1
|
Ioannou M, Leonidou E, Chaziri I, Mouzarou A. Direct Oral Anticoagulants: Navigating Through Clinical Challenges. Cardiovasc Drugs Ther 2024; 38:637-650. [PMID: 37552381 DOI: 10.1007/s10557-023-07499-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
PURPOSE Direct oral anticoagulants (DOACs) have been approved, for over a decade, by both European and American medicine agencies, for treatment and prevention of several cardiovascular conditions. Since then, an increasing amount of data has been added to the medical literature day by day, resulting in a dichotomy in selection of the appropriate agent, dosage, and duration of treatment for special populations with multiple comorbidities. Considering these issues, we have prepared a comprehensive review for the clinical practitioner, to optimize the DOAC utilization in clinical practice. METHODS A thorough literature search and review was conducted, concerning mainly the last decade. Our review focused on the current guidelines and the most recently published studies in PubMed, Science Direct Scopus, and Google Scholar to date. CONCLUSION The purpose of this study is to provide guidance for healthcare professionals for making proper decisions when confronted with clinical challenges. Nevertheless, further research is required to establish DOAC superiority in complicated cases, where there is clinical uncertainty.
Collapse
Affiliation(s)
- Maria Ioannou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus.
| | - Elena Leonidou
- Department of Cardiology, General Hospital Limassol, State Health Organization Services, 4131, Limassol, Cyprus
| | - Ioanna Chaziri
- Department of Pneumonology, Northern Älvborg County Hospital, Trollhättan, Sweden
| | - Angeliki Mouzarou
- Department of Cardiology, General Hospital Paphos, State Health Organization Services, Paphos, Cyprus
| |
Collapse
|
2
|
Okada M, Inoue K, Tanaka N, Tanaka K, Hirao Y, Iwakura K, Egami Y, Masuda M, Watanabe T, Minamiguchi H, Oka T, Hikoso S, Sunaga A, Okada K, Nakatani D, Sotomi Y, Sakata Y. Impact of left atrial appendage flow velocity on thrombus resolution and clinical outcomes in patients with atrial fibrillation and silent left atrial thrombi: insights from the LAT study. Europace 2024; 26:euae120. [PMID: 38691672 PMCID: PMC11106584 DOI: 10.1093/europace/euae120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/14/2024] [Accepted: 04/25/2024] [Indexed: 05/03/2024] Open
Abstract
AIMS Blood stasis is crucial in developing left atrial (LA) thrombi. LA appendage peak flow velocity (LAAFV) is a quantitative parameter for estimating thromboembolic risk. However, its impact on LA thrombus resolution and clinical outcomes remains unclear. METHODS AND RESULTS The LAT study was a multicentre observational study investigating patients with atrial fibrillation (AF) and silent LA thrombi detected by transoesophageal echocardiography (TEE). Among 17 436 TEE procedures for patients with AF, 297 patients (1.7%) had silent LA thrombi. Excluding patients without follow-up examinations, we enrolled 169 whose baseline LAAFV was available. Oral anticoagulation use increased from 85.7% at baseline to 97.0% at the final follow-up (P < 0.001). During 1 year, LA thrombus resolution was confirmed in 130 (76.9%) patients within 76 (34-138) days. Conversely, 26 had residual LA thrombi, 8 had thromboembolisms, and 5 required surgical removal. These patients with failed thrombus resolution had lower baseline LAAFV than those with successful resolution (18.0 [15.8-22.0] vs. 22.2 [17.0-35.0], P = 0.003). Despite limited predictive power (area under the curve, 0.659; P = 0.001), LAAFV ≤ 20.0 cm/s (best cut-off) significantly predicted failed LA thrombus resolution, even after adjusting for potential confounders (odds ratio, 2.72; 95% confidence interval, 1.22-6.09; P = 0.015). The incidence of adverse outcomes including ischaemic stroke/systemic embolism, major bleeding, or all-cause death was significantly higher in patients with reduced LAAFV than in those with preserved LAAFV (28.4% vs. 11.6%, log-rank P = 0.005). CONCLUSION Failed LA thrombus resolution was not rare in patients with AF and silent LA thrombi. Reduced LAAFV was associated with failed LA thrombus resolution and adverse clinical outcomes.
Collapse
Affiliation(s)
- Masato Okada
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Koichi Inoue
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
- Cardiovascular Division, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Nobuaki Tanaka
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Koji Tanaka
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Yuko Hirao
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Katsuomi Iwakura
- Cardiovascular Centre, Sakurabashi Watanabe Hospital, 2-4-32 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Yasuyuki Egami
- Division of Cardiology, Osaka Rosai Hospital, Osaka, Japan
| | - Masaharu Masuda
- Cardiovascular Centre, Kansai Rosai Hospital, Amagasaki, Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Centre, Osaka, Japan
| | | | - Takafumi Oka
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Shungo Hikoso
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
| | - Akihiro Sunaga
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Katsuki Okada
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
- Department of Medical Informatics, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisaku Nakatani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yohei Sotomi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| |
Collapse
|
3
|
Ma C, Wu S, Liu S, Han Y. Chinese guidelines for the diagnosis and management of atrial fibrillation. Pacing Clin Electrophysiol 2024. [PMID: 38687179 DOI: 10.1111/pace.14920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 11/30/2023] [Indexed: 05/02/2024]
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
Collapse
Affiliation(s)
- Changsheng Ma
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shulin Wu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Shaowen Liu
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| | - Yaling Han
- Chinese Society of Cardiology, Chinese Medical Association, Heart Rhythm Committee of Chinese Society of Biomedical Engineering, Beijing, China
| |
Collapse
|
4
|
MA CS, WU SL, LIU SW, HAN YL. Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. J Geriatr Cardiol 2024; 21:251-314. [PMID: 38665287 PMCID: PMC11040055 DOI: 10.26599/1671-5411.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.
Collapse
|
5
|
Hu T, Chen C, Maduray K, Han W, Chen T, Zhong J. Comparative effectiveness and safety of DOACs vs. VKAs in treatment of left ventricular thrombus- a meta-analysis update. Thromb J 2024; 22:23. [PMID: 38429631 PMCID: PMC10905864 DOI: 10.1186/s12959-024-00585-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 01/22/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Left ventricular thrombus (LVT) formation in patients with acute myocardial infarction (AMI) or cardiomyopathies is not uncommon. The optimal oral anticoagulation therapy for resolving LVT has been under intense debate. Vitamin K antagonists (VKAs) remain the anticoagulant of choice for this condition, according to practice guidelines. Evidence supporting the use of direct oral anticoagulants (DOACs) in the management of LVT continues to grow. We performed a systematic review and meta-analysis to compare the efficacy and safety of DOACs versus VKAs. METHODS A comprehensive literature search was carried out in PubMed, Cochrane Library, Web of Science, Embase, and Scopus databases in July 2023. The efficacy outcomes of this study were thrombus resolution, ischemic stroke, systemic embolism, stroke/systemic embolism, all-cause mortality, and adverse cardiovascular events. The safety outcomes were any bleeding, major bleeding, and intracranial hemorrhage. A total of twenty-seven eligible studies were included in the meta-analysis. Data were analyzed utilizing Stata software version 15.1. RESULTS There was no significant difference between DOACs and VKAs with regard to LVT resolution (RR = 1.00, 95% CI 0.95-1.05, P = 0.99). In the overall analysis, DOACs significantly reduced the risk of stroke (RR = 0.74, 95% CI 0.57-0.96, P = 0.021), all-cause mortality (RR = 0.70, 95% CI 0.57-0.86, P = 0.001), any bleeding (RR = 0.75, 95% CI 0.61-0.92, P = 0.006) and major bleeding (RR = 0.67, 95% CI 0.52-0.85, P = 0.001) when compared to VKAs. Meanwhile, in the sub-analysis examining randomized controlled trials (RCTs), the aforementioned outcomes no longer differed significantly between the DOACs and VKAs groups. The incidences of systemic embolism (RR = 0.81, 95% CI 0.54-1.22, P = 0.32), stroke/systemic embolism (RR = 0.85, 95% CI 0.72-1.00, P = 0.056), intracranial hemorrhage (RR = 0.59, 95% CI 0.23-1.54, P = 0.28), and adverse cardiovascular events (RR = 0.99, 95% CI 0.63-1.56, P = 0.92) were comparable between the DOACs and VKAs groups. A subgroup analysis showed that patients treated with rivaroxaban had a significantly lower risk of stroke (RR = 0.24, 95% CI 0.08-0.72, P = 0.011) than those in the VKAs group. CONCLUSION With non-inferior efficacy and superior safety, DOACs are promising therapeutic alternatives to VKAs in the treatment of LVT. Further robust investigations are warranted to confirm our findings.
Collapse
Affiliation(s)
- Tong Hu
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China
| | - Changli Chen
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China
| | - Kellina Maduray
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China
| | - Wenqiang Han
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China
| | - Tongshuai Chen
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China.
| | - Jingquan Zhong
- National Key Laboratory for Innovation and Transformation of Luobing Theory; The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences; Department of Cardiology, Qilu Hospital of Shandong University, 107 Wen Hua Xi Road, Jinan, 250012, China.
- Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, 758 Hefei Road, Qingdao, 266035, Shandong, China.
| |
Collapse
|
6
|
Ashraf T, Aamir KF, Nadeem A, Murtaza S, Akhtar P, Haque SY, Ghaffar R, Hassan MU, Tipoo FA. Left atrial appendage thrombus with severe mitral stenosis: Responders and non-responders to anticoagulation. Rev Port Cardiol 2024:S0870-2551(24)00070-2. [PMID: 38401704 DOI: 10.1016/j.repc.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 02/26/2024] Open
Abstract
INTRODUCTION AND OBJECTIVE Mitral stenosis (MS) is one of the most frequently observed valvular heart lesions in developing countries and is due to different etiologies. The effects of anticoagulation in different types of left atrial appendage (LAA) are unknown. The current study aimed to determine the resolution of LAA thrombus on transesophageal echocardiography (TEE) after three months of optimal anticoagulation in patients with different types of LAA at baseline cardiac computed tomography of patients with severe MS. METHODS This prospective cohort study observed the frequency of LAA thrombus resolution after three months of anticoagulation therapy in patients with severe MS. The response rate in different morphologies of LAA and locations was also assessed. Thrombus resolution after three months of warfarin therapy was assessed on repeat TEE. RESULTS A total of 88 patients were included, mean age 37.95±11.87 years. Repeat TEE showed thrombus resolution in only 27.3% of patients. The rate of thrombus resolution was 8/12 (66.7%), 4/28 (14.3%), 8/36 (22.2%), and 4/12 (33.3%) for patients with cactus, cauliflower, chicken wing, and windsock LAA type, respectively. The resolution rate was 0/12 (0%), 4/44 (9.1%), and 20/32 (62.5%) for patients with thrombus in the base, body, and tip of the LAA, respectively. CONCLUSION The cactus type of LAA morphology and thrombus at the LAA tip responded well to three months of anticoagulation, however, patients with thrombus in the LAA base and body and cauliflower and chicken wing morphology were non-responders and could benefit from early referral for surgical management.
Collapse
Affiliation(s)
- Tariq Ashraf
- Karachi Institute of Heart Diseases, Karachi, Pakistan.
| | | | - Asif Nadeem
- Armed Forces Institute of Cardiology & National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan
| | | | - Parveen Akhtar
- National Institute of Cardiovascular Diseases (NICVD), Karachi, Pakistan
| | | | | | | | | |
Collapse
|
7
|
Zhang J, Li C, Zhou L, Sang C, Li S, Ma C. Characteristics and outcome of patients with left atrial appendage closure in China: a single-center experience. BMC Cardiovasc Disord 2024; 24:108. [PMID: 38355458 PMCID: PMC10865656 DOI: 10.1186/s12872-023-03651-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 12/01/2023] [Indexed: 02/16/2024] Open
Abstract
BACKGROUND Clinical characteristics and long-term data on the safety and efficacy of LAAC in preventing cerebrovascular accident and thromboembolism among Chinese patients with non-valvular AF (NVAF) remain limited. METHODS Data of consecutive NVAF patients who underwent LAAC at Beijing Anzhen Hospital, Capital Medical University, from June 1, 2014, to December 31, 2021, were collected and analyzed retrospectively. The primary effectiveness endpoint was the composite endpoint of stroke/transient ischemic attack, systemic embolism, and death from cardiovascular causes. The primary safety endpoint is the severe bleeding defined by the LAAC Munich consensus. RESULTS Of the 222 patients enrolled, the mean age was 66.90 ± 9.62 years, with a majority being male (77.03%). Many patients are non-paroxysmal AF (71.19%) with a median duration of AF of 4.00 years. The mean CHA2DS2-VASc score was 3.78 ± 1.49, and the mean HAS-BLED score was 1.68 ± 0.86. Thromboembolic events (76.58%) were the most common indication for LAAC. The device, technical, and procedural success rates were 98.65%, 98.65%, and 93.69%, respectively. The anticoagulation continuation rate was 56.36%, 31.25%, and 22.60% at 3-, 6- and 12 months post-procedure, respectively. Throughout a mean 2.81 years of follow-up, the incidence of the primary efficacy endpoint was 4.27 per 100 patient-years, predominantly attributable to stroke/TIA (3.12 per 100 PYs). Five patients experienced major bleeding during the follow-up period. Post-procedure imaging revealed minimal complications, with only one substantial peri-device leak. Device-related thrombus occurred in 2.33% of patients, resolving with anticoagulation. CONCLUSION The study demonstrates that LAAC is a safe and effective alternative option for Chinese patients with AF, with a high success rate, few complications as well as fewer long-term adverse outcome events.
Collapse
Affiliation(s)
- Jingrui Zhang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Changyi Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Lu Zhou
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Caihua Sang
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China
| | - Songnan Li
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital affiliated Capital Medical University, No. 2 Anzhen Road, Chaoyang District, Beijing, 100026, China.
- National Clinical Research Center for Cardiovascular Diseases, Beijing, China.
| |
Collapse
|
8
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
Collapse
|
10
|
Beemsterboer C, Rinkel L, Guglielmi V, Groeneveld NS, Lobé N, Boekholdt S, Bouma B, Muller F, Beenen L, Marquering H, Majoie C, Roos Y, van Randen A, Planken R, Coutinho J. Cardiac thrombus dissolution in acute ischemic stroke: A substudy of Mind the Heart. Heliyon 2023; 9:e20627. [PMID: 37842570 PMCID: PMC10570568 DOI: 10.1016/j.heliyon.2023.e20627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023] Open
Abstract
Background Cardiac thrombi are an important cause of ischemic stroke but are infrequently detected on cardiac imaging. We hypothesized that this might be explained by early dissolution of these cardiac thrombi after stroke occurrence. Methods We performed a single-center observational pilot study between November 2019 and November 2020, embedded in the larger "Mind-the-Heart" study. We included patients with AIS and a cardiac thrombus in the left atrium or ventricle (filling defect <100 Hounsfield Units) diagnosed on cardiac CT that was acquired during the initial stroke imaging protocol. We repeated cardiac CT within one week to determine if the thrombus had dissolved. Results Five patients (four men, median age 52 years, three with atrial fibrillation and one with anticoagulation therapy at baseline) were included. Median time from symptom onset to first cardiac CT was 383 (range 42-852) minutes and median time from first to second cardiac CT was three days (range 1-7). Two patients received intravenous thrombolysis (IVT). In total, six thrombi were seen on initial CT imaging (one in the left ventricle, four in the left atrial appendage, one in the left atrium). The left atrium thrombus and one left atrial appendage thrombus had dissolved on follow-up cardiac CT, one of which was in a patient with IVT treatment. Conclusion This pilot study illustrates that cardiac thrombi can dissolve within days of stroke occurrence both with and without IVT treatment.
Collapse
Affiliation(s)
| | - L.A. Rinkel
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| | - V. Guglielmi
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| | - N.-S. Groeneveld
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| | - N.H.J. Lobé
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
| | - S.M. Boekholdt
- Department of Cardiology, Amsterdam UMC, Location AMC, the Netherlands
| | - B.J. Bouma
- Department of Cardiology, Amsterdam UMC, Location AMC, the Netherlands
| | - F.F. Muller
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| | - L.F.M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
| | - H.A. Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, the Netherlands
| | - C.B.L.M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
| | - Y.B.W.E.M. Roos
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| | - A. van Randen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
| | - R.N. Planken
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, the Netherlands
| | - J.M. Coutinho
- Department of Neurology, Amsterdam UMC, Location AMC, the Netherlands
| |
Collapse
|
11
|
Segan L, Nanayakkara S, Spear E, Shirwaiker A, Chieng D, Prabhu S, Sugumar H, Ling L, Kaye DM, Kalman JM, Voskoboinik A, Kistler PM. Identifying Patients at High Risk of Left Atrial Appendage Thrombus Before Cardioversion: The CLOTS-AF Score. J Am Heart Assoc 2023; 12:e029259. [PMID: 37301743 PMCID: PMC10356043 DOI: 10.1161/jaha.122.029259] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/13/2023] [Indexed: 06/12/2023]
Abstract
Background Transesophageal echocardiography-guided direct cardioversion is recommended in patients who are inadequately anticoagulated due to perceived risk of left atrial appendage thrombus (LAAT); however, LAAT risk factors remain poorly defined. Methods and Results We evaluated clinical and transthoracic echocardiographic parameters to predict LAAT risk in consecutive patients with atrial fibrillation (AF)/atrial flutter undergoing transesophageal echocardiography before cardioversion between 2002 and 2022. Regression analysis identified predictors of LAAT, combined to create the novel CLOTS-AF risk score (comprising clinical and echocardiographic LAAT predictors), which was developed in the derivation cohort (70%) and validated in the remaining 30%. A total of 1001 patients (mean age, 62±13 years; 25% women; left ventricular ejection fraction, 49.8±14%) underwent transesophageal echocardiography, with LAAT identified in 140 of 1001 patients (14%) and dense spontaneous echo contrast precluding cardioversion in a further 75 patients (7.5%). AF duration, AF rhythm, creatinine, stroke, diabetes, and echocardiographic parameters were univariate LAAT predictors; age, female sex, body mass index, anticoagulant type, and duration were not (all P>0.05). CHADS2VASc, though significant on univariate analysis (P<0.001), was not significant after adjustment (P=0.12). The novel CLOTS-AF risk model comprised significant multivariable predictors categorized and weighted according to clinically relevant thresholds (Creatinine >1.5 mg/dL, Left ventricular ejection fraction <50%, Overload (left atrial volume index >34 mL/m2), Tricuspid Annular Plane Systolic Excursion (TAPSE) <17 mm, Stroke, and AF rhythm). The unweighted risk model had excellent predictive performance with an area under the curve of 0.820 (95% CI, 0.752-0.887). The weighted CLOTS-AF risk score maintained good predictive performance (AUC, 0.780) with an accuracy of 72%. Conclusions The incidence of LAAT or dense spontaneous echo contrast precluding cardioversion in patients with AF who are inadequately anticoagulated is 21%. Clinical and noninvasive echocardiographic parameters may identify patients at increased risk of LAAT better managed with a suitable period of anticoagulation before undertaking cardioversion.
Collapse
Affiliation(s)
- Louise Segan
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Shane Nanayakkara
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | | | | | - David Chieng
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Sandeep Prabhu
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Hariharan Sugumar
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - Liang‐Han Ling
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
| | - David M. Kaye
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Jonathan M. Kalman
- University of MelbourneMelbourneAustralia
- Royal Melbourne HospitalMelbourneAustralia
| | - Aleksandr Voskoboinik
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- Monash UniversityMelbourneAustralia
| | - Peter M. Kistler
- The Alfred HospitalMelbourneAustralia
- The Baker Heart and Diabetes Research InstituteMelbourneAustralia
- University of MelbourneMelbourneAustralia
- Monash UniversityMelbourneAustralia
| |
Collapse
|
12
|
Platzbecker K, Müller-Fielitz H, Foraita R, Koepp MJ, Voss A, Pflock R, Linder R, Pigeot I, Schink T, Schwaninger M. In atrial fibrillation epilepsy risk differs between oral anticoagulants: active comparator, nested case-control study. Europace 2023; 25:euad087. [PMID: 37013704 PMCID: PMC10228540 DOI: 10.1093/europace/euad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 03/16/2023] [Indexed: 04/05/2023] Open
Abstract
AIMS Atrial fibrillation (AF) is a risk factor for brain infarction, which can lead to epilepsy. We aimed to investigate whether treatment of AF with direct oral anticoagulants (DOACs) affects the risk of epilepsy in comparison to treatment with the vitamin K antagonist phenprocoumon (PPC). METHODS AND RESULTS We performed an active comparator, nested case-control study based on the German Pharmacoepidemiological Research Database that includes claims data from statutory health insurance providers of about 25 million persons since 2004. In 2011-17, 227 707 AF patients initiated treatment with a DOAC or PPC, of which 1828 cases developed epilepsy on current treatment with an oral anticoagulant. They were matched to 19 084 controls without epilepsy. Patients with DOAC treatment for AF had an overall higher risk of epilepsy with an odds ratio of 1.39, 95% CI (1.24; 1.55) compared to current PPC treatment. Cases had higher baseline CHA2DS2-VASc scores and more frequently a history of stroke than controls. After excluding patients with ischaemic stroke prior to the diagnosis of epilepsy, the risk of epilepsy was still higher on DOACs than on PPC. In contrast, within a cohort of patients with venous thromboembolism, the risk of epilepsy on treatment with DOACs was less elevated [adjusted odds ratio 1.15, 95% CI (0.98; 1.34)]. CONCLUSION In patients with AF initiating oral anticoagulation, treatment with a DOAC was associated with an increased risk of epilepsy compared to the vitamin K antagonist PPC. Covert brain infarction may explain the observed elevated risk of epilepsy.
Collapse
Affiliation(s)
- Katharina Platzbecker
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Helge Müller-Fielitz
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Ronja Foraita
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, University College London Queen Square Institute of Neurology, Queen Square, Box 29, London WC1N 3BG, United Kingdom
| | - Annemarie Voss
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - René Pflock
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Roland Linder
- Techniker Krankenkasse, Bramfelder Straße 140, 22305 Hamburg, Germany
| | - Iris Pigeot
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
- Faculty of Mathematics and Computer Science, University of Bremen, Bibliothekstraße 5, 28334 Bremen, Germany
| | - Tania Schink
- Leibniz Institute for Prevention Research and Epidemiology—BIPS, Achterstraße 30, 28359 Bremen, Germany
| | - Markus Schwaninger
- Institute for Experimental and Clinical Pharmacology and Toxicology, University of Lübeck, Ratzeburger Allee 160, 23562 Lübeck, Germany
- DZHK (German Research Centre for Cardiovascular Research), Hamburg-Lübeck-Kiel, Germany
| |
Collapse
|
13
|
Qiao Y, Zhao Z, Cai X, Guo Y, Liu K, Guo J, Guo T, Niu G. Prevalence, predictors and management of left atrial appendage thrombogenic milieu in atrial fibrillation with low thromboembolic risk. Thromb J 2023; 21:34. [PMID: 36998006 PMCID: PMC10064768 DOI: 10.1186/s12959-023-00478-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/22/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND The present study aimed to investigate the prevalence, predictors, and management of left atrial appendage (LAA) thrombogenic milieu (TM) identified with transesophageal echocardiography (TEE) in non-valvular atrial fibrillation (NVAF) patients with low to moderate thromboembolic (TE) risk. METHODS We retrospectively analyzed the baseline clinical data and TEE findings in 391 NVAF patients (54.7 ± 8.9 years, 69.1% male) with low to moderate TE risk according to the CHA2DS2-VASc score. LAA TM was defined as LAA thrombus (LAAT), sludge or spontaneous echo contrast (SEC). Management of LAA TM was at the discretion of the treating physician. RESULTS A total of 43 patients (11.0%) were detected with LAA TM, including 5 with LAAT (11.6%), 4 with LAAT + Sect. (9.3%), 3 with sludge (7.0%), and 31 with Sect. (72.1%). In multivariate model, non-paroxysmal AF (OR 3.121; 95% CI 1.205-8.083, p = 0.019), and a larger left atrial diameter (LAD) (OR 1.134; 95% CI 1.060-1.213, p < 0.001) were significantly associated with the presence of LAA TM. All LAATs or sludges effectively resolved after mean duration of 117.5 ± 20.0 days for oral anticoagulant (OAC) medication. TE events occurred in 3 patients (18.8%) among those discontinuing OAC over a mean follow-up of 26.2 ± 8.8 months, while no TE events occurred in patients with continuous OAC. CONCLUSIONS LAA TM could be identified in 11.0% in NVAF patients with low to moderate TE risk, especially in those with non-paroxysmal AF and enlarged LAD. Short-term OAC medication could effectively resolve the LAAT or sludge.
Collapse
Affiliation(s)
- Yu Qiao
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Zhen Zhao
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Xiang Cai
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Yulong Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Ke Liu
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Jinrui Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Tao Guo
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China
| | - Guodong Niu
- Department of Cardiac Arrhythmia, Fuwai Yunnan Cardiovascular Hospital, Kunming Medical University, Kunming, Yunnan, 650032, People's Republic of China.
- State Key Laboratory of Cardiovascular Disease, Cardiac Arrhythmia Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, 100037, People's Republic of China.
| |
Collapse
|
14
|
Yang Q, Quan X, Zhang Y, Feng G, Zhang T, Wang C, Yu D, Yu L, Yang Y, Zhu J, Liang Y. An exploratory study of effectiveness and safety of rivaroxaban in patients with left ventricular thrombus (R-DISSOLVE). J Thromb Thrombolysis 2023; 55:649-659. [PMID: 36940069 PMCID: PMC10026792 DOI: 10.1007/s11239-023-02790-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/21/2023]
Abstract
Evidence on the treatment for left ventricular (LV) thrombus is limited and mainly derives from retrospective studies. The aim of R-DISSOLVE was to explore the effectiveness and safety of rivaroxaban in patients with LV thrombus. R-DISSOLVE was a prospective, interventional, single-arm study, conducted from Oct 2020 to June 2022 at Fuwai Hospital, China. Patients with a history of LV thrombus < 3 months and with systemic anticoagulation therapy < 1 month were included. The thrombus was quantitatively confirmed by contrast-enhanced echocardiography (CE) at baseline and follow-up visits. Eligible patients were assigned to rivaroxaban (20 mg once daily or 15 mg if creatinine clearance was between 30 and 49 mL/min) and its concentration was determined by detecting anti-Xa activity. The primary efficacy outcome was the rate of LV thrombus resolution at 12 weeks. The main safety outcome was the composite of ISTH major and clinically relevant non-major bleeding. A total of 64 patients with complete CE results were analyzed for efficacy outcomes. The mean LV ejection fraction was 25.4 ± 9.0%. The dose-response curve of rivaroxaban was satisfactory based on the peak and trough plasma levels and all concentrations were in the recommended treatment range according to NOAC guidelines. The incidence rate of thrombus resolution at 6 weeks was 66.1% (41/62, 95% CI 53.0-77.7%), and of thrombus resolution or reduction was 95.2% (59/62, 95% CI 86.5-99.0%). At 12 weeks, the thrombus resolution rate was 78.1% (50/64, 95% CI 66.0-87.5%) while the rate of thrombus resolution or reduction was 95.3% (61/64, 95% CI 86.9-99.0%). The main safety outcome occurred in 4 of 75 patients (5.3%) (2 ISTH major bleeding and 2 clinically relevant non-major bleeding). In patients with LV thrombus, we reported a high thrombus resolution rate with acceptable safety by rivaroxaban, which could be a potential option for further LV thrombus treatment.Trial registration This study was registered at ClinicalTrials.gov as NCT04970381.
Collapse
Affiliation(s)
- Qing Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Xin Quan
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Echocardiographic, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yang Zhang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Laboratory Medicine, National Center for Cardiovascular Diseases and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Guangxun Feng
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Tao Zhang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Chuangshi Wang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Room 101-106, Block A, Shilong West Road, Mentougou District, Beijing, China
| | - Dongze Yu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Department of Laboratory Medicine, National Center for Cardiovascular Diseases and Fuwai Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, 100037, China
| | - Litian Yu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yanmin Yang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Jun Zhu
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
- Emergency Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Yan Liang
- National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
- Intensive Care Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| |
Collapse
|
15
|
Liu H, Lin M, Han W, Ge J, Maduray K, Zhong J. The risk factors of thrombus formation and the effect of catheter ablation on repetitive thrombus formation in patients with atrial fibrillation: a single center retrospective study in China. BMC Cardiovasc Disord 2023; 23:28. [PMID: 36650447 PMCID: PMC9843887 DOI: 10.1186/s12872-023-03050-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 01/06/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) predisposes patients to the formation of atrial thrombi. The CHA2DS2-VASc score does not include all risk factors for atrial thrombosis. The present study is designed to explore the influencing factors of thrombus formation in patients with AF and to investigate the effect of catheter ablation (CA) on recurrent thrombosis in patients with a history of intracardiac thrombus. METHODS (1) This study consisted of 1726 patients that underwent CA, among which 58 patients had a history of intracardiac thrombus prior to CA. The risk factors for thrombus formation were explored by comparing the baseline clinical characteristics of patients with and without atrial thrombus. (2) The left atrial appendage flow velocity (LAAFV) in patients with a history of intracardiac thrombus who were willing to undergo transesophageal echocardiography (TEE) at the latest follow-up were examined, and comparisons of the LAAFV was made before and after CA. RESULTS The median follow-up period is 13 months. Persistent AF was found to be the only independent risk factor affecting the formation of atrial thrombus among the investigated factors (OR 3.152; 95%CI 1.806-5.500; p < 0.001). Twenty-seven patients agreed to undergo TEE during follow-up, no clinical ischemic stroke events were recorded, no recurrent intracardiac thrombus formation was detected in patients, 15 patients maintained sinus rhythm (55.6%) during follow-up; successful CA significantly increased LAAFV (difference between latest evaluation prior to CA 17.46 ± 14.81 cm/s, p < 0.001). CONCLUSIONS Persistent AF is the only independent risk factor for thrombus formation. Successful CA may improve the LAAFV and thereby decrease the risk of intracardiac thrombus formation.
Collapse
Affiliation(s)
- Huiyu Liu
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China ,Department of Cardiology, Nanyang Central Hospital, Nanyang, China
| | - Mingjie Lin
- grid.27255.370000 0004 1761 1174Department of Cardiology, Qilu Hospital (Qingdao) of Shandong University, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, 758 Hefei Road, Qingdao, 266035 Shandong China
| | - Wenqiang Han
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Junye Ge
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Kellina Maduray
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China
| | - Jingquan Zhong
- grid.452402.50000 0004 1808 3430The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital of Shandong University, Jinan, China ,grid.27255.370000 0004 1761 1174Department of Cardiology, Qilu Hospital (Qingdao) of Shandong University, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, 758 Hefei Road, Qingdao, 266035 Shandong China
| |
Collapse
|
16
|
Badescu MC, Sorodoc V, Lionte C, Ouatu A, Haliga RE, Costache AD, Buliga-Finis ON, Simon I, Sorodoc L, Costache II, Rezus C. Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus. J Pers Med 2023; 13:jpm13010158. [PMID: 36675819 PMCID: PMC9866081 DOI: 10.3390/jpm13010158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/17/2022] [Accepted: 01/12/2023] [Indexed: 01/18/2023] Open
Abstract
In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.
Collapse
Affiliation(s)
- Minerva Codruta Badescu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Victorita Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Catalina Lionte
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
- Correspondence: (V.S.); (C.L.)
| | - Anca Ouatu
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Raluca Ecaterina Haliga
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Alexandru Dan Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiovascular Rehabilitation Clinic, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Oana Nicoleta Buliga-Finis
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ioan Simon
- Department of Surgery, Faculty of Medicine, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laurentiu Sorodoc
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- II Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Irina-Iuliana Costache
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Cardiology Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- III Internal Medicine Clinic, “St. Spiridon” County Emergency Clinical Hospital, 700111 Iasi, Romania
| |
Collapse
|
17
|
The Comparative Effectiveness and Safety of Different Anticoagulation Strategies for Treatment of Left Atrial Appendage Thrombus in the Setting of Chronic Anticoagulation for Atrial Fibrillation or Flutter. Cardiovasc Drugs Ther 2023; 37:159-168. [PMID: 34669102 PMCID: PMC9834361 DOI: 10.1007/s10557-021-07278-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 01/16/2023]
Abstract
PURPOSE To compare effectiveness of different treatments for atrial fibrillation (AF) patients who were scheduled for cardioversion (CV) or ablation (CA) presenting with left atrium appendage (LAA) thrombus despite chronic oral anticoagulation therapy (OAC). METHODS This was a retrospective cohort study. We analyzed 2014-2019 medical records of patients scheduled for CV or CA of AF who were diagnosed with LAA thrombus despite optimal OAC and had a follow-up transesophageal echocardiogram (TOE). Changes in treatment were divided into the following groups: switch to a drug with different mechanism of action, switch to a drug with similar mechanism of action, initiation of combination therapy, or deliberate no change in treatment. Patients with contraindications to non-vitamin K antagonists were excluded from the analysis. RESULTS We analyzed data of 129 patients comprising 181 cycles of treatment. The overall effectiveness of LAA thrombus dissolution was 51.9% regardless of the number of cycles and 42.6% for the first cycle of treatment. Any change of treatment was more effective than deliberate no change-OR 2.97 [95% CI: 1.07-8.25], P = 0.031, but no particular strategy seemed to be more effective than the other. Left atrium area (OR 0.908 [95% CI: 0.842-0.979]) and number of treatment cycles (OR 0.457 [95% CI: 0.239-0.872]) were both adversely related to thrombus resolution. There was one ischemic and three bleeding adverse events during the treatment. CONCLUSION LAA thrombus resolution in patients already on OAC may require a change of previous OAC treatment but the overall effectiveness of dissolution seems to be about 50%.
Collapse
|
18
|
Touboul O, Algalarrondo V, Oghina S, Elbaz N, Rouffiac S, Hamon D, Extramiana F, Gandjbakhch E, D'Humieres T, Marijon E, Dhanjal TS, Teiger E, Damy T, Lellouche N. Electrical cardioversion of atrial arrhythmias with cardiac amyloidosis in the era of direct oral anticogulants. ESC Heart Fail 2022; 9:3556-3564. [PMID: 35903879 DOI: 10.1002/ehf2.14082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/10/2022] [Accepted: 07/18/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Atrial fibrillation (AF)/atrial flutter is common during cardiac amyloidosis (CA). Electrical cardioversion (EC) is a strategy to restore sinus rhythm (SR). However, left atrial thrombus (LAT) represents a contraindication for EC. CA patients with AF/atrial flutter have a high prevalence of LAT. We aimed to evaluate EC characteristics, LAT prevalence and risk factors, and AF/atrial flutter outcome in CA patients undergoing EC, predominantly treated with direct oral anticoagulants (DOACs). METHODS AND RESULTS All patients with CA and AF/atrial flutter referred for the first time to our national referral centre of amyloidosis for EC from June 2017 to February 2021 were included in this study. In total, 66 patients (median age 74.5 [70;80.75] years, 67% male) were included with anticoagulation consisted of DOAC in 74% of cases. All patients underwent cardiac imaging before EC to rule out LAT. EC was cancelled due to LAT in 14% of cases. Complete thrombus resolution was observed in only 17% of cases. The two independent parameters associated with LAT were creatinine [hazard ratio (HR) = 1.01; confidence interval (CI) = 1.00-1.03, P = 0.036] and the use of antiplatelet agents (HR = 13.47; CI = 1.85-98.02). EC acute success rate was 88%, and we observed no complication after EC. With 64% of patients under amiodarone, AF/atrial flutter recurrence rate following EC was 51% after a mean follow-up of 30 ± 27 months. CONCLUSIONS Left atrial thrombus was observed in 14% of CA patients listed for EC and mainly treated with DOAC. The acute EC success rate was high with no complication. The long-term EC success rate was acceptable (49%).
Collapse
Affiliation(s)
- Olivier Touboul
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | | | - Silvia Oghina
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nathalie Elbaz
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Segolene Rouffiac
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - David Hamon
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Fabrice Extramiana
- Department of Cardiology, AP-HP, University Hospital Bichat, Paris, France
| | - Estelle Gandjbakhch
- Department of Cardiology, AP-HP, University Hospital Pitié-Salpétrière, Paris, France
| | - Thomas D'Humieres
- Department of Physiology, AP-HP, University Hospital Henri Mondor, Creteil, France
| | - Eloi Marijon
- Department of Cardiology, AP-HP, University Hopital Européen Georges Pompidou, Paris, France
| | - Tarvinder S Dhanjal
- Department of Cardiac Electrophysiology, University of Warwick, Gibbet Hill, Coventry, UK
| | - Emmanuel Teiger
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Thibaud Damy
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| | - Nicolas Lellouche
- Department of Cardiology, AP-HP, University Hospital Henri Mondor, 51, Avenue du Maréchal de Lattre de Tassigny, 94000, Creteil, France
| |
Collapse
|
19
|
Ge J, Chen T, Ma C, Maduray K, Zhong J. Can intracardiac echocardiography completely replace transesophageal echocardiography to guide left atrial appendage closure?-The comparisons of intracardiac echocardiography with transesophageal echocardiography. J Card Surg 2022; 37:2766-2775. [PMID: 35726669 DOI: 10.1111/jocs.16695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/30/2022] [Indexed: 11/27/2022]
Abstract
Left atrial appendage closure (LAAC) is an effective means of preventing ischemic stroke in patients with nonvalvular atrial fibrillation. Transesophageal echocardiography (TEE) is the primary imaging technique to guide LAAC. Its shortcomings, namely the use of general anesthesia and tracheal intubation, inevitably increase procedural risks. Intracardiac echocardiography (ICE), a novel imaging modality for guiding LAAC, has proven more advantageous over TEE due to use of local anesthesia, shortened procedural time, and reduced radiation exposure. This review highlights the differences between ICE and TEE guided LAAC, aiming to provide a reference for clinical decision-making.
Collapse
Affiliation(s)
- Junye Ge
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Tongshuai Chen
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Chuanzhen Ma
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Kellina Maduray
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jingquan Zhong
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| |
Collapse
|
20
|
Sebag FA, Garot P, Galea R, de Backer O, Lepillier A, De Meesteer A, Hildick-Smith D, Armero S, Moubarak G, Ducrocq G, Eschalier R, Aminian A, Sauguet A, Lellouche N, Mahmoudi K, Räber L, Amabile N. Left atrial appendage closure for thrombus trapping: the international, multicentre TRAPEUR registry. EUROINTERVENTION 2022; 18:50-57. [PMID: 34794937 PMCID: PMC9903160 DOI: 10.4244/eij-d-21-00713] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Although the presence of a thrombus contraindicates left atrial appendage closure procedure (LAAC), a previous study reported the feasibility of the thrombus trapping procedure (TTP) technique to overcome this limitation. AIMS This study aimed to analyse the short-term outcomes in a series of patients who underwent LAAC using the TTP (TTP-LAAC). METHODS This retrospective series included patients who underwent TTP-LAAC between January 2018 and May 2020 in 13 European centres. Device choice, pre-interventional work-up and post-discharge antithrombotic therapy regimens were left to the discretion of the operators. The primary endpoint was the 30-day occurrence of stroke, systemic embolism or cardiovascular death. RESULTS During the study period, a total of 1,918 patients underwent LAAC. A thrombus was identified in 71 cases but completely disappeared in 24 patients before procedure. TTP-LAAC was finally performed in 53 cases (3%). Thrombi were identified ahead of the actual day of implantation in 47 patients (87%) and were mostly limited in size (50 cases with extension <50% of the LAA surface). The Amplatzer Amulet and WATCHMAN FLX occluders were implanted in 44 and 9 patients, respectively. A single deployment approach was applied in 70% and a cerebral embolic protection system was used in 9% of the patients. The overall success rate was 100%. Small pericardial effusion without tamponade was observed in 6% of the cases. Patients were discharged with 72% under antiplatelet therapy and 10% under short-term oral anticoagulation. The primary endpoint occurred in one patient. CONCLUSIONS TTP-LAAC might be used in a minority of LAAC procedures but appears to be feasible and safe in the short-term, in select cases.
Collapse
Affiliation(s)
- Frederic A. Sebag
- Service de Cardiologie, Institut Mutualiste Montsouris, 42 boulevard Jourdan, 75014 Paris, France
| | - Philippe Garot
- Hôpital Privé Jacques Cartier, Institut Cardiovasculaire Paris Sud (ICPS), Ramsay Santé, Massy, France
| | - Roberto Galea
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Ole de Backer
- Department of Cardiology, Rigshospital, Copenhagen, Denmark
| | - Antoine Lepillier
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | | | - David Hildick-Smith
- Cardiology Department, Royal Sussex Cardiac Centre, Brighton, United Kingdom
| | | | | | - Gregory Ducrocq
- Department of Cardiology, Hôpital Bichat - Claude-Bernard, Paris, France
| | - Romain Eschalier
- Department of Cardiology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Adel Aminian
- Department of Cardiology, C.H.U. de Charleroi, Charleroi, Belgium
| | | | | | - Khalil Mahmoudi
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern, Switzerland
| | - Nicolas Amabile
- Department of Cardiology, Institut Mutualiste Montsouris, Paris, France
| |
Collapse
|
21
|
Biller K, Biller B, Findeisen H, Eckardt L, Wedekind H. Resolution of left atrial appendage thrombi: No difference between phenprocoumon and non-vitamin K-dependent oral antagonists. Clin Cardiol 2022; 45:650-656. [PMID: 35373849 PMCID: PMC9175243 DOI: 10.1002/clc.23823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/13/2022] [Indexed: 11/12/2022] Open
Abstract
Background Atrial fibrillation is the most important risk factor for left atrial appendage (LAA) thrombi, a potentially life‐threatening condition. Thrombus resolution may prevent embolic events and allow rhythm‐control strategies, which have been shown to reduce cardiovascular complications. Hypothesis There is no significant difference between phenprocoumon and non‐Vitamin K‐dependent oral anticoagulants (NOACs) in the resolution of LAA‐thrombi in a real‐world setting. Methods Consecutive patients with LAA‐thrombi from June 2013 to June 2017 were included in an observational single‐center analysis. The primary endpoint was defined as the resolution of the thrombus. The observational period was 1 year. Resolutions rates in patients on phenprocoumon or NOACs were compared and the time to resolution was analyzed. Results We identified 114 patients with LAA‐thrombi. There was no significant difference in the efficacy of resolution between phenprocoumon and NOACs (p = .499) at the time of first control which took place after a mean of 58 ± 42.2 (median 48) days. At first control most thrombi were dissolved (74.6%). The analysis after set‐time intervals revealed a resolution rate of 2/3 of LAA‐thrombi after 8–10 weeks in the phenprocoumon and NOAC groups. After 12 weeks a higher number of thrombi had resolved in the presence of NOAC (89.3%) whereas in the presence of phenprocoumon 68.3% had resolved (p = .046). Conclusion In this large observational study NOACs were found to be potent drugs for the resolution of LAA‐thrombi. In addition, the resolution of LAA‐thrombi was found to be faster in the presence of NOAC as compared to phenprocoumon.
Collapse
Affiliation(s)
- Katharina Biller
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital, Münster, Germany
| | - Benedikt Biller
- Department of Cardiology II-Electrophysiology, University Hospital, Münster, Germany
| | - Hannes Findeisen
- Department of Cardiology I-Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital, Münster, Germany
| | - Lars Eckardt
- Department of Cardiology II-Electrophysiology, University Hospital, Münster, Germany
| | - Horst Wedekind
- Department of Cardiology, St. Franziskus-Hospital, Münster, Germany
| |
Collapse
|
22
|
Dong SJ, Luo CY, Xiao CL, Zhang FZ, Li L, Han ZL, Zhai SD. Efficacy and Safety Profile of Novel Oral Anticoagulants in the Treatment of Left Atrial Thrombosis: A Systematic Review and Meta-Analysis. Curr Ther Res Clin Exp 2022; 96:100670. [PMID: 35515958 PMCID: PMC9062445 DOI: 10.1016/j.curtheres.2022.100670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The presence of left atrial/left atrial appendage thrombosis is associated with a higher risk of thromboembolic events in patients with atrial fibrillation. The optimal antithrombotic strategy is not established to date. Objective Our aim was to compare the efficacy and safety profile of novel oral anticoagulants with warfarin in the treatment of left atrial/left atrial appendage thrombosis. Methods We conducted a systematic search in PubMed, Embase, Cochrane Library, ClinicalTrials.gov, and 3 Chinese databases for all randomized controlled trials and cohort studies (PROSPERO, CRD42021238952) from inception to 7 May 2021. Two authors independently performed the articles selection, data extraction, and quality assessment. The efficacy outcome was the resolution of left atrial/left atrial appendage thrombosis, and the safety outcomes were bleeding and stroke/transient ischemic attack. Results One randomized controlled trial and 5 cohort studies were included, with a total of 353 patients. Compared with warfarin, novel oral anticoagulants were associated with increased probability of left atrial/left atrial appendage thrombosis resolution (OR = 2.20; 95% CI, 1.35–3.60; I2 = 0%). Compared with warfarin, novel oral anticoagulants had a similar risk of bleeding (OR = 0.91; 95% CI, 0.39–2.13; I2 = 0%). There was no evidence of increased risk of stroke/transient ischemic attack (OR = 0.42; 95% CI, 0.12–1.45; I2 = 0%). Conclusions Novel oral anticoagulants were more effective than warfarin in promoting the resolution of left atrial/left atrial appendage thrombosis, without increased risks of bleeding and stroke/transient ischemic attack. Our study provides valuable insight into clinical practice. Further well-designed randomized controlled trials are needed to fully evaluate the benefits and risks in these patients. PROSPERO Registration No.: CRD42021238952.
Collapse
Affiliation(s)
- Shu-Jie Dong
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Cong-Yan Luo
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Department of Pharmacy, Karamay Second People's Hospital, Karamay, China
| | - Cui-Lan Xiao
- Department of Pharmacy, Karamay Second People's Hospital, Karamay, China
| | - Feng-Zhe Zhang
- School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Lei Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital, Beijing, China
| | - Zhong-Ling Han
- Department of Pharmacy, Beijing Road Medical Area of Xinjiang Military Region General Hospital, Urumqi, China
| | - Suo-Di Zhai
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Address correspondence to: Suo-Di Zhai, BSc, Department of Pharmacy, Peking University Third Hospital, No. 49 N Garden Rd, Haidian District, Beijing, China.
| |
Collapse
|
23
|
A Prospective Study to Evaluate the Effectiveness of Edoxaban for the Resolution of Left Atrial Thrombosis in Patients with Atrial Fibrillation. J Clin Med 2022; 11:jcm11071945. [PMID: 35407553 PMCID: PMC8999540 DOI: 10.3390/jcm11071945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/22/2022] [Accepted: 03/28/2022] [Indexed: 11/16/2022] Open
Abstract
Available evidence on left atrial (LA) thrombus dissolution in patients with atrial fibrillation (AF) largely refers to the use of vitamin K antagonist oral anticoagulants (VKAs), showing >50% thrombus resolution over a 4-week to 12-month treatment period. Available data on non-vitamin K antagonist anticoagulants (NOACs) in this setting are limited and derive from isolated case reports or observational small-sized investigations with dabigatran, rivaroxaban or apixaban. The aim of this study was to investigate the extent of thrombus resolution with edoxaban therapy in patients with AF and LA thrombosis. We conducted a prospective, observational, open-label pilot study in seven Italian institutions. We included a total of 25 patients with non-valvular AF and LA (or left atrial appendage (LAA)) thrombosis, documented by transesophageal echocardiography (TEE). All patients received edoxaban OD treatment (n = 23 on 60 mg daily; n = 2 on 30 mg daily) and underwent TEE examination after 4 weeks. The primary endpoint was the percentage of patients with complete thrombus resolution by TEE imaging at 4 weeks. The mean age of the study population was 68.3 ± 10.8 years with a female population of 16%. AF was permanent in all cases, with a mean arrhythmia duration of 4.3 ± 1.7 years. CHA2DS2-VASc and HAS-BLED scores were 3.2 ± 1.5 and 1.9 ± 1.1, respectively. We were able to demonstrate a complete thrombus resolution in 14 patients (56%) at 4 weeks. In patients with residual atrial thrombosis (n = 11), we observed a 15.4 ± 14.9% reduction in the thrombus area from baseline. As compared with patients without thrombus dissolution, those with thrombus resolution had a numerically lower-indexed LA diameter (27.9 ± 9.3 vs 34.8 ± 16.1 mm/m2), a smaller maximum thrombus area at baseline (45.5 ± 44.6 vs 63.9 ± 43.5 mm2), a higher left ventricular ejection fraction (47.4 ± 21.0% vs 38.4 ± 20.6%) and higher maximum LAA flow velocities (26.3 ± 15.2 vs 19.3 ± 10.0 cm/s). Figures on the percentage of thrombus resolution in this study are comparable to those reported in the literature for the other OACs. We conclude that, in patients with AF, the use of edoxaban is associated with a >50% resolution of atrial thrombus at 4 weeks, similar to studies using VKAs and the other NOACs (ClinicalTrials.gov identifier number: NCT034899395).
Collapse
|
24
|
Abdelnabi M, Benjanuwattra J, Okasha O, Almaghraby A, Saleh Y, Gerges F. Switching from warfarin to direct-acting oral anticoagulants: it is time to move forward! Egypt Heart J 2022; 74:18. [PMID: 35347478 PMCID: PMC8960500 DOI: 10.1186/s43044-022-00259-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 03/20/2022] [Indexed: 11/12/2022] Open
Abstract
Oral vitamin K antagonists (VKAs), warfarin, have been in routine clinical use for almost 70 years for various cardiovascular conditions. Direct-Acting Oral Anticoagulants (DOACs) have emerged as competitive alternatives for VKAs to prevent stroke in patients with non-valvular atrial fibrillation (AF) and have become the preferred choice in several clinical indications for anticoagulation. Recent guidelines have limited the use of DOACs to patients with non-valvular AF to reduce the risk of cardioembolic complications and to treat venous thromboembolism (VTE). Although emerging evidence is suggestive of its high efficacy, there was a lack of data to support DOACs safety profile in patients with mechanical valve prosthesis, intracardiac thrombi, or other conditions such as cardiac device implantation or catheter ablation. Therefore, several clinical trials have been conducted to assess the beneficial effects of using DOACs, instead of VKAs, for various non-guideline-approved indications. This review aimed to discuss the current guideline-approved indications for DOACs, advantages, and limitations of DOACs use in various clinical indications highlighting the potential emerging indications and remaining challenges for DOACs use. Several considerations are in favour of switching from warfarin to DOACs including superior efficacy, better adverse effect profile, fewer drug-drug interactions, and they do not require frequent international normalized ratio (INR) monitoring. Large randomized controlled trials are required to determine the safety and efficacy of their use in various clinical indications.
Collapse
Affiliation(s)
- Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA. .,Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria University, Alexandria, Egypt.
| | - Juthipong Benjanuwattra
- Internal Medicine Department, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Osama Okasha
- Internal Medicine Department, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Abdallah Almaghraby
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yehia Saleh
- Cardiology Department, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
| | - Fady Gerges
- Department of Cardiovascular Science, Mediclinic Al Jowhara Hospital, Al Ain, UAE
| |
Collapse
|
25
|
Left atrial thrombus and smoke resolution in patients with atrial fibrillation under chronic oral anticoagulation. J Interv Card Electrophysiol 2022; 64:773-781. [DOI: 10.1007/s10840-022-01169-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/22/2022] [Indexed: 10/18/2022]
|
26
|
Prevalence and Rate of Resolution of Left Atrial Thrombus in Patients with Non-Valvular Atrial Fibrillation: A Two-Center Retrospective Real-World Study. J Clin Med 2022; 11:jcm11061520. [PMID: 35329845 PMCID: PMC8948620 DOI: 10.3390/jcm11061520] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/27/2022] [Accepted: 03/08/2022] [Indexed: 12/30/2022] Open
Abstract
Background and aim. Thromboembolic events due to left atrial appendage (LAA) thrombosis are the main complication of non-valvular atrial fibrillation (NVAF). Although anticoagulants are effective in patients with NVAF, a minimal residual thromboembolic risk persists. Little is known about the prevalence of LAA thrombus and the rate of resolution after the recommended period of anticoagulation therapy, including vitamin K antagonists (VKA), heparin, and non-vitamin K antagonist oral anticoagulants (NOACs). Methods and results. We aimed to study the prevalence of LAA thrombus in an unselected cohort of patients undergoing transesophageal echocardiogram (TEE), and the determinants of LAA thrombus resolution. We retrospectively analyzed 8888 consecutive TEEs performed over five years in two high-volume centers and included all patients with LAA thrombus. A total of 265 patients (3%) had an LAA thrombus. Among these, 97% presented with AF. Fifty-eight percent of patients were on anticoagulants at least three weeks before the diagnosis. After the LAA thrombus diagnosis, VKAs were prescribed in 52%, heparin in 18.5%, and NOAC in 27% of patients. Among the 183 patients with repeat TEE, performed at (25–75th) 39 days (21–84), 67% showed resolution of the LAA thrombus. Although the rate of thrombus resolution was higher in patients treated with NOACs (NOACs 71%, VKA 66%, Heparin 60%) the difference between anticoagulants was statistically non-significant (VKA, OR 0.9, p = 0.83; NOAC, OR 1.23, p = 0.42; heparin, OR 0.69, p = 0.35). Thus, NOACs were demonstrated to be at least as effective as other anticoagulants in the rate of LAA thrombus resolution. Upon multivariate-adjusted analysis, higher LAA emptying velocities were the only predictor of thrombus resolution. In conclusion, the majority of patients were already on anticoagulants. NOACs could be at least as effective as other anticoagulants, yielding an LAA thrombus resolution in two-thirds of patients. This may have clinical relevance, especially in patients undergoing cardioversion or catheter ablation.
Collapse
|
27
|
Risk of Death and Ischemic Stroke in Patients with Atrial Arrhythmia and Thrombus or Sludge in Left Atrial Appendage at One-Year Follow-Up. J Clin Med 2022; 11:jcm11041128. [PMID: 35207399 PMCID: PMC8879808 DOI: 10.3390/jcm11041128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/11/2022] [Accepted: 02/16/2022] [Indexed: 12/10/2022] Open
Abstract
Thrombus in the left atrial appendage is a contraindication for cardioversion. Sludge is considered similarly as threatening as thrombus; however, the risk of death and ischemic stroke in patients with atrial arrhythmia and thrombus or sludge is not well-known. This study focused on assessing the risk of death and ischemic stroke at one-year follow-up in patients with atrial arrhythmia and thrombus or sludge, as well as the effectiveness of anticoagulation in thrombus resolution. 77 out of 267 (29%) of patients who were scheduled for cardioversion were diagnosed with thrombus or sludge. The annual mortality in patients with thrombus or sludge was 23%. In the group without thrombus, the annual mortality was 1.6%. Overall, 17% of patients with thrombus or sludge experienced ischemic stroke. In patients without thrombus, the risk of stroke was 1%. Sludge increased risk of stroke compared to those without thrombus or sludge by 11% vs. 1%, respectively. No differences in mortality or stroke prevalence were observed between sludge and thrombus. Thrombus or sludge in the LAA have a poor prognosis. A diagnosis of sludge has a similar impact on risk of ischemic strokes as does a diagnosis of thrombus.
Collapse
|
28
|
Ito T, Akamatsu K, Hasegawa H, Sakatani Y, Miyamura M, Hoshiga M. Relationship of warfarin versus DOACs with thrombogenic milieu in the left atrium among patients with nonvalvular atrial fibrillation. Echocardiography 2022; 39:483-489. [PMID: 35137446 DOI: 10.1111/echo.15319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 01/25/2022] [Accepted: 01/30/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Thrombogenic milieu (TM) within the left atrium plays a pivotal role in the pathogenesis of thromboembolic events, for which anticoagulation treatment is indicated typically on the mandatory basis. Little is known, however, about which regimen of anticoagulation, warfarin or direct oral anticoagulants (DOACs), is more likely associated with TM. We evaluated relative relationship of the two treatment options with concurrently-observed TM in patients with nonvalvular atrial fibrillation (AF) who underwent transesophageal echocardiography. METHODS TM was defined as the presence of either left atrial spontaneous echo contrast (SEC) or thrombus, or both. To determine which regimen was more likely related to TM, we firstly compared the prevalence of TM in 208 patients taking warfarin (Warfarin group) versus 486 patients taking DOACs (DOAC group); and secondly, did the same analysis after propensity score matching. RESULTS Warfarin group was more likely associated with TM compared with DOAC group (46% vs 29%, p < 0.001). Similar findings were observed for dense SEC (18% vs 7%, p < 0.001) and thrombus (4% vs 1%, p = 0.057). The propensity score matching (198 patients for each group), where several baseline parameters were matched including age, gender, chronicity of AF, estimated glomerular filtration rate and B-type natriuretic peptide as well as the left ventricular ejection fraction, resulted in similar findings to the original groups (TM, 47% vs 32%, p = 0.002; dense SEC, 18% vs 7%, p = 0.001; thrombus, 4% vs 1%, p = 0.047). CONCLUSIONS This study may strengthen the data on randomized trials that DOACs are superior to warfarin in preventing thromboembolic events in nonvalvular AF patients. Further studies are required to elucidate the details behind this difference.
Collapse
Affiliation(s)
- Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Hitomi Hasegawa
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Yuka Sakatani
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masatoshi Miyamura
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| |
Collapse
|
29
|
Ben H, Changsheng M, Shulin W. 2019 Chinese expert consensus statement on left atrial appendage closure in patients with atrial fibrillation. Pacing Clin Electrophysiol 2022; 45:535-555. [PMID: 35032332 PMCID: PMC9314806 DOI: 10.1111/pace.14448] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 11/29/2022]
Abstract
The left atrial appendage closure (LAAC), the efficacy and safety of which has been proved by a number of randomized controlled trials and registries, is recommended by several guidelines to prevent stroke in high‐risk patients with non‐valvular atrial fibrillation. However, current guidelines only discuss the indications and contraindications of LAAC, as an emerging technology, there still lacks comprehensive recommendations involved with LAAC, including devices, image assessment modality, identification and treatment of complications, perioperative medication, and postoperative management. Therefore, the Chinese Society of Cardiology (CSC) of Chinese Medical Association (CMA) and the Editorial Board of Chinese Journal of Cardiology jointly issued the expert consensus statement on LAAC in the prevention of stroke in patients with atrial fibrillation after comprehensive discussion by experts with different backgrounds. This consensus provided three levels of recommendations to guide and standardize the clinical application of LAAC based on existing evidence and clinical practice experience, including appropriate (more potential benefits or fewer harms), uncertain (somehow reasonable but need more evidence), and inappropriate (unlikely to benefit, or have more complications).
Collapse
Affiliation(s)
- He Ben
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Ma Changsheng
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wu Shulin
- Department of Cardiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| |
Collapse
|
30
|
Chang P, Xiao J, Hu Z, Kwan AC, Fan Z. Imaging of left heart intracardiac thrombus: clinical needs, current imaging, and emerging cardiac magnetic resonance techniques. Ther Adv Cardiovasc Dis 2022; 16:17539447221107737. [PMID: 35762763 PMCID: PMC9243573 DOI: 10.1177/17539447221107737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Intracardiac thrombus in the left atrium and atrial appendage (LA/LAA) and left ventricle (LV) increases the risk of systemic thromboembolism and causes potentially devastating diseases such as ischemic stroke and acute ischemia in abdominal organs and lower extremities. Detecting the presence and monitoring the resolution of left heart intracardiac thrombus are of vital importance for stratifying patients and guiding treatment decisions. Currently, echocardiography is the most frequently used method for the above clinical needs, followed by computed tomography. An increasing number of studies have been performed to investigate the value of cardiac magnetic resonance (CMR) as an alternative imaging modality given its several unique strengths. This article provides an overview of the clinical relevance of the LA/LAA and LV thrombus as well as the diagnostic performance of the current imaging modalities and emerging CMR techniques.
Collapse
Affiliation(s)
- Peng Chang
- Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA.,Department of Cardiovascular, Lanzhou University Second Hospital, Lanzhou, China
| | - Jiayu Xiao
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Zhehao Hu
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Bioengineering, University of California, Los Angeles, Los Angeles, CA, USA
| | - Alan C Kwan
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zhaoyang Fan
- Department of Radiology, Keck School of Medicine, University of Southern California, 2250 Alcazar Street, CSC Room 104, Los Angeles, CA 90033, USA.,Department of Radiation Oncology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Department of Biomedical Engineering, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
31
|
Morais P, Nelles D, Vij V, Al-Kassou B, Weber M, Nickenig G, Schrickel JW, Vilaça JL, Sedaghat A. Assessment of LAA Strain and Thrombus Mobility and Its Impact on Thrombus Resolution-Added-Value of a Novel Echocardiographic Thrombus Tracking Method. Cardiovasc Eng Technol 2022; 13:950-960. [PMID: 35562637 PMCID: PMC9750899 DOI: 10.1007/s13239-022-00629-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 04/27/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE The mobility of left atrial appendage (LAA) thrombi and changes hereof under anticoagulation may serve as a marker of both risk of embolism and efficacy of treatment. In this study, we sought to evaluate thrombus mobility and hypothesized that LAA dynamics and thrombus mobility could serve as a baseline marker of thrombus dissolvability. METHODS Patients with two-dimensional transesophageal echocardiographic images of the LAA, and with evidence of LAA thrombus were included in this study. Using a speckle tracking algorithm, functional information from the LAA and thrombi of different patients was computed. While the LAA motion was quantified through the longitudinal strain, thrombus mobility was evaluated using a novel method by directly tracking the thrombus, isolated from the global cardiac motion. Baseline characteristics and echocardiographic parameters were compared between responders (thrombus resolution) and non-responders (thrombus persistence) to anticoagulation. RESULTS We included 35 patients with atrial fibrillation with evidence of LAA thrombi. Patients had a mean age of 72.9 ± 14.1 years, exhibited a high risk for thromboembolism (CHA2DS2-VASc-Score 4.1 ± 1.5) and had moderately reduced LVEF (41.7 ± 14.4%) and signs of diastolic dysfunction (E/E' = 19.7 ± 8.5). While anticoagulation was initiated in all patients, resolution was achieved in 51.4% of patients. Significantly higher LAA peak strain (- 3.0 ± 1.3 vs. - 1.6 ± 1.5%, p < 0.01) and thrombus mobility (0.33 ± 0.13 mm vs. 0.18 ± 0.08 mm, p < 0.01) were observed in patients in whom thrombi resolved (i.e. responders against non-responders). Receiver operating characteristic (ROC) analysis revealed a high discriminatory ability for thrombus mobility with regards to thrombus resolution (AUC 0.89). CONCLUSION Isolated tracking of thrombus mobility from echocardiographic images is feasible. In patients with LAA thrombus, higher thrombus mobility appeared to be associated with thrombus resolution. Future studies should be conducted to evaluate the role of the described technique to predict LAA thrombus resolution or persistence.
Collapse
Affiliation(s)
- Pedro Morais
- 2Ai – School of Technology, IPCA, Barcelos, Portugal
| | - Dominik Nelles
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | - Vivian Vij
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | - Baravan Al-Kassou
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | - Marcel Weber
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | - Georg Nickenig
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | - Jan Wilko Schrickel
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Alexander Sedaghat
- Med. Klinik und Poliklinik II, Herzzentrum Bonn, Universitätsklinikum Bonn, Bonn, Germany
| |
Collapse
|
32
|
Mazur ES, Mazur VV, Bazhenov ND, Orlov YA. Efficiency of the Left Atrial Appendage Thrombus Dissolution in Patients with Persistent Nonvalvular Atrial Fibrillation with Warfarin or Direct Oral Anticoagulants Therapy. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-10-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Aim. Compare the incidence of the left atrial appendage (LAA) thrombus dissolution in patients with persistent nonvalvular atrial fibrillation receiving warfarin and direct oral anticoagulants (DOAC).Materials and methods. 68 patients with persistent nonvalvular atrial fibrillation were included in a retrospective study (age was 59.7±9.8 years, 60.3% men), in whom at least one repeated transesophageal echocardiographic examination was performed after detecting a thrombus. After detecting a thrombus in the LAA, 37 (54.4%) patients started or continued taking warfarin in doses that ensure the INR maintenance at the level of 2-3, 14 (20.6%) started or continued taking dabigatran at a dose of 150 mg 2 times/day, 14 (20.6%) started or continued taking rivaroxaban 20 mg 1 time/day and 3 (4.4%) started or continued taking apixaban 5 mg 2 times/day. Repeated transesophageal echocardiographic examination was performed on average 33.3±14.2 days after the first one.Results. Dissolution of a previously identified thrombus was found in 26 (83.9%) of 31 patients receiving DOAC and in 19 (51.4%) of 37 patients receiving warfarin (p=0.011). The logistic regression analysis showed that the chances of a thrombus dissolution in LAA while taking DOAC are 14.8 times (95% confidence interval [CI] was 2.469-88.72) higher than while taking warfarin. The size and the rate at which blood is expelled from the LAA also have an independent influence on the chances of thrombus dissolution. An increase in the size of a thrombus by 1 mm reduces the chances of a thrombus dissolution by 1.136 (95% CI was 1.040-1.244) times, and an increase in the rate of blood expulsion from the LAA by 1 cm/sec increases these chances by 1.105 (95% CI was 1.003-1.219) times.Conclusion. In the present study, the incidence of the LAA thrombus dissolution in patients with persistent nonvalvular atrial fibrillation while receiving DOAC was higher than while receiving warfarin.
Collapse
|
33
|
Patel M, Wei X, Weigel K, Gertz ZM, Kron J, Robinson AA, Trankle CR. Diagnosis and Treatment of Intracardiac Thrombus. J Cardiovasc Pharmacol 2021; 78:361-371. [PMID: 34074905 DOI: 10.1097/fjc.0000000000001064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/01/2021] [Indexed: 11/27/2022]
Abstract
ABSTRACT Intracardiac thrombi can occur in a variety of locations and are frequently encountered in clinical practice. Yet evidence-based guidance for clinicians managing patients with intracardiac thrombi is often limited. This review summarizes what is known regarding the prevalence of intracardiac thrombus, diagnostic strategies, clinical relevance, and treatment options, focusing on four specific types of thrombus for which recent research has shifted clinical understanding and treatment decisions: (1) left atrial appendage thrombus, (2) cardiac implantable electronic device lead thrombus, (3) bioprosthetic aortic valve thrombus, and (4) left ventricular thrombus. Additional studies, ideally prospective, randomized, and head-to-head in design, are needed to better inform best practices in patients with intracardiac thrombi.
Collapse
Affiliation(s)
- Murti Patel
- Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA
| | - Xin Wei
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Kylie Weigel
- School of Pharmacy, Virginia Commonwealth University, Richmond, VA; and
| | - Zachary M Gertz
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | - Jordana Kron
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| | | | - Cory R Trankle
- Division of Cardiology, Pauley Heart Center, Virginia Commonwealth University, Richmond, VA
| |
Collapse
|
34
|
Anticoagulants for stroke prevention in heart failure with reduced ejection fraction. Clin Res Cardiol 2021; 111:1-13. [PMID: 34448932 PMCID: PMC8766365 DOI: 10.1007/s00392-021-01930-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/17/2021] [Indexed: 11/08/2022]
Abstract
Impaired left-ventricular ejection-fraction (LV-EF) is a known risk factor for ischemic stroke and systemic embolism in patients with heart failure (HF) even in the absence of atrial fibrillation. While stroke risk is inversely correlated with LV-EF in HF patients with sinus rhythm, strategies using anticoagulation with Vitamin-K antagonists (VKA) were futile as the increase in major bleedings outweighed the potential benefit in stroke reduction. Non-Vitamin K oral anticoagulants (NOACs) proved to be an effective and in general safer approach for stroke prevention in patients with atrial fibrillation and may also have a favourable risk–benefit profile in HF patients. In HF patients with sinus rhythm, the COMPASS trial suggested a potential benefit for rivaroxaban, whereas the more dedicated COMMANDER-HF trial remained neutral on overall ischemic benefit owed to a higher mortality which was not influenced by anticoagulation. More recent data from subgroups in the COMMANDER-HF trial, however, suggest that there might be a benefit of rivaroxaban regarding stroke prevention under certain circumstances. In this article, we review the existing evidence for NOACs in HF patients with atrial fibrillation, elaborate the rationale for stroke prevention in HF patients with sinus rhythm, summarise the available data from anticoagulation trials in HF with sinus rhythm, and describe the patient who might eventually profit from an individualised strategy aiming to reduce stroke risk.
Collapse
|
35
|
Backhaus JF, Pflaumbaum A, Krogias C, Kreimer F, Mügge A, Gold R, Gotzmann M. Short- and long-term outcome of patients with spontaneous echo contrast or thrombus in the left atrial appendage in the era of the direct acting anticoagulants. Clin Res Cardiol 2021; 110:1811-1821. [PMID: 34436659 PMCID: PMC8563546 DOI: 10.1007/s00392-021-01926-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/16/2021] [Indexed: 12/21/2022]
Abstract
Background Thrombi and spontaneous echo contrast (SEC) in the left atrial appendage (LAA) are associated with thromboembolic events and poor prognosis. There are very few data on long-term outcome, especially with the use of direct acting anticoagulants (DOAC). Methods In this retrospective study, all transoesophageal echocardiographies performed at a tertiary care university hospital from 2015 to 2020 were analyzed. All patients with thrombus or SEC in the LAA were included. Medical history, laboratory, echocardiographic parameters and medication at discharge were documented. The primary endpoint of the study was a composite endpoint (all-cause mortality, non-fatal stroke or transient ischaemic attack [TIA], non-fatal systemic embolization, non-fatal major bleeding and non-fatal myocardial infarction). Results Of a total of 4062 transoesophageal echocardiographies, thrombi were detected in 51 patients (1.2%) and SEC in 251 patients (6.2%). These patients formed the final study cohort (n = 302). During a mean follow-up period of 956 ± 663 days, 87 patients (29%) suffered the primary point. The following baseline characteristics predicted the primary endpoint: age, haemoglobin, a previous coronary artery bypass grafting, dialysis and choice of anticoagulation. Prescription of apixaban at discharge was associated with lower rate of adverse events (hazard ratio 0.564, confidence interval 0.331–0.960; p = 0.035) while prescription of dabigatran was associated with higher rate of adverse events (hazard ratio 3.091, confidence interval 1.506–6.347; p = 0.002). Conclusion Even in the DOAC era, the occurrence of thrombus or SEC in the LAA is associated with a high rate of MACCE. Our study suggests that the choice of DOAC therapy may have an impact on long-term survival. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01926-8.
Collapse
Affiliation(s)
- Julian Felix Backhaus
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Pflaumbaum
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Christos Krogias
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Fabienne Kreimer
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Andreas Mügge
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Ralf Gold
- Neurology, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany
| | - Michael Gotzmann
- Cardiology and Rhythmology, University Hospital St. Josef Hospital, Ruhr-University Bochum, Gudrunstraße 56, 44791, Bochum, Germany.
| |
Collapse
|
36
|
Zhang Z, Si D, Zhang Q, Qu M, Yu M, Jiang Z, Li D, Yang P, Zhang W. Rivaroxaban versus Vitamin K Antagonists (warfarin) based on the triple therapy for left ventricular thrombus after ST-Elevation myocardial infarction. Heart Vessels 2021; 37:374-384. [PMID: 34420077 DOI: 10.1007/s00380-021-01921-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 08/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Left ventricular thrombus (LVT) can complicate ST-Elevation myocardial infarction (STEMI) and is associated with poor outcomes. Conventional triple anticoagulation [Vitamin K Antagonists (VKA) plus dual-antiplatelet therapy (DAPT)] is the first-line therapy for LVT after STEMI. In patients with LVT following STEMI, contemporary data of triple therapy with rivaroxaban are lacking. METHODS We conducted a retrospective cohort study involving 1335 STEMI patients who underwent primary percutaneous coronary intervention (PCI). Among patients who developed LVT after STEMI, we observed differences in efficacy between rivaroxaban plus DAPT therapy and VKA plus DAPT. The time of LVT resolution was also evaluated, as well as net clinical adverse events, and rates of bleeding events. RESULTS In 1335 patients with STEMI, a total of 77 (5.7%) developed LVT over the follow-up period (median 25.0 months). Of the patients diagnosed with LVT, 31 patients were started on triple therapy with VKA, 33 patients on triple therapy with rivaroxaban. There was a consistent similarity in LVT resolution with rivaroxaban application compared to VKA application during the follow-up period [HR (log-rank test) 1.57(95% CI 0.89-2.77), p = 0.096; Adjusted HR 1.70(95% CI 0.90-3.22), p = 0.104]. Triple therapy with rivaroxaban showed quicker resolution than with VKA (6 months: p = 0.049; 12 months: p = 0.044; 18 months: p = 0.045). Similar risks of ISTH bleeding were not significantly different between the 2 groups [VKA 9.7% vs Rivaroxaban 6.1%, Adjusted HR 0.48 (95% CI 0.73-3.20); p = 0.444)]. Fewer net adverse clinical events (NACE) were observed in the rivaroxaban group [VKA 58.1% vs Rivaroxaban 24.2%; HR (log-rank test) 0.31(95% CI 0.14-0.68), p = 0.003; Adjusted HR 0.23(95% CI 0.09-0.57), p = 0.001]. CONCLUSION In the observational study, triple therapy with rivaroxaban has similar and quicker LVT resolution in patients with LVT after STEMI, compared with triple therapy with VKA, and perhaps was associated with a better clinical benefit. Larger sample sizes and randomized controlled trials are needed to confirm this observation.
Collapse
Affiliation(s)
- Zhongfan Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Daoyuan Si
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Qian Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ming Qu
- Department of Gastroenterology, Endoscopy Center, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Miao Yu
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Zhenya Jiang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Delin Li
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Ping Yang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China
| | - Wenqi Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Xiantai Street NO.126, Changchun, China.
| |
Collapse
|
37
|
Farkowski MM, Jubele K, Marín F, Gandjbakhch E, Ptaszynski P, Merino JL, Lenarczyk R, Potpara TS. Diagnosis and management of left atrial appendage thrombus in patients with atrial fibrillation undergoing cardioversion or percutaneous left atrial procedures: results of the European Heart Rhythm Association survey. Europace 2021; 22:162-169. [PMID: 31501852 DOI: 10.1093/europace/euz257] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 08/19/2019] [Indexed: 12/24/2022] Open
Abstract
Practices regarding indications and timing for transoesophageal echocardiography (TOE) before cardioversion (CV) of atrial fibrillation (AF) or left atrial (LA) interventional procedures, and preferred imaging techniques and pharmacotherapy, in cases of thrombus resistant to chronic oral anticoagulation (OAC) treatment, are largely unknown. The European Heart Rhythm Association (EHRA) conducted a survey to capture contemporary clinical practice in those areas of AF care. A 22-item online questionnaire was developed and distributed among the EHRA electrophysiology research network centres. The survey contained questions regarding indications, type and timing of imaging before CV or LA procedures and management of LA appendage (LAA) thrombus with special emphasis on thrombus resistant to OAC. Of 54 responding centres 63% were university hospitals. Most commonly, TOE would be performed in cases of inadequate or unclear pre-procedural anticoagulation, even in AF lasting <48 h (52% and 50%, respectively), and 15% of centres would perform TOE before AF ablation in all patients. If thrombus was diagnosed despite chronic OAC, the prevalent strategy was to change current OAC to another with different mechanism of action; 51% of centres would wait 3-4 weeks after changing the OAC before using another imaging test, and 60% of centres reported two attempts to dissolve the thrombus. Our survey showed a significant utilization of TOE before CV or AF ablation in European centres, extending beyond AF guidelines-suggested indications. When thrombus was diagnosed despite chronic pre-procedural OAC, most centres would use another anticoagulant drug with different mode of action.
Collapse
Affiliation(s)
- Michal M Farkowski
- Heart Arrhythmia Ward, II Department of Coronary Artery Disease, Institute of Cardiology, Alpejska 42, Warsaw, Poland
| | - Kristine Jubele
- P. Stradins Clinical University Hospital, Riga Stradins University, Riga, Latvia
| | - Francisco Marín
- Department of Cardiology, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, University of Murcia, Murcia, Spain
| | - Estelle Gandjbakhch
- Sorbonne Universités, APHP, Institute of Cardiology ICAN, Pitié-Salpêtrière University Hospital, Paris, France
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland
| | - Jose L Merino
- Unidad de Arritmias y Electrofisiología Robotizada, La Paz University Hospital, IDIPAZ, Universidad Autonoma de Madrid, Madrid, Spain
| | - Radoslaw Lenarczyk
- First Department of Cardiology and Angiology, Silesian Centre for Heart Disease, Zabrze, Poland
| | - Tatjana S Potpara
- School of Medicine, Belgrade University; Cardiology Clinic, Clinical Center of Serbia, Belgrade, Serbia
| |
Collapse
|
38
|
Brandes A, Crijns HJGM, Rienstra M, Kirchhof P, Grove EL, Pedersen KB, Van Gelder IC. Cardioversion of atrial fibrillation and atrial flutter revisited: current evidence and practical guidance for a common procedure. Europace 2021; 22:1149-1161. [PMID: 32337542 PMCID: PMC7399700 DOI: 10.1093/europace/euaa057] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 02/25/2020] [Indexed: 12/17/2022] Open
Abstract
Cardioversion is widely used in patients with atrial fibrillation (AF) and atrial flutter when a rhythm control strategy is pursued. We sought to summarize the current evidence on this important area of clinical management of patients with AF including electrical and pharmacological cardioversion, peri-procedural anticoagulation and thromboembolic complications, success rate, and risk factors for recurrence to give practical guidance.
Collapse
Affiliation(s)
- Axel Brandes
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Corresponding author. Tel: +45 30 43 36 50. E-mail address:
| | - Harry J G M Crijns
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, College of Medical and Dental Sciences, University of Birmingham, UHB and Sandwell & West Birmingham Hospitals, NHS Trusts, Birmingham, UK
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Kenneth Bruun Pedersen
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
| | - Isabelle C Van Gelder
- Department of Cardiology, Odense University Hospital, J.B. Winsløws Vej 4, 5000 Odense C, Denmark
- Department of Clinical Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Department of Cardiology, University of Groningen, University Medical Centre, Groningen, The Netherlands
| |
Collapse
|
39
|
Lurie A, Wang J, Hinnegan KJ, McIntyre WF, Belley-Côté EP, Amit G, Healey JS, Connolly SJ, Wong JA. Prevalence of Left Atrial Thrombus in Anticoagulated Patients With Atrial Fibrillation. J Am Coll Cardiol 2021; 77:2875-2886. [PMID: 34112315 DOI: 10.1016/j.jacc.2021.04.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND The prevalence of left atrial (LA) thrombus in patients with atrial fibrillation (AF) or atrial flutter (AFL) on guideline-directed anticoagulation is not well known, yet this may inform transesophageal echocardiogram (TEE) use before cardioversion or catheter ablation. OBJECTIVES The purpose of this study was to quantify LA thrombus prevalence among patients with AF/AFL on guideline-directed anticoagulation and to identify high-risk subgroups. METHODS EMBASE, MEDLINE, and CENTRAL were systematically searched from inception to July 2020 for studies reporting on LA thrombus prevalence among patients with AF/AFL undergoing TEE following at least 3 weeks of continuous therapeutic oral anticoagulation with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Meta-analysis was performed using random effects models. RESULTS Thirty-five studies describing 14,653 patients were identified. The mean-weighted LA thrombus prevalence was 2.73% (95% confidence interval [CI]: 1.95% to 3.80%). LA thrombus prevalence was similar for VKA- and DOAC-treated patients (2.80%; 95% CI: 1.86% to 4.21% vs. 3.12%; 95% CI: 1.92% to 5.03%; p = 0.674). Patients with nonparoxysmal AF/AFL had a 4-fold higher LA thrombus prevalence compared with paroxysmal patients (4.81%; 95% CI: 3.35% to 6.86% vs. 1.03%; 95% CI: 0.52% to 2.03%; p < 0.001). LA thrombus prevalence was higher among patients undergoing cardioversion versus ablation (5.55%; 95% CI: 3.15% to 9.58% vs. 1.65%; 95% CI: 1.07% to 2.53%; p < 0.001). Patients with CHA2DS2-VASc scores ≥3 had a higher LA thrombus prevalence compared with patients with scores ≤2 (6.31%; 95% CI: 3.72% to 10.49% vs. 1.06%; 95% CI: 0.45% to 2.49%; p < 0.001). CONCLUSIONS LA thrombus prevalence is high in subgroups of anticoagulated patients with AF/AFL, who may benefit from routine pre-procedural TEE use before cardioversion or catheter ablation.
Collapse
Affiliation(s)
- Antony Lurie
- Population Health Research Institute, Hamilton, Ontario, Canada; University of Western Ontario, London, Ontario, Canada
| | - Jia Wang
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | | | - William F McIntyre
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Guy Amit
- Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Hamilton Health Sciences Centre, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
| |
Collapse
|
40
|
Are Three Weeks of Oral Anticoagulation Sufficient for Safe Cardioversion in Atrial Fibrillation? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57060554. [PMID: 34072778 PMCID: PMC8229733 DOI: 10.3390/medicina57060554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022]
Abstract
Background and Objectives: Patients with atrial fibrillation (AF), lasting >48 h, considered for cardioversion, are recommended ≥3 weeks of oral anticoagulation before sinus rhythm restoration because of high risk of development of left atrial thrombosis (LAT) and stroke. However, the optimal duration of anticoagulation in the presence of overt LAT is unknown. Materials and Methods: An open-label study aimed to investigate the prevalence of spontaneous echo contrast (SEC) and LAT before and after 3 weeks of direct oral anticoagulant (DOAC) treatment. We included 51 consecutive patients (50.9% males), mean age 69.3 ± 7.4 years with paroxysmal/unknown duration of AF, considered for cardioversion, who agreed to have transesophageal echocardiography at enrollment and 3 weeks later. Results: At baseline SEC was present in 26 (50.9%) and LAT in 10 (19.6%) of 51 patients. After 3 weeks on DOAC, SEC persisted in 12 (25.0%) and LAT in 7 (14.5%) of 48 patients, p < 0.05 vs. baseline. Factors, associated most strongly with persistence of SEC/LAT, were left atrial appendage (LAA) emptying velocity <20 cm/s (OR = 2.82), LAA lobes >2 (OR = 1.84), and indexed left atrial volume ≥34 mL/m2 (OR = 1.37). Conclusions: In our study the incidence of SEC/LAT, particularly in AF with unknown duration, was not as low as we expected. The prevalence of SEC/LAT seemed to be dependent on factors not routinely evaluated in AF patients planned for cardioversion (indexed LA volume, LAA morphology and number of lobules, LAA emptying velocity, etc.). Our data suggested an individualized approach for DOAC duration in AF patients before an attempt for restoration of sinus rhythm is made, taking into consideration the LAA morphology and function.
Collapse
|
41
|
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, Meir ML, Lane DA, Lebeau JP, Lettino M, Lip GY, Pinto FJ, Neil Thomas G, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. Guía ESC 2020 sobre el diagnóstico y tratamiento de la fibrilación auricular, desarrollada en colaboración de la European Association of Cardio-Thoracic Surgery (EACTS). Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
42
|
Xuan H, Chen YM, Dai YL, Zhou J, Jiang YF, Zhou YF. Safety and Efficacy of Vitamin K Antagonists vs. Novel Oral Anticoagulants in Patients With Left Ventricular Thrombus: A Meta-Analysis. Front Cardiovasc Med 2021; 8:636491. [PMID: 33996936 PMCID: PMC8118127 DOI: 10.3389/fcvm.2021.636491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Aims: A meta-analysis was conducted to evaluate the safety and efficacy of novel oral anticoagulants (NOACs) compared with vitamin K antagonists (VKAs) in patients with left ventricular thrombus (LVT). Methods and Results: We searched PubMed, Web of Science, and Cochrane Library for cohort studies comparing the use of VKAs vs. NOACs for the treatment of LVT from the earliest date available to September 30, 2020. The predetermined efficacy and safety outcomes included thromboembolic events, resolution of LVT, clinically significant bleedings, and all-cause death. Fixed-effects model was used to estimate the pooled effects. Publication bias analyses and sensitivity analyses were conducted to check the robustness of results. A total of 6 studies enrolling 837 patients (mean age 60.2 ± 1.6 years; 77.2% were male) were included. We found no significant differences in thromboembolic events [relative risk (RR) 1.69, 95% confidence interval (CI) 0.94–3.06, P 0.08, I2 12.7%], the rate of resolution of thrombus (RR 1.08, 95% CI 0.96–1.21, P 0.21, I2 4.8%), and clinically significant bleedings (RR 0.70, 95% CI 0.37–1.32, P 0.27, I2 0%) between the VKAs and NOACs group. Additionally, no significant difference in all-cause mortality was found between the two groups (RR 1.24, 95% CI 0.79–1.96, P 0.35, I2 0.0%). Sensitivity analyses, using the “1-study removed” method, detected no significant differences. Conclusion: NOACs and VKAs have similar efficacy and safety in treating LVT, prompting the inference that NOACs are the possible alternatives of VKAs in LVT therapy.
Collapse
Affiliation(s)
- He Xuan
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Yi-Ming Chen
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Yun-Lang Dai
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Zhou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu-Feng Jiang
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Ya-Feng Zhou
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| |
Collapse
|
43
|
Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 411] [Impact Index Per Article: 137.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| |
Collapse
|
44
|
Abdelaziz HK, Megaly M, Debski M, Abdelrahman A, Abdelaziz S, Kamal D, Patel B, More R, Choudhury T. Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus. Expert Rev Cardiovasc Ther 2021; 19:427-432. [PMID: 33830867 DOI: 10.1080/14779072.2021.1915134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: To compare vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death.Areas covered: Five observational studies were included (total n = 700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.29-1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR = 1.00, 95% CI = 0.58-1.73, p = 0.99), bleeding (8.2% vs. 4.4%; OR = 1.62, 95% CI = 0.69-3.77, p = 0.27), or death (12.7% vs. 11.8%; OR = 1.09, 95% CI = 0.59-2.0, p = 0.79) was noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25-0.93, p = 0.03).Expert opinion: The current meta-analysis suggests a trend toward higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to retain the preferred management of LV thrombus with cautious off-label use of DOACs.
Collapse
Affiliation(s)
- Hesham K Abdelaziz
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK.,Ain Shams Medical School, Ain Shams University, Cairo, Egypt
| | - Michael Megaly
- Banner University Medical Center, UA College of Medicine, Phoenix, AZ, USA
| | - Maciej Debski
- Norfolk and Norwich University Hospital and Norwich Medical School, University of East Anglia, Norwich, UK
| | - Amr Abdelrahman
- Cardiology Department, Airedale NHS Foundation Trust, Airedale, UK
| | | | - Diaa Kamal
- Ain Shams Medical School, Ain Shams University, Cairo, Egypt
| | - Billal Patel
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
| | - Ranjit More
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
| | - Tawfiq Choudhury
- Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool, UK
| |
Collapse
|
45
|
Cruz Rodriguez JB, Okajima K, Greenberg BH. Management of left ventricular thrombus: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:520. [PMID: 33850917 PMCID: PMC8039643 DOI: 10.21037/atm-20-7839] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.
Collapse
Affiliation(s)
- Jose B Cruz Rodriguez
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center, El Paso, TX, USA
| | - Kazue Okajima
- Division of Cardiovascular Diseases, Texas Tech University Health Science Center, El Paso, TX, USA
| | - Barry H Greenberg
- Heart Failure/Cardiac Transplantation Program, University of California, San Diego, CA, USA
| |
Collapse
|
46
|
Kaczmarek K, Cygankiewicz I, Streb W, Plaksej R, Jakubowski P, Kalarus Z, Ptaszynski P, Wranicz JK, Babicz-Sadowska A, Markiewicz A, Grygier M. Percutaneous Occlusion of the Left Atrial Appendage with Thrombus Irresponsive to Antithrombotic Therapy. J Clin Med 2021; 10:jcm10040726. [PMID: 33673147 PMCID: PMC7918449 DOI: 10.3390/jcm10040726] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 11/16/2022] Open
Abstract
We analyzed clinical experience with percutaneous closure of instances of left atrial appendage with thrombus (LAAT) irresponsive to antithrombotic therapy in patients treated in three high-volume cardiology centers. Clinical and procedural data regarding consecutive patients who underwent percutaneous left atrial appendage closure (PLAAC) due to LAAT were retrospectively analyzed. The study population consisted of 17 patients (11 men; 68 ± 14 years; CHA2DS2VASC 4.7 ± 1.9; HASBLED 3 (0-5)) with LAAT confirmed by transesophageal echocardiography, and included 5 patients with mechanical heart valves. Most of the patients (94.1%) received anticoagulation therapy before PLAAC. All LAATs were located in distal portions of the appendage and occupied less than 30% of its volume. Occluding-device implantation was successful in 17 patients; in one, a residual leak was disclosed. Appropriate positioning of occluders required more than 1 attempt in 6 individuals (35.3%); in 3 others (17.6%), the subjects' devices had contact with thrombi. No procedural complications were noted. Midterm follow-up (median: 10 months) revealed no procedure-related complications or clinically diagnosed thromboembolism. Transesophageal echocardiography (TEE) performed after six months revealed device-related thrombus in one patient. We concluded that LAAT irresponsive to antithrombotic therapy might be effectively treated with PLAAC, even in patients with mechanical-valve prostheses.
Collapse
Affiliation(s)
- Krzysztof Kaczmarek
- Department of Electrocardiology, Medical University of Lodz, Pomorska Str 251, 92-213 Lodz, Poland; (I.C.); (P.J.); (P.P.); (J.K.W.)
- Correspondence: ; Tel.: +48-604-960-450
| | - Iwona Cygankiewicz
- Department of Electrocardiology, Medical University of Lodz, Pomorska Str 251, 92-213 Lodz, Poland; (I.C.); (P.J.); (P.P.); (J.K.W.)
| | - Witold Streb
- Silesian Center for Heart Disease, 1st Department of Cardiology and Angiology, 41-800 Zabrze, Poland; (W.S.); (Z.K.)
| | - Rafal Plaksej
- Regional Center of Cardiology, Copper Medical Center 66 M. Skłodowska–Curie St., 59-300 Lubin, Poland; (R.P.); (A.B.-S.)
| | - Piotr Jakubowski
- Department of Electrocardiology, Medical University of Lodz, Pomorska Str 251, 92-213 Lodz, Poland; (I.C.); (P.J.); (P.P.); (J.K.W.)
| | - Zbigniew Kalarus
- Silesian Center for Heart Disease, 1st Department of Cardiology and Angiology, 41-800 Zabrze, Poland; (W.S.); (Z.K.)
| | - Pawel Ptaszynski
- Department of Electrocardiology, Medical University of Lodz, Pomorska Str 251, 92-213 Lodz, Poland; (I.C.); (P.J.); (P.P.); (J.K.W.)
| | - Jerzy Krzysztof Wranicz
- Department of Electrocardiology, Medical University of Lodz, Pomorska Str 251, 92-213 Lodz, Poland; (I.C.); (P.J.); (P.P.); (J.K.W.)
| | - Anna Babicz-Sadowska
- Regional Center of Cardiology, Copper Medical Center 66 M. Skłodowska–Curie St., 59-300 Lubin, Poland; (R.P.); (A.B.-S.)
| | - Agata Markiewicz
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga1/2, 61-848 Poznan, Poland; (A.M.); (M.G.)
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University of Medical Sciences, Dluga1/2, 61-848 Poznan, Poland; (A.M.); (M.G.)
| |
Collapse
|
47
|
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, Boriani G, Castella M, Dan GA, Dilaveris PE, Fauchier L, Filippatos G, Kalman JM, La Meir M, Lane DA, Lebeau JP, Lettino M, Lip GYH, Pinto FJ, Thomas GN, Valgimigli M, Van Gelder IC, Van Putte BP, Watkins CL. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J 2021; 42:373-498. [PMID: 32860505 DOI: 10.1093/eurheartj/ehaa612] [Citation(s) in RCA: 4833] [Impact Index Per Article: 1611.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
48
|
Robinson AA, Trankle CR, Eubanks G, Schumann C, Thompson P, Wallace RL, Gottiparthi S, Ruth B, Kramer CM, Salerno M, Bilchick KC, Deen C, Kontos MC, Dent J. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol 2021; 5:685-692. [PMID: 32320043 DOI: 10.1001/jamacardio.2020.0652] [Citation(s) in RCA: 138] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication. Objective To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi. Design, Setting, and Participants A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period. Exposures Type and duration of anticoagulant use. Main Outcomes and Measures Clinically apparent SSE. Results A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE. Conclusions and Relevance In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.
Collapse
Affiliation(s)
- Austin A Robinson
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Cory R Trankle
- Virginia Commonwealth University Pauley Heart Center, Virginia Commonwealth University, Richmond
| | - Grayson Eubanks
- Department of Medicine, University of North Carolina, Chapel Hill
| | - Christopher Schumann
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Paul Thompson
- Department of Internal Medicine, Scripps Health, La Jolla, California
| | - Ryan L Wallace
- Virginia Commonwealth University Pauley Heart Center, Virginia Commonwealth University, Richmond
| | | | - Benjamin Ruth
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Christopher M Kramer
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville.,Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville
| | - Michael Salerno
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville.,Department of Radiology and Medical Imaging, University of Virginia Health System, Charlottesville.,Cardiovascular Imaging Center, Department of Biomedical Engineering, University of Virginia Health System, Charlottesville
| | - Kenneth C Bilchick
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville
| | - Cody Deen
- Department of Medicine, University of North Carolina, Chapel Hill
| | - Michael C Kontos
- Virginia Commonwealth University Pauley Heart Center, Virginia Commonwealth University, Richmond
| | - John Dent
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health System, Charlottesville
| |
Collapse
|
49
|
Zhang H, Yu M, Xia Y, Li X, Liu J, Fang P. The differences of atrial thrombus locations and variable response to anticoagulation in nonvalvular atrial fibrillation with ventricular cardiomyopathy. J Arrhythm 2020; 36:1016-1022. [PMID: 33335618 PMCID: PMC7733561 DOI: 10.1002/joa3.12422] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/03/2020] [Accepted: 08/06/2020] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES This study aims to research the clinical features of atrial thrombi in patients with nonvalvular atrial fibrillation (AF). METHODS This study included 191 patients of AF who had atrial thrombi. One hundred and twenty-eight of them were assigned into nonventricular cardiomyopathy group (non-VCM), and the remaining 63 into ventricular cardiomyopathy group (VCM). After atrial thrombi diagnosed, all patients had taken oral anticoagulant therapy. The resolution rates of thrombi within 12 months were compared between the two groups, as well as the locations of thrombi. RESULTS Of all 191 patients, 161 had thrombi only detected in left atrial appendage (LAA), 20 in both left atrium (LA) and LAA, six in LA only, and four in right atrium only. More patients had thrombi out of LAA in the VCM group than in the non-VCM group (30.2% vs 8.6%, P < .001). After propensity score matching, the atrial thrombi were resolved faster in the non-VCM group than in the VCM group (mean time length: 22 ± 2 weeks vs 30 ± 3 weeks, P = .038), and the resolution rate within 12 months was higher in the non-VCM group than in the VCM group (88.7% vs 61.4%, Log-rank, P = .038). In Cox proportional hazards model, absence of ventricular cardiomyopathy was an independent predictor for the resolution of atrial thrombus (hazard ratio: 1.76; P = .035). CONCLUSIONS The patients of atrial fibrillation with ventricular cardiomyopathies have higher incidence of thrombosis in the body of left atrium or right atrium. And the resolution rate was lower in these patients.
Collapse
Affiliation(s)
- Hao Zhang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
- Department of CardiologyChongqing General HospitalUniversity of Chinese Academy of SciencesChongqingChina
| | - Miao Yu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Yu Xia
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Xiaofeng Li
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Jun Liu
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| | - Pihua Fang
- Chinese Academy of Medical Sciences and Peking Union Medical CollegeFuwai HospitalBeijingChina
| |
Collapse
|
50
|
Ionin VA. [Prevention of thromboembolic complications during cardioversion and catheter ablation in patients with atrial fibrillation: review of key randomized trials]. ACTA ACUST UNITED AC 2020; 60:99-106. [PMID: 33228512 DOI: 10.18087/cardio.2020.10.n1289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/18/2022]
Abstract
This review focuses on the relevance of sinus rhythm control in patients with atrial fibrillation in real-life clinical practice and specific clinical features of patients with this arrhythmia. The authors presented current guidelines on prevention of thromboembolic complications and a review of results from major clinical studies of direct oral anticoagulants. The search for literature and selection of clinical studies for 2009-2020 were performed on websites of the European and Russian Societies of Cardiology, the All-Russian Scientific Society of Arrhythmologists, and in online databases PubMed, EMBASE, eLibrary, and Google Scholar using the key words atrial fibrillation, anticoagulants, ablation, cardioversion, and efficacy and safety.
Collapse
Affiliation(s)
- V A Ionin
- Almazov National Medical Research Centre, Saint-Petersburg, Russia Pavlov University, Saint-Petersburg, Russia
| |
Collapse
|