Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug

Ischemic outcomes after left atrial appendage closure following intracerebral hemorrhage: a retrospective inverse probability weighting analysis from the HANSE-LAAC registry

BACKGROUND

Intracerebral hemorrhage (ICH) is associated with worse outcomes and subsequent high risk for acute arterial ischemic events. Percutaneous left atrial appendage closure (LAAC) is an established procedure in case of atrial fibrillation and adverse events, such as severe bleeding. Clinical benefits of LAAC in patients with ICH are currently unclear.

METHODS

The single-center registry HANSE-LAAC included consecutively treated patients from 2014 to 2022. Index-procedure and standardized follow-ups at 3 and 12 months were analyzed regarding safety and efficacy retrospectively. Mortality, major adverse cardiovascular, and bleeding events were compared between patients with or without ICH. We used Cox proportional hazard models and inverse probability weights to adjust confounders.

RESULTS

401 patients received percutaneous LAAC (ICH 15.2%, n = 61 and non-ICH 84.8%, n = 340). The composite endpoint of death, MACE, and bleeding was significantly lower in the ICH group (HR 0.35, confidence interval [CI] 0.05-4.62, p = 0.0044). This clinical benefit was mainly driven by a significant reduction in bleeding events (HR 0.27; CI 0.06-1.15, p = 0.04). Re-hospitalization was significantly lower as well (HR 0.36; CI 0.20-0.64, p < 0.0001). Adjustment for confounders and inverse probability weighting for the probability of ICH showed no statistically significant difference in mortality (HR 0.53, CI 0.15-1.92, p = 0.33), stroke (HR 0.32 CI 0.03-3.13, p = 0.33), bleeding (HR 0.26; CI 0.05-1.29, p = 0.02), and MACE (HR 0.29; CI 0.04-2.36, p = 0.002).

CONCLUSION

LAAC in ICH was safe and associated with less MACE, bleeding, and re-hospitalization. Randomized-controlled trials are needed to confirm these first positive signs.

Clinical Value of CT-Based 3D Computational Modeling in Left Atrial Appendage Occlusion: An In-Depth Analysis of the PRECISE LAAO Study

BACKGROUND

Standard of care (SoC) assessment based on computed tomography (CT) and/or transesophageal echocardiography is suboptimal for adequate preprocedural evaluation for left atrial appendage occlusion (LAAO). This can be improved through CT-based 3D computational modeling of the LAA-device interaction using FEops HEARTguide. This study aims to assess the decisional impact of FEops in preprocedural planning for LAAO.

METHODS

The PRECISE LAAO is a prospective multi-center self-controlled study evaluating the use of FEops in LAAO with Amulet. Preprocedural device size selection and degree of certainty (scale 0-10) were registered before (Decision SoC) and after accessing FEops (Decision FEops), followed by device implantation. Concordance was compared between the Decisions and the final implanted device. After the procedure, clinicians rated the subjective value of FEops on a scale from -3 (futile) to +3 (most helpful).

RESULTS

One hundred two patients were included. Decision SoC was concordant with the implanted device in 61 patients (59.8%), whereas Decision FEops was concordant in 92 (90.2%, p < 0.0001). FEops induced a size change in 35 patients, which was correct in 33 (32.4%). Certainty SoC was 6.7 ± 1.3 and increased after FEops assessment to 7.6 ± 1.3 (p < 0.0001). In the 33 patients with FEops-induced positive corrections, Certainty SoC was lower (6.2 ± 1.5, suggesting a more complex procedure) and increased to 7.2 ± 1.2 with FEops (p = 0.004). Clinicians rated FEops as helpful (subjective score ≥ 1) in 90.2% of cases.

CONCLUSIONS

CT-based computational modeling using FEops has a positive decisional impact in LAAO, inducing a change in Amulet size selection in almost one out of three patients and increasing procedural confidence. Trials Trial Registration: NCT04640051.

Antithrombotic therapy after left atrial appendage occlusion

INTRODUCTION

Left atrial appendage occlusion (LAAO) represents a strategy to minimize thromboembolic risk in atrial fibrillation (AF) patients. However, LAAO carries some risks of periprocedural bleeding, device embolization, peri-device leaks or device-related thrombosis; the latter is due to direct blood contact with the device, justifying and represents the rationale behind antithrombotic therapy following LAAO.

AREAS COVERED

A comprehensive literature search (PubMed, Web of Science, Cochrane) has been performed up to November 2024. Antithrombotic drugs after LAAO include vitamin K antagonists (VKA), direct oral anticoagulants (DOAC), antiplatelet drugs, and their combinations. Initially, high-intensity regimens were implemented, while current strategies prioritize simplified approaches to promote device healing without increasing the bleeding risk. The aims of our review were to define the rationale and implications for post-LAAO antithrombotic therapy and provide an overview of current evidence on various antithrombotic regimens.

EXPERT OPINION

The optimal post-LAAO antithrombotic regimen remains controversial, highlighting the need for randomized trials on this topic. Current data suggest that DOACs have the lowest probability of thromboembolic events and major bleeding, while DAPT may be preferred in patients who do not tolerate OAC; finally, single antiplatelet therapy or no antithrombotic therapy are alternative options for patients at high bleeding risk.

[Efficacy and safety of concomitant left atrial appendage clipping during heart valve surgery: a report of 58 cases]

OBJECTIVES

To analyze the efficacy and safety of concomitant left atrial appendage clipping during heart valve surgery for valvular heart disease patients with atrial fibrillation.

METHODS

Fifty-eight patients who underwent concomitant left atrial appendage clipping during cardiac valve surgery in the Second Affiliated Hospital of Nanchang University from January 2017 to June 2023 were included in the analysis, including 1 case who underwent aortic valve replacement, 49 cases who underwent mitral valve replace-ment (or valvuloplasty)+tricuspid valvuloplasty, and 8 cases who underwent double valve replacement+tricuspid valvuloplasty (3 cases combined with coronary artery bypass grafting). The patients were followed up for 3-36 months [(16.69±6.61) months] after operation, and the changes of cardiac function and the occurrence of serious adverse complications were evaluated.

RESULTS

The cardiopulmonary bypass time ranged from 75 to 145 min [(102.50±21.03) min], and the aortic cross-clamp time ranged from 35 to 80 min [(58.02±14.63) min]. The length of postoperative intensive care unit stay was 1 to 5 days [(2.47±0.82) d], and the length of postoperative hospital stay was 7 to 22 days [(10.84±2.69) d]. Cardiac ultrasound indicated complete closure of the left atrial appendage in all cases. During the follow-up, New York Heart Association (NYHA) functional classifications were improved in 54 patients. No left atrial appendage-related bleeding events or other perioperative complications were observed; and no cerebral infarction, limb embolism events, or mortality cases occurred during the follow-up.

CONCLUSIONS

For valvular heart disease patients with atrial fibrillation, concomitant left atrial appendage clipping during cardiac valve surgery demonstrates efficacy and safety, with no severe adverse events during a medium-term follow-up.

Epicardial Ligation of the Left Atrial Appendage in Octogenarians: Safety and Long-Term Efficacy

Introduction: Due to the aging population, the number of elderly patients with atrial fibrillation and contraindications for anticoagulation due to bleeding complications is growing. After the epicardial ligation of the left atrial appendage (LAA), anticoagulation can be omitted. We present the single-center procedure data and long-term data of octogenarians being treated with LARIAT®. Method: Out of 145 patients eligible for the epicardial ligation of the LAA, 45 were older than 80 y and included in this analysis. After successful ligation, patients were screened at 6 weeks of follow-up (FUP), at 12 weeks and after 12 months for transesophageal echocardiography (TOE) and clinical events. During long-term FUP, TOE sessions and clinical events for embolic events and death were documented. Results: The procedure was successful in 93% of patients, with a mean CHA2DS2VASC score of 4.6 and HASBLED score of 3.7 and a mean age of 82 y. One major complication occurred, with the laceration of the LAA and surgical closure of the LAA with an Atriclip. The 6-week FUP data were available in 39 patients, with the detection of four leaks (1-3 mm, median 2 mm) and three thrombi; one thrombus occurred at the site of a leak. The 12-week FUP (in 26 patients) showed that three leaks were closed, one leak persisted and one new thrombus developed at the site of the leak. All thrombi were resolved. The 12-month FUP showed the persistent resolution of three thrombi; one thrombus recurred after the withdrawal of the anticoagulant, and no new gap or thrombus could be detected. The long-term FUP (mean 38 months) was documented in 30 patients, with no new gaps and no new thrombi; one patient suffered from a stroke, with a good long-term result of LAA closure in TOE (stroke rate 1%/y, absolute risk reduction of 4.4% to a stroke rate of 5.4% related to the score, relative CHA2DS2VASC risk reduction of 88%). Eleven patients died: four in the first year of ligation and seven during long-term FUP. Conclusions: The epicardial ligation of the LAA for stroke prevention in octogenarians is highly safe and effective. Early TOE FUP is crucial for the detection of thrombi and establishing an optimal anticoagulation regime. No late development of thrombi or gaps can be observed at up to 5 years.

Left Atrial Appendage Closure: What Do We Know?

Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.

WATCHMAN versus LACbes® device for percutaneous left atrial appendage closure: a single-center, propensity-matched study

BACKGROUND

Different left atrial appendage closure (LAAC) devices have been introduced into the clinical setting. A new dual-seal mechanism LACbes® occluder with isogenous barbs for LAAC has been designed to facilitate easier delivery and improve safety. The purpose of this study is to compare the clinical outcomes of the WATCHMAN with those of the LACbes® device for LAAC.

METHODS

Consecutive patients with atrial fibrillation (AF) who had undergone LAAC performed using a WATCHMAN or LACbes® device from June 2016 to February 2022 were included. The primary efficacy endpoint included ischemic stroke, cardiovascular/unexplained death and device-related thrombus, while the primary safety endpoint included major peri-procedural complications and major bleeding events during clinical follow-ups. 1:1 propensity score matching (PSM) was performed.

RESULTS

After PSM, 184 patients were included in each group. The mean CHA2DS2-VASc score was 3.1 ± 1.5 (LACbes®) vs. 3.1 ± 1.4 (WATCHMAN), and the HAS-BLED score was 2.7 ± 1.1 vs. 2.7 ± 1.0. At a mean follow-up of 2.5 ± 1.5 vs. 2.4 ± 0.9 years, the defined three endpoints were comparable between the two groups. The occurrence of all-cause stroke was lower in 5/452 (1.8%) with LACbes® vs. 16/433 (3.7%) with WATCHMAN occluders (HR, 0.40, 95% confidence interval (CI), 0.18-0.89, P = 0.023), and the incidence of any bleeding was higher in the WATCHMAN group (41/433, 9.5% vs. 8/452, 1.8%; HR, 0.19, 95% CI, 0.11-0.33).

CONCLUSION

The LACbes® occluder exhibited comparable safety and efficacy of stroke prevention for AF when compared with the WATCHMAN device.

An International Consensus Practical Guide on Left Atrial Appendage Closure for the Non-implanting Physician: Executive Summary

Many patients with atrial fibrillation (AF) who are in need of stroke prevention are not treated with oral anticoagulation or discontinue treatment shortly after its initiation. Despite the availability of direct oral anticoagulants (DOACs), such undertreatment has improved somewhat but is still evident. This is due to continued risks of bleeding events or ischemic strokes while on DOAC, poor treatment compliance, or aversion to anticoagulant therapy. Because of significant improvements in procedural safety over the years left atrial appendage closure (LAAC), using a catheter-based, device implantation approach, is increasingly favored for the prevention of thromboembolic events in AF patients who cannot have long-term oral anticoagulation. This article is an executive summary of a practical guide recently published by an international expert consensus group, which introduces the LAAC devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. This practical guide, aligned with published guideline/guidance, is aimed at those non-implanting physicians who may need to refer patients for consideration of LAAC.

Percutaneous left atrial appendage closure with SeaLA device in non-valvular atrial fibrillation

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.

Advancements in 3D Transoesophageal Echocardiography (TOE) and Computed Tomography (CT) for Stroke Prevention in Left Atrial Appendage Occlusion Interventions

Left atrial appendage occlusion (LAAO) has emerged as a highly effective alternative to oral anticoagulation for stroke prevention in patients with non-valvular atrial fibrillation. Precise pre-procedural planning and meticulous post-procedural follow-up are essential for achieving successful LAAO outcomes. This review explores the latest advancements in three-dimensional (3D) transoesophageal echocardiography (TOE) and computed tomography (CT) imaging modalities, which have considerably improved the planning, intra-procedural guidance, and follow-up processes for LAAO interventions. Innovations in 3D TOE and CT imaging have transformed the approach to LAAO by providing a more detailed and accurate assessment of the left atrial appendage, enabling clinicians to acquire comprehensive anatomical and morphological information, crucial for optimising device selection and positioning, thus reducing the risk of complications and enhancing the overall safety and efficacy of the procedure. Post-procedurally, CT and TOE imaging are invaluable in the monitoring of patients, ensuring that the device is correctly positioned and functioning as intended. Early detection of any complications (e.g., device-related thrombus and peri-device leaks) can help to risk-stratify patient at increased risk of stroke and initiate timely interventions, thereby improving long-term outcomes for patients.

Zero-contrast left atrial appendage closure, a feasible alternative for patients with a high risk of contrast-induced nephropathy: Systematic literature review and meta-analysis

BACKGROUND

Left atrial appendage closure (LAAC) is an alternative to reduce thrombotic risk in patients with nonvalvular atrial fibrillation. This procedure conventionally requires the use of a contrast agent. A significant proportion of patients who undergo this procedure have chronic kidney disease, with a high risk of contrast-induced nephropathy.

OBJECTIVE

We aimed to systematically review existing literature regarding the feasibility and safety of a zero-contrast LAAC technique.

METHODS

We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies comparing a zero-contrast LAAC technique with conventional LAAC up to April 2024. From each study, we extracted baseline characteristics, feasibility, and safety outcomes. A random model meta-analysis was used to compare outcomes between groups.

RESULTS

Five studies reporting data from 367 patients were included. A 100% successful implantation rate was reported in all the zero-contrast groups. The mean number of recaptures reached no significant difference between the groups (mean difference, -0.15; CI, -0.67 to 0.37; I2 = 0%; P = .58). The zero-contrast group had a significantly shorter fluoroscopy time (mean difference, -4.03; CI, -7.72 to -0.34; I2 = 67%; P = .03). Complications related to the procedure, peridevice leak, and device-associated thrombus rates were not significantly different between the groups.

CONCLUSION

Zero-contrast LAAC is a feasible alternative. The success and complication rates are consistent with those of conventional LAAC. Aside from the inherent benefit of zero-contrast exposure, this technique allows a reduction in fluoroscopy time.

Infective endocarditis associated with left atrial appendage occlusion device: a contemporary systematic review

BACKGROUND

Data are limited regarding infective endocarditis (IE) complicating left atrial appendage occlusion (LAAO) device procedures. This systematic review examines the etiology, diagnosis, and management of infective endocarditis (IE) following LAAO.

METHODS

A comprehensive search of six databases was performed between 2007 and 2022. In selecting studies, articles were included if they provided information about IE complicating LAAO, with relevant clinical and imaging details. Articles were excluded if they were editorials, study protocols, letters, or abstracts.

RESULTS

We identified seven cases of IE complicating LAAO published between 2007 and 2022, from the United States and Europe, highlighting the exceedingly rare reported incidence of the condition. Staphylococcus aureus is the predominant organism implicated in LAAO infections. Echocardiography is a key imaging modality for diagnosing LAAO IE. Both antibiotic therapy and surgical intervention in appropriate patients are important for managing LAAO device-related IE.

CONCLUSIONS

The limited data in the current literature regarding LAAO IE underscores the need for prospective clinical trials to establish evidence-based guidelines for infection prophylaxis, diagnosis, and management. Our findings emphasize the importance of vigilance for device-related infections, especially as the use of LAAO devices continues to grow worldwide.

LAA occlusion is effective and safe in very high-risk atrial fibrillation patients with prior stroke: results from the multicentre German LAARGE registry

BACKGROUND

Interventional left atrial appendage occlusion (LAAO) mitigates the risk of thromboembolic events in nonvalvular atrial fibrillation (AF) patients with contraindication for long-term oral anticoagulation (OAC). Patients with prior stroke have a relevantly increased risk of recurrent stroke, so the effectiveness of LAAO could be reduced in this specific very high-risk patient group.

AIM

This sub-study of the LAARGE registry investigates the effectiveness and safety of LAAO for secondary prevention in nonvalvular AF patients with a history of stroke.

METHODS

LAARGE is a prospective, non-randomised registry on the clinical reality of LAAO. The current sub-study employs data from index procedure and 1-year follow-up. Effectiveness and safety were assessed by documentation of all-cause mortality, non-fatal thromboembolism, procedure-related complications, and bleeding events.

RESULTS

A total of 638 patients were consecutively included from 38 hospitals in Germany and divided into two groups: 137 patients with a history of stroke (21.5%) and 501 patients without. Successful implantation was consistent between both groups (98.5% vs. 97.4%, p = NS), while peri-procedural MACCE and other complications were rare (0% vs. 0.6% and 4.4% vs. 4.0%, respectively; each p = NS). Kaplan-Meier estimate showed no significant difference in primary effectiveness outcome measure (freedom from all-cause death or non-fatal stroke) between both groups at follow-up (87.8% vs. 87.7%, p = NS). The incidence of transient ischemic attack or systemic embolism at follow-up was low (0% vs. 0.5% and 0.9% vs. 0%, respectively; each p = NS). Severe bleeding events after hospital discharge were rare (0% vs. 0.7%, p = NS).

CONCLUSIONS

Patients with prior stroke demonstrated similar effectiveness and safety profile for LAAO as compared to patients without prior stroke. LAAO could serve as a feasible alternative to OAC for secondary stroke prevention in this selected group of nonvalvular AF patients.

CLINICALTRIALS

GOV IDENTIFIER

NCT02230748.

1-Year Clinical Outcomes and the Impact of Procedural Configurations in Left Atrial Appendage Occlusion Patients

Background

The clinical performance of left atrial appendage occlusion (LAAO) as a procedure and the long-term impact of its varied implantation configurations and anticoagulation regimens remain unclear.

Objectives

This study sought to provide data in routine practice from a prospective multicenter registry.

Methods

A total of 3,096 consecutive patients from 39 Chinese centers undergoing LAAO were enrolled between April 1, 2019, and October 31, 2020.

Results

The baseline CHA2DS2-VASc and HAS-BLED scores were 4.0 ± 1.8 and 2.4 ± 1.2, respectively; mean age was 69 ± 9 years. One-year follow-up was completed in 3,013 (97.8%) patients. The ischemic endpoint of death, stroke, and systemic embolism occurred in 133 (4.51%) patients, and life-threatening, disabling, or major bleeding occurred in 71 (2.36%) patients. After inverse probability of treatment weighting, no significant association was found between anesthesia type (moderate sedation vs general anesthesia) or image guidance (transesophageal/intracardiac echocardiography vs fluoroscopy) and ischemic or bleeding events. In 1,295 (42.0%) cases, LAAO combined with catheter ablation was associated with a significantly lower rate of death, stroke, or systemic embolism than LAAO only (3.5% vs 5.2%, inverse probability of treatment weighting HR: 0.68; 95% CI: 0.47-0.99). The most common post-LAAO antithrombotic regimen was warfarin/direct oral anticoagulant monotherapy for 45 days, followed by single-/dual-antiplatelet therapy (38.1%).

Conclusions

In Chinese centers, patients undergoing LAAO had low rates of ischemic and bleeding events at 1 year. Combining LAAO with catheter ablation was associated with a lower rate of ischemic events than LAAO only. (Registry to Evaluate Chinese Real-World Clinical Outcomes in Patients With Atrial Fibrillation Using the Watchman Left Atrial Appendage Closure Technology [RECORD]; NCT03917563).

Left Atrial Appendage Closure: A Single-Center Experience in a Population With a High Prevalence of End-Stage Renal Disease

Background Left atrial appendage closure (LAAC) has emerged as an alternative approach for mitigating thrombotic risk in nonvalvular atrial fibrillation patients. However, existing registries often lack representation of the Hispanic population, motivating this study to elucidate the demographic, clinical, and procedural characteristics, specifically among Hispanic patients undergoing this procedure. Methods Adult patients who underwent percutaneous LAAC between June 2017 and July 2022 at a high-complexity hospital in Bogotá, COL, were included. Baseline and procedural characteristics are reported. For patients with available follow-up data, major bleeding, thromboembolic events, and cardiovascular mortality were assessed. A subgroup analysis was conducted for patients with end-stage renal disease on dialysis. Results We included 33 patients. Follow-up data were available for 27 patients, with a mean follow-up period of 12.4 months. The median age of the cohort was 70 years (SD 9), with 58% being women. The median CHADS2 and HAS-BLED scores were 3 points (IQR 2 to 4) and 4 points (IQR 3 to 4), respectively. The 90-day cardiovascular mortality rate was 3.7%, whereas cardioembolic episodes and major bleeding events were reported at rates of 10.8 and 14.4 per 100 patient years, respectively. The long-term outcomes of patients on dialysis were comparable to those of nondialysis patients. Conclusions Our study reinforces existing evidence supporting the safety of LAAC, particularly in a multimorbid patient population with elevated bleeding and thrombotic risks. In this high-risk cohort, LAAC emerges as a feasible alternative for reducing thromboembolic risk. Notably, patients on dialysis demonstrated comparable long-term outcomes, suggesting the procedure's viability in this subgroup as well.

Left Atrial Appendage Closure Compared With Oral Anticoagulants for Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) has been suggested as an alternative to long-term oral anticoagulation for nonvalvular atrial fibrillation, but comparative data remain scarce. We aimed to assess ischemic and bleeding outcomes of LAAC compared with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for the prevention of cardioembolic events in patients with atrial fibrillation.

METHODS AND RESULTS

Embase and MEDLINE were searched for randomized trials comparing LAAC, VKAs, and DOACs. The primary efficacy end point was any stroke or systemic embolism. Treatment effects were calculated from a network meta-analysis and ranked according to the surface under the cumulative ranking curve. Seven trials and 73 199 patients were included. The risk of the primary end point was not statistically different between LAAC versus VKAs (odds ratio [OR], 0.92 [95% CI, 0.62-1.50]) and LAAC versus DOACs (OR, 1.11 [95% CI, 0.71-1.73]). LAAC and DOACs resulted in similar risk of major or minor (OR, 0.93 [95% CI, 0.61-1.42]) and major bleeding (OR, 0.92 [95% CI, 0.58-1.46]); however, after exclusion of procedural bleeding, bleeding risk was significantly lower in those undergoing LAAC. Both LAAC and DOACs reduced the risk of all-cause death  compared with VKAs (LAAC versus VKAs: OR, 0.70 [95% CI, 0.53-0.91]; DOACs versus VKAs: OR, 0.90 [95% CI, 0.85-0.95], respectively). DOACs ranked as the best treatment for stroke or systemic embolism prevention (66.9%) and LAAC for reducing major bleeding (63.9%) and death (96.4%).

CONCLUSIONS

As a nonpharmacological alternative to oral anticoagulation for atrial fibrillation, LAAC showed similar efficacy and safety compared with VKAs or DOACs. Prospective confirmation from larger studies is warranted.

Impact of gender in patients with device-related thrombosis after left atrial appendage closure - A sub-analysis from the multicenter EUROC-DRT-registry

BACKGROUND

Device-related thrombosis (DRT) is a common finding after left atrial appendage closure (LAAC) and is associated with worse outcomes. As women are underrepresented in clinical studies, further understanding of sex differences in DRT patients is warranted.

METHODS AND RESULTS

This sub-analysis from the EUROC-DRT-registry compromises 176 patients with diagnosis of DRT after LAAC. Women, who accounted for 34.7% (61/176) of patients, were older (78.0 ± 6.7 vs. 74.9 ± 9.1 years, p = .06) with lower rates of comorbidities. While DRT was detected significantly later in women (173 ± 267 vs. 127 ± 192 days, p = .01), anticoagulation therapy was escalated similarly, mainly with initiation of novel oral anticoagulant (NOAC), vitamin K antagonist (VKA) or heparin. DRT resolution was achieved in 67.5% (27/40) of women and in 75.0% (54/72) of men (p = .40). In the remaining cases, an intensification/switch of anticoagulation was conducted in 50.% (9/18) of men and in 41.7% (5/12) of women. Final resolution was achieved in 72.5% (29/40) cases in women, and in 81.9% (59/72) cases in men (p = .24). Women were followed-up for a similar time as men (779 ± 520 vs. 908 ± 687 days, p = .51). Kaplan-Meier analysis revealed no difference in mortality rates in women (Hazard Ratio [HR]: 1.73, 95%-Confidence interval [95%-CI]: .68-4.37, p = .25) and no differences in stroke (HR: .83, 95%-CI: .30-2.32, p = .72) within 2 years after LAAC.

CONCLUSION

Evaluation of risk factors and outcome revealed no differences between men and women, with DRT in women being diagnosed significantly later. Women should be monitored closely to assess for DRT formation/resolution. Treatment strategies appear to be equally effective.

Clinical outcome and intraprocedural characteristics of left atrial appendage occlusion: a comparison between single-occlusive plug-type and dual-occlusive disc-type devices

Background

Percutaneous interventional left atrial appendage occlusion (LAAO) is a reliable, safe, and effective alternative for stroke prevention in selected patients with atrial fibrillation (AF).

Methods

In a retrospective observational study, 149 patients underwent LAAO between 2016 and 2022 at the Department of Cardiology of the Charité-Universitätsmedizin Berlin, Campus Virchow, with AF for prevention of thromboembolic complications. We compared patient characteristics, intraoperative details and postoperative outcomes between single-occlusive plug-type (SOPT) and dual-occlusive disc-type (DODT) devices.

Results

In all patients, the device implantation was successful. 60 patients received a SOPT occluder, including Watchman (35%) and Watchman FLX Occluders (65%), while 89 patients received a DODT occluder, including Amplatzer Cardiac Plug (37.1%), the Amplatzer Amulet (25.8%), and the LAmbre occluder (37.1%) systems. Procedure duration was significantly longer for DODT occluder implantation (49 ± 33 vs. 41 ± 25 min, p = 0.018). There were no in-hospital deaths or thromboembolic events reported after LAAO in both groups. Beyond that, a low rate of bleeding or access-side-related complications and pericardial tamponades were observed. Anticoagulation at discharge varied. About 60.8% of patients received dual antiplatelet therapy at hospital discharge, and 33.1% received direct oral anticoagulants. A 6-month follow-up was obtained in 85% of the patients. All implanted devices were in the desired position. However, in 5.7% of the patients, a device-related thrombus formation was detected in the SOPT group, while no thrombus was seen in the DODT group (p = 0.11). Thromboembolic events were noticed in 3.1%, without any difference between the device types. There was a statistically non-significant trend for less residual device leaks after SOPT vs. DODT implantation (no leak in 71.7% vs. 62.2%, p = 0.07; minor leaks <5 mm, 9.4% vs. 20.3%, p = 0.1). In the SOPT group, less bleeding complications were reported after LAAO (11.3% vs. 17.6%, p = 0.1).

Conclusion

Our data suggest the safety and efficiency of LAAO with a very high procedural implantation success rate irrespective of the used LAA device. Furthermore, no relevant procedural or device-related complication occurred during the 6-month follow-up in all patients.

Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Comprehensive Review

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with an increased risk of stroke due to disrupted heart function and potential clot formation. This review examines current management strategies for stroke prevention in AF, focusing on the efficacy, safety, and long-term outcomes of anticoagulation therapies. Anticoagulants, including novel oral anticoagulants (NOACs) and vitamin K antagonists, play a crucial role in reducing stroke risk by preventing clot formation in the heart. Recent studies highlight NOACs as superior alternatives to traditional therapies, offering improved safety profiles and enhanced patient adherence. Despite the risk of bleeding complications, judicious use of anticoagulants significantly improves clinical outcomes in AF patients. The review synthesizes evidence from clinical trials and meta-analyses to underscore the pivotal role of NOACs in transforming stroke prevention strategies in AF. Moreover, it discusses emerging interventions such as left atrial appendage occlusion and emphasizes the importance of personalized, patient-centered care in optimizing treatment decisions for AF patients at risk of stroke.

Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review

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.

Comparative Assessment of Percutaneous Left-Atrial Appendage Occlusion (LAAO) Devices-A Single Center Cohort Study

BACKGROUND

Percutaneous left-atrial appendage closure (LAAC) is an established method for preventing strokes in patients with atrial fibrillation, offering an alternative to oral anticoagulation. Various occluder devices have been developed to cater to individual anatomical needs and ensure a safe and effective procedure. In this retrospective, monocentric cohort study, we compare different LAAO devices with respect to clinical outcomes, LAA sealing properties, and device-related complications.

METHODS

We conducted a retrospective analysis of 270 patients who underwent percutaneous LAA closure in our center between 2009 and 2023. Patient data were extracted from medical records, including gender, age at implantation, indication, device type and size, laboratory values, LAA anatomy, periprocedural complications, ECG parameters, transthoracic and transesophageal echocardiography parameters (TTE and TEE), as well as medication at discharge. Moreover, fluoroscopy time and implantation duration, as well as post-implantation clinical events up to 1 year, were collected. Endpoints were bleeding events, recurrent stroke, thrombi on devices, and death.

RESULTS

The implanted devices were the Watchman 2.5, Watchman FLX, Amplatzer Cardiac Plug (ACP), and Amulet. The procedural success rate was 95.7% (n = 265), with cactus anatomy posing the most challenges across all devices. The mean patient age was 75.5 ± 7.7 years, with 64.5% being male. The median CHA2DS2-VASc score was 4.8 ± 1.5 and the median HAS-BLED score was 3.8 ± 1.0. Indications for LAA closure included past bleeding events and elevated bleeding risk. Periprocedural complications were most commonly bleeding at the puncture site, particularly after ACP implantation (p = 0.014). Significant peridevice leaks (PDL) were observed in 21.4% of simple sealing mechanism devices versus 0% in double sealing mechanism devices (p = 0.004). Thrombi were detected on devices in six patients, with no subsequent ischemic stroke or thromboembolic event. Comparative analysis revealed no significant differences in the occurrence of stroke, transient ischemic attack (TIA), thromboembolic events, device-related thrombi, or mortality among different device types. A 62.3% relative risk reduction in thromboembolic events and 38.6% in major bleedings could be observed over 568.2 patient years.

CONCLUSIONS

In summary, our study highlights the efficacy and safety of LAA closure using various occluder devices despite anatomical challenges. Our long-term follow-up findings support LAA closure as a promising option for stroke prevention in selected patient cohorts. Further research is needed to refine patient selection criteria and optimize outcomes in LAA closure procedures.

Massive Hemoptysis: An Unusual Complication of Left Atrial Appendage Occlusion Device in Two Patients

Left atrial appendage occlusion (LAAO) devices have emerged as a promising alternative for stroke prevention in non-valvular atrial fibrillation (NVAF) patients with contraindications to chronic anticoagulation therapy. The most common life-threatening procedural complications described in the literature include pericardial effusion, air embolism, and stroke. We here present a case report of two patients who experienced identical but rare post-procedural complications of pulmonary venous bleed, presenting as hemoptysis.

Outcomes Associated With Left Atrial Appendage Occlusion Via Implanted Device in Atrial Fibrillation

OBJECTIVE

To compare outcomes after left atrial appendage occlusion (LAAO) via implanted device vs no LAAO in a matched cohort of patients with atrial fibrillation (AF).

METHODS

This longitudinal retrospective cohort study was based on the national database covering hospital care for the entire French population. Adults (≥18 years of age) who had been hospitalized with AF (January 1, 2015, to January 1, 2020) who underwent LAAO were identified. Propensity score matching was used to control for potential confounders of the treatment-outcome relationship. The primary outcome was a composite of ischemic stroke, major bleeding, or all-cause death during follow-up.

RESULTS

After propensity score matching, 1216 patients with AF who were treated with LAAO were matched with 1216 controls (patients AF who were not treated with LAAO). Mean follow-up was 14.5 months (median, 13 months; IQR, 7-21 months). Patients with LAAO had a lower risk of the composite outcome (HR, 0.48; 95% CI, 0.42 to 0.55). Total events (309 for LAAO vs 640 for controls) and event rates (23.3% vs 44.0%/year, respectively) were lower for LAAO, driven primarily by a decreased risk of all-cause death (HR, 0.39; 95% CI, 0.33 to 0.46; P<.0001), whereas ischemic stroke risk was higher (HR, 1.75; 95% CI, 1.17 to 2.64). Significant interactions were observed in subgroups with a history of ischemic stroke (P<.001) and of bleeding (P=.002).

CONCLUSION

Among AF patients at high bleeding risk, our nationwide study highlights a high risk of clinical events during follow-up. LAAO appeared less effective than no LAAO in preventing stroke but more effective in preventing death. Left atrial appendage occlusion is particularly effective in patients with previous ischemic stroke or any episode of bleeding.

Safety of Amulet Left Atrial Appendage Occluder and Watchman Device for Left Atrial Appendage Closure in Patients With Atrial Fibrillation

BACKGROUND

Left atrial appendage (LAA) closure is an alternative to chronic anticoagulation for stroke prevention in patients with nonvalvular atrial fibrillation. Multiple devices were used for LAA closure, with the Amplatzer Amulet LAA Occluder (Abbott, Chicago, IL, USA) and Watchman device (Boston Scientific, Marlborough, MA, USA) being the most commonly used in clinical practice. In August 2021, the FDA approved the use of the Amplatzer Amulet LAA Occluder. There is still a knowledge gap in the safety profile of the Amplatzer Amulet LAA Occluder device in comparison to the Watchman device.

OBJECTIVE

The aim of this study was to assess and compare the safety profile peri-procedure and post-procedure between the Amplatzer Amulet LAA Occluder and Watchman devices.

METHODS

Patients who underwent LAA closure using Watchman or Amulet devices from July 2015 to August 2020 at the American University of Beirut Medical Center were included in the analysis. Primary endpoints included peri-operative and post-procedural complications (thromboembolic events, bleeding complications, vascular access complications, pericardial effusion/tamponade, device positional complications and in-hospital death).

RESULTS

The study included 37 patients (21 had Watchman devices, 16 had Amplatzer Amulet LAA Occluder devices, and 28 were men, mean age 76.57 ± 9.3 years). Seven patients developed post-procedural iatrogenic atrial septal defects (four in the Watchman group vs three in the Amulet group, p-value=0.982). Three patients developed pericardial effusion (one in the Watchman vs two in the Amulet group, p-value=0.394). Only one patient developed peri-device leak (one in the Watchman group vs none in the Amulet group, p-value=0.283). One device could not be deployed (one in the Amulet group vs none in the Watchman group, p-value=0.191). None of the patients developed in-hospital death, cardiac tamponade, device embolism, device thrombosis, stroke/transient ischemic attack (TIA), cranial bleeding, or arrhythmias after the procedure. The rate of peri-operative complications was similar between both groups. Both groups displayed low rates of adverse events in the peri-operative and post-operative periods.

CONCLUSION

There was no significant difference in the safety profile of Amplatzer Amulet LAA Occluders and Watchman devices. There was a low incidence of peri-operative and post-operative adverse events with the implanted devices.

5-year stroke rates in nonvalvular atrial fibrillation after watchman compared to direct oral anticoagulants

BACKGROUND

The WATCHMAN device (Boston Scientific; Marlborough, MA, USA) is noninferior to warfarin in preventing ischemic strokes while reducing bleeding risks associated with long term anticoagulation in nonvalvular atrial fibrillation (AFib). The device's performance compared to direct oral anticoagulants (DOAC) is less well known.

OBJECTIVE

To compare 5-year major bleeding and ischemic stroke rates in patients with nonvalvular AFib who received a WATCHMAN device or DOAC therapy after a major bleeding event.

METHODS

This retrospective, multicenter, 1:1 matched cohort study was derived from the PearlDiver Mariner database from 2010 to 2020. Patients with nonvalvular AFib on oral anticoagulation who had a major bleeding event were identified. Those who received either WATCHMAN or DOAC after resolution of the bleeding event were selected. The two groups were exactly matched 1:1 based on various comorbidities. Rates of ischemic stroke, transient ischemic attack (TIA), major bleeding, and hemorrhagic stroke were compared over 5 years.

RESULTS

Each cohort consisted of 2248 patients after 1:1 matching. The mean CHADS2-VASC score was 4.81 ± 1.25. At 5 years, the WATCHMAN cohort had significantly lower rates of major bleeding events [OR 0.24 (0.21, 0.27)], TIAs [OR 0.75 (0.58, 0.95)], and ischemic strokes [OR 0.72 (0.61, 0.86)]. There was no significant difference in hemorrhagic strokes [OR 1.14 (0.83, 1.58)].

CONCLUSION

Even in a high-risk population, the WATCHMAN is comparable to DOAC therapy in the primary prevention of hemorrhagic strokes and may provide benefit in the rates of bleeding events, TIAs, and ischemic strokes.

State-of-the-Art of Transcatheter Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in patients with atrial fibrillation, especially in patients with absolute/relative contraindications to these therapies. This review will cover three main aspects of the procedure. In the fist part of the manuscript, we focus on patient selection. We describe three main categories of patients with primary indication to LAAO, namely patients with previous or at a high risk of intracerebral bleeding, patients with a history of major gastrointestinal bleeding and patients with end-stage renal disease and absolute contraindication to novel oral anticoagulants. Some other potential indications are also described. In the second part of the manuscript, we review available devices, trying to highlight different aspects and potential specific advantages. The last section overviews different ways for pre-, intra- and postprocedural imaging, in order to improve procedural safety and efficacy and ameliorate patient outcome. The characteristics of available contemporary devices and the role of imaging in procedural planning, intraprocedural guidance and follow-up are described.

Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness

INTRODUCTION AND OBJECTIVES

The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events.

METHODS

This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up.

RESULTS

The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%).

CONCLUSIONS

SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.

Left atrial appendage closure in very elderly patients in the French National Registry

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).

Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis

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.

Is spontaneous echo contrast associated with device-related thrombus or embolic events after left atrial appendage occlusion? - Insights from the multicenter German LAARGE registry

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.

Effectiveness and safety of short-term anticoagulant regimens after left atrial appendage occlusion: A systematic review and meta-analysis

INTRODUCTION

Left atrial appendage occlusion (LAAO) provides an alternative for poor candidates of long-term oral anticoagulant (OAC) therapy; however, anticoagulant therapy after surgical procedures has limited use due to associated uncertainties. We aimed to evaluate the effectiveness and safety of the short-term use of direct oral anticoagulant (DOAC) and warfarin after LAAO.

METHOD

Electronic databases such as PubMed, Embase, Medline, and Cochrane Library databases were searched up to November 11, 2022. Our study compared DOAC therapy and warfarin in patients after LAAO. A meta-analysis was conducted with the Review Manager software (version 5.4).

RESULTS

The meta-analysis included 13 cohort studies with a total of 32,607 patients. Our findings indicated that the incidence of stroke/TIA/SE, peri-device leaks>5 mm, device-related thrombosis, and all-cause mortality were not significantly different between the two groups after LAAO (P > 0.05). The DOAC group had a significantly lower incidence of major bleeding (OR = 0.83, 95 % CI: 0.74-0.94, P = 0.003), any bleeding (OR = 0.34, 95 % CI: 0.23-0.51, P < 0.001), stroke/TIA/SE and major bleeding (OR = 0.57, 95 % CI: 0.34-0.95, P = 0.03), and any major adverse event (OR = 0.89, 95 % CI:0.82-0.97, P = 0.010) than the warfarin group. The subgroup analysis revealed that the rate of stroke/TIA/SE was similar in the two groups in terms of the different regions, follow-up time, study type, anticoagulant strategy, and bleeding risk. The incidence of major bleeding in the DOAC group was significantly lower than that in the warfarin group in North America, as well as at follow-up period ≤6 months, retrospective cohort, HAS-BLED average score ≥ 3. In addition, the risk of major bleeding was higher with the combination of OAC and single antiplatelet therapy (SAPT) than with OAC alone. Finally, in the North American region, retrospective cohort, and HAS-BLED average score ≥ 3, the incidence of any serious adverse event in the DOAC group was still significantly lower than that in the warfarin group.

CONCLUSION

Compared to warfarin, DOAC reduced the risk of major bleeding and any serious adverse event in patients after LAAO. This advantage was particularly notable in North America and high-risk populations for bleeding. In addition, the incidence of device-related thrombosis, peri-device leaks, stroke/TIA/SE and all-cause mortality were similar in both groups. The risk of major bleeding was lower in patients taking OAC alone compared with those taking OAC plus SAPT, without increasing the risk of thrombosis.

Symptomatic vs. non-symptomatic device-related thrombus after LAAC: a sub-analysis from the multicenter EUROC-DRT registry

BACKGROUND

Device-related thrombus (DRT) after left atrial appendage closure (LAAC) is associated with adverse outcomes, i.e. ischemic stroke or systemic embolism (SE). Data on predictors of stroke/SE in the context of DRT are limited.

AIMS

This study aimed to identify predisposing factors for stroke/SE in DRT patients. In addition, the temporal connection of stroke/SE to DRT diagnosis was analyzed.

METHODS

The EUROC-DRT registry included 176 patients, in whom DRT after LAAC were diagnosed. Patients with symptomatic DRT, defined as stroke/SE in the context of DRT diagnosis, were compared against patients with non-symptomatic DRT. Baseline characteristics, anti-thrombotic regimens, device position, and timing of stroke/SE were compared.

RESULTS

Stroke/SE occurred in 25/176 (14.2%) patients diagnosed with DRT (symptomatic DRT). Stroke/SE occurred after a median of 198 days (IQR 37-558) after LAAC. In 45.8% stroke/SE occurred within one month before/after DRT diagnosis (DRT-related stroke). Patients with symptomatic DRT had lower left ventricular ejection fractions (50.0 ± 9.1% vs. 54.2 ± 11.0%, p = 0.03) and higher rates of non-paroxysmal atrial fibrillation (84.0% vs. 64.9%, p = 0.06). Other baseline parameters and device positions were not different. Most ischemic events occurred among patients with single antiplatelet therapy (50%), however, stroke/SE was also observed under dual antiplatelet therapy (25%) or oral anticoagulation (20%).

CONCLUSION

Stroke/SE are documented in 14.2% and occur both in close temporal relation to the DRT finding and chronologically independently therefrom. Identification of risk factors remains cumbersome, putting all DRT patients at substantial risk for stroke/SE. Further studies are necessary to minimize the risk of DRT and ischemic events.

Left atrial appendage occlusion in an older population cohort

BACKGROUND

Atrial fibrillation is the most common cardiac arrhythmia and is a major risk factor for stroke, with an incidence rate of 4-5% per year. The use of DOACs is recommended for specific patient populations however the risk of bleeding commonly precludes their use. Left atrial appendage occlusion is a relatively novel procedure recommended for such patients. We set out to analyse the initial success and safety of this procedure in a single site.

RESULTS

Twenty patients were included in the study with an average age of 81 years. Seventy percent (n = 14) were male. Ninety percent (n = 18) had a history of major bleeding, an absolute contraindication to anticoagulation. The mean CHADS2VaSc and HASBLED scores were 4.75 and 3.7, respectively. The technical success rate was 95% comparable with existing data. The procedural success rate in our study was 80%. The most frequent complication was cardiac tamponade, occurring in 10% of cases.

CONCLUSION

We report lower technical success and procedural success rates in an older population cohort than historically studied, 90% of whom had an absolute contraindication to oral anticoagulation, with higher CHADS2VaSc and HASBLED scores than commonly studied.

Splenic Infarction with Myocardial Injury in a Diabetic Patient: A Case Report

Splenic infarction (SI) is an uncommon complication of type 2 diabetes (T2D). Diabetes predisposes individuals to blood vessel abnormalities, such as atherosclerosis or thrombosis, increasing the risk of vessel occlusion and subsequent tissue infarction. If the diabetic patient has other serious diseases, such as a severe pneumonia infection and acute cardiac infarction, SI incidence may go unrecognized, making it challenging for physicians to identify. This case report discussed an 80-year-old hospitalized diabetic woman with a history of chronic bronchitis and 20 years of T2D who suffered an SI. The patient was at elevated risk for thrombosis of atrial fibrillation, manifested as an embolism of the spleen characterized by a high concentration of white blood cells. This patient also demonstrated a rapid increase in cardiac biomarkers troponin I, suggesting acute myocardial infarction (AMI) and increased amylase, which could not preclude the concern about the existence of acute pancreatitis. Abdominal CT displayed the calcification of only the splenic and other arteries, and low-density shadows were observed at the center portion of the spleen. This case demonstrated the significant occurrence of thrombotic complications in various blood vessels of multiple organs in T2D patients. Thus, clinicians should be aware of the possibility of simultaneous acute vascular infarction of several organs in diabetic patients with prior vascular constriction.

Cerebral embolic protection during transcatheter heart interventions

Stroke remains a devastating complication of transcatheter aortic valve replacement (TAVR), with the incidence of clinically apparent stroke seemingly fixed at around 3% despite TAVR's significant evolution during the past decade. Embolic showers of debris (calcium, atheroma, valve material, foreign material) are captured in the majority of patients who have TAVR using a filter-based cerebral embolic protection device (CEPD). Additionally, in systematic brain imaging studies, the majority of patients receiving TAVR exhibit new cerebral lesions. Mechanistic studies have shown reductions in the volume of new cerebral lesions using CEPDs, yet the first randomised trial powered for periprocedural stroke within 72 hours of a transfemoral TAVR failed to meet its primary endpoint of showing superiority of the SENTINEL CEPD. The present review summarises the clinicopathological rationale for the development of CEPDs, the evidence behind these devices to date and the emerging recognition of cerebral embolisation in many non-TAVR transcatheter procedures. Given the uniqueness of each of the various CEPDs under development, specific trials tailored to their designs will need to be undertaken to broaden the CEPD field, in addition to evaluating the role of CEPD in non-TAVR transcatheter heart interventions. Importantly, the cost-effectiveness of these devices will require assessment to broaden the adoption of CEPDs globally.

Progress in the study and treatment of peri-device leak after left atrial appendage closure

For patients with atrial fibrillation with an increased risk of stroke and contraindications to long-term anticoagulation, percutaneous left atrial appendage closure (LAAC) has become an important alternative to long-term oral anticoagulation. Incomplete closure of the LAAC during the procedure leads to faster blood flow in the interstitial space around the device, resulting in peri-device leak (PDL), which is not uncommon. Studies are still inconclusive in determining the incidence, long-term safety, and management of PDL. Therefore, this article reviewed the progress made in the research and treatment of PDL after LAAC.

Clinical Implications of CT-detected Hypoattenuation Thickening on Left Atrial Appendage Occlusion Devices

Background At follow-up CT after left atrial appendage occlusion (LAAO), hypoattenuation thickening (HAT) on the atrial aspect of the device is a common finding but the clinical implications require further study. Purpose To assess the association of HAT grade at follow-up CT with clinical characteristics and outcomes in patients who underwent LAAO. Materials and Methods This prospective study included consecutive participants with atrial fibrillation and who were at high risk for stroke (CHA2DS2-VASc score ≥4) who underwent LAAO and were administered pacifier or nonpacifier devices at two French medical centers between January 2012 and November 2020. Postprocedure CT images were evaluated by two radiologists in consensus and device-specific interpretation algorithms were applied to classify HAT as low grade (low suspicion of thrombosis) or high grade (high suspicion of thrombosis). The association between HAT grade and clinical characteristics was assessed using multinomial logistic regression, and variables associated with risk of stroke were assessed using a Cox proportional hazard model. Results This study included 412 participants (mean age, 76 years ± 8 [SD]; 284 male participants) who underwent follow-up CT at a mean of 4.2 months ± 1.7 after LAAO. Low-grade and high-grade HAT were depicted in 98 of 412 (23.8%) and 21 of 412 (5.1%) participants, respectively. High-grade HAT was associated with higher odds of antithrombotic drug discontinuation during follow-up (odds ratio, 9.5; 95% CI: 3.1, 29.1; P < .001), whereas low-grade HAT was associated with lower odds of persisting left atrial appendage patency (odds ratio, 0.46; 95% CI: 0.27, 0.79; P = .005). During a median follow-up of 17 months (IQR, 11-41 months), stroke occurred in 24 of 412 (5.8%) participants. High-grade HAT was associated with stroke (hazard ratio, 4.6; 95% CI: 1.5, 14.0; P = .008) and low-grade HAT (P = .62) was not. Conclusion Low-grade HAT was a more common finding at CT performed after LAAO CT (24%) than was high-grade HAT (5%), but it was associated with more favorable outcomes than high-grade HAT, which was associated with higher stroke risk. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Choe in this issue.

Left Atrial Appendage Occlusion Under Miniaturized Transesophageal Echocardiographic Guidance and Conscious Sedation: Multicenter European Experience

BACKGROUND

Left atrial appendage occlusion (LAAO) procedures are widely guided by standard transesophageal echocardiography (TEE) probes, requiring general anesthesia in most patients. The use of miniaturized TEE probes allows for LAAO guidance under local anesthesia and offers an attractive imaging alternative to standard TEE probes.

OBJECTIVES

The aim of this study was to assess the safety and efficacy of miniaturized TEE probes for procedural guidance of LAAO.

METHODS

Multicenter retrospective observational study of LAAO procedures performed under miniaturized TEE guidance and conscious sedation. The primary efficacy endpoint was technical success. The secondary efficacy endpoint was procedural success (technical success without major periprocedural complications). The safety outcome was a composite of major periprocedural complications.

RESULTS

A total of 546 consecutive LAAO procedures were performed in 5 European centers. Technical success was achieved in 534 (98.0%) patients. Sixteen major periprocedural complications occurred in 15 (2.9%) patients, yielding a procedural success rate of 97.0%. Conversion to general anesthesia was required in 4 (0.7%) patients. Short-term imaging follow-up was available in 422 patients with an incidence of major (>5 mm) TEE-detected residual leaks of 0.7%, complete LAA occlusion of 82.2% on cardiac computed tomography, and device-related thrombus of 5%. As compared with procedural 2-dimensional imaging for device sizing, preprocedural assessment by 3-dimensional imaging resulted in improved technical success (100% vs 95.0%; P < 0.001).

CONCLUSIONS

LAAO under conscious sedation and miniaturized TEE guidance is safe and feasible with a high rate of technical success and a low rate of periprocedural complications.

Safety and Healthcare Resource Utilization in Patients Undergoing Left Atrial Appendage Closure-A Nationwide Analysis

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.

Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long?

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.

Leap or lag: left atrial appendage closure and guidelines

Atrial fibrillation (AF) is associated with life-threatening thromboembolism. Most emboli stem from thrombosis in the left atrial appendage (LAA). The current treatment of choice is oral anticoagulants (OACs), but a small proportion of patients cannot take OACs predominantly because of the so-called unacceptable bleeding risks. However, many who initially accept OACs subsequently stop therapy or reduce the OAC treatment to a potentially non-effective dose leaving them exposed to thromboembolic risk. A relatively simple alternative therapy involves the catheter-based insertion of a LAA closure (LAAC) device to prevent thromboembolism from the LAA. There is a considerable evidence base for this therapy consisting of clinical trials and observational data which suggests comparable therapeutic efficacy with a possible small excess of ischaemic strokes. Although LAAC has been very closely examined by regulators and approved for market release, guidelines from most professional societies give only weak recommendations for use of this device which may be the only known effective therapy available to some at-risk AF patients. Guidance materials from the same societies more enthusiastically endorse LAAC. Clinical practice is running well ahead of the guidelines because equipoise has been lost by physicians faced with patients for whom they have no other effective therapy. Guideline writers are correct in providing recommendations which are less strong for LAAC than for OACs, for those who are able and willing to take OAC treatment, but for those who are not, a stronger recommendation is needed. But, should the guidelines lag behind or leap ahead of the available evidence?

Appropriate Use Criteria of Left Atrial Appendage Closure Devices: Latest Evidences

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.

Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives

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.

Evaluating Gender-based Differences in Clinical Outcomes for Patients Undergoing Left Atrial Appendage Occlusion: A Single Centre Experience

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.

The role of cardiac imaging before and after left atrial appendage standalone thoracoscopic exclusion

AIMS

To assess the characteristics of left atrial appendage (LAA) stump and left atrial (LA) volume after standalone totally thoracoscopic LAA exclusion in 40 patients with nonvalvular atrial fibrillation (NVAF) and contraindications to oral anticoagulation (OAC), using cardiac computed tomography (CCT) and transoesophageal echocardiography (TOE).

METHODS

Using CCT and TOE, we evaluated correct AtriClip Pro II positioning, the presence and characteristics of the LAA stump and the postprocedural LA volume, at 3 months' follow-up. Stump depth was measured with both CCT and TOE using a new method, based on left circumflex artery (LCX) course.

RESULTS

After placement of AtriClip, all 40 patients discontinued OAC, and no stroke occurred. LAA exclusion was achieved in 40/40 patients at 3 months' follow-up. LAA stump (depth <10 mm in 12/18 stump, 67%) was observed in 18 patients. The overall (LA + LAA) volume and isolated LA volume were statistically different when comparing cases with and without LAA stump (P < 0.02). LAA ostium dimensions (perimeter and area) and LAA volume correlate with stump depth (P < 0.02). There was a high correlation between CCT and TOE in stump identification and depth measurement (P < 0.02). Compared with the baseline, CCT LA volume increased (P < 0.01) at 3 months' follow-up.

CONCLUSION

Preprocedural and postprocedural CCT and TOE are useful and comparable in patients undergoing standalone totally thoracoscopic exclusion of LAA, because these imaging methods can identify anatomical LAA and LA characteristics predisposing for a postprocedural residual stump.

Impact and predictors of device-related thrombus after percutaneous left atrial appendage closure

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.

Left atrial appendage occlusion with Watchman device after incomplete surgical ligation

Non-valvular atrial fibrillation (NVAF) is the most common cause of cardioembolic stroke. The left atrial appendage (LAA) is the major source of cardiac emboli in patients with NVAF. Anticoagulation (AC) is the standard of care for stroke prevention in atrial fibrillation (AF), but many patients are intolerant of AC. Surgical exclusion of the LAA may result in incomplete closure and is associated with an increased risk of embolism. We report a case of a woman in her 50s with a history of persistent AF, mitral valve prolapse s/p repair with surgical LAA exclusion, and multifocal haemorrhagic stroke presented for elective LAA closure who underwent a Watchman placement successfully. This case demonstrates that a percutaneous approach for occlusion of the LAA when surgical exclusion was incomplete may be feasible with appropriate planning. Clinical outcome data for this patient group are needed.

Infective endocarditis of a left atrial appendage closure device: a case report and literature review

Background

Due to advances in interventional cardiology in recent years, more and more patients are currently receiving cardiac devices, with a subsequent increase in the number of patients with device-associated endocarditis. Device-associated endocarditis is a life-threatening disease with special diagnostic and therapeutic challenges. Interventional devices for left atrial appendage (LAA) closure have been available for several years. However, there have been very few case reports of LAA closure device–associated endocarditis.

Case summary

An 83-year-old woman presented with fever and fatigue. She had a history of permanent atrial fibrillation and recurrent bleeding on oral anticoagulation. Consequently, the patient underwent interventional LAA closure ∼20 months earlier. Blood cultures grew Staphylococcus aureus. Transoesophageal echocardiography revealed an LAA closure device–associated mobile, echo-dense mass that was consistent with infectious vegetation in this clinical context. Intravenous antibiotic therapy was started, and our heart team recommended complete removal of the device, which the patient refused. The patient subsequently died as a result of progressive endocarditis and multiple pre-existing co-morbidities.

Discussion

Left atrial appendage occlusion device–associated endocarditis has rarely been reported. Due to the increase in LAA closure device implantation, device-associated endocarditis is expected to increase in the future. Transoesophageal echocardiography is required for correct diagnosis. Our case report suggests that an infection can occur long after implantation.