Reduction in risk of stroke and bleeding after left atrial appendage closure with LARIAT device in patients with increased risk of stroke and bleeding: Long term results

Anatomical description of malformations of the neck of the left atrial appendage

The recently-described left atrial appendage (LAA) neck is a truncated cone-shaped structure that connects the LAA orifice to its lobe. It shows malformations in some cases, but their exact description and clinical significance are unknown. Therefore, the aim of this study was to provide a detailed anatomical and morphometric analysis of LAA neck malformations in clinical context. A total of 250 autopsied human hearts (20.0% women, 46.7 ± 18.2 years old) were examined for mural malformations: spikes and bulges. Endocardial roughness of the LAA neck with a depth <2 mm and no recognizable epicardial protrusion was defined as ectopic trabeculation. LAA neck malformations were found in 13.6%, bulges in 10.0% of the hearts examined, spikes in only 3.2%, and ectopic trabeculations in 24.8%. In one case, both a bulge and a spike were found in the LAA neck. Most LAA neck roughness was observed on the aortic and venous surfaces of the LAA neck. Those surfaces were the most common locations for malformations and ectopic trabeculations. The LAA wall was significantly thinner than the surrounding neck wall within the bulges and the ectopic trabeculations, but not in the spikes.

Catheter based left atrial appendage closure in-hospital outcomes in Germany from 2016 to 2020

BACKGROUND

New and refined catheter based left atrial appendage (LAA) closure devices have been introduced in the past decade. The procedure can be performed using either an endocardial occlusion device or an epicardial loop stitch. We aimed to analyzed recent procedural safety.

METHODS

Catheter based LAA closures were identified in a complete nationwide German dataset via ICD and OPS codes from 2016 to 2020.

RESULTS

From 2016 to 2020, 28,039 endocardial and 213 epicardial occlusions were performed. Numbers of endocardial procedures increased from 5259 in 2016 to 5917 in 2020 (p = 0.020) in 387 centers with shifting of patients' characteristics towards older age (β = 0.29, p < 0.001), more heart failure (β = 1.01, p < 0.001) and renal disease (β = 0.67, p = 0.001) and without a significant trend for in-hospital safety except more bleeding (β = 0.12, p = 0.05). In-hospital major adverse cardiac and cerebrovascular events (MACCE) or pericardial puncture were independent on center procedure numbers. The loop stitch procedure was performed in 15 centers. Patients were younger (76.17 ± 8.16 vs. 73.16 ± 8.99, p < 0.001) and had a lower comorbidity index (2.29 ± 1.93 vs. 1.92 ± 1.64, p = 0.005). Adjusted risk difference for pericardial effusion (8.04%; 95% CI 3.01-13.08%; p = 0.002) and pericardial puncture (6.60%; 95% CI 3.85-9.35%; p < 0.001) was higher for the loop stitch procedure, while risk of bleeding (- 1.85%; 95% CI - 3.01 to - 0.69%; p = 0.002), intracerebral bleeding (- 0.37%; 95% CI - 0.59 to - 0.15%; p = 0.001) and shock (- 1.41%; 95% CI - 2.44 to - 0.39%; p = 0.007) was lower. No significant difference was observed for in-hospital MACCE.

CONCLUSIONS

Endocardial occlusion was the major catheter based LAA closure procedure in Germany without improvements in in-hospital safety from 2016 to 2020. In-hospital MACCE was independent on endocardial LAAC center volumes. Conclusions on the comparison between the two procedure types must be made cautious as the LAA loop stitch occlusion was utilized limited in a minor number of centers.

Definition and anatomical description of the left atrial appendage neck

The left atrial appendage (LAA) is well known as a source of cardiac thrombus formation. Despite its clinical importance, the LAA neck is still anatomically poorly defined. Therefore, this study aimed to define the LAA neck and determine its morphometric characteristics. We performed three-dimensional reconstructions of the heart chambers based on contrast-enhanced electrocardiography-gated computed tomography scans of 200 patients (47% females, 66.5 ± 13.6 years old). The LAA neck was defined as a truncated cone-shaped canal bounded proximally by the LAA orifice and distally by the lobe origin and was present in 98.0% of cases. The central axis of the LAA neck was 14.7 ± 2.3 mm. The mean area of the LAA neck walls was 856.6 ± 316.7 mm2 . The LAA neck can be divided into aortic, arterial (the smallest), venous (the largest), and free surfaces. All areas have a trapezoidal shape with a broader proximal base. There were no statistically significant differences in the morphometric characteristics of the LAA neck between LAA types. Statistically significant differences between the sexes in the main morphometric parameters of the LAA neck were found in the central axis length and the LAA neck wall area. The LAA neck can be evaluated from computed tomography scans and their three-dimensional reconstructions. The current study provides a complex morphometric analysis of the LAA neck. The precise definition and morphometric details of the LAA neck presented in this study may influence the effectiveness and safety of LAA exclusion procedures.

Anticoagulants versus Left Atrial Appendage Occlusion in Patients with Atrial Fibrillation and Co-Morbid Thrombocytopenia

Left atrial appendage closure (LAAC) is an alternative approach to anticoagulants. Nonetheless, data regarding the outcomes of LAAC procedures in patients with thrombocytopenia remain lacking. The primary objective was to determine the incidence of the composite endpoint comprising ischemic stroke, intracranial hemorrhage, major bleeding, and cardiac cause of death among patients with atrial fibrillation (AF) and thrombocytopenia who were either undergoing LAAC or receiving oral anticoagulants. The secondary endpoint was the determination of total mortality. Data from a prospective, single-center registry of patients undergoing LAAC procedures were analyzed. A subset of 50 consecutive patients with thrombocytopenia were selected. Thrombocytopenia was defined as a thrombocyte count below 150,000. Subsequently, from patients hospitalized with AF receiving oral anticoagulants, 50 patients were further chosen based on propensity score matching, ensuring comparability with the study group. The primary endpoint occurred in 2% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.097). Additionally, a significant difference was noted in the occurrence of the secondary endpoint, which was observed in 0% of patients in the LAAC group and 10% of patients in the non-LAAC group (p = 0.025). In patients with thrombocytopenia the LAAC procedure improves prognosis compared with continued anticoagulant treatment.

Changes in fibrinolytic activity and coagulation factors after epicardial left atrial appendage closure in patients with atrial fibrillation

BACKGROUND

The left atrial appendage (LAA) is known to be the primary source of thrombus formation in atrial fibrillation (AF). We investigate whether epicardial LAA occlusion (LAAO) from the cardiovascular system has an effect on coagulation and prothrombotic status in AF.

METHODS

Twenty-two patients with nonvalvular AF, who were not currently receiving oral anticoagulation (OAC) therapy, participated in a single-center prospective study. We measured fibrinogen and plasminogen levels along with plasma fibrin clot permeability, clot lysis time (CLT) and endogenous thrombin potential (ETP) before the LAAO procedure, at discharge and 1 month afterward.

RESULTS

One month after the LAAO procedure, plasma fibrin clot permeability improved by 39.3% as measured by clots prepared from peripheral blood (P=0.019) and also after adjustment for fibrinogen (P=0.027). Higher plasma fibrin clot permeability was associated with improved clot susceptibility to lysis (r=-0.67, P=0.013). CLT was reduced by 10.3% (P=0.0020), plasminogen activator inhibitor-1 antigen levels were reduced by 52% (P=0.023) and plasminogen activity was increased by 8.9% (P=0.0077). A trend toward decreased thrombin generation, reflected by a decreased ETP and peak thrombin generated was also observed 1 month after LAAO procedure (P=0.072 and P=0.087, respectively). No differences were observed in tissue-type plasminogen activator and thrombin-activatable fibrinolysis inhibitor plasma levels (both P>0.05).

CONCLUSIONS

Obtained results seem to confirm that LAA plays a key role in thrombogenesis. Elimination of LAA from the circulatory system may improve fibrin clot permeability and susceptibility to fibrinolysis in peripheral blood.

Left Atrial Appendage Morphology and Course of the Circumflex Artery: Anatomical Implications for Left Atrial Appendage Occlusion Procedures

OBJECTIVE

The aim of this study was to evaluate the anatomic topography of the circumflex artery (Cx) and left atrial appendage (LAA) and to determine the safety zones for epicardial LAA closure and LAA occlusion procedures.

METHODS

The left coronary artery was segmented and visualized from 116 computed tomography angiography scans. Four points were located on the Cx portion periappendicularly, starting from the entry point. The landing zone plane was defined as parallel to the LAA orifice at the level of the beginning of the periappendicular course of the Cx, and the plane of the neck bend was located at the end of the LAA neck. A distance smaller than 2 mm was considered a dangerous distance.

RESULTS

The distance between the Cx and the LAA landing zone was 4.3 ± 2 mm. The distance between the Cx and the LAA neck bend was 5.1 ± 2.2 mm. The distance between the Cx and the LAA bottom surface was 5.8 ± 2.9 mm. In 38.8% of patients, at least 1 distance between Cx and LAA was smaller than 2 mm in at least 1 dimension. These distances occurred in 30.2% of the LAA landing zone dimensions, 19.8% of LAA neck bend dimensions, and 11.2% of the LAA bottom surface distances.

CONCLUSIONS

The study showed that most dangerous distances (30.2%) occurred in the LAA landing zone dimension. The data showed that landing zones more distal from the orifice of the LAA are safer in terms of Cx damage. Therefore, LAA closure should always be performed with caution, to avoid iatrogenic complications.

Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives

Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.

Metabolic Effects of the Left Atrial Appendage Exclusion (THE HEART HORMONE STUDY)

OBJECTIVE

The effect of epicardial LAA occlusion therapy on lipid and glucose metabolism in AF patients over the long term follow up is unclear.

METHODS

In a single-center prospective observational study, 60 patients with longstanding persistent AF with cardiovascular risk factors had undergone an epicardial exclusion procedure. Anthropometric parameters and glucose, glycated hemoglobin (HbA1c), insulin, leptin, adiponectin, free fatty acids, beta-hydroxybutyrate, and total cholesterol levels were evaluated on fasting at baseline before the procedure and compared with levels at 24 hours, 7 days, 1 month, 3 months, 6 months, and 24 months follow the procedure.

RESULTS

The mean age of the patients was 67.5 ± 8.1. Insulin levels significantly increased at 7 days, 1 month, 3 months, 6 months, 12 months, and 24 months follow-up. The leptin levels showed a significant increase in 6 months, 12 months, and 24 months when compared to baseline. Whereas the adiponectin levels showed a significant decrease at 3 months, 6 months, 12 months, and 24 months when compared to baseline levels. In patients with the epicardial procedure, when compared to baseline, glucose, glycated hemoglobin, total cholesterol, and beta-hydroxybutyrate levels did not show any significant changes at baseline and 24 months follow up.

CONCLUSION

The epicardial exclusion ligation in AF patients was associated with significant changes in insulin, leptin, and adiponectin over long follow up. This article is protected by copyright. All rights reserved.

Safety and effectiveness of left atrial appendage closure in patients with non-valvular atrial fibrillation and prior major bleeding

OBJECTIVES

To investigate safety and effectiveness of left atrial appendage closure (LAAC) in atrial fibrillation patients with prior major bleeding.

METHODS

A total of 377 consecutive patients scheduled for LAAC with Watchman device were divided into bleeding group (n = 137) and non-bleeding group (n = 240). Data were compared between groups.

RESULTS

The bleeding group had more patients ≥75 years old (P = 0.044), higher CHA₂DS₂-VASc (P = 0.029) and HAS-BLED scores (P = 0.001) than the non-bleeding group. During the long-term follow-up, except for thromboembolism event (P = 0.031), the incidences of major bleeding  , all-cause death  , co-primary efficacy events  , and the cumulative survival ratio after adjustment of confounding factors    were comparable. The observed thromboembolism rate was reduced by 86.3% (P = 0.0002) and 55.1% (P = 0.0293) and the observed major bleeding rate was decreased by 61.9% (P = 0.0393) and 35.7% (P = 0.2426) compared with expected risks in bleeding and non-bleeding groups, respectively. The risk reduction in thromboembolism and major bleeding were significantly greater in bleeding group versus non-bleeding group (all P < 0.0001).

CONCLUSIONS

Among patients with prior bleeding, LAAC is a safe and effective alternative to anticoagulation therapy and seems to emerge as a higher efficacy in risk reduction of thromboembolism and major bleeding compared to those without prior bleeding.

Long-term effect of anticoagulation following left atrial appendage occlusion with the LARIAT device in patients with nonvalvular atrial fibrillation: impact on thromboembolism, bleeding and mortality. Real life data

Introduction

Indications for left atrial appendage occlusion (LAAO) are varied and patients require individual management strategies. However, currently no guidelines exist for postprocedure oral anticoagulation (OAC) after an LAAO procedure.

Aim

To evaluate the effect of OAC on thromboembolism, bleeding and mortality following the LAAO procedure for patients with AF.

Material and methods

One hundred and thirty-nine consecutive patients with nonvalvular atrial fibrillation (NVAF) who underwent LAAO with the LARIAT device were followed for at least 40 months. Decisions about OAC and its modifications were individualized based on clinical presentation, patient and physician preferences.

Results

Following LAAO, 52 (41%) patients did not receive OAC (No-OAC group) and 75 (59%) patients received OAC (OAC group), without any intergroup differences in CHADS₂, CHA₂DS₂-VASc score or other thromboembolic risk factors. The median HAS-BLED score was higher in the OAC-group (median 3 (3-4) vs. 3 (2-4), p = 0.014). During a median follow-up time of 51 (43-57) vs. 55 (48-59) months in the No-OAC group and in the OAC group (p = 0.19) there were no significant differences between groups in ischemic stroke/TIA, 0 (0%) vs. 2 (2.7%), other thromboembolic events, 0 (0%) vs. 1 (1.3%), life-threatening, disabling or major events, 2 (3.7%) vs. 2 (2.7%), or annual mortality rate, 1.9% vs. 0.9%, respectively.

Conclusions

There is no need for OAC after the LAAO procedure. Omitting OAC after an LAAO procedure in AF patients: (1) has similar stroke prevention rates as patients on OAC, (2) has similar bleeding prevention rates as patients on OAC, (3) has similar safety endpoints and long-term efficacy as patients on OAC.

The effect and mechanism of combination of total paeony glycosides and total ligustici phenolic acids against focal cerebral ischemia

The root of Paeonia lactiflora Pall. (Chishao, CS) and Ligusticum chuanxiong Hort. (Chuanxiong, CX) were widely used as a drug pair in Chinese Medicine, and the combination of CS and CX showed a more significant inhibition on neuronal apoptosis in our previous study. In the present study, total paeony glycosides (TPGs) from CS and total ligustici phenolic acids (TLPAs) from CX were combined to evaluate the synergistic effects against focal cerebral ischemia both in vitro and in vivo. The combination of TPGs and TLPAs at 7:3 had the best anti-oxidative stress and anti-inflammatory effect on OGD-induced HUVEC. Additionally, the infarction area proportion and neuron apoptosis of rats by TPGs:TLPAs (7:3) was significantly lower than their alone in MCAO rats. Moreover, TPGs: TLPAs of 7:3 showed a more significant effect on decreasing the expression of MMP-2 and MMP-9, and increasing the protein expression or mRNA level of TIMP-1 than other combinations. The optimal ratio of TPGs and TLPAs at 7:3 could bring more remarkable protective effects against focal cerebral ischemia in MCAO rats by alleviating oxidative stress, inflammatory and neuronal apoptosis to protect the blood-brain barrier. Overall, the present study provided benefical evidence for clinical application of CS and CX as a "drug pair".

Risk of thromboembolic events after percutaneous left atrial appendage ligation in patients with atrial fibrillation: Long-term results of a multicenter study

BACKGROUND

Percutaneous left atrial appendage (LAA) occlusion with Lariat has emerged as a viable alternative to oral anticoagulation (OAC) to prevent thromboembolic (TE) events in patients with atrial fibrillation.

OBJECTIVE

We evaluated the long-term TE risk in post-Lariat patients.

METHODS

Consecutive patients undergoing LAA ligation with the Lariat device at multiple centers with at least 1-year follow-up were included in the analysis. Transesophageal echocardiography (TEE) was performed at 4 weeks, 6 months, and 12 months to assess the completeness of LAA occlusion. OAC was discontinued if 4-week TEE revealed no device-related thrombus and complete closure of the appendage. Patients remained on 81 mg of aspirin per day after discontinuation of the blood thinner.

RESULTS

A total of 306 patients were included in the study (mean age 68.8 ± 11.0 years; mean CHA₂DS₂-VASc score 3.6 ± 1.7). Four-week TEE revealed leaks in 81 patients (26.5%); all leaks were less than 5 mm in diameter. At 6-month TEE, spontaneous closure of the leak was demonstrated in 21 patients (25.9%), 26 patients (32%) underwent a successful leak closure procedure, and the remaining 34 (42%) patients were placed on OAC. At the median follow-up period of 15.9 ± 9.2 months, 9 TE events (2.9%) were reported: 7 with persistent leak and 2 without any detectable leaks on 2-dimensional TEE (P < .001).

CONCLUSION

Complete occlusion of the LAA with the Lariat device was associated with the low rate of TE events at long-term follow-up. However, residual leaks were common after Lariat closure and the stroke rate was significantly higher in patients with incomplete occlusion, even with small leaks.