Impact of chronic kidney disease on Watchman implantation: experience with 300 consecutive left atrial appendage closures at a single center

Association of chronic kidney disease and kidney failure with replacement therapy with procedural and long-term outcomes after first-generation Watchman device: Insights from the NCDR LAAO Registry

BACKGROUND

Chronic kidney disease (CKD) and kidney failure with replacement therapy (KFRT) are prevalent in patients with atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to analyze procedural and long-term outcomes in AF patients with underlying CKD and KFRT after left atrial appendage occlusion (LAAO) device implantation.

METHODS

Data were extracted from the National Cardiovascular Data Registry LAAO Registry from January 2017 to December 2019 and linked to Centers for Medicare & Medicaid Services billing claims. Patients were stratified into 3 groups: no CKD, CKD, and KFRT. Multivariate analyses were used to assess the associations of CKD and KFRT with procedural and long-term outcomes, respectively.

RESULTS

A total of 59,190 patients were enrolled in our study. CKD and KFRT were found to be independently associated with any complication from the procedure (odds ratio [OR] 1.149, 95% confidence interval [CI] 1.058-1.;247 and OR 2.163, 95% CI 1.763-2.652) and in-hospital death (OR 1.603, 95% CI 1.054-2.437; and OR 5.488, 95% CI 2.686-11.213). At 1 year, CKD and KFRT were associated with a higher risk of any major adverse event (hazard ratio [HR] 1.402, 95% CI 1.333-1.474; and HR 2.506, 95% CI 2.236-2.809) and death (HR 1.662, 95% CI 1.553-1.779; and HR 3.422, 95% CI 2.989-3.919), but no difference in the competing risk of stroke (HR 0.972, 95% CI 0.819-1.152; and HR 0.794, 95% CI 0.434-1.451).

CONCLUSION

CKD and KFRT were associated with higher rates of procedural complications and 1-year adverse events and death, but no difference in the 1-year rate of stroke.

Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative.

OBJECTIVE

This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD).

METHODS

Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies.

RESULTS

We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade.

CONCLUSIONS

Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO.

Adverse outcomes with left atrial appendage occlusion device implantation in chronic and end stage kidney disease: A systemic review and meta-analysis

BACKGROUND

Chronic kidney disease (CKD) and end stage renal disease (ESRD) are associated with increased risk of bleeding events, including hemorrhagic stroke, and periprocedural and gastrointestinal bleeding among patients with atrial fibrillation who are on anticoagulation. Safety of percutaneous left atrial appendage occlusion (LAAO) among this patient population has been uncertain with studies showing contradictory results.

METHODS

PubMed and Google Scholar databases were queried for studies comparing outcomes among patients with and without significant CKD, and with and without ESRD who underwent LAAO device implantation. Data on outcomes from the selected studies were extracted and analyzed using random effects model. Heterogeneity was assessed using I2 test.

RESULTS

Data from eleven studies with 61,724 patients with and without kidney disease were included in the final analyses. There was an increased risk of in-hospital mortality (OR 2.76, 95 % CI [1.15-6.64]; p = 0.02) and peri-procedural bleeding (1.51 [1.33-1.71]; p < 0.01) associated with kidney disease. There was no significant difference in risk of stroke (1.19 [0.70-2.03]; p = 0.53), pericardial effusion (1.22 [0.77-1.92]; p = 0.40), vascular complications (1.18 [0.92-1.52]; p = 0.20), or device related thrombus (1.13 [0.53-2.40]; p = 0.75).

CONCLUSIONS

This study shows an increased risk of complications among patients with kidney disease, who undergo LAAO device implantation. These findings suggest the need for studies with randomized control design specifically designed to compare outcomes with LAAO versus anticoagulation in the CKD and ESRD populations.

Impact of chronic kidney disease on left atrial appendage occlusion: A meta-analysis of procedural outcomes and complications

BACKGROUND

Patients with chronic kidney disease (CKD) experience atrial fibrillation more frequently. The balance of medical management for stroke prevention and bleeding events presents a challenging issue in CKD population. Left atrial appendage occlusion (LAAO) may be an effective solution for stroke prevention in patients who experience frequent bleeding with oral anticoagulants. However, the specific impact of CKD on the procedural success, complications, and outcomes of LAAO implantations remains underexplored.

METHODS

We conducted a search of various databases for articles published before October 31, 2023. This search yielded 7 studies, comparing outcomes between CKD and non-CKD cohorts undergoing LAAO implantation. Our analysis focused on CHA2DS2-VASc scores, average eGFR, use of oral anticoagulants, procedural success rates, procedural complications, and associated outcomes.

RESULTS

The meta-analysis included data from 2576 patients, with 1131 identified as having CKD. The CKD group also had higher CHA2DS2-VASc scores (4.7 ± 1.4 vs 4.0 ± 1.5; P < .001) and HAS-BLED scores (3.8 ± 1.1 vs 3.1 ± 1.0; P < .001) than the non-CKD group. CKD patients showed a nonreduction in procedural success rates and a nonsignificant increase in total complications. The risks of stroke and transient ischemic attack, major bleeding, and cardiovascular mortality were not significantly different between the 2 groups. However, a significantly lower rate of total mortality was observed in the non-CKD group (odds ratio: 0.43; 95% confidence interval, 0.32-0.60).

CONCLUSION

While CKD is associated with a nonsignificant decrease in procedural success and a nonsignificant increase in complication risks, the outcomes of LAAO implantation are comparably favorable between CKD and non-CKD groups. Despite similar procedural outcomes, the CKD group exhibited a higher rate of all-cause mortality.

Long-term outcomes of left atrial appendage occlusion in patients with atrial fibrillation and end stage renal disease

OBJECTIVE

In patients with atrial fibrillation (AF) and end-stage renal disease (ESRD), oral anticoagulants are contraindicated, and left atrial appendage occlusion (LAAO) is an alternative treatment. However, the efficacy of thromboembolic prevention using LAAO in these patients has rarely been reported in Asian populations. To our knowledge, this is the first long-term LAAO study in patients with AF undergoing dialysis in Asia.

METHODS

In this study, 310 patients (179 men) with a mean age of 71.3 ± 9.6 years and mean CHA2DS2-VASc 4.2 ± 1.8 were consecutively enrolled at multiple centers in Taiwan. The outcomes of 29 patients with AF and ESRD undergoing dialysis who underwent LAAO were compared to those without ESRD. The primary composite outcomes were stroke, systemic embolization, or death.

RESULTS

No difference in mean CHADS-VASc score was noted between patients with versus without ESRD (4.1 ± 1.8 vs. 4.6 ± 1.9, p = 0.453). After a mean follow-up of 38 ± 16 months, the composite endpoint was significantly higher in patients with ESRD (hazard ratio, 5.12 [1.4-18.6]; p = 0.013) than in those without ESRD after LAAO therapy. Mortality was also higher in patients with ESRD (hazard ratio, 6.6 [1.1-39.7]; p = 0.038). The stroke rate was numerically higher in patients with versus without ESRD, but the difference was not statistically significant (hazard ratio, 3.2 [0.6-17.7]; p = 0.183). Additionally, ESRD was associated with device-related thrombosis (odds ratio, 6.15; p = 0.047).

CONCLUSION

Long-term outcomes of LAAO therapy may be less favorable in patients with AF undergoing dialysis, possibly because of the poor condition of patients with ESRD.

Efficacy and safety of patients with chronic kidney disease undergoing left atrial appendage closure for atrial fibrillation

BACKGROUND

The relative safety and efficacy of left atrial appendage closure (LAAC) for atrial fibrillation (AF) in patients with chronic kidney disease (CKD) have not been well defined. To evaluate the results in this cohort, we conducted a systematic review and meta-analysis of observational studies.

METHODS

We searched the PubMed, EMBASE, Web of Science, and Cochrane Library databases from inception to January 2023 for all relevant studies. Our inclusion criteria were met by twelve observational studies that included 61324 patients altogether.

RESULTS

Compared with no CKD group, in-hospital mortality (OR: 2.84, 95% CI: 2.12-3.81, p<0.01, I2 = 0%), acute kidney injury (AKI) (OR: 4.39,95% CI:4.00-4.83, P<0.01, I2 = 3%), major bleeding events (OR: 1.44, 95% CI: 1.29-1.60, p<0.01 I2 = 0%), and pericardial effusion/tamponade (OR 1.30; 95% CI 1.13-1.51, p < 0.01; I2 = 0%) were more common in the CKD group, especially in patients with end-stage renal disease (ESRD). No significant difference was observed in the occurrence of stroke (OR: 1.24, 95% CI: 0.86-1.78, P = 0.25, I2 = 0%), LAAC success rates (OR: 1.02, 95% CI: 0.33-3.16, p = 0.97, I2 = 58%) and vascular access complications (OR: 1.13, 95% CI: 0.91-1.39, p = 0.28, I2 = 0%) between the two groups. During the follow-up, there was no difference in the risk of stroke between the two groups.

CONCLUSIONS

CKD patients who receive LAAC have a greater risk of in-hospital mortality, AKI, pericardial effusion/tamponade, and major bleeding events than those without CKD, especially in patients with ESRD. No significant difference in the risk of stroke was found in the long-term follow-up after LAAC between the two groups, demonstrating a similar efficacy of LAAC to prevent stroke in CKD patients.

Comparative Effectiveness of Different Anticoagulation Strategies in Atrial Fibrillation and Renal Dysfunction: A Systematic Review

Atrial fibrillation (AF) is a common cardiac arrhythmia that increases the risk of stroke and thromboembolism. Anticoagulation therapy can reduce this risk, but the optimal choice of anticoagulant in patients with AF and renal dysfunction is challenging. Renal dysfunction is a common comorbidity seen in patients with AF. Renal dysfunction would affect the pharmacokinetics and pharmacodynamics of anticoagulants and make the patient more prone to bleeding complications. This complicates the assessment of the risks, benefits, and ratio for starting anticoagulant drugs in patients with renal dysfunction. Therefore, there is always a therapeutic conundrum due to the increased risk of bleeding and thromboembolic events in AF patients with renal dysfunction. We conducted a systematic review to summarize the current literature and identify the challenges of anticoagulation strategies in AF with renal dysfunction. We examined 180 articles from reputable journals published from 2018 to June 2023 and selected eight papers for detailed analysis. The studies we chose included a variety of drug treatments, such as traditional therapies like vitamin K antagonists, factor Xa inhibitors, heparins, and direct thrombin inhibitors. This systematic review will provide comprehensive information on the latest data on the effectiveness of various pharmacological treatments (anticoagulation strategies) in AF patients with renal dysfunction. The aim is to help doctors and other healthcare decision-makers choose the best anticoagulation strategy in AF patients with renal dysfunction and to overcome their dilemma between bleeding risk and systemic thromboembolic events.

Left atrial appendage closure in end-stage renal disease and hemodialysis: Data from a German multicenter registry

BACKGROUND

Left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF). OAC treatment has been proven feasible in mild-to-moderate chronic kidney disease (CKD). In contrast, the optimal antithrombotic management of AF patients with end-stage renal disease (ESRD) is unknown and LAAC has not been proven in these patients in prospective randomized clinical trials.

OBJECTIVES

The objective of this study is to evaluate safety and efficacy of LAAC in patients with ESRD.

METHODS

Patients undergoing LAAC were collected in a German multicenter real-world observational registry. A composite endpoint consisting of the occurrence of ischemic stroke/transient ischemic attack, systemic embolism, and/or major clinical bleeding was assessed. Patients with ESRD were compared with propensity score-matched patients without severe CKD. ESRD was defined as a glomerular filtration rate < 15 ml/min/1.73 m² or chronic hemodialysis treatment.

RESULTS

A total of 604 patients were analyzed, including 57 with ESRD and 57 propensity-matched patients. Overall, 596 endocardial and 8 epicardial LAAC procedures were performed. Frequency of major complications was 7.0% (42/604 patients) in the overall cohort, 8.8% (5/57 patients) in patients with ESRD, and 10.5% (6/57 patients) in matched controls (p = 0.75). The estimated event-free survival of the combined endpoint after 500 days was 90.7 ± 4.5% in patients with ESRD and 90.2 ± 5.5% in matched controls (p = 0.33).

CONCLUSIONS

LAAC had comparable procedural safety and clinical efficacy in patients with ESRD and patients without severe CKD.

Prognostic impact of the presence of chronic kidney disease on percutaneous left trial appendage closure for atrial fibrillation: A single center experience

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation (NVAF) to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with NVAF and chronic kidney disease (CKD), since they exhibit both high thromboembolic and bleeding risks.

OBJECTIVE

To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function.

METHODS

Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients.

RESULTS

The median age was 75,5 years (IQR 67,6-80) and 62,1% were men, the median of CHA₂DS₂-Vasc and HASBLED scores was 4 (IQR 3-4) for both scores. Up to 57,3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs 4.06/100PY, P =,09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, P =,033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, P =,009), with an odds ratio of 2.711 (95% CI 1,96-6,95). In the multivariate analysis a preserved eGFR was independently associated with a lower mortality risk.

CONCLUSIONS

LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.

Latest outcomes of transcatheter left atrial appendage closure devices and direct oral anticoagulant therapy in patients with atrial fibrillation over the past 5 years: a systematic review and meta-analysis

Left atrial appendage closure (LAAC) are emerging treatment for patients with atrial fibrillation (AF). However, data on the safety, efficacy, and medications for LAAC devices in patients with AF are lacking. We aimed to investigate the incidence of all-cause mortality, stroke, and major bleeding in AF patients with LAAC devices and DOACs. Moreover, we aimed to investigate the incidence rate of device-related thrombus (DRT) and the medications used in the management of AF patients with LAAC devices to gain insights into achieving better outcome. Based on a literature search using PubMed, EMBASE, Cochrane Library, and Web of Science databases between January 2015 and December 2020, eight LAAC device studies that used WATCHMAN and Amulet, and three DOAC studies that used rivaroxaban, with a total of 24,055 AF patients (LAAC devices, n = 2855; DOAC, n = 21,200), were included. A random-effects model was used to incorporate heterogeneity among studies. The pooled incidence of events per person-years were as follows: all-cause mortality, 0.06 (95% confidence interval [CI] 0.02-0.10) for WATCHMAN, 0.04 (95% CI 0.00-0.14) for Amulet, and 0.03 (95% CI 0.01-0.04) for rivaroxaban; stroke; 0.02 (95% CI 0.00-0.04) for WATCHMAN, 0 for Amulet, and 0.01 (95% CI 0.01-0.02) for rivaroxaban; major bleeding, 0.04 (95% CI 0.02-0.06) for WATCHMAN, 0.02 (95% CI 0.00-0.06) for Amulet, and 0.02 (95% CI 0.01-0.03) for rivaroxaban. The incidence rate of DRT was 2.3%, and complications were reported in 9%. The incidence of all-cause mortality, stroke, and major bleeding were similar between LAAC devices and DOACs. The rate of complications was acceptable, and those of DRT were lower than the average incidence reported in previous studies. However, further follow-up is needed. Concomitant anticoagulant and antiplatelet therapies should be further evaluated to find the optimal regimen for AF patients with LAAC devices.

Left Atrial Appendage Closure: An Alternative to Anticoagulation for Stroke Prevention in Patients with Kidney Disease

Anticoagulation to reduce thromboembolic stroke risk due to nonvalvular atrial fibrillation in ESKD is associated with increased bleeding. There is an existing debate in ESKD centers around the pros and cons of anticoagulation. We propose percutaneous left atrial appendage occlusion as a third alternative to balance thrombosis and bleeding risks in this high-risk population.

Patient characteristics, care patterns, and outcomes of atrial fibrillation associated hospitalizations in patients with chronic kidney disease and end-stage renal disease

BACKGROUND

Chronic Kidney Disease (CKD) and end-stage renal disease (ESRD) are associated with poor outcomes in patients with cardiovascular disease. There is a paucity of contemporary data on in-hospital outcomes and care patterns of atrial fibrillation (AF) associated hospitalizations CKD and ESRD.

METHODS

Outcomes and care patterns were evaluated in GWTG-AFIB database (Jan 2013-Dec 2018), including in-hospital mortality, use of a rhythm control strategy, and oral anticoagulation (OAC) prescription at discharge among eligible patients. Generalized logistic regression models with generalized estimating equations were used to ascertain differences in outcomes. Hospital-level variation in OAC prescription and rhythm control was also evaluated.

RESULTS

Among 50,154 patients from 105 hospitals the median age was 70 years (interquartile range 61-79) and 47.3% were women. The prevalence of CKD was 36.0% while that of ESRD was 1.6%. Among eligible patients, discharge OAC prescription rates were 93.6% for CKD and 89.1% for ESRD. After adjustment, CKD and ESRD were associated with higher in-hospital mortality (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.57-6.03 for ESRD and OR 2.02, 95% CI 1.52-2.67 for CKD), lower odds of OAC prescription at discharge (OR 0.59, 95% CI 0.44-0.79 for ESRD and OR 0.84, 95% CI 0.75-0.94 for CKD) compared with normal renal function. CKD was associated with lower utilization of rhythm control strategy (OR 0.92, 95% CI 0.87-0.98) with no significant difference between ESRD and normal renal function (OR 1.32, 95% CI 0.79-1.11). There was large hospital-level variation in OAC prescription at discharge (MOR 2.34, 95% CI 2.05-2.76) and utilization of a rhythm control strategy (MOR 2.69, 95% CI 2.34-3.21).

CONCLUSIONS

CKD/ESRD is associated with higher in-hospital mortality, less frequent rhythm control, and less OAC prescription among patients hospitalized for AF. There is wide hospital-level variation in utilization of a rhythm control strategy and OAC prescription at discharge highlighting potential opportunities to improve care and outcomes for these patients, and better define standards of care in this patient population.

Association of chronic kidney disease and end-stage renal disease with procedural complications and in-hospital outcomes from left atrial appendage occlusion device implantation in patients with atrial fibrillation: Insights from the national inpatient sample of 36,065 procedures

Background

Left atrial appendage occlusion (LAAO) has emerged as an alternative strategy to oral anticoagulation for mitigating ischemic stroke risk in selected patients with atrial fibrillation (AF), but safety data in patients with significant kidney disease are limited.

Objective

To determine the association of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with procedural complications and in-hospital outcomes after LAAO in AF patients.

Methods

Data were extracted from National Inpatient Sample for calendar years 2015–2018. Watchman implantations were identified on the basis of International Classification of Diseases, 9th and 10th Revision, Clinical Modification codes of 37.90 and 02L73DK. The outcomes assessed in our study included complications, inpatient mortality, and resource utilization with LAAO.

Results

A total of 36,065 Watchman recipients were included in the final analysis. CKD (9.8%, n = 3545) and ESRD (3%, n = 1155) were associated with a higher prevalence of major complications and mortality in crude analysis compared to no CKD. After multivariate adjustment for potential confounders, CKD was associated with length of stay (LOS) >1 day (adjusted odds ratio [aOR] 1.355; 95% confidence interval [CI] 1.234–1.488), median cost >$24,663 (aOR 1.267; 95% CI 1.176–1.365), and acute kidney injury (aOR 4.134; 95% CI 3.536–4.833), while ESRD was associated with in-patient mortality (aOR 7.156; 95% CI 3.294–15.544).

Conclusion

The prevalence of CKD and ESRD was approximately 13% in AF patients undergoing Watchman LAAO implantations. CKD was independently associated with prolonged LOS, higher hospitalization costs, and acute kidney injury, while ESRD was independently associated with in-patient mortality.

[Left atrial appendage closure : Current data and future developments]

Catheter-based left atrial appendage closure (LAAC) is currently a potential treatment option for stroke prevention in patients with atrial fibrillation and high risk for stroke/embolism as well as high bleeding risk. Due to improvements in LAAC devices, advances in implantation techniques and growing experience of the interventional teams, the safety profile of LAAC has significantly improved in recent years. These developments have led to a currently comprehensive exploration of novel indications for LAAC, such as patients with atrial fibrillation and a low risk of hemorrhage, patients with atrial fibrillation after pulmonary vein ablation or patients after electrical isolation of the left atrial appendage. The treatment principle of closure of the left atrial appendage is supported by new data, which show the effectiveness of surgical closure of the left atrial appendage with respect to a reduction of the risk of stroke, at least partly in conjunction with oral anticoagulation during cardiological surgical interventions. Currently, the application in the clinical practice is reflected by a high degree of active studies. These randomized studies are testing the use of LAAC in new fields of application and together with the new developments in implantation techniques should define the optimal future use of the methods for the clinical practice. The current potential indications for the LAAC procedure, ongoing randomized clinical trials and advances in device development, implantation planning and technique as well as future developments in the field of LAAC treatment are summarized and discussed in this review article.

The Association of Chronic Kidney Disease With Outcomes Following Percutaneous Left Atrial Appendage Closure

OBJECTIVES

The aim of this study was to investigate the associations of chronic kidney disease (CKD) and end-stage renal disease (ESRD) with in-hospital and short-term outcomes using a large national database representative of contemporary clinical practice.

BACKGROUND

CKD and ESRD are associated with increased risk for stroke and bleeding in patients with atrial fibrillation on oral anticoagulation. Left atrial appendage closure (LAAC) may provide a reasonable alternative for these patients; however, the impact of CKD and ESRD on in-hospital and short-term outcomes following LAAC remain largely unknown.

METHODS

The Nationwide Readmissions Database was used to identify LAAC procedures from 2016 to 2017 in patients with no CKD, CKD (stages I-V), and ESRD. Multivariable logistic regression models were used to assess in-hospital and short-term outcomes. The primary outcome was in-hospital mortality.

RESULTS

Of 21,274 patients who underwent LAAC during the study period, 3,954 (18.6%) had CKD and 571 (2.7%) had ESRD. ESRD was associated with increased risk for in-hospital mortality compared with no CKD (3.3% vs 0.4%; adjusted odds ratio: 6.48; 95% confidence interval: 3.35-12.50; P < 0.001) and CKD (3.3% vs 0.5%; adjusted odds ratio: 11.43; 95% confidence interval: 4.77-27.39; P < 0.001). CKD was associated with increased risk for in-hospital acute kidney injury or hemodialysis and stroke or transient ischemic attack. ESRD and CKD were associated with increased readmissions extending to 90 days compared with no CKD, and ESRD was associated with increased readmissions compared with CKD. There was no difference with respect to other in-hospital outcomes.

CONCLUSIONS

ESRD is associated with higher in-hospital mortality, and CKD is associated with higher rates of stroke or transient ischemic attack in patients undergoing LAAC. Further research is needed to assess the impact of CKD and ESRD on long-term outcomes in these patients.

Prognostic impact of the presence of chronic kidney disease on percutaneous left trial appendage closure for atrial fibrillation: A single center experience

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) has been proposed as an alternative to anticoagulation therapy in patients with nonvalvular atrial fibrillation to decrease the thromboembolic risk, while avoiding the risks of chronic anticoagulation. This option may be attractive in patients with nonvalvular atrial fibrillation and chronic kidney disease (CKD), since they exhibit both high-thromboembolic and bleeding risks.

OBJECTIVE

To evaluate the prognostic impact of the presence of CKD in patients with atrial fibrillation undergoing LAAC peri-procedure and during the follow-up as compared with patients with preserved renal function.

METHODS

Retrospective, observational study that included 124 consecutive patients with atrial fibrillation undergoing LAAC in a university hospital, and the results were evaluated according to the baseline renal function of the patients.

RESULTS

The median age was 75.5 years (IQR 67.6-80) and 62.1% were men, the median of CHA2DS2-Vasc and HASBLED scores was 4 (IQR 3-4) for both scores. Up to 57.3% of the total sample had CKD. Baseline characteristics were similar between groups, but CKD patients were older and had a higher HASBLED score. During the procedure, no thromboembolic, bleeding events, or deaths were observed. Combining the time of hospitalization and follow-up, no significant differences were observed between groups in the annual rate of thromboembolic events (0.97/100 patient-years [100PY] vs. 4.06/100PY, p=.09), but there was a higher rate of bleeding events (5.67/100PY vs. 13.3/100PY, p=.033) and mortality among CKD patients (6.50/100PY vs. 17.2/100PY, p=.009), with an odds ratio of 2.711 (95% CI 1.96-6.95). In the multivariate analysis, a preserved eGFR was independently associated with a lower mortality risk.

CONCLUSIONS

LAAC is a valid alternative to oral anticoagulation in patients with CKD and atrial fibrillation, with a low-rate of peri- and post-procedure complications, although CKD patients exhibited a higher risk of bleeding and mortality during the follow-up. However, these higher rates may not be necessarily related to the procedure.

Anti-thrombotic activity of phenolic acids obtained from Salvia miltiorrhiza f. alba in TNF-α-stimulated endothelial cells via the NF-κB/JNK/p38 MAPK signaling pathway

Over the past 100 years, Salvia miltiorrhiza f. alba (Lamiaceae) (RSMA) roots have been used to cure thromboangiitis obliterans (TAO) in local clinics. This study aimed to confirm the anti-thrombotic efficacy of 12 phenolic acids obtained from RSMA and to clarify the possible underlying mechanisms. The results of quantitative real-time polymerase chain reaction (qRT-PCR) and enzyme-linked immunosorbent assay (ELISA) experiments demonstrated that most of the phenolic acids markedly inhibited PAI-1 protein and mRNA levels but increased t-PA protein and mRNA levels in TNF-α-induced EA.hy926 cells (P < 0.05 or 0.001), with lithospermic acid displaying the strongest effect. In vitro anticoagulation and antiplatelet aggregation assays showed that lithospermic acid and salvianolic acid B significantly prolonged prothrombin time (PT), activated partial thromboplastin time (APTT), decreased fibrinogen concentration (FIB), and inhibited platelet aggregation induced by adenosine diphosphate (ADP) in rat blood. Both lithospermic acid and salvianolic acid B markedly down-regulated the expression of factor Xa and factor IIa on the external surface of EA.hy926 cells and demonstrated significant anti-factor IIa and anti-factor Xa activity using chromogenic substrates in vitro. Western blot results revealed that both lithospermic acid and salvianolic acid B also significantly inhibited the expression of TF, p-p65, p-p38, and pJNK proteins induced by TNF-α. These results indicated that all of the phenolic acids appeared to have some anti-thrombotic activity, with salvianolic acid B and lithospermic acid markedly decreasing the chance of thrombosis by regulating the NF-κB/JNK/p38 MAPK signaling pathway in response to TNF-α.

Outcomes on safety and efficacy of left atrial appendage occlusion in end stage renal disease patients undergoing dialysis

BACKGROUND

In patients with end stage renal disease and atrial fibrillation (AF), undergoing chronic dialysis, direct oral agents are contraindicated and warfarin does not fully prevent embolic events while increasing the bleeding risk. The high hemorrhagic risk represents the main problem in this population. Aim of the study was to estimate the safety and efficacy for thromboembolic prevention of left atrial appendage (LAA) occlusion in a cohort of dialysis patients with AF and high hemorrhagic risk.

METHODS

Ninety-two dialysis patients with AF who underwent LAA occlusion were recruited. For comparative purposes, two cohorts of dialysis patients with AF, one taking warfarin (oral anticoagulant therapy, OAT cohort, n = 114) and the other not taking any OAT (no-therapy cohort, n = 148) were included in the study. Primary endpoints were (1) incidence of peri-procedural complications, (2) incidence of 2-year thromboembolic and hemorrhagic events, (3) mortality at 2 years. In order to evaluate the effect of the LAA occlusion on the endpoints with respect to the OAT and No-therapy cohorts, a multivariable Cox regression model was applied adjusted for possible confounding factors.

RESULTS

The device was successfully implanted in 100% of cases. Two major peri-procedural complications were reported. No thromboembolic events occurred at 2-year follow-up. The adjusted multivariable Cox regression model showed no difference in bleeding risk in the OAT compared to the LAA occlusion cohort in the first 3 months of follow-up [HR 1.65 (95% CI 0.43-6.33)], when most of patients were taking two antiplatelet drugs. In the following 21 months the bleeding incidence became higher in OAT patients [HR 6.48 (95% CI 1.32-31.72)]. Overall mortality was greater in both the OAT [HR 2.76 (95% CI 1.31-5.86)] and No-Therapy [HR 3.09 (95% CI 1.59-5.98)] cohorts compared to LAA occlusion patients.

CONCLUSIONS

The study could open the way to a non-pharmacological option for thromboembolic protection in dialysis patients with AF and high bleeding risk.

Thromboembolic and Bleeding Risk in Atrial Fibrillation Patients with Chronic Kidney Disease: Role of Anticoagulation Therapy

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients.

Unprotected discharge: absence of stroke prevention strategies in patients with atrial fibrillation admitted for bleeding

PURPOSE

Patients with atrial fibrillation or flutter (AF) on anticoagulation (AC) for stroke prevention are at an increased risk of bleeding. A common clinical dilemma is deciding when to safely restart AC following a bleed. Although studies have shown better outcomes with re-initiation of AC after hemostasis, there are clinical barriers to restarting AC. Left atrial appendage occlusion (LAAO) is a safe and efficacious alternative for patients who are unable to tolerate AC following major bleeding. We aimed to evaluate the rate of stroke prevention strategies instituted at time of discharge in patients with AF on AC who had been hospitalized for a bleeding event.

METHODS

We retrospectively identified patients with AF on AC admitted for bleeding between January 2016 and August 2019. The type of AC, form of bleeding, and CHA₂DS₂VASc were collected. Stroke prevention strategies upon discharge and at 3 months were noted.

RESULTS

One hundred seventy-four patients with AF on AC were hospitalized with a bleeding event, of which 10.9% died. Among patients who survived, AC was restarted in 45.2% of patients, 9.7% were referred for LAAO, and 45.1% were discharged without stroke prevention strategy. At 3 months, 32.6% of patients still had no documented stroke prophylaxis. Those referred for LAAO had, on average, higher CHA₂DS₂VASc (5 ± 1 vs 4 ± 1, p = 0.007).

CONCLUSIONS

A significant number of patients with AF hospitalized for bleeding were discharged with no plan for stroke prophylaxis. Despite its safety and efficacy, LAAO appears to be an underutilized alternative in AF patients with high bleeding risk.

Calciphylaxis in the Setting of Hemodialysis, Liver Cirrhosis, and Warfarin Therapy for Atrial Fibrillation: An Argument for Alternative Anti-Embolic Therapy

Calciphylaxis, also referred to as calcific uremic arteriolopathy, is a rare, life-threatening cutaneous systemic disease that typically occurs in the setting of end-stage renal disease (ESRD). ESRD is the most recognized risk factor for calciphylaxis but it is not the sole risk factor. Calciphylaxis has also been associated with liver cirrhosis with or without concurrent renal disease. The current case describes a patient who developed calciphylaxis in the setting of hemodialysis, liver cirrhosis, and atrial fibrillation managed with warfarin therapy, all risk factors for calciphylaxis. The need for alternatives to warfarin therapy, specifically in patients with atrial fibrillation on hemodialysis for ESRD who are at increased risk for calciphylaxis, is discussed. Specifically, the left atrial appendage occluder device is described and the need for interdisciplinary management of these patients is stressed.

Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis

OBJECTIVES

The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO).

BACKGROUND

Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated.

METHODS

A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model.

RESULTS

A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices.

CONCLUSIONS

In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.

Stroke Prophylaxis in Patients with Atrial Fibrillation and End-Stage Renal Disease

Atrial fibrillation (AF) is an important comorbidity in patients with end-stage renal disease (ESRD) undergoing dialysis that portends increased health care utilization, morbidity, and mortality in this already high-risk population. Patients with ESRD have a particularly high stroke risk, which is further compounded by AF. However, the role of anticoagulation for stroke prophylaxis in ESRD and AF is debated. The ESRD population presents a unique challenge because of the combination of elevated stroke and bleeding risks. Warfarin has been traditionally used in this population, but it is associated with significant risks of minor and major bleeding, particularly intracranial, thus leading many clinicians to forgo anticoagulation altogether. When anticoagulation is prescribed, rates of adherence and persistence are poor, leaving many patients untreated. The direct oral anticoagulants (DOACs) may offer an alternative to warfarin in ESRD patients, but these agents have not been extensively studied in this population and uncertainties regarding comparative effectiveness (versus warfarin, each other, and no treatment) remain. In this review, we discuss the current evidence on the risk and benefits of anticoagulants in this challenging population and comparisons between warfarin and DOACs, and review future directions including options for non-pharmacologic stroke prevention.

Diagnosis of coronary artery disease in patients with atrial fibrillation using low tube voltage coronary CT angiography with isotonic low-concentration contrast agent

This prospective study evaluated the image quality and accuracy of coronary computed tomography angiography (CCTA) for diagnosing coronary artery disease (CAD) in patients with atrial fibrillation (AF), in which CCTA used adaptive iterative dose reduction (AIDR) with a low tube voltage and low concentration of isotonic contrast agent. Sixty-eight consecutive patients with AF and suspected CAD were equally and randomly apportioned to two groups and underwent CCTA. In the experimental group, the contrast agent was iodixanol (270 mg I/mL), patients were scanned with 100 kV, and reconstruction was by AIDR. In the conventional scanning (control) group, the contrast agent was iopromide (370 mg I/mL), patients were scanned with 120 kV, and reconstruction was by filtered back projection. The image quality, effective radiation dose (E), and total iodine intake of the groups were compared. Thirty-nine patients with coronary artery stenosis later were given invasive coronary angiography (ICA). The groups were similar with regard to mean CT value, noise, and signal-to-noise and contrast-to-noise ratios. The figure of merit of the experimental group was significantly higher than that of the control group, while the E and total iodine were significantly lower. Using ICA as the diagnostic reference, the groups shared similar sensitivity, specificity, and false positive and false negative rates for diagnosing coronary artery stenosis. For determining CAD in patients with AF, CCTA with isotonic low-concentration contrast agent and low-voltage scanning is a feasible alternative that improves accuracy and reduces radiation dose and iodine intake.

Atrial fibrillation and chronic kidney disease: A review of options for therapeutic anticoagulation to reduce thromboembolism risk

Atrial fibrillation and chronic kidney disease (CKD) commonly occur together, which poses a therapeutic dilemma due to increased risk of both systemic thromboembolism and bleeding. Chronic kidney disease also has implications for medication selection. The objective of this review is to evaluate the options for anticoagulation for thromboembolism prevention in patients with atrial fibrillation and chronic kidney disease. We searched PubMed for studies of patients with atrial fibrillation and CKD on warfarin or a direct oral anticoagulant (DOAC) for thromboembolism prevention through January 1 2018, in addition to evaluating major trials evaluating DOACs and warfarin use as well as society guidelines. For patients with mild to moderate chronic kidney disease, primarily observational data supports the use of warfarin, and high quality trial data and meta-analyses support the use and possible superiority of DOACs. For patients with severe chronic kidney disease, there are limited data on warfarin which supports its use, and data for DOACs is limited primarily to pharmacologic studies which support dose reductions but lack information on patient outcomes. For patients with end-stage renal disease, studies on warfarin are conflicting, but the majority suggest a lack of benefit and possible harm; studies in DOACs are very limited, but apixaban is the least renally cleared and may be both safe and effective. In conclusion, warfarin or DOACs may be used based on the degree of severity of chronic kidney disease, but further study in needed in patients with end-stage renal disease.