1
|
Basu Ray I, Khanra D, Shah S, Char S, Jia X, Lam W, Mathuria N, Razavi M, Jain B, Lakkireddy D, Kar S, Natale A, Adeboye A, Jefferies JL, Bangalore S, Asirvatham S, Saeed M. Meta-Analysis Comparing Watchman TM and Amplatzer Devices for Stroke Prevention in Atrial Fibrillation. Front Cardiovasc Med 2020; 7:89. [PMID: 32656246 PMCID: PMC7322993 DOI: 10.3389/fcvm.2020.00089] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/27/2020] [Indexed: 01/28/2023] Open
Abstract
Background: For patients with atrial fibrillation who are at high risk for bleeding or who cannot tolerate oral anticoagulation, left atrial appendage (LAA) closure represents an alternative therapy for reducing risk for thromboembolic events. Objectives: To compare the efficacy and safety of the Amplatzer and WatchmanTM LAA closure devices. Methods: A meta-analysis was performed of studies comparing the safety and efficacy outcomes of the two devices. The Newcastle-Ottawa Scale was used to appraise study quality. Results: Six studies encompassing 614 patients were included in the meta-analysis. Overall event rates were low for both devices. No significant differences between the devices were found in safety outcomes (i.e., pericardial effusion, cardiac tamponade, device embolization, air embolism, and vascular complications) or in the rates of all-cause mortality, cardiac death, stroke/transient ischemic attack, or device-related thrombosis. The total bleeding rate was significantly lower in the WatchmanTM group (Log OR = -0.90; 95% CI = -1.76 to -0.04; p = 0.04), yet no significant differences was found when the bleeding rate was categorized into major and minor bleeding. Total peridevice leakage rate and insignificant peridevice leakage rate were significantly higher in the WatchmanTM group (Log OR = 1.32; 95% CI = 0.76 to 1.87; p < 0.01 and Log OR = 1.11; 95% CI = 0.50 to 1.72; p < 0.01, respectively). However, significant peridevice leakages were similar in both the devices. Conclusions: The LAA closure devices had low complication rates and low event rates. Efficacy and safety were similar between the systems, except for a higher percentage of insignificant peridevice leakages in the WatchmanTM group. A randomized controlled trial comparing both devices is underway, which may provide more insight on the safety and efficacy outcomes comparison of the devices.
Collapse
Affiliation(s)
- Indranill Basu Ray
- Memphis VA Hospital, Memphis, TN, United States.,University of Memphis, Memphis, TN, United States.,All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Dibbendhu Khanra
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | - Sumit Shah
- University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Sudhanva Char
- Biostatistics, Life University, Marietta, GA, United States
| | - Xiaoming Jia
- Baylor College of Medicine, Houston, TX, United States
| | - Wilson Lam
- Baylor College of Medicine, Houston, TX, United States
| | - Nilesh Mathuria
- Baylor College of Medicine, Houston, TX, United States.,Texas Heart Institute, Houston, TX, United States
| | - Mehdi Razavi
- Baylor College of Medicine, Houston, TX, United States.,Texas Heart Institute, Houston, TX, United States
| | - Bhavna Jain
- All India Institute of Medical Sciences (AIIMS), Rishikesh, India
| | | | - Saibal Kar
- Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, TX, United States
| | - Adedayo Adeboye
- University of Tennessee Health Science Center, Memphis, TN, United States
| | | | - Sripal Bangalore
- New York University School of Medicine, New York, NY, United States
| | | | - Mohammad Saeed
- Baylor College of Medicine, Houston, TX, United States.,Texas Heart Institute, Houston, TX, United States
| |
Collapse
|
2
|
Sharma SP, Murtaza G, Madoukh B, Atkins D, Nydegger C, Jeffery C, Bommana S, Wang E, Gopinathannair R, Saw J, Natale A, Lakkireddy D. Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices. J Atr Fibrillation 2020; 12:2256. [PMID: 32002118 DOI: 10.4022/jafib.2256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/14/2019] [Accepted: 07/26/2019] [Indexed: 11/10/2022]
Abstract
Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.
Collapse
Affiliation(s)
| | - Ghulam Murtaza
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Bader Madoukh
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Donita Atkins
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Cherie Nydegger
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Courtney Jeffery
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Sudha Bommana
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Edward Wang
- Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Rakesh Gopinathannair
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| | - Jacqueline Saw
- Vancouver General Hospital, 2775 Laurel St, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA
| |
Collapse
|
3
|
Bertrand PB, Habran M, Kenis K, Lecomte J, Moonen L, Stroobants D, Benit E. Dual antiplatelet therapy after percutaneous left atrial appendage occlusion: single center experience with the Amplatzer Cardiac Plug. Acta Cardiol 2019; 74:74-81. [PMID: 29607737 DOI: 10.1080/00015385.2018.1455946] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage occlusion (LAAO) is an alternative to anticoagulation in atrial fibrillation patients at high bleeding risk. Dual antiplatelet therapy (DAPT) is generally recommended in the months following the procedure to prevent thrombotic complications. The aim of this study was to evaluate the safety and efficacy of DAPT after LAAO in a single-centre population of high bleeding risk patients. METHODS All patients who received DAPT after LAAO using the Amplatzer Cardiac Plug at Jessa Hospital (Hasselt, BE) between February 2011 and October 2016 were included. Patient characteristics, procedural outcome and clinical events (bleeding, stroke and adverse events) were prospectively followed. Changes in antithrombotic and/or anticoagulant regimens were assessed. RESULTS Thirty-nine patients (77 ± 7 years, 51% male, CHA2DS2-VASc 5(3-6), Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly (HAS-BLED) 3(3-4)) were included. An initial strategy of one month DAPT (n = 2) was changed to six months DAPT (n = 37) after one thrombotic complication (device thrombosis) at 4.5 months. Post-procedural DAPT duration was 6.1 ± 3.7 months, after which aspirin monotherapy (62%), no antiplatelet/anticoagulant therapy (15%) or a tailored antithrombotic regimen was maintained. At mean follow-up of 21 ± 13 months, seven patients had died (18%), no strokes had occurred (0%) and nine bleedings of which four were major (10%). All major bleedings occurred within the first six months after the procedure during DAPT. CONCLUSION Antithrombotic therapy after percutaneous LAAO is needed to prevent thrombotic complications, yet these impose bleeding complications in this high-risk population. Further efforts are needed to define the optimal duration of DAPT, aimed at reducing bleeding complications while maintaining a low thrombosis rate.
Collapse
Affiliation(s)
- Philippe B. Bertrand
- Heart Center Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Melanie Habran
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Karlijn Kenis
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Julie Lecomte
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Linde Moonen
- Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | | | - Edouard Benit
- Heart Center Hasselt, Jessa Ziekenhuis, Hasselt, Belgium
| |
Collapse
|
4
|
|
5
|
Budts W, Laenens D, Van Calenbergh F, Vermeersch P, De Potter T, Aminian A, Benit E, Stammen F, Kefer J. Left atrial appendage occlusion with the Amplatzer Cardiac Plug could improve survival and prevent thrombo-embolic and major bleeding events in atrial fibrillation patients with increased bleeding risk. Acta Cardiol 2016; 71:135-43. [PMID: 27090034 DOI: 10.2143/ac.71.2.3141842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIMS Literature suggests a beneficial effect of percutaneous left atrial appendage occlusion (LAAO) to prevent thrombo-embolic events in patients with non-rheumatic atrial fibrillation (AF). We compared outcome of LAAO versus ‘suboptimal standard’ treatment in AF patients with high bleeding risk. METHODS AND RESULTS Patients with sufficient follow-up data (n = 125) who underwent LAAO with the Amplatzer Cardiac Plug (ACP) were selected from the Belgian ACP database. AF patients who survived intracranial haemorrhage were recruited from the Leuven Neurosurgical Registry (LNR, n = 113). After propensity score adjustment, the outcome of both groups was compared for the combined end point (death, stroke, transient ischaemic attack, systemic emboli, and major bleeding event). The LAAO group did not differ from the LNR group for mean age and gender (74 ± 7 versus 75 ± 10 years, P = 0.29; female 39% versus 48%, P = 0.18). However, the CHA2DS2-VASc and HAS-BLED scores were both higher in the LAAO group (4.8 ± 1.7 versus 3.9 ± 1.7, P = 0.0001; 3.5 ± 1.4 versus 3.2 ± 1.4, P = 0.036). After propensity score adjustment, the risk for the primary end point was significantly higher for the LNR group (HR 2.012, 95% CI 1.113-3.638). CONCLUSION LAAO with ACP seems to improve the combination of survival and the prevention of thrombo-embolic and major bleeding events in patients with atrial fibrillation and increased bleeding risk.
Collapse
|
6
|
Shetty RK, Chandra GSN, Agarwal S, Nayak K, Rao MS. Percutaneous left atrial appendage closure in AF using Amplatzer Cardiac Plug: First single center experience from India. Indian Heart J 2015; 67 Suppl 2:S35-9. [PMID: 26688150 DOI: 10.1016/j.ihj.2015.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 05/08/2015] [Accepted: 07/07/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is one of the most common arrhythmias accounting for significant mortality and morbidity, especially in elderly. Though oral anticoagulation (OAC) is an effective mode of prevention of stroke in patients of AF, bleeding complication remains a major concern. Because of these issues, a significant proportion of patients either does not receive or receive suboptimal doses of OAC. METHODS In such patients, percutaneous left atrial appendage (LAA) closure remains an interesting option. Experience and literature of this procedure from India have been sparse. We report the first single center experience, from India, of percutaneous LAA closure with Amplatzer Cardiac Plug in 10 patients of non-valvular AF. These patients had contraindications for OAC or had high risk of bleeding or labile international normalized ratio (INR) on therapy. RESULTS We successfully deployed the devices in all of the cases with no major complications perioperatively and on short-term follow-up. We also report a comprehensive review on the technique of percutaneous LAA closure using Amplatzer Cardiac Plug, including some novel modification with our experience of doing percutaneous mitral balloon valvuloplasty.
Collapse
Affiliation(s)
- Ranjan K Shetty
- Professor of Cardiology, KMC Manipal, Manipal University, India
| | - G S Naveen Chandra
- Assistant Professor of Cardiology, KMC Manipal, Manipal University, India
| | - Sumit Agarwal
- Senior Resident, KMC Manipal, Manipal University, India
| | | | | |
Collapse
|
7
|
Saw J, Lempereur M. Percutaneous left atrial appendage closure: procedural techniques and outcomes. JACC Cardiovasc Interv. 2014;7:1205-1220. [PMID: 25459035 DOI: 10.1016/j.jcin.2014.05.026] [Citation(s) in RCA: 122] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/01/2014] [Accepted: 05/08/2014] [Indexed: 12/25/2022]
Abstract
Percutaneous left atrial appendage closure technology for stroke prevention in patients with atrial fibrillation has significantly advanced in the past 2 decades. Several devices are under clinical investigation, and a few have already received Conformité Européene (CE)-mark approval and are available in many countries. The WATCHMAN device (Boston Scientific, Natick, Massachusetts) has the most supportive data and is under evaluation by the U.S. Food and Drug Administration for warfarin-eligible patients. The Amplatzer Cardiac Plug (St. Jude Medical, Plymouth, Minnesota) has a large real-world experience over the past 5 years, and a randomized trial comparing Amplatzer Cardiac Plug with the WATCHMAN device is anticipated in the near future. The Lariat procedure (SentreHEART Inc., Redwood City, California) has also gained interest lately, but early studies were concerning for high rates of serious pericardial effusion and major bleeding. The current real-world experience predominantly involves patients who are not long-term anticoagulation candidates or who are perceived to have high bleeding risks. This pattern of practice is expected to change when the U.S. Food and Drug Administration approves the WATCHMAN device for warfarin-eligible patients. This paper reviews in depth the procedural techniques, safety, and outcomes of the current leading devices.
Collapse
|
8
|
Le DL, Khodjaev SD, Morelli RL. Percutaneous methods of left atrial appendage exclusion: an alternative to the internist. J Community Hosp Intern Med Perspect 2014; 4:22719. [PMID: 24596651 PMCID: PMC3937565 DOI: 10.3402/jchimp.v4.22719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/09/2013] [Accepted: 11/27/2013] [Indexed: 11/22/2022] Open
Abstract
Thromboembolic stroke from the left atrial appendage (LAA) is the most feared complication in patients with atrial fibrillation (AF). The cornerstone for the management of chronic non-valvular AF is stroke reduction with oral anticoagulation (OAC). However, poor compliance, maintaining a narrow therapeutic window, and major side effects such as bleeding have severely limited their use, which creates a therapeutic dilemma. As much as 20% of AF patients are not receiving OAC due to contraindications and less than half of AF patients are not on OAC due to reluctance of the prescribing physician and/or patient non-compliance. Fortunately, over the past decade, there have been great interests in providing an alternative strategy unbeknownst to the practicing internist. The introduction of percutaneous approaches for LAA occlusion has added a different dimension to the management of chronic AF in patients with OAC intolerance. Occlusion devices such as the Amplatzer Cardiac Plug and WATCHMAN device are currently being investigated for stroke prophylaxis. More recently, the LARIAT device may provide an alternative means for potential stroke prophylaxis without the need for short-term post-procedural OAC. We aim to review the current literature and bring attention to an alternative strategy for high-risk AF patients intolerant to OAC.
Collapse
Affiliation(s)
- Duong L Le
- Department of Internal Medicine, St Mary's Medical Center, San Francisco, CA, USA
| | - Soidjon D Khodjaev
- Department of Internal Medicine, St Mary's Medical Center, San Francisco, CA, USA
| | - Remo L Morelli
- Department of Internal Medicine, St Mary's Medical Center, San Francisco, CA, USA
| |
Collapse
|
9
|
Chun KRJ, Bordignon S, Urban V, Perrotta L, Dugo D, Fürnkranz A, Nowak B, Schmidt B. Left atrial appendage closure followed by 6 weeks of antithrombotic therapy: a prospective single-center experience. Heart Rhythm 2013; 10:1792-9. [PMID: 23973952 DOI: 10.1016/j.hrthm.2013.08.025] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Currently, 2 different left atrial appendage (LAA) closure systems are available for stroke prevention in nonvalvular atrial fibrillation but comparative data are lacking. OBJECTIVES To prospectively compare procedural data and patient outcome for 2 contemporary LAA closure systems and to investigate an alternative antithrombotic treatment regimen in high-risk patients. METHODS Patients with nonvalvular atrial fibrillation, with high risk for stroke, and who either had contraindication or were not willing to accept oral anticoagulation were prospectively enrolled. Watchman (Boston Scientific, Natick, MA; group A) or Amplatzer Cardiac Plug (St Jude Medical, Minneapolis, MN; group B) devices were implanted. All patients received antithrombotic therapy for 6 weeks. After repeat transesophageal echocardiography, patients were switched to aspirin. RESULTS Eighty patients were enrolled. There was no statistical difference in patient characteristics in groups A and B: CHA2DS2VASC score: 4.1 ± 1.5 versus 4.5 ± 1.8; HASBLED score: 3.1 ± 1.1 versus 3.1 ± 1.1, respectively. LAA closure was achieved in 78 of 80 patients (98%) (group A: 38 of 40 [95%] vs group B: 40 of 40 [100%]). There was no difference in procedure time (group A: 48 ± 16 minutes vs group B: 47 ± 15 minutes; P = .69) and fluoroscopy time (group A: 6.0 ± 4.7 minutes vs group B: 7.3 ± 4.4 minutes; P = .25). Major complications included 1 air embolism and delayed tamponade in each group. After 6 weeks, 1 device dislodgment and 4 device-related thrombi were detected. Ninety-four percent of the patients (73 of 77) were switched to aspirin after 6 weeks. During a median follow-up of 364 days (Q1-Q3: 283-539 days), no systemic embolism occurred, but 3 patients died (heart failure: n = 2; bleeding: n = 1). CONCLUSIONS Implantation of both LAA closure devices can be performed with high success rates in high-risk patients. Postprocedural 6 weeks antithrombotic therapy followed by aspirin therapy needs to be confirmed in a larger study.
Collapse
Affiliation(s)
- K R Julian Chun
- Medizinische Klinik III, Cardioangiologisches Centrum Bethanien, Markus Krankenhaus, Frankfurt am Main, Germany.
| | | | | | | | | | | | | | | |
Collapse
|