Impact of atrial flow regulator implantation on survival in patients with heart failure with reduced and preserved ejection fraction: a post-hoc analysis of the PRELIEVE study

Purpose

This analysis aims to assess the theoretical impact of atrial flow regulator implantation on mortality by comparing the observed survival rate with the median predicted probability for one-year survival.

Methods

The prospective, multicentre, open-label, non-randomised PRELIEVE study assessed the safety and efficacy of the atrial flow regulator in patients with symptomatic HFrEF (left ventricular ejection fraction (LVEF) ≥15% and <40%) or HFpEF (LVEF ≥40% and <70%) and elevated PCWP (≥15mmHg at rest or ≥25mmHg during exercise). In this analysis, after the first 60 patients completed twelve months of follow-up, the theoretical impact of atrial flow regulator implantation on survival was assessed by comparing the observed mortality rate with the median predicted probability for one-year mortality. Each subject's risk of mortality was predicted from individual baseline data using the Meta-Analysis Global Group in Chronic HF (MAGGIC) prognostic model.

Results

A total of 87 patients had undergone successful device implantation for the treatment of HFrEF (53%) and HFpEF (47%). Sixty patients had a complete twelve-month follow-up. The median follow-up was 351 days (interquartile range [IQR] 202–370). A total of six (7%) patients died during follow-up (8.6 deaths per 100 patient-years; 95% confidence interval [CI] 2.7 to 15.5), all of which had HFrEF. The median predicted mortality rate for the overall study population was 12.2 deaths per 100 patient-years (95% CI 10.2 to 14.7). While the observed mortality rate (0 deaths per 100 patient-years) was significantly lower than the median predicted mortality rate (9.3 deaths per 100 patient-years; 95% CI 8.4 to 11.1) in patients with HFpEF (−9.3 deaths per 100 patient-years; 95% CI −11.1 to −8.4), there was no difference in patients with HFrEF (−3.6 deaths per 100 patient-years; 95% CI −9.5 to 3.0) (Figure 1). Four deaths were HF-related deaths (5.7 HF-related deaths per 100 patient-years; 95% CI 1.4 to 11.9; 10.8 HF-related deaths per 100 patient-years; 95% CI 2.5 to 23.1 in the HFrEF subgroup).

Conclusion

In patients with HFpEF, the mortality rate following atrial flow regulator implantation was lower than the predicted mortality rate. These findings need to be confirmed by larger randomised, controlled trials.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Occlutech International AB

The learning curve for interventional cardiologists performing acute stroke interventions

Background

Endovascular treatment for acute stroke because of large vessel occlusion became the standard of care in certain clinical settings. Due to lack of trainees and specialized centers, interventional cardiologists joined multidisciplinary stroke teams, and contribute their extensive knowledge on acute cardiovascular interventions and catheter skills to optimize patient management and outcomes.

Purpose

To investigate if a learning curve exists for interventional cardiologists performing acute stroke interventions.

Methods

Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020 at our center were reviewed. The interventional approach, lesion preparation and material selection were at the discretion of the performing cardiologist. Baseline characteristics, procedural information and in-hospital outcomes were retrospectively collected. Cases were chronologically sorted, divided into quartiles and outcomes were compared.

Results

One-hundred-thirteen patients underwent endovascular procedures for acute stroke treatment. Patients were 72.9 SD 13.3 years old, and 51.5% were female. NIHSS at baseline was 15 [12–18]. In 92% the blood flow of the anterior circulation was affected. The door to needle (DTN) time decreased over time (Q1 1:19h [range0:54–1:58] vs. Q2 0:49h [range 0:34–1:32] vs. Q3 1:13h [range 0:56–1:31] vs. Q4 0:54 [range 0:37–1:08], p=0.003), as well as the procedure duration (time of vascular access to (full) reperfusion Q1 1:24h [range 0:44–2:23] vs. Q2 0:52h [range 0:32–1:16] vs. Q3 0:49h [range 0:27–1:15] vs. 0:44h [range 0:28–1:17], p=0.014) and the use of contrast medium (Q1 103.3mL [range 75.1–147.7] vs. Q2 123.5mL [range 60.5–149.9] vs. Q3 99.8mL [range 73–132] vs. Q4 74.8 mL [range 52.4–94.6], p=0.014). A stent retriever only strategy was preferred in the early stages (Q1 42.8% vs. Q2 53.5% vs. Q3 32.1% vs. Q4 17.2%. p=0.010), whereas a stent retriever plus aspiration strategy (Q1 17.8% vs. Q2 14.2% vs. Q3 28.5% vs. Q4 50%, p=0.122) became more popular later on. The combined quality endpoint comprising of TICI IIb/III flow after the procedure, no embolization to new territories and no symptomatic intracranial bleeding was reached 84%, with no difference between groups. Vascular access site complications were low (overall 3.5%) and NIHSS prior to discharge was comparable (Q1 3 [range 1.75–7.25] vs. Q2 4.5 [range 1.75–8.25] vs. Q3 5 [range 2–8] vs. Q4 4 [range 2–7], p=0.725). In-hospital death occurred in 21 (18.5%) patients.

Conclusions

A learning curve for interventional cardiologist performing acute stroke interventions could be observed in terms of optimized management strategies such as a reduced door to needle time and procedural aspects, like decreased procedure duration and contrast medium use over time. However, the quality of care was unaffected and continuously high.

Funding Acknowledgement

Type of funding sources: None.

Regular hours vs. on-call endovascular interventions for acute stroke treatment: initial single-center experience by interventional cardiologists

Background

Endovascular treatment for acute stroke with large vessel occlusion became the mainstay therapy but remains limited due to lack of trainees and specialized centers. To offer this therapeutical option to a vast population, interventional cardiologists joined interdisciplinary stroke teams. Because of limited experience, it remains unclear if the timing of the procedure (i.e., regular hours vs. on-call time) may influence quality, time-effectiveness and outcomes.

Purpose

To investigate if the timing of the procedure (i.e., regular hours vs. on-call time) significantly influences procedural parameters and outcomes of patients undergoing acute endovascular stroke treatment.

Methods

Consecutive patients undergoing acute endovascular stroke treatment from 07/2012 – 10/2020, treated by cardiologists, were reviewed. Baseline characteristics, procedural aspects and clinical outcomes were retrospectively collected. Cases were divided into two groups, depending on the timing of the procedure: on-call time (OC, i.e., weekend days, public holidays and documented “call in” of the on-call service) vs. regular hours (RH, i.e., all other procedures) and outcomes subsequently compared.

Results

One-hundred-thirteen consecutive patients underwent endovascular treatment for acute stroke; of those 77 (68.1%) during regular hours and 36 (31.9%) during on-call time. Patients were in their early 70ies and risk factors such as arterial hypertension, diabetes mellitus, dyslipidemia and atrial fibrillation were evenly distributed. Modified Ranking Scale (mRS) at presentation was 5 in both groups and decreased to 3 at discharge. The anterior circulation was most often affected (RH: 90.9% vs. OC: 94.4%, p=0.518) and a stent retriever only strategy commonly chosen (RH: 42.8% vs. OC: 30.5%, p=0.211), followed by a combined approach of stent retriever use and aspiration (RH: 25.9% vs. OC: 27.7%, p=0.752). Door-to-needle time (RH: 0:55h IQR [0:45–1:22] vs. OC: 1:05h IQR [0:54–1:30], p=0.237) and procedure duration (RH: 0:48h IQR [0:30–1:25] vs. OC: 0:58h IQR [0:35–1:46], p=0.214) were comparable. Contrast agent use and radiation time (RH: 17.6 min IQR [11.7–29.3] vs. OC: 17.6 min IQR [12.1–33.6]) did not differ between groups, however patients in the OC group experienced a higher dose area product (RH: 4827mGy cm2 IQR [1567–14092] vs. 12727mGy cm2 [6732–18889], p<0.001). The combined quality endpoint, comprising of TICI IIb/III flow after the procedure, no embolization to new territory and no symptomatic intracranial bleeding during in hospital stay was met in 85.5% of patients in the RH group and 80.5% of the on-call group (p=0.485). Death during in-hospital stay was observed in 22% of patients in the RH group and 11.1% of the OC group (p=0.163).

Conclusions

Endovascular intervention for acute stroke treatment during on-call time is as effective and safe as if performed during regular hours but associated with a higher dose area product.

Funding Acknowledgement

Type of funding sources: None.

Impact of atrial fibrillation pattern on left atrial appendage closure: insights from the prospective LAARGE registry

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Stiftung für Herzinfarkforschung

Background

 Non-paroxysmal (NPAF) forms of atrial fibrillation (AF) have been reported to be associated with an increased risk for systemic embolism or death compared with paroxysmal AF (PAF). This study investigates the procedural safety and long-term outcomes of left atrial appendage closure (LAAC) in patients with different forms of AF.

Methods

 Comparison of procedural details and long-term outcomes in patients (pts) with PAF against controls with NPAF in the prospective, multicentre observational registry of patients undergoing LAAC in Germany (LAARGE). 

Results

 A total of 638 pts (PAF 274 pts, NPAF 364 pts) were enrolled. NPAF consisted of 31.6% patients with persistent AF and 68.4% with longstanding persistent AF or permanent AF. In both groups, a history of PVI was rare (4.0% vs 1.6%, p = 0.066). The PAF group had significantly less history of heart failure (19.0% vs 33.0%, p < 0.001) while the current median LVEF was similar (60% vs 60%, p = 0.26). The total CHA2DS2-VASc score was lower in the PAF group (4.4 ± 1.5 vs 4.6 ± 1.5, p = 0.033), but no difference in the HAS-BLED score (3.8 ± 1.1 vs 3.9 ± 1.1, p = 0.40) was observed. The rate of successful implantation was equally high (97.4% vs 97.8%, p = 0.77) in both groups. In the three-month echo follow-up, device-related thrombi (2.1% vs 7.3%, p = 0.12) and peridevice leak >5 mm (0.0% vs 7.1%, p= 0.53) were numerically higher in the NPAF group. Overall, in-hospital complications occurred in 15.0% of the PAF cohort and 10.7% of the NPAF cohort (p = 0.12). In the one-year follow-up, unadjusted mortality (8.4% vs 14.0%, p = 0.039) and combined outcome of death, stroke and systemic embolism (8.8% vs 15.1%, p = 0.022) were significantly higher in the NPAF cohort. After adjusting for CHA2DS2-VASc and previous bleeding, NPAF was associated with increased death/stroke/systemic embolism (HR 1.67, 95%-CI: 1.02-2.72).

Conclusion

 Atrial fibrillation type did not impair periprocedural safety or in-hospital MACE of patients undergoing LAAC. However, after one year, NPAF was associated with higher mortality and combined outcome of death, stroke and systemic embolism.

Results of the multicenter, prospective, randomised STRENGTH (Study To evaluate the use of RENalGuard to proTect patients at High risk of acute kidney injury) study

Aim

Radio-contrast agents are widely used in coronary, peripheral and structural interventions. Use of these iodine-containing agents can be associated with contrast-induced acute kidney injury (CI-AKI) that can cause substantial morbidity and mortality. The RenalGuard system induces a forced diuresis with a matched hydration and has been shown beneficial in patients requiring coronary angiogram and PCI.

Methods

STRENGTH is a prospective, randomised (1:1), open-labeled, parallel-group, multicenter (10 centers in Germany and France) study where patients at high risk of CI-AKI were randomly assigned to RenalGuard® therapy or conventional strategy including preventive hydration before complex percutaneous cardiovascular intervention (PCI, peripheral and structural). In the RenalGuard arm, matched fluid replacement was started 60 minutes pre-procedure and maintained for up to 4 hours afterwards. Patients were given an initial i.v. bolus of up to 250 ml of normal saline over 30 minutes and then an i.v. bolus of furosemide (0.5 mg/kg). To be enrolled, patients had to have moderate to severe renal failure (defined as 15≤eGFR≤40 mL/min/m2) and a high-volume contrast requiring cardiovascular procedure (estimated contrast volume>3 times eGFR value). The main exclusion criterion was administration of iodine contrast media within 5 days before index procedure. The primary endpoint was CI-AKI defined as an increase in sCr ≥0.3 mg/dL or an increase of 25% of basal value or requiring dialysis within 5 days after procedure. The primary analysis for efficacy is performed in a modified intention-to-treat basis. The trial was designed and monitored by an independent CRO (Cardiovascular European Research Center, CERC, Massy, France).

Results

A total of 259 patients aged 79.1±8.8 yrs were included in the study. Among them, 129 were assigned to RenalGuard therapy and 130 to preventive saline hydration. Their mean baseline eGFR was 32 (25; 37) vs. 33 (25; 39) mL/min/m2, respectively (p=0.88). Total fluid intake volume within 24hrs before the procedure was 2383±1146 vs. 1386±842mL, respectively (p<0.0001). Procedure type was complex PCI (48%), TAVI (25%), peripheral intervention (18%), other structural intervention (9%) with no difference between groups (p=0.56). The total amount of contrast used for the procedure was 116.3±68.2mL in the RenalGuard arm vs. 104.1±56.7 mL in the conventional arm (p=0.26). A staged procedure was performed in 24 patients, including 16 in the RenalGuard and 8 in the control arm with a mean interval from the first intervention of 43±29 days and 24±19 days, respectively. For this second procedure, the total amount of contrast was 80±59 vs. 87±73mL.

Conclusion

The primary and secondary endpoints of the Study To evaluate the use of RENalGuard to proTect patients at High risk of CI-AKI comparing RenalGuard therapy to conventional hydration in 259 patients requiring complex percutaneous cardiovascular intervention will be presented.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): CERC

Use and success evaluation of percutaneous aortic balloon valvuloplasty in different hemodynamic entities of severe aortic stenosis in the TAVR era

Background

In the era of transcatheter aortic valve replacement (TAVR), there is renewed interest in percutaneous balloon aortic valvuloplasty (BAV), which may qualify as the primary treatment option of choice in special clinical situations. Success of BAV is commonly defined as a significant mean pressure gradient reduction after the procedure.

Purpose

To evaluate the correlation of the mean pressure gradient reduction and increase in the aortic valve area (AVA) in different flow and gradient patterns of severe aortic stenosis (AS).

Methods

Consecutive patients from 01/2010 to 03/2018 undergoing BAV were divided into normal-flow high-gradient (NFHG), low-flow low-gradient (LFLG) and paradoxical low-flow low-gradient (pLFLG) AS. Baseline characteristics, hemodynamic and clinical information were collected and compared. Additionally, the clinical pathway of patients (BAV as a stand-alone procedure or BAV as a bridge to aortic valve replacement) was followed-up.

Results

One-hundred-fifty-six patients were grouped into NFHG (n=68, 43.5%), LFLG (n=68, 43.5%) and pLFLG (n=20, 12.8%) AS. Underlying reasons for BAV and not TAVR/SAVR as the primary treatment option are displayed in Figure 1. Spearman correlation revealed that the mean pressure gradient reduction had a moderate correlation with the increase in the AVA in patients with NFHG AS (r: 0.529, p<0.001) but showed no association in patients with LFLG (r: 0.145, p=0.239) and pLFLG (r: 0.030, p=0.889) AS. Underlying reasons for patients to undergo BAV and not TAVR/SAVR varied between groups, however cardiogenic shock or refractory heart failure (overall 46.8%) were the most common ones. After the procedure, independent of the hemodynamic AS entity, patients showed a functional improvement, represented by substantially lower NYHA class levels (p<0.001), lower NT-pro BNP levels (p=0.003) and a numerical but non-significant improvement in other echocardiographic parameters like the left ventricular ejection fraction (p=0.163) and tricuspid annular plane systolic excursion (TAPSE, p=0.066). An unplanned cardiac re-admission due to heart failure was necessary in 23.7% patients. Less than half of the patients (44.2%) received BAV as a bridge to TAVR/SAVR (median time to bridge 64 days). Survival was significantly increased in patients having BAV as a staged procedure (log-rank p<0.001).

Conclusion

In daily clinical practice, the mean pressure gradient reduction might be an adequate surrogate of BAV success in patients with NFHG AS but is not suitable for patients with other hemodynamic entities of AS. In those patients, TTE should be directly performed in the catheter laboratory to correctly assess the increase of the AVA. BAV as a staged procedure in selected clinical scenarios increases survival and is a considerable option in all flow states of severe AS. (NCT04053192)

Figure 1

Funding Acknowledgement

Type of funding source: None

WATCHMAN versus ACP or amulet for left atrial appendage closure. Results from the LAARGE registry

Background

Several left atrial appendage (LAA) closure systems are available and due to differences in device design safety and efficacy of specific occluders derived from trials cannot be simply generalized to all devices.

Purpose

The present analysis sought to assess two contemporary LAA closure devices in clinical practice.

Methods

The present work represents a non-randomized sub-analysis of the prospective, multicenter, Left-Atrium-Appendage Occluder Register - GErmany (LAARGE) registry. The WATCHMAN (group 1) and the Amplatzer Cardiac Plug (ACP) or Amulet occluder (group 2) were assessed regarding technical success and procedural safety.

Results

A total of 641 patients at 38 centers were enrolled. Of them, 278 (43%) and 340 (53%) patients received the WATCHMAN and ACP/Amulet occluder, respectively. High technical success was achieved with a slight difference between the groups (96% in group 1 vs. 99% in group 2; p=0.007). Procedural safety did not differ (98% in group 1 vs. 97% in group 2; p=0.55). Chicken wing morphology of the LAA seemed to trigger the use of the ACP/Amulet (chicken wing in 36% of the cases in group 1 vs. 55% in group 2; p<0.001). The Kaplan Meier estimated 1-year composite of death or stroke was 12.0% and 12.9%, respectively (Figure 1A). The respective rates for the composite endpoint of death, stroke or systemic embolism were 12.0% and 13.2% (Figure 1B).

Conclusions

Both the WATCHMAN and the ACP/Amulet occluder provide excellent procedural results with comparable implantation success and no differences regarding procedural safety and long-term effectiveness.

Figure 1. Composite endpoints at 1-year

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Stiftung Institut für Herzinfarktforschung (IHF)

Initial and long-term antithrombotic therapy after left atrial appendage closure with the WATCHMAN

Background

Evidence regarding post-procedural antithrombotic regimes other than used in randomized trials assessing percutaneous left atrial appendage (LAA) closure is limited.

Purpose

The present work aimed to compare different antithrombotic strategies applied in the real-world EWOLUTION study.

Methods

A total of 998 patients with successful WATCHMAN implantation at 47 centers were available for the present analysis. The composite ischemic endpoint of stroke, TIA, systemic embolism and device thrombus as well as the bleeding endpoint defined as at least major bleeding according to BARC were assessed during an initial period (from implant until first medication change) and long-term period (from first change until up to 2 years).

Results

The antithrombotic medication chosen in the initial phase was dual antiplatelet therapy (DAPT) in 60%, oral anticoagulation (OAC) in 27%, single antiplatelet therapy (SAPT) in 7% and no medication in 6%. In the long-term phase SAPT was used in 65%, DAPT in 23%, no therapy in 8% and OAC in 4%. No significant differences were found between the groups regarding the ischemic endpoint both in the initial period (Kaplan-Meier estimated rate 2.9% for DAPT vs. 4.3% for OAC vs. 3.9% for SAPT or no therapy; p=0.97) and in the second period (4.2% for SAPT vs. 1.8% for DAPT vs. 3.5% for no therapy; p=0.36). With respect to bleeding events the only difference was found in the initial phase with a higher incidence in patients under SAPT or no therapy (1.0% for DAPT vs. 0.8% for OAC vs. 7.4% for SAPT or no therapy; p=0.01). No differences in bleeding complications were observed during the second period (2.6% for SAPT vs. 2.9% for DAPT vs. 2.2% for no therapy; p=0.88).

Conclusions

Tailored antithrombotic treatment using even very reduced strategies such as SAPT or no therapy showed no significant differences regarding ischemic complications after LAA closure.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Boston Scientific

P4714Individual patient data meta-analysis comparing general anesthesia and deep sedation on safety and length of intensive care unit stay in patients undergoing percutaneous mitral valve repair

Background

Percutaneous edge-to-edge mitral valve repair (PMVR) has emerged as a treatment option for patients with severe mitral regurgitation not considered suitable candidates for surgery. The procedure can be performed in general anesthesia (GA) or deep sedation (DS) without mechanical ventilation. However, debate remains about the optimal approach.

Purpose

To compare the impact of the anesthetic method on efficacy, safety, and length of intensive care stay.

Methods

We identified studies comparing GA versus DS in patients undergoing PMVR by searching PubMed and CENTRAL. We included studies for which investigators agreed to provide individual patient data. Analyzed outcomes were a composite safety endpoint comprising all-cause death, stroke, pneumonia, and major to life-threating bleeding as well as length of intensive care unit stay. We performed an one-stage and two-stage meta-analysis on each outcome after multiple imputation of missing data. For two-stage meta-analysis, between-study heterogeneity was estimated according to Paule-Mandel and confidence intervals were derived using the method proposed by Hartung and Knapp.

Results

We included five observational studies (n=647 patients). Procedural success was achieved in 618 of 647 (95.5%) patients. The composite safety endpoint occurred in 92 of 647 (14.2%) patients with no difference between patients treated with GA or DS. In this regard, risk ratio was 0.78 (95% confidence interval, 0.53 to 1.14; P=0.20) following the one-stage approach and 0.73 (95% confidence interval, 0.30 to 1.80; P=0.39) following the two-stage approach. Length of intensive care stay was longer after GA as compared to DS (adjusted mixed linear regression model, 1.94 days, 95% confidence interval, 1.29 to 2.59 days, P<0.001; random effects model pooling study-specific estimates from adjusted linear models 1.40 days, 95% confidence interval, 0.54 to 2.22 days, P=0.0104).

Conclusion

Both, DS and GA offer good procedural success rates and a similar safety profile. However, length of intensive care stay is shorter after DS.

P3727Left atrial appendage closure in patients with a reduced left ventricular ejection fraction: results from the prospective multicenter German LAARGE registry

Background and purpose

Atrial fibrillation (AF) patients with increased thromboembolic risk and contraindications for standard oral anticoagulation (OAC) can profit from an interventional left atrial appendage closure (LAAC). While impaired left ventricular ejection fraction (LVEF) is associated with an increased thromboembolic risk in AF patients, cardiac interventions are often associated with an increase in complications in this patient population, and, therefore, the LAAC procedure's success and benefit has yet to be investigated in this subgroup.

Methods

This prospective, observational LAAC registry included 622 patients with documented LVEF from 37 German centers between April 2014 and January 2016. Patients were categorized into one of three groups: LVEF >55% (preserved; p), LVEF 35–55% (mid-range; mr) and LVEF <35% (reduced; r). Procedure was conducted in a standard fashion, and baseline characteristics, imaging as well as procedural data, intra-hospital and one-year follow-up outcome were registered for each group.

Results

55.3% of patients had a pLVEF, 38.7% a mrLVEF and 5.9% a rLVEF. Patients with rLVEF were more often affected by coronary artery disease (p<0.001 for trend), and had an elevated CHA2DS2-VASc (4.3±1.5 vs. 4.8±1.5 vs. 5.3±1.6; p<0.001) and HAS-BLED score (3.7±1.1 vs. 4.1±1.2 vs. 4.3±0.9; p<0.001). Percentage of prior cerebrovascular events and major bleedings was comparable at baseline (each p=n.s.). Procedural success was high (97.9%), while rates of intra-hospital MACCE (0.5%) and other major complications (4.2%) were low, with no significant difference between the groups (each p=n.s.). MACCE during follow-up was more frequent in rLVEF patients (11.0 vs. 11.3 vs. 27.8%; p=0.013), which was mainly driven by myocardial infarctions and all-cause deaths in this high risk collective. Likewise, Kaplan-Meier estimation showed a lower overall survival in this group (89.7 vs. 89.3 vs. 74.6%; p<0.01). On the contrary, rates of stroke were extremely low across all groups and statistically similar (0.3 vs. 1.0 vs. 0%; p=n.s.). This was 93.4, 82.7 and 100.0% less in comparison to the estimated risk calculated from the CHA2DS2-VASc score

Conclusions

The LVEF had no influence on the procedural success as well as the intra-hospital complications after LAAC. Annual rate of stroke was low across all groups, and risk reduction was substantial especially in this high risk collective, as compared to the estimated risk.

Acknowledgement/Funding

Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany

P3724Impact of chronic kidney disease on efficacy and safety of interventional left atrial appendage closure – results from the prospective multicenter LAARGE registry

Background

The interventional left atrial appendage closure (LAAC) is an effective and safe alternative to standard oral anticoagulation (OAC) for stroke prevention in atrial fibrillation (AF) patients with contraindications for long-term OAC. Chronic kidney disease (CKD) has a high prevalence among AF patients, and was shown to increase the number of peri-procedural complications in cardiac interventions.

Purpose

This subanalysis of the LAARGE registry aimed to investigate CKD's impact on outcomes after LAAC.

Methods

This prospective, real-world LAAC registry included 625 patients with documented renal function from 37 German centers between April 2014 and January 2016. CKD was defined by an eGFR <60 mL/min/1.73 m2. Procedure was conducted with different LAAC devices considering the relevant recommendations. Baseline characteristics, procedural data, intra-hospital and one-year follow-up outcome were registered for CKD and non-CKD patients stratified by the different CKD stages.

Results

CKD patients (n=300; 48.0%) had a more pronounced cardiovascular risk profile, a higher stroke (CHA2DS2-VASc score 4.9±1.5 vs. 4.2±1.5; p<0.001) and bleeding risk (HAS-BLED score 4.3±1.0 vs. 3.5±1.0; p<0.001), and had experienced more prior bleedings (83.7 vs. 76.3%; p=0.022). Implantation success was similarly high between both groups (97.9%; p=n.s.). In CKD patients, MACCE during one-year follow-up was more frequent (18.1 vs. 6.8%; p<0.001) mainly being triggered by all-cause deaths, but in-hospital MACCE was not (0.3 vs. 0.3%; p=n.s.). Kaplan-Meier estimation showed a lower one-year survival among CKD patients (82.4 vs. 94.4%; p<0.001) without significant accentuation in patients with advanced CKD (i.e., <30 mL/min/1.73 m2; p=n.s. to other CKD patients). While annual rate of device associated complications (2.6 vs. 2.8%; p=n.s.) and strokes (0 vs. 1.0%; p=n.s.) was comparable during follow-up, annual severe bleeding rate was higher in CKD patients (2.6 vs. 0.3%; p=0.027) which was 71.4 and 94.4% less than expected from the HAS-BLED score (p<0.01 for the comparison to the estimated risks, but no significant interaction between groups).

Conclusions

Despite an increased cardiovascular risk profile of CKD patients, device implantation was safe, and annual stroke rate was statistically indifferent to non-CKD patients across all CKD stages after LAAC. Moreover, a substantial reduction of annual stroke and major bleeding risk was observed, as compared to the estimated annual risk.

Acknowledgement/Funding

Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Germany

P4505VECTOR-HF: The first human experience with the V-LAP, a wireless left atrial pressure monitoring system for patients with heart failure

Background/Introduction

Invasive pressure-guided therapy has been shown to improve outcomes in patients with heart failure (HF). Thus far, only right-sided pressure sensors have shown clinical efficacy and safety. The Vectorious Medical Technologies V-LAP™ is a novel battery-less and wireless left-sided pressure monitoring system, directly assessing left-atrial pressure (LAP) in an ambulatory setting. In pre-clinical studies, it was shown to enable accurate and safe measurement of LAP. We hereby describe the first human experience with the device.

Methods

The V-LAP left atrial monitoring systEm for patients with Chronic sysTOlic and diastolic congestive heart failuRe first-in-human (VECTOR) study is a prospective, multicenter, single arm, open-label clinical trial to assess the safety, performance and usability of the V-LAP system in patients with heart failure. The V-LAP™ wireless sensor is implanted using a trans-septal access, under angiographic and echocardiographic guidance. The system includes an external unit, which both powers the implant and collects data via radio frequency communication upon activation, designed to be operated on a daily basis. We hereby describe the first cases, implanted in the CardioVascular Center, in Frankfurt, Germany.

Results

At this point in time, there have been two successful implantations of the V-LAP™, performed in two NYHA Class III patients. Both were admitted repeatedly for exacerbations of HF, and demonstrated elevated NT-ProBNP levels. They were therefore considered appropriate candidates for the monitoring system, to enable optimal medical therapy. The procedure was performed in a trans-femoral, trans-septal fashion, under mild sedation, with a successful implantation of a V-LAP™, and calibration for pressure measurement. There were no complications, data showed accurate LAP reading (Figure 1).

Conclusions

In the first-in-human cases, the implantation of the novel wireless left atrial pressure sensor V-LAP™ was feasible, safe, and showed good accuracy and precision. We now await both short and long-term efficacy and safety outcomes of the device, with the hopes of optimizing care according to ambulatory LAP data for patients with HF.

Acknowledgement/Funding

Vectorious Medical Technologies

P4730Underweight is associated with unfavourable short- and long-term outcomes after MitraClip therapy: a body mass index derived subgroup analysis of the German Transcatheter Mitral Valve Interventions (

Background

Underweight and obesity represent classical risk factors for patients undergoing cardiac surgery or interventional treatment. The multicentre German Transcatheter Mitral Valve Interventions (TRAMI) registry comprises a large and prospectively enrolled real-world cohort of patients treated by MitraClip implantation.

Aims

The current analysis examines the impact of underweight, overweight and obesity on intra-hospital, short and long-term outcomes in patients treated by MitraClip therapy.

Methods and results

From 08/2010 until 07/2013, 799 patients (age 75.3±8.6 years, male gender 60.7%, median logistic EuroSCORE 20% [12; 31], functional mitral regurgitation (MR): 69.3%) were prospectively enrolled into the multicentre, industry-independent German Transcatheter Mitral Valve Interventions registry. Patients were stratified according to body mass index (BMI) into four groups: BMI<20 kg/m2 (underweight, n=49), BMI 20.0 to <25.0 kg/m2 (normal weight, n=293), BMI 25.0 to <30.0 kg/m2 (overweight, n=296) and BMI≥30 kg/m2 (obese, n=132). Procedure and radiation time were comparable among all groups. Significant increased rates of procedural failure (12.2% vs. 2.1 [normal weight], p<0.001), transfusion/bleeding (20.8% vs. normal weight: 5.6%, obesity: 7.0%, p<0.01), sepsis or multiorgan failure and low cardiac output failure were found for underweight patients only. Kaplan-Meier survival curves demonstrated inferior survival for underweight patients, but comparable outcomes for all other patients (global log rank test, p<0.01). Multivariable Cox-regression analysis (adjusted for age, gender, creatinine≥1.5mg/dl, diabetes, left ventricular ejection fraction<30% and chronic obstructive pulmonary disease) confirmed underweight (as compared to normal weight) as an independent risk factor of death (hazard ratio [HR]: 1.58, 95%-confidence interval (CI): 1.01–2.46, p=0.044) and overweight as protective against death (HR: 0.71; 95%-CI: 0.55–0.93; p=0.011).

Conclusion

Underweight patients are exposed to increased rates of procedural failure, bleeding and low cardiac output as well as increased short- and long-term mortality rates when undergoing MitraClip implantation and should therefore be carefully discussed within the heart team.

Acknowledgement/Funding

The TRAMI registry has been supported by proprietary means of IHF. Additional funding is provided by “Deutsche Herzstiftung” and a grant from Abbott.

PFO closure: rational, procedure and devices

Patent foramen ovale (PFO) is a common anatomical variant occurring in 20-25% of the population. In most cases, a PFO remains asymptomatic. However it allows for any venous particle such as thrombus, air or vasoactive substances to bypass the lung and enter the arterial circulation. Accordingly, PFO's have been linked to cryptogenic stroke, migraine and decompression illness. While the number of device closures have been increasing the therapy remains controversial as ‑ until recently ‑ data supporting PFO closure came from non randomized studies only. In this review we will discuss the existing data on PFO closure including results of the three randomized controlled trials comparing device closure with medical therapy in patients with cryptogenic stroke. We will also focus on the implantation technique, the complications and the different devices that are used for this procedure.

A novel technique to remove a right atrial thrombotic mass attached to a patent foramen ovale (PFO) closure device

Any percutaneously implanted foreign device carries the potential risk of thrombus formation. If a thrombus is detected after device implantation during follow-up, in most cases anticoagulation therapy is sufficient to resolve the thrombus. If the anticoagulation concept fails, surgery has been the only alternative option to remove thrombotic masses. This case of a patient with a large thrombus formation attached to a PFO closure device who denied surgery demonstrates that mechanical percutaneous clot retrieval is feasible with the AngioVac aspiration system (Vortex Medical, Inc., Norwell, MA). © 2013 Wiley Periodicals, Inc.

Complications during carotid artery stenting

Carotid stenting has become a commonly used procedure for the treatment of carotid artery stenosis. Though equipment and techniques have improved tremendously over the recent 3 decades, complications do occur. It is important for carotid operators to be familiar with potential complications and adverse events. In this article complications and adverse events of carotid stenting including those that are related to the vascular access site, vessel spasm, dissection, perforation, thrombotic occlusion and hemodynamic instability and arrhythmias are reviewed. In addition, management strategies are discussed.

Comparison of stent free cell area and cerebral lesions after unprotected carotid artery stent placement

OBJECTIVE

This study evaluates the correlation between closed, semi-closed and open-cell stent design and the association between stent type and clinical outcome as well as magnetic resonance imaging (MRI) findings.

DESIGN

A total of 194 patients who underwent unprotected carotid artery stenting (CAS) as well as diffusion-weighted magnetic resonance imaging (DW-MRI) before and after intervention were retrospectively reviewed.

MATERIALS AND METHODS

Three stent designs were studied: closed cell, semi-closed cell and open cell. Spearman's Rho test was performed between the stent free cell area and the number and area of ischaemic lesions found after intervention. Adverse events were evaluated.

RESULTS

There was no significant difference in clinical outcome between the three stent groups (Zilver, Cook Europe, Denmark; Smart, Codman, MA; and Wallstent, Stryker, MN, USA). A significant correlation was found between the stent free cell area and the number and area of new ischaemic lesions on DW-MRI (P = 0.023). There were significantly fewer new lesions with an open-cell design (Zilver; 12.76 mm(2) free cell area) than with a closed-cell design (Wallstent; 1.08 mm(2) free cell area).

CONCLUSIONS

Open-cell stent was related to a lower number and area of silent cerebral ischaemic lesions after unprotected CAS. However, clinical outcome, measured by incidence of adverse events and clinical neurologic assessment, was not significantly different between patients with different stent designs.

Percutaneous approaches to mitral valve regurgitation

Mitral regurgitation is a common problem associated with significant morbidity and mortality. Mitral valve surgery has been the treatment of choice for symptomatic patients with severe mitral regurgitation or asymptomatic patients with high-risk clinical features. However, a significant number of patients remain untreated related mainly due to a projected high surgical risk. Therefore, alternative percutaneous treatments including indirect annuloplasty, which takes advantage of the coronary sinus, and direct annuloplasty have recently been explored. Most recently, promising results of the first randomized trial comparing conventional mitral valve surgery to percutaneous therapy with a clip creating a double orifice much like the surgical Alfieri approach have been presented. Finally, percutaneous mitral valve replacement in an animal model has been pursued. This review serves to familiarize the reader with some anatomical concepts and devices for percutaneous mitral repair.