarin oral anticoagulants (NOAC) for preventing major neurological, cardiovascular or bleeding events in high-risk patients with atrial fibrillation (AF). OBJECTIVE To assess the pre-specified long-term (4-year) outcomes in PRAGUE-17. METHODS PRAGUE-17 was a randomized non-inferiority trial comparing percutaneous LAAC (Watchman or Amulet) with NOACs (95% apixaban) in non-valvular AF patients with a history of cardioembolism, clinically-relevant bleeding, or both CHA2DS2-VASc > 3 and HASBLED > 2. The primary endpoint was a composite of cardioembolic events (stroke, transient ischemic attack, or systemic embolism), cardiovascular death, clinically-relevant bleeding, or procedure/device-related complications (LAAC group only). The primary analysis was modified intention-to-treat (mITT). RESULTS We randomized 402 AF patients (201 per group, age 73.3±7.0 years, 65.7% male, CHA2DS2-VASc 4.7+1.5, HASBLED 3.1+0.9). After 3.5 years median follow-up (1,354 patients-years), LAAC was non-inferior to NOAC for the primary endpoint by mITT (subdistribution hazard ratio[sHR] 0.81, 95% CI 0.56-1.18; p=0.27; p for non-inferiority=0.006). For the components of the composite endpoint, the corresponding sHRs (and 95% CIs) were 0.68 (0.39-1.20; p=0.19) for cardiovascular death, 1.14 (0.56-2.30; p=0.72) for all-stroke/TIA, 0.75 (0.44-1.27; p=0.28) for clinically-relevant bleeding, and 0.55 (0.31-0.97; p=0.039) for non-procedural clinically-relevant bleeding. The primary endpoint outcomes were similar in the per-protocol [sHR 0.80 (95% CI 0.54-1.18), p=0.25] and on-treatment [sHR 0.82 (95% CI 0.56-1.20), p=0.30] analyses. CONCLUSION In long-term follow-up of PRAGUE-17, LAAC remains non-inferior to NOACs for preventing major cardiovascular, neurological or bleeding events. Furthermore, non-procedural bleeding was significantly reduced with LAAC.
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Affiliation(s)
- Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic.
| | - Dalibor Herman
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Neuzil
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Pavel Hala
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Milos Taborsky
- Cardiocenter, Dept. of Cardiology, University Hospital Olomouc, Czech Republic
| | - Petr Kala
- Clinic of Cardiology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | - Martin Poloczek
- Clinic of Cardiology, Masaryk University and University Hospital Brno, Brno, Czech Republic
| | - Josef Stasek
- 1(st) Department of Internal Medicine, Faculty of Medicine, University Hospital Hradec Kralove, Charles University Prague, Czech Republic
| | - Ludek Haman
- 1(st) Department of Internal Medicine, Faculty of Medicine, University Hospital Hradec Kralove, Charles University Prague, Czech Republic
| | - Marian Branny
- Department of Cardiology, Cardiocenter, Hospital Podlesí a.s., Trinec, Czech Republic
| | - Jan Chovancik
- Department of Cardiology, Cardiocenter, Hospital Podlesí a.s., Trinec, Czech Republic
| | - Pavel Cervinka
- Department of Cardiology, Krajská zdravotni a.s., Masaryk hospital and UJEP, Usti nad Labem, Czech Republic
| | - Jiri Holy
- Department of Cardiology, Krajská zdravotni a.s., Masaryk hospital and UJEP, Usti nad Labem, Czech Republic
| | - Tomas Kovarnik
- Cardiocenter, 2nd internal clinic - Cardiology and Angiology, Charles University, General Faculty Hospital, Prague Czech Republic
| | - David Zemanek
- Cardiocenter, 2nd internal clinic - Cardiology and Angiology, Charles University, General Faculty Hospital, Prague Czech Republic
| | - Stepan Havranek
- Cardiocenter, 2nd internal clinic - Cardiology and Angiology, Charles University, General Faculty Hospital, Prague Czech Republic
| | - Vlastimil Vancura
- Department of Cardiology, University Hospital and Faculty of Medicine Pilsen, Pilsen, Czech Republic
| | - Petr Peichl
- Cardiocenter, Institute of Clinical and Experimental Medicine, Prague, Czech Republic
| | - Petr Tousek
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Veronika Lekesova
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic
| | - Jiri Jarkovsky
- Institute of Biostatistics and Analysis, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martina Novackova
- Institute of Biostatistics and Analysis, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Klara Benesova
- Institute of Biostatistics and Analysis, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University Prague and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Vivek Y Reddy
- Cardiocenter, Department of Cardiology, Na Homolce Hospital, Prague, Czech Republic; Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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17
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Kleinecke C, Buffle E, Link J, Häner J, Sedaghat A, Galea R, Streit SR, Windecker S, Meier B, Gloekler S. Amplatzer left atrial appendage closure: Single versus combined procedures. Catheter Cardiovasc Interv 2021; 97:E973-E981. [PMID: 32930492 DOI: 10.1002/ccd.29271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/27/2020] [Accepted: 08/31/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This study compares procedural and late clinical outcomes of left atrial appendage closure (LAAC) with Amplatzer devices as a single versus a combined procedure with other structural or coronary interventions. BACKGROUND Multiple cardiac conditions are frequent among elderly patients and invite simultaneous treatment to ensure a favorable patient outcomes. METHODS 559 consecutive patients (73.3 ± 11.1 years) underwent LAAC with Amplatzer devices at two centres (Bern and Zurich university hospitals, Switzerland) either as a single procedure or combined with other interventions. The primary safety endpoint was a composite of major peri-procedural complications and major bleeding at follow-up, the primary efficacy endpoint included stroke, systemic embolism, and cardiovascular/unexplained death. All event rates are reported per 100 patient-years. RESULTS In 263 single and 296 combined procedures with percutaneous coronary interventions (47.6%), closure of an atrial septal defect (8.4%) or a patent foramen ovale (36.5%), transcatheter aortic valve implantation (10.1%), mitral clipping (4.1%), atrial fibrillation ablation (8.8%), or another procedure (3.0%) were analyzed. Device success (96.6% [single] vs. 99.0% [combined], p = .08) did not differ between the groups. After a mean follow-up of 2.6 ± 1.5 vs. 2.5 ± 1.5 years and a total of 1,422 patient-years, the primary efficacy (40/677, 5.9% [single] vs. 37/745, 5.0% [combined]; HR, 1.2, 95% CI, 0.8-1.9, p = .44), as well as the primary safety endpoint (25/677, 3.7% vs 28/745, 3.8%; HR, 1.0, 95% CI, 0.6-1.8, p = .89) were comparable. CONCLUSIONS LAAC with Amplatzer devices combined with structural, coronary, and electrophysiological procedures offers procedural feasibility and safety, as well as long-term efficacy.
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Affiliation(s)
- Caroline Kleinecke
- Cardiology, Klinikum Lichtenfels, Lichtenfels, Germany.,Cardiology, Klinikum Hochrhein, Waldshut-Tiengen, Germany
| | - Eric Buffle
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Juergen Link
- Department of Anesthesiology, Dreifaltigkeits-Hospital, Wesseling, Germany
| | - Jonas Häner
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | | | - Roberto Galea
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Samuel R Streit
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Stephan Windecker
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Steffen Gloekler
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland.,Cardiology, Klinikum Hochrhein, Waldshut-Tiengen, Germany
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18
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Teiger E, Thambo JB, Defaye P, Hermida JS, Abbey S, Klug D, Juliard JM, Spaulding C, Armero S, Champagnac D, Bhugaloo H, Ternacle J, Lellouche N, Audureau E, Le Corvoisier P. Left atrial appendage closure for stroke prevention in atrial fibrillation: Final report from the French left atrial appendage closure registry. Catheter Cardiovasc Interv 2021; 98:788-799. [PMID: 34051135 DOI: 10.1002/ccd.29795] [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: 01/19/2021] [Revised: 05/10/2021] [Accepted: 05/19/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES The French left atrial appendage (LAA) closure registry (FLAAC) aimed to assess the safety and efficacy of LAA closure in daily practice. BACKGROUND LAA closure has emerged as an alternative for preventing thromboembolic events (TE) in patients with non-valvular atrial fibrillation (NVAF). Clinical data in this field remains limited and few investigator-initiated, real-world registries have been reported. METHODS This nationwide, prospective study was performed in 36 French centers. The primary endpoint was the TE rate after successful LAA closure. RESULTS The FLAAC registry included 816 patients with a mean age of 75.5 ± 0.3 years, mean follow-up of 16.0 ± 0.3 months, high TE (CHA2 DS2 -VASc score: 4.6 ± 0.1) and bleeding risks (HAS-BLED score: 3.2 ± 0.05) and common contraindications to long-term anticoagulation (95.7%). Procedure or device-related serious adverse events occurred in 49 (6.0%) patients. The annual rate of ischemic stroke/systemic embolism was 3.3% (2.4-4.6). This suggests a relative 57% reduction compared to the risk of stroke in historical NVAF populations without antithrombotic therapy. By multivariate analysis, history of TE was the only factor associated with stroke/systemic embolism during follow-up (HR, 3.3 [1.58-6.89], p = 0.001). The annual mortality rate was 10.2% (8.4-12.3). Most of the deaths were due to comorbidities or underlying cardiovascular diseases and unrelated to the device or to TE. CONCLUSIONS Our study suggests that LAA closure can be an option in patients with NVAF. Long-term follow-up mortality was high, mostly due to comorbidities and underlying cardiovascular diseases, highlighting the importance of multidisciplinary management after LAA closure. REGISTRATION NCT02252861.
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Affiliation(s)
- Emmanuel Teiger
- Department of Cardiology, Henri Mondor University Hospital, AP-HP, Creteil, France
| | - Jean-Benoit Thambo
- Department of Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, France
| | - Pascal Defaye
- Department of Rhythmology, University Hospital of Grenoble-Alpes, Grenoble, France
| | | | - Sélim Abbey
- Interventional Cardiology Unit, Hôpital Prive du Confluent, Nantes, France
| | - Didier Klug
- Department of Electrophysiology, Lille University Hospital, Lille, France
| | - Jean-Michel Juliard
- Département de Cardiologie, Hôpital Bichat, Université Paris-Diderot, Inserm U-1148, AP-HP, Paris, France
| | - Christian Spaulding
- Department of Cardiology, European Hospital Georges Pompidou, AP-HP, Paris Descartes University, INSERM U 970, Sudden Cardiac Death Expert Center, Paris, France
| | | | | | - Hamza Bhugaloo
- Inserm, CIC 1430, Henri Mondor University Hospital, Creteil, France
| | - Julien Ternacle
- Department of Cardiology, Henri Mondor University Hospital, AP-HP, Creteil, France
| | - Nicolas Lellouche
- Department of Cardiology, Henri Mondor University Hospital, AP-HP, Creteil, France
| | - Etienne Audureau
- Public Health Department, Hôpital Henri Mondor, Créteil, France.,U955-IMRB, Equipe CEpiA, Inserm, UPEC, Créteil, France
| | - Philippe Le Corvoisier
- Inserm, CIC 1430, Henri Mondor University Hospital, Creteil, France.,U955-IMRB, Equipe 03, Inserm, UPEC, Ecole Nationale Vétérinaire d'Alfort, Créteil, France
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19
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Widimsky P, Osmancik P. Left atrial appendage closure - ready for widespread clinical use? EUROINTERVENTION 2020; 16:e701-e702. [PMID: 33034289 DOI: 10.4244/eijv16i9a129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
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20
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Kleinecke C, Gloekler S, Meier B. Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation: an update on patient outcomes. Expert Rev Cardiovasc Ther 2020; 18:517-530. [DOI: 10.1080/14779072.2020.1794820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Caroline Kleinecke
- Cardiology, Internal Medicine Department, Klinikum Lichtenfels, Lichtenfels, Germany
| | - Steffen Gloekler
- Cardiology, Internal Medicine Department, Klinikum Hochrhein, Waldshut-Tiengen, Germany and Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
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