Clinical relevance of incomplete device endothelialization after left atrial appendage closure

Association Between Triglyceride-Glucose Index and Incomplete Device Endothelialization After Left Atrial Appendage Occlusion: A Retrospective Observational Study

BACKGROUND

The triglyceride-glucose (TyG) index, a biomarker for insulin resistance, has been shown to be associated with cardiovascular diseases. However, its association with delayed device endothelialization after left atrial appendage occlusion (LAAO) has not yet been explored.

METHODS

This retrospective study included 594 patients with non-valvular atrial fibrillation (NVAF) who underwent LAAO with the Watchman2.5 device at the Electrophysiology Center of Taizhou People's Hospital, Nanjing Medical University. Postoperative follow-up was performed at 3 months using Contrast-Enhanced Computed Tomography Angiography (CCTA). Patients were grouped based on quartiles of the TyG index. Logistic regression analysis and restricted cubic spline (RCS) regression models were used to evaluate the association between the TyG index and incomplete device endothelialization (IDE) postprocedure.

RESULTS

The TyG index was divided into four groups based on quartiles, with Group 1 (TyG index ≤ 8.17) serving as the reference. In Groups 3 (8.32 < TyG index ≤ 8.50) and 4 (TyG index > 8.50), the TyG index was identified as an independent risk factor for IDE postprocedure. The RCS model confirmed a significant linear relationship between the TyG index and IDE postprocedure. Furthermore, the association between the TyG index and IDE was consistent across different subgroups.

CONCLUSION

A higher TyG index was significantly associated with IDE after LAAO, suggesting that it could serve as a simple, cost-effective biomarker for predicting the risk of IDE in this population.

Optimal duration of anticoagulation after left atrial appendage closure: a systematic review and meta-analysis

BACKGROUND

Left atrial appendage closure (LAAC) has become the treatment of choice for stroke prevention in patients with nonvalvular atrial fibrillation who are at high risk of bleeding or with contraindications for anticoagulation. However, the optimal duration of anticoagulation after LAAC remains uncertain. The aim of this study was to evaluate the optimal duration of treatment with novel oral anticoagulants (NOACs) after LAAC.

METHOD

We searched the PubMed, Embase, Cochrane Library, and Web of Science databases for studies related to LAAC published from inception to 20 December 2023, and performed a meta-analysis comparing the efficacy and safety of 45-day and 3-month postoperative NOAC treatment using R4.3.1 software.

RESULTS

A total of 14 studies were included in this study, of which 4 were prospective cohort studies and 10 were retrospective cohort studies. The incidence of stroke or transient ischaemic attack (0.018 [95% CI: 0.007-0.033] in the 3-month group and 0.005 [95% CI: 0.001-0.011] in the 45-day group; P = 0.07) and the incidence of device-related thrombus (0.025 [95% CI: 0.002-0.065] in the 3-month group and 0.020 [ 95% CI: 0.007-0.037] in the 45-day group; P = 0.81) were not significantly different. However, the incidence of major bleeding was significantly greater in the 3-month group than in the 45-day group (0.033 [95% CI: 0.018-0.053] in the 3-month group and 0.003 [95% CI: 0.000-0.008] in the 45-day group; P < 0.01).

CONCLUSIONS

Compared with the 3-month scheme, 45 days of postoperative anticoagulation significantly reduced the risk of major bleeding in patients without compromising the efficacy of preventing stroke or transient ischaemic attack and device-related thrombus.

TRIAL REGISTRATION

Our meta-analysis was registered in the PROSPERO international database (CRD42024524661).

Comparison of prognosis and analysis of related risk factors among three different left atrial appendage occlusion procedures in patients with atrial fibrillation

Background

Left atrial appendage occlusion (LAAO) serves as an alternative to oral anticoagulation (OAC) for atrial fibrillation (AF) patients at high risk of bleeding. The aim of this study was to compare the peri-procedural safety, complete or incomplete occlusion, the incidence of the peri-device leak (PDL), and device-related thrombosis (DRT) among LAAO, cryoballoon ablation (CBA) combined with LAAO, and radiofrequency catheter ablation (RFCA) combined with LAAO and to explore the risk factors of PDL and incomplete occlusion.

Methods

382 patients with non-valvular AF who underwent either LAAO alone (n = 117), CBA combined with LAAO (n = 125), or RFCA combined with LAAO (n = 140) were included in the retrospective study. The study assessed peri-procedural complications and imaging results (3 months post-procedure). Multivariable logistic regression was employed to identify risk factors for incomplete occlusion and PDL.

Results

Peri-procedural complication rates were low among all groups, with 2.9% in the RFCA combined with the LAAO group. In contrast, the LAAO alone and CBA combined with LAAO groups reported no major complications (p = 0.347). At the 3-month follow-up, the incidence of DRT was 1.7% in the LAAO group, 2.4% in the CBA combined with the LAAO group, and 2.1% in the RFCA combined with the LAAO group (p = 0.930). Complete occlusion rates were comparable among the groups: 64.8% for CBA combined with LAAO, 62.4% for LAAO alone, and 60.7% for RFCA combined with LAAO (p = 0.794). PDL occurred in 33.3% of LAAO-alone patients, 34.4% of CBA combined with LAAO patients, and 38.6% of RFCA combined with LAAO patients (p = 0.644). Multivariable analysis identified persistent AF and serum creatinine (SCr) as independent predictors of PDL and incomplete occlusion.

Conclusion

Peri-procedural complications, complete occlusion, PDL, and DRT rates were similar across the three treatment strategies. Persistent AF and SCr were significant risk factors for incomplete occlusion and PDL. These findings highlight the importance of individualized treatment strategies based on patient-specific risk factors for optimizing outcomes.

Clinical incidence and relevance of incomplete endothelialization in atrial fibrillation patients with Left Atrial Appendage Closure

BACKGROUND

The objective of this study is to investigate the incidence, potential risk factors, and clinical outcomes of incomplete device endothelialization (IDE) in atrial fibrillation (AF) patients undergoing Watchman left atrial appendage closure (LAAC).

METHODS

In this study, 68 AF patients who underwent successful implantation of the Watchman device without peri-device leak (PDL) during follow-up were included. The endothelialization status was assessed using Transesophageal echocardiography (TEE) and LAA computed tomography angiography (CTA) at 6 weeks and 6 months post-implantation. Adverse cerebro-cardiac events were documented at one-year follow-up. Baseline characteristics, including age, device sizes, and clinical indicators, were analyzed as potential predictors for IDE.

RESULTS

IDE was observed in 70.6% and 67.6% of patients at 6 weeks and 6 months after implantation, respectively. Higher levels of high-density lipoprotein cholesterol (HDL-C) [odds ratio (OR): 15.109, 95% confidence interval (CI): 1.637-139.478, p = 0.017 and OR: 11.015, 95% CI: 1.365-88.896, p = 0.024] and lower aspartate aminotransferase (AST) (OR 0.924, 95% CI: 0.865-0.986, p = 0.017 and OR: 0.930, 95% CI: 0.874-0.990, p = 0.023) at baseline were found to be significantly associated with IDE at 6 weeks and 6 months, respectively, although no significant difference in adverse cerebro-cardiac events was noted between incomplete and complete DE groups during 1-year follow-up CONCLUSIONS: IDE is found to be a prevalent occurrence in humans following LAAC. Elevated HDL-C and reduced AST levels are shown to be linked to an increased risk of IDE after LAAC.

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

BACKGROUND

Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation.

METHODS

This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management.

RESULTS

A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy.

CONCLUSION

Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.