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Nicol E, Karim N, Semple T, Baleswaran S, Owen R, Riad O, Markides V, Padley SPG, Wong T. Left Atrial Appendage Pseudothrombus Is Associated With Stroke History in Patients With Atrial Fibrillation Undergoing Cardiac Computed Tomography. J Am Heart Assoc 2024:e030147. [PMID: 38842331 DOI: 10.1161/jaha.123.030147] [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: 10/27/2023] [Accepted: 02/28/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND In nonvalvular atrial fibrillation (NVAF), the left atrial appendage (LAA) is the source of thrombus in up to 90% of patients. LAA pseudothrombus (LAAPT), defined as a filling defect on the initial but not the 60-second delayed acquisition on cardiovascular computed tomography scan (CCT), is a recognized phenomenon in NVAF, with unknown clinical relevance. We aimed to determine the relationship between LAAPT and history of stroke in patients with NVAF. METHODS AND RESULTS The study included 213 consecutive patients with NVAF undergoing CCT who were assessed for LAAPT. LA and LAA dimensions and LAA morphology correlated with clinical demographics including cardiovascular risk factors, history of stroke, thromboembolic stroke, and transient ischemic attack. Mean age (±SD) was 65.1±10.5 years (range 31-89) and 150 of 213 (70.4%) were men. LAAPT was present in 59 of 213 (27.7%) patients. Greater mean LAA ostium area (5.7 versus 4.5, P<0.001), greater mean LAA ostium area:curved length (0.11 versus 0.08, P<0.001), increased LAA volume (14.0 versus 10.2, P<0.001), and lower mean LAA tortuosity index (1.17 versus 1.38, P<0.001) were all associated with the presence of LAAPT. On multivariable analysis, LAAPT on CCT (odds ratio [OR], 3.20 [95% CI, 1.40-7.20]; P<0.006) and higher CHA2DS2-VASc score (OR, 1.65 [95% CI, 1.16-2.35]; P=0.01) were associated with all strokes, with LAAPT remaining a statistically significant risk factor even after adjustment for CHA2DS2-VASc score. CONCLUSIONS LAAPT on CCT is common in patients with NVAF. It has a strong positive association with stroke prevalence, even after adjustment for CHA2DS2-VASc score. LAAPT on CCT may potentially allow further stratification for stroke risk, additive to the CHA2DS2-VASc score.
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Affiliation(s)
- Edward Nicol
- Cardiology Department Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
- Radiology Department Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
- School of Biomedical Engineering and Imaging Sciences King's College London UK
| | - Nabeela Karim
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
| | - Tom Semple
- Radiology Department Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
| | - Saranya Baleswaran
- Radiology Department, Guy's and St Thomas' NHS Foundation Trust London UK
| | - Ruth Owen
- London School of Hygiene & Tropical Medicine University of London London UK
| | - Omar Riad
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
- Cardiology department, faculty of Medicine Ain Shams University Cairo Egypt
| | - Vias Markides
- Cardiology Department Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
| | - Simon P G Padley
- Radiology Department Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
| | - Tom Wong
- Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust London UK
- School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences & Medicine King's College London London UK
- National Heart and Lung Institute Faculty of Medicine, Imperial College London UK
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2
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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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Ding WY, Lip GYH, Gupta D. Left Atrial Appendage Occlusion-A Choice or a Last Resort? How to Approach the Patient. Card Electrophysiol Clin 2023; 15:133-140. [PMID: 37076225 DOI: 10.1016/j.ccep.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion. Overall, an individualized and multidisciplinary team approach should be adopted in patients who are being considered for LAA occlusion.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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4
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Iqbal AM, Li KY, Gautam S. Colchicine usage for prevention of post atrial fibrillation ablation pericarditis in patients undergoing high-power short-duration ablation. J Cardiovasc Electrophysiol 2023; 34:1370-1376. [PMID: 37232420 DOI: 10.1111/jce.15941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/05/2023] [Accepted: 05/12/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) for atrial fibrillation (AF) has been associated with variable incidence (0.88%-10%) of pericarditis manifested as chest pain, possibly more prevalent with the advent of high-power short-duration (HPSD) ablation. This has led to the widespread use of colchicine in preventative protocols for postablation pericarditis. However, the efficacy of preventative colchicine has not been validated yet. OBJECTIVE To evaluate the efficacy of a routine postoperative colchicine regimen (0.6 mg twice a day for 14 days post-AF ablation) for prevention of postablation pericarditis in patients undergoing HPSD ablation. METHOD We retrospectively evaluated consecutive single-operator HPSD AF ablation procedures at our institution from June 2019 to July 2022. A colchicine protocol was introduced in June 2021 for the prevention of postablation pericarditis. All ablations were performed with 50 watts. Patients were divided into colchicine and noncolchicine groups. We recorded incidence of postablation chest pain, emergency room (ER) visit for chest pain, pericardial effusion, pericardiocentesis, any ER visit, hospitalization, AF recurrence, and cardioversion for AF within the first 30 days following ablation. We also recorded colchicine-related side effects and medication compliance. RESULTS Two hundred and ninety-four consecutive HPSD AF ablation patients were screened for the study. After implementing the prespecified exclusion criteria, a total of 205 patients were included in the final analysis, yielding 101 patients in the colchicine group and 104 patients in the noncolchicine group. Both groups were well-matched for demographic and procedural parameters. There was no significant difference in postablation chest pain (9.9% vs. 8.6%, p = .7), pericardial effusion (2.9% vs. 0.9%, p = .1), ER visits (11.9% vs. 12.5%, p = .2), 30-day hospitalization for AF recurrence (0.9% vs. 0.96%, p = .3), and 30-day need for cardioversion for AF (3.9% vs. 5.7%, p = .2). Fifteen (15) patients had severe colchicine-related diarrhea, out of which 12 discontinued it prematurely. There were no major procedural complications in either group. CONCLUSION In this single-operator retrospective analysis, prophylactic colchicine was not associated with significant reduction in the incidence of postablation chest pain, pericarditis, 30 day hospitalization, ER visits, or AF recurrence or need of cardioversion within first 30 days after HPSD ablation for AF. However, its usage was associated with significant diarrhea. This study concludes no additional advantage of prophylactic use of colchicine after HPSD AF ablation.
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Affiliation(s)
- Arshad Muhammad Iqbal
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Kai Yu Li
- Department of Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - Sandeep Gautam
- Division of Cardiovascular Medicine, University of Missouri School of Medicine, Columbia, Missouri, USA
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5
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Lee RJ, Hanke T. The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture). Card Electrophysiol Clin 2023; 15:201-213. [PMID: 37076232 DOI: 10.1016/j.ccep.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.
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Affiliation(s)
- Randall J Lee
- Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143, USA.
| | - Thorsten Hanke
- Department of Cardiovascular Surgery, ASKLEPIOS Klinikum Harburg, Abteilung Herzchirurgie, Eißendorfer Pferdeweg 52, 21075 Hamburg, Germany
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [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: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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7
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Theofilis P, Oikonomou E, Antonopoulos AS, Siasos G, Tsioufis K, Tousoulis D. Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives. Biomedicines 2022; 10:biomedicines10092268. [PMID: 36140368 PMCID: PMC9496262 DOI: 10.3390/biomedicines10092268] [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: 08/11/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 11/17/2022] Open
Abstract
Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.
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Affiliation(s)
- Panagiotis Theofilis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Evangelos Oikonomou
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Alexios S. Antonopoulos
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Gerasimos Siasos
- Third Department of Cardiology, Thoracic Diseases General Hospital “Sotiria”, University of Athens Medical School, 11527 Athens, Greece
| | - Konstantinos Tsioufis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, “Hippokration” General Hospital, University of Athens Medical School, 11527 Athens, Greece
- Correspondence:
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8
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Lee RJ, Hanke T. The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture). Interv Cardiol Clin 2022; 11:205-217. [PMID: 35361465 DOI: 10.1016/j.iccl.2022.01.001] [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] [Indexed: 06/14/2023]
Abstract
Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.
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Affiliation(s)
- Randall J Lee
- Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143, USA.
| | - Thorsten Hanke
- Department of Cardiovascular Surgery, ASKLEPIOS Klinikum Harburg, Abteilung Herzchirurgie, Eißendorfer Pferdeweg 52, 21075 Hamburg, Germany
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9
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Ding WY, Lip GYH, Gupta D. Left Atrial Appendage Occlusion-A Choice or a Last Resort? How to Approach the Patient. Interv Cardiol Clin 2022; 11:135-142. [PMID: 35361458 DOI: 10.1016/j.iccl.2021.11.006] [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] [Indexed: 06/14/2023]
Abstract
Left atrial appendage (LAA) occlusion is emerging as a viable alternative to oral anticoagulation in high-risk patients with atrial fibrillation. However, there remains limited evidence for this approach, especially in certain subgroups, and therefore patient selection is an important aspect of treatment. Here, the authors present arguments for LAA occlusion as either a last resort versus patient choice by evaluating contemporary studies on this topic and discuss practical steps in the approach of patients who may be suitable for LAA occlusion. Overall, an individualized and multidisciplinary team approach should be adopted in patients who are being considered for LAA occlusion.
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Affiliation(s)
- Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dhiraj Gupta
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.
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10
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Asymptomatic Stroke in the Setting of Percutaneous Non-Coronary Intervention Procedures. Medicina (B Aires) 2021; 58:medicina58010045. [PMID: 35056353 PMCID: PMC8778528 DOI: 10.3390/medicina58010045] [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: 11/27/2021] [Revised: 12/21/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022] Open
Abstract
Advancements in clinical management, pharmacological therapy and interventional procedures have strongly improved the survival rate for cardiovascular diseases (CVDs). Nevertheless, the patients affected by CVDs are more often elderly and present several comorbidities such as atrial fibrillation, valvular heart disease, heart failure, and chronic coronary syndrome. Standard treatments are frequently not available for “frail patients”, in particular due to high surgical risk or drug interaction. In the past decades, novel less-invasive procedures such as transcatheter aortic valve implantation (TAVI), MitraClip or left atrial appendage occlusion have been proposed to treat CVD patients who are not candidates for standard procedures. These procedures have been confirmed to be effective and safe compared to conventional surgery, and symptomatic thromboembolic stroke represents a rare complication. However, while the peri-procedural risk of symptomatic stroke is low, several studies highlight the presence of a high number of silent ischemic brain lesions occurring mainly in areas with a low clinical impact. The silent brain damage could cause neuropsychological deficits or worse, a preexisting dementia, suggesting the need to systematically evaluate the impact of these procedures on neurological function.
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11
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Dhorepatil A, Lang AL, Lang M, Butt M, Arbune A, Hoffman D, Almahmeed S, Ziv O. Long-Term Stroke Risk in Patients Undergoing Left Atrial Appendage Ablation With and Without Complete Isolation. Front Cardiovasc Med 2021; 8:762839. [PMID: 34957252 PMCID: PMC8695675 DOI: 10.3389/fcvm.2021.762839] [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: 08/23/2021] [Accepted: 11/15/2021] [Indexed: 11/19/2022] Open
Abstract
Background: Catheter ablation (CA) for atrial fibrillation (AF), may require ablation beyond the pulmonary veins. Prior data suggest that additional LA ablation, particularly left atrial appendage (LAA) ablation, may alter atrial function leading to increased risk of ischemic stroke or transient ischemic attack (IS/TIA). We sought to study the long-term risk of IS/TIA in patients receiving ablation at the LAA compared to those receiving PVI alone and those receiving PVI with additional non-LAA locations. Methods: 350 patients who underwent CA for AF from 2008 to 2018 were included in the study. Locations of ablation in LA evaluated were the posterior wall, anterior wall, inferior wall, inter-atrial septum, lateral wall and the left atrial appendage (LAA). Patients undergoing LAA ablation were further divided as complete isolation (LAAi) and without complete isolation (LAAa). Results: Mean follow up of 4.8 years. In entire cohort, risk of IS/TIA was 1.62/100 patient-years (pys). The risk was highest in patients with LAAi (3.81/100 pys), followed by ablation LAAa (3.74/100 pys). Amongst all LA locations, only LAAi (HR 3.32, p = 0.03) and LAAa (HR 3.18, p = 0.02) were statistically significant predictors of IS/TIA after adjusting for OAC (Oral anticoagulant) use and baseline CHA2DS2VASc score. Conclusions: During long term follow-up, only ablation at the left atrial appendage with and without complete isolation was independently associated with an increased risk of IS/TIA in patients undergoing CA for AF. Potential strategies to reduce stroke risk, such as LAA closure, should be considered in these patients.
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Affiliation(s)
- Aneesh Dhorepatil
- Heart and Vascular Institute, Tulane University, New Orleans, LA, United States
| | - Angela L Lang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Min Lang
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Muhammad Butt
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Amit Arbune
- Division of Cardiology, Gill Heart Institute, University of Kentucky, Lexington, KY, United States
| | - David Hoffman
- Heart Associates, Mercy Health St. Elizabeth Youngstown Hospital, Youngstown, OH, United States
| | - Soufian Almahmeed
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
| | - Ohad Ziv
- Department of Cardiovascular Diseases, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States
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12
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Chiu FC, Huang PS, Chen JJ, Hwang JJ, Tsai CT. Long-term outcomes of percutaneous left atrial appendage closure for the prevention of stroke in patients with atrial fibrillation: Asia-Pacific experience. J Formos Med Assoc 2021; 121:1442-1449. [PMID: 34799213 DOI: 10.1016/j.jfma.2021.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 09/30/2021] [Accepted: 10/14/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND/PURPOSE In patients with non-valvular atrial fibrillation (NVAF), the left atrial appendage occluder (LAAO) is an alternative treatment for stroke prevention. However, the long-term outcomes in Asia was generally unknown. METHODS AND RESULTS This was a retrospective longitudinal study and a total of 124 patients with contraindications to oral anticoagulants or stroke despite under anticoagulants had been enrolled since 2013. Primary efficacy was defined as any type of stroke/systemic embolization and adverse event as any procedure or anti-thrombotic related complications. Twelve patients were excluded due to thrombus in the LAA or oversize LAA. Watchman was successfully implanted in 55 patients (98%) and ACP/Amulet also 55 patients (98%). During follow-up, the ischemic stroke rate was 1.9 in the Watchman and 1.4 per 100 patient-year in the ACP/Amulet group. There were 2 Watchman patients experiencing intracranial hemorrhage. Device-related thrombus (DRT) was noted in 3 patients (2.7%).There was no patient with peri-device lead ≧5 mm. In those patients receiving only local anesthesia, the follow-up echocardiography showed no significant peri-device leak, malposition of LAAO and DRT. CONCLUSION This long-term follow-up study shows that percutaneous closure of LAA is a safe and technically feasible procedure with satisfactory outcomes in Asia. The procedure success rate, efficacy and adverse event were similar to those reported in the Caucasian populations.
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Affiliation(s)
- Fu-Chun Chiu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Pang-Shuo Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Jien-Jiun Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital Yun-Lin Branch, Yun-Lin, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Chia-Ti Tsai
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
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13
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Collado FMS, Lama von Buchwald CM, Anderson CK, Madan N, Suradi HS, Huang HD, Jneid H, Kavinsky CJ. Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation. J Am Heart Assoc 2021; 10:e022274. [PMID: 34668395 PMCID: PMC8751840 DOI: 10.1161/jaha.121.022274] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.
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14
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Sundhu MA, Waheed TA, Nasir U, Handa R, Dever R, Macciocca M, Scollan D, Minhas AMK, Nazir S, Ramanathan PK, Ahuja KR. Thirty-Day Readmissions After Percutaneous Left Atrial Appendage Occlusion: Insights from the Nationwide Readmissions Database. Curr Probl Cardiol 2021; 47:101006. [PMID: 34610349 DOI: 10.1016/j.cpcardiol.2021.101006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 09/22/2021] [Indexed: 11/27/2022]
Abstract
Percutaneous left atrial appendage occlusion (LAAO) provides a nonpharmacological alternative of preventing stroke in patients with non-valvular atrial fibrillation who are poor candidates for oral anticoagulation. Data on 30 day readmission measures following LAAO is limited. Index LAAO procedures and 30 day readmissions were identified using the Nationwide Readmissions Database (NRD) from 2016 to 2018. The rates and causes of 30 day readmissions were studied. Complex samples multivariable logistic regression models were used to identify predictors of 30 day readmission. Among 29,367 patients undergoing LAAO, the rates of 30 day readmissions were 9.2%. The most common overall cause of 30 day readmission was gastrointestinal bleeding (18.5%), followed by heart failure (13.1%), and infection (7.3%). Female gender (OR1.22; 95% CI 1.08-1.38), HF (OR 1.30; 95% CI 1.15-1.47), anemia (OR 1.37; 95% CI 1.11-1.68), chronic lung disease (OR 1.42; 95% CI 1.25-1.62), End stage renal disease (OR 2.75; 95% CI 2.13-3.55), Acute kidney injury (OR 1.66; 95% CI 1.25-2.20), bleeding/transfusion (OR 1.63; 95% CI 1.28-2.09) were found to be independent predictors of 30 days Readmission. The overall rate of 30 day readmission after LAAO was 9.2% with non-cardiac causes (gastrointestinal bleeding) being the most common. Reducing in-hospital complications and identifying optimal post procedural anticoagulation/antithrombotic regimen may help decrease readmissions following LAAO.
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Affiliation(s)
- Murtaza Ali Sundhu
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA.
| | - Tayyab Ali Waheed
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
| | - Usama Nasir
- Department of Internal Medicine, Reading Hospital Tower Health, West Reading, PA
| | - Rishin Handa
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
| | - Rachel Dever
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
| | - Michael Macciocca
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
| | - David Scollan
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
| | | | - Salik Nazir
- Department of Cardiovascular Disease, University of Toledo, Toledo, OH
| | - P Kasi Ramanathan
- Department of Cardiovascular Disease, University of Toledo, Toledo, OH
| | - Keerat Rai Ahuja
- Department of Cardiology, Reading Hospital Tower Health, West Reading, PA
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15
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Sabzwari SRA, Mehta NA, Garg L, Racharla L, Kurtz E, Afzal MR, Turagam MK, Lakkireddy D. Safety and efficacy of left atrial appendage closure using an epicardial suture snaring device: Systematic review and current status. J Cardiovasc Electrophysiol 2021; 32:2189-2198. [PMID: 34164881 DOI: 10.1111/jce.15132] [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: 12/23/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The LARIAT epicardial suture snaring device has been fraught with technical challenges and procedural complications. Over time, technique modification and improved operator experience have helped overcome many of these challenges. METHODS AND RESULTS: Studies reporting left atrial appendage epicardial closure over a 12-year period from 2009 to 2020 were evaluated. The primary efficacy outcome evaluated was left atrial appendage closure with residual flow ≤1 mm. Safety outcomes evaluated were periprocedural and long term complications after device placement. Nine studies consisting of 1430 patients were included in this analysis, of which 1386 (97%) underwent successful device placement. The mean age was 69.3 years, with a mean CHADS2 -VASC score of 3.78. Primary efficacy end point was achieved in 95.8% patients immediately after device placement, and in 92.8% patients on long term follow-up. Early procedural complications consisted of pericardial effusion 5.6%, cardiac perforation 2.7%, pericarditis 2.6%, and need for open heart surgery 1.5%. Long term complications consisted of all-cause mortality 2.3%, stroke 1.5%, and left atrial appendage thrombus 2.3%. Reduced complications were noted using micropuncture needles (2.20% vs. 10.14%; p < .0001), a longer duration pericardial drainage, and use of anti-inflammatory medications (1.58% vs. 8.4%). Oral anticoagulation use decreased from 44.7% to 22.9% post device implantation, and to 8.5% on last clinical follow up. CONCLUSIONS The LARIAT device is effective in epicardial closure of the left atrial appendage. Improvement in device techniques such as use of micropuncture needle, prophylactic colchicine, and maintenance of a pericardial drain have helped improve safety over time.
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Affiliation(s)
| | - Nikhil A Mehta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Lohit Garg
- Department of Electrophysiology, Hospital of the University of Pennsylvania, Pennsylvania, USA
| | - Lekha Racharla
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Emilee Kurtz
- Department of Internal Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Muhammad R Afzal
- Department of Electrophysiology, Ohio State University, Columbus, Ohio, USA
| | - Mohit K Turagam
- Department of Electrophysiology, The Mount Sinai Hospital, New York City, New York, USA
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Overland Park Regional Medical Center, Overland Park, Kansas, USA
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16
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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]
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17
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Jang SJ, Wong SC, Mosadegh B. Leaks after Left Atrial Appendage Closure: Ignored or Neglected? Cardiology 2021; 146:384-391. [PMID: 33735867 DOI: 10.1159/000513901] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/12/2020] [Indexed: 11/19/2022]
Abstract
Left atrial appendage (LAA) closure has recently been approved as an alternative management for stroke prevention in patients with chronic atrial fibrillation who have difficulties with long-term oral anticoagulation. The various shapes and sizes of LAA and orientation of the atrial ostium may contribute to the incomplete LAA closure from circular design devices and orientation of the non-steerable delivery catheter. Incomplete closure of LAA leads to a high-velocity blood flow through the peri-device gap, resulting in peri-device leak (PDL). Residual leaks are frequently diagnosed after LAA closure procedures, regardless of closure methods. There is a controversy in the clinical significance of the leaks, particularly about its association with thromboembolic events. PDL <5 mm was not associated with any increase of risk for thromboembolism. Current literatures with small study population have not been sufficient to clarify the role of the leaks after LAA closure. Nevertheless, management of severe leaks has been a challenging concern for cardiologists. Leaks after epicardial LAA closures are at the neck of the incompletely closed LAA and have shown to increase the risk of thromboembolism. Percutaneous closure of the leaks after LAA closure has been attempted with good safety and success, but long-term safety and efficacy remains unclear. Further large long-term studies which aim to assess the role of leaks or PDLs in predicting thromboembolic events and management strategies are warranted.
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Affiliation(s)
- Sun-Joo Jang
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | - S Chiu Wong
- Greenberg Cardiology Division, Weill Cornell Medicine, New York, New York, USA
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA,
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18
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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: 4876] [Impact Index Per Article: 1625.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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19
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Nentwich K, Ene E, Halbfass P, Berkowitz A, Sonne K, Kerber S, Lee R, Deneke T. Concomitant epicardial left atrial appendage ligation and left atrial ablation of atrial fibrillation: Safety, feasibility and outcome. Indian Pacing Electrophysiol J 2021; 21:75-79. [PMID: 33460777 PMCID: PMC7952894 DOI: 10.1016/j.ipej.2021.01.001] [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: 09/03/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction We present initial results of patients undergoing a combined procedure of epicardial LAA ligation in addition to left atrial ablation for AF. Methods 9 patients were included for additional use of LARIAT as an individual treatment approach for AF. First an epicardial LAA ligation was performed, in the same procedure left atrial ablations consisting of PVI and additional substrate based modifying ablations were performed. Follow–up at 3 months and 12 months was performed. Results There was only 1 minor procedural complication (11%) involving epicardial bleeding and 2 late adverse events of pericardial tamponade and stroke. At the final follow-up (median 20 months) 7 patients were in stable sinus rhythm (78%) and 2 pts had reduced AF burden. Conclusion Concomitant epicardial LAA ligation and ablation is feasible in selected patients with a reasonable risk profile. More prospective data are required to validate the safety and efficacy.
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Affiliation(s)
- Karin Nentwich
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany.
| | - Elena Ene
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Philipp Halbfass
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Arthur Berkowitz
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Kai Sonne
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Sebastian Kerber
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Randall Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, 500 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Thomas Deneke
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
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20
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Gianni C, Della Rocca DG, Natale A, Horton RP. Interventional Treatment for Stroke Prevention. Korean Circ J 2021; 51:1-14. [PMID: 33377326 PMCID: PMC7779816 DOI: 10.4070/kcj.2020.0416] [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: 09/24/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022] Open
Abstract
Closure of the left atrial appendage using percutaneous transcatheter occlusion devices is used for stroke prevention as an alternative for patients with a high risk or contraindications for long-term oral anticoagulation use. Herein, we will discuss the practical aspects of five among the available devices used for interventional left atrial appendage occlusion: Watchman, Amulet, WaveCrest, LAmbre, and Lariat.
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Affiliation(s)
- Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- HCA National Medical Director of Cardiac Electrophysiology, USA
- Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
- Department of Biomedical Engineering, University of Texas, Austin, TX, USA.
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21
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Riddle M, McCallum R, Ojha CP, Paul TK, Gupta V, Baran DA, Prakash BV, Misra A, Mares AC, Abedin M, Kedar A, Mulukutla V, Ibrahim A, Nagarajarao H. Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations. J Investig Med 2020; 68:1317-1333. [PMID: 33203786 DOI: 10.1136/jim-2020-001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2020] [Indexed: 11/04/2022]
Abstract
Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.
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Affiliation(s)
- Malini Riddle
- Paul L Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Richard McCallum
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Chandra Prakash Ojha
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Timir Kumar Paul
- Internal Medicine, East Tennessee State University James H Quillen College of Medicine, Johnson City, Tennessee, USA
| | - Vineet Gupta
- Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - David Alan Baran
- Cardiovascular Diseases, Sentara Healthcare Inc, Norfolk, Virginia, USA
| | - Bharat Ved Prakash
- Department of Medicine, Texas Tech University Health Sciences Center El Paso, Transmountain Campus, El Paso, Texas, USA
| | - Amogh Misra
- Department of Biochemistry, The University of Texas at Austin, Austin, Texas, USA
| | - Adriana Camila Mares
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Moeen Abedin
- Division of Cardiology, University Medical Center of El Paso, El Paso, Texas, USA
| | - Archana Kedar
- Internal Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | | | - Ahmed Ibrahim
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Harsha Nagarajarao
- Internal Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
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22
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Sanchez JM, Lee A, Bartus K, Lee RJ. Percutaneous epicardial approach for LAA ligation. J Interv Card Electrophysiol 2020; 62:293-297. [PMID: 33085054 DOI: 10.1007/s10840-020-00894-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 09/29/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE The left atrial appendage (LAA) is believed to be a source for thrombus formation and an ancillary structure involved in the initiation and maintenance of atrial fibrillation (AF). LAA ligation has been proposed as adjunctive therapy for the treatment of AF. This study will determine the feasibility of a percutaneous epicardial approach for LAA ligation. METHODS The pericardium of 5 dogs was accessed via percutaneous subxyphoid approach. A 20F epicardial cannula was inserted into the pericardial space and contrast-injected to visualize the LAA. Under fluoroscopic guidance, a suction cup catheter was inserted and attached to the LAA. A 12F snare device was inserted over the vacuum cup to ligate the LAA. The closure of the LAA was verified with LA angiography, in the first 2 dogs, and ICE in all 5 animals. All animals were sacrificed for post hoc assessment of LAA closure. RESULTS All 5 dogs underwent successful epicardial suture ligation of the LAA. In the first 2 dogs, LA angiography demonstrated complete closure of the LAA. All dogs underwent gross examination of the LAA. Post hoc assessment was notable for a small well-circumscribed hematoma on the LAA, consistent with point of suction cup attachment, as well as complete closure of the entire LAA. No laceration or perforation was noted on the LAA. CONCLUSIONS Exclusion of the LAA via a novel percutaneous epicardial-only approach was successful without complications. This demonstrates the feasibility of this technique in an animal model, and may provide an effective approach for epicardial-only LAA exclusion in humans.
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Affiliation(s)
- José M Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Randall J Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA.
- , San Francisco, USA.
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23
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Perino AC, Kaiser DW, Lee RJ, Fan J, Askari M, Schmitt SK, Turakhia MP. Incidence and outcomes of patients with atrial fibrillation and major bleeding complications: from the TREAT-AF study. J Interv Card Electrophysiol 2020; 62:133-142. [PMID: 32986177 DOI: 10.1007/s10840-020-00873-0] [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: 04/10/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Optimal stroke prevention strategies for patients with atrial fibrillation (AF) who experience a major bleed are poorly defined. We sought to estimate the effectiveness and safety of oral anticoagulation (OAC) represcription after an OAC contraindication. METHODS TREAT-AF is a retrospective cohort study of patients with newly diagnosed AF (2004-2012), treated in the Veterans Health Administration. From this cohort, we identified patients with a contraindication to OAC after AF diagnoses, defined as incident intracranial bleeding, non-intracranial bleeding requiring hospitalization, or unrepaired cerebral aneurysm or aortic dissection. We used multivariate Cox proportional hazards to estimate the association of OAC prescription in the 90 days following OAC contraindication to ischemic stroke and rebleeding. RESULTS Among 167,190 patients with newly diagnosed AF (70 ± 11 years, 1.7% female, CHA2DS2-VASc 2.7 ± 1.7), 19,285 patients (11.5%) had an incident bleed (n = 18,342) or an unrepaired cerebral aneurysm or aortic dissection (n = 943). For OAC-contraindicated patients with a CHA2DS2-VASc ≥2 (N = 16,194), OAC was represcribed in 4075 patients (25%) and was associated with a higher risk of non-intracranial bleeding (HR 1.49; 95% CI 1.37-1.61; p < 0.0001) but no difference in intracranial bleeding. There was a trend toward decreased stroke risk (HR 0.85; 95% CI 0.71-1.02; p 0.09). CONCLUSIONS Development of contraindication to OAC after diagnosis of AF is common (11.5%), with most events requiring hospitalization. OAC reinitiation was associated with non-intracranial bleeding risk, with a trend toward reduced stroke risk. These data suggest that stroke prevention approaches after major bleeding events could be beneficial if bleeding risk can be successfully mitigated.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Daniel W Kaiser
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Randall J Lee
- Department of Medicine and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Susan K Schmitt
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA. .,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA.
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Recurrent Left Pleural Effusion Following Left Atrial Appendage Closure With the Watchman Device. JACC Case Rep 2020; 2:1789-1792. [PMID: 34317057 PMCID: PMC8312112 DOI: 10.1016/j.jaccas.2020.07.044] [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: 05/08/2020] [Revised: 07/17/2020] [Accepted: 07/28/2020] [Indexed: 11/20/2022]
Abstract
A 75-year-old woman with recent left atrial appendage closure with the Watchman device (Boston Scientific, Natick, Massachusetts) presented with recurrent left pleural effusion. The constellation of chest pain, pericardial effusion, and exudative pleural effusion were suggestive of an inflammatory process precipitated by microperforation of the fixation anchors during the Watchman placement. (Level of Difficulty: Intermediate.)
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25
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Wunderlich NC, Lorch GC, Honold J, Franke J, Küx H. Why Follow-up Examinations After Left Atrial Appendage Closure Are Important: Detection of Complications During Follow-up and How to Deal with Them. Curr Cardiol Rep 2020; 22:113. [PMID: 32770393 DOI: 10.1007/s11886-020-01357-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Device-related thrombus (DRT) formation and incomplete left atrial appendage closure (LAAC) are the two major complications that can occur after LAAC and can potentially limit the success of such a procedure. This review discusses the incidence, clinical and/or prognostic significance, detection methods, treatment options, and potential strategies to prevent these complications. RECENT FINDINGS It has recently been proven that the presence of a DRT represents an independent predictor for ischemic stroke after LAAC. Continued need for anticoagulation due to incomplete LAAC is clinically relevant to the patient. The appearances of a DRT or an incompletely closed LAA after a LAAC procedure are not rare complications. Due to the clinical and/or prognostic significance of these complications, it is important to detect them in a timely manner during follow-up by using the appropriate diagnostic imaging techniques. Since a DRT is associated with an increased risk of stroke, the therapy should be aggressive. In the case of incomplete LAA closure, an additional closure device may be used to complete occlusion and avoid lifelong anticoagulation therapy.
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Affiliation(s)
- Nina C Wunderlich
- Cardiovascular Center Darmstadt, Dieburgerstrasse 31c, 64287, Darmstadt, Germany.
| | - Gabriele C Lorch
- Cardiovascular Center Darmstadt, Dieburgerstrasse 31c, 64287, Darmstadt, Germany
| | - Jörg Honold
- Cardiovascular Center Darmstadt, Dieburgerstrasse 31c, 64287, Darmstadt, Germany
- Division of Cardiology, Department of Internal Medicine III, Goethe University Frankfurt, Frankfurt, Germany
| | - Jennifer Franke
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Harald Küx
- Cardiovascular Center Darmstadt, Dieburgerstrasse 31c, 64287, Darmstadt, Germany
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Sharma SP, Turagam MK, Mohanty S, Di Biase L, Burkhardt D, Horton R, Natale A, Lakkireddy D. Epicardial Interventions: Impact of Liposomal Bupivacaine on Postprocedural Management (The EPI-LIBRE Study). Circ Arrhythm Electrophysiol 2020; 13:e007425. [DOI: 10.1161/circep.119.007425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Electrophysiological procedures such as epicardial ventricular tachycardia ablation and Lariat left atrial appendage ligation that involve the epicardial space are typically associated with significant postoperative pain due to mechanical irritation and associated inflammation. There is an unmet need for an effective pain management strategy in this group of patients. We studied how this impacts patient comfort and duration of hospitalization and other associated comorbidities related to pericardial access.
Methods:
This is a multicenter retrospective study including 104 patients who underwent epicardial ventricular tachycardia ablation and Lariat left atrial appendage exclusion. We compared 53 patients who received postprocedural intrapericardial liposomal bupivacaine (LB)+oral colchicine (LB group) and 51 patients who received colchicine alone (non-LB group) between January 2015 and March 2018.
Results:
LB was associated with significant lowering of median pain scale at 6 hours (1.0 [0–2.0] versus 8.0 [6.0–8.0],
P
<0.001), 12 hours (1.0 [1.0–2.0] versus 6.0 [5.0–6.0],
P
<0.001), and up to 48 hours postprocedure. Incidence of acute severe pericarditis delayed pericardial effusion and gastrointestinal adverse effects were similar in both groups. Median length of stay was significantly lower in LB group (2.0 versus 3.0; adjusted linear coefficient −1 [CI −1.3 to −0.6],
P
<0.001). Subgroup analysis demonstrated similar favorable outcomes in both Lariat and epicardial ventricular tachycardia ablation groups.
Conclusions:
Addition of intrapericardial postprocedural LB to oral colchicine in patients undergoing epicardial access during ventricular tachycardia ablation or Lariat procedure is associated with significantly decreased numeric pain score up to 48 hours compared with colchicine alone. It is also associated with significantly shorter length of hospital stay without an increase in the risk of adverse events.
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Affiliation(s)
- Sharan Prakash Sharma
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, KS (S.P.S., D.L.)
| | | | | | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, Austin (S.M., L.D.B., D.B., R.H., A.N.)
| | - David Burkhardt
- Texas Cardiac Arrhythmia Institute, Austin (S.M., L.D.B., D.B., R.H., A.N.)
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, Austin (S.M., L.D.B., D.B., R.H., A.N.)
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin (S.M., L.D.B., D.B., R.H., A.N.)
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, KS (S.P.S., D.L.)
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Akella K, Yarlagadda B, Murtaza G, Della Rocca DG, Gopinathannair R, Natale A, Lakkireddy D. Epicardial versus Endocardial Closure: Is One Better than the Other? Card Electrophysiol Clin 2020; 12:97-108. [PMID: 32067652 DOI: 10.1016/j.ccep.2019.11.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Left atrial appendage occlusion is an evolving technology with demonstrable benefits of stroke prophylaxis in patients with atrial fibrillation unsuitable for anticoagulation. This has resulted in the development of a plethora of transcatheter devices to achieve epicardial exclusion and endocardial occlusion. In this review, the authors summarize the differences in technique, target patient population, outcomes, and complication profiles of endocardial and epicardial techniques.
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Affiliation(s)
- Krishna Akella
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Bharath Yarlagadda
- Department of Cardiology, University of New Mexico, 1 University of New Mexico, Albuquerque, NM 87131, USA
| | - Ghulam Murtaza
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Domenico G Della Rocca
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Rakesh Gopinathannair
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Center for Atrial Fibrillation at St. David's Medical Center, 1015 East 32nd Street, Suite 516, Austin, TX 78705, USA; Department of Biomedical Engineering, University of Texas, 107 West Dean Keeton Street, Austin, TX 78712, USA
| | - Dhanunjaya Lakkireddy
- The Kansas City heart rhythm institution and research foundation, HCA MIDWEST HEALTH, Second Floor, 5100 W 110th St, Overland Park, KS 66211, USA.
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Sahore A, Della Rocca DG, Anannab A, Mohanty S, Akella K, Murtaza G, Trivedi C, Gianni C, Chen Q, Bassiouny M, Ahmadian-Tehrani A, Macdonald B, Al-Ahmad A, Tarantino N, Cirone D, Horton RP, Romero J, Lakkireddy D, Di Biase L, Natale A. Clinical Implications and Management Strategies for Left Atrial Appendage Leaks. Card Electrophysiol Clin 2020; 12:89-96. [PMID: 32067651 DOI: 10.1016/j.ccep.2019.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Left atrial appendage (LAA) is the dominant source of systemic thromboembolic (TE) events in patients with nonvalvular atrial fibrillation (AF). In patients with significant bleeding risk, various LAA exclusion strategies have been developed as an alternative to pharmacologic TE prophylaxis. Nevertheless, in a relatively small percentage of patients, incomplete LAA closure can be documented, either at the time of procedure or during follow-up. This persistent patency can potentially jeopardize an effective stroke prophylaxis. Hereby, we report an update on the current clinical implications of LAA leaks and how to manage them.
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Affiliation(s)
- Anu Sahore
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | | | - Alisara Anannab
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Department of Cardiovascular Intervention, Central Chest Institute of Thailand, Nonthaburi, Thailand
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Krishna Akella
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, KS, USA
| | - Ghulam Murtaza
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, KS, USA
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Qiong Chen
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Mohamed Bassiouny
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Ashkan Ahmadian-Tehrani
- Department of Medicine, Division of Internal Medicine, University of Texas Health Science Center, San Antonio, TX, USA
| | - Bryan Macdonald
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Nicola Tarantino
- Arrhythmia Services, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Rodney P Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA
| | - Jorge Romero
- Arrhythmia Services, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | | | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Arrhythmia Services, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA; Department of Internal Medicine, Dell Medical School, University of Texas, Austin, TX, USA; Department of Biomedical Engineering, Cockrell School of Engineering, University of Texas, Austin, TX, USA; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, TX, USA; Department of Internal Medicine, Dell Medical School, University of Texas, Austin, TX, USA; Department of Biomedical Engineering, Cockrell School of Engineering, University of Texas, Austin, TX, USA; Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; Interventional Electrophysiology, Scripps Clinic, La Jolla, CA, USA; Department of Cardiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA; Division of Cardiology, Stanford University, Stanford, CA, USA
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29
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Tilz RR, Fink T, Bartus K, Wong T, Vogler J, Nentwich K, Panniker S, Fang Q, Piorkowski C, Liosis S, Gaspar T, Sawan N, Metzner A, Nietlispach F, Maisano F, Lee RJ, Foran JP, Ouyang F, Sievert H, Deneke T, Kuck KH. A collective European experience with left atrial appendage suture ligation using the LARIAT+ device. Europace 2020; 22:924-931. [DOI: 10.1093/europace/euaa004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/23/2019] [Accepted: 01/29/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
We report the collective European experience of percutaneous left atrial appendage (LAA) suture ligation using the recent generation LARIAT+ suture delivery device.
Methods and results
A total of 141 patients with non-valvular atrial fibrillation and contraindication to oral anticoagulation (OAC), thrombo-embolic events despite OAC or electrical LAA isolation were enrolled at seven European hospitals to undergo LAA ligation. Patients were followed up by clinical visits and transoesophageal echocardiography (TOE) following LAA closure. Left atrial appendage ligation was completed in 138/141 patients (97.8%). Three patients did not undergo attempted deployment of the LARIAT device due to pericardial adhesion after previous epicardial ventricular tachycardia ablation (n = 1), a pericardial access-related complication (n = 1), and multiple posterior LAA lobes (n = 1). Serious 30-day procedural adverse events occurred in 4/141 patients (2.8%). There were two device-related LAA perforations (1.4%) not resulting in any corrective intervention as the LAA was completely sealed with the LARIAT. Minor adverse events occurred in 19 patients (13.5%), including two pericardial effusions due to procedure-related pericarditis requiring pericardiocentesis. Transoesophageal echocardiography was performed after LAA ligation in 103/138 patients (74.6%) after a mean of 181 ± 72 days. Complete LAA closure was documented in 100 patients (97.1%). Two patients (1.8% of patients with follow-up) experienced a transient ischaemic attack at 4 and 7 months follow-up, although there was no leak observed with TOE. There were two deaths during long-term follow-up which were both not device related.
Conclusion
Initial experience with the LARIAT+ device demonstrates feasibility of LAA exclusion. Further larger prospective studies with longer follow-up are warranted.
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Affiliation(s)
- Roland Richard Tilz
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Thomas Fink
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Tom Wong
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Julia Vogler
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Karin Nentwich
- Clinic for Cardiology II (Interventional Electrophysiology), Cardiovascular Center, Bad Neustadt, Germany
| | - Sandeep Panniker
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Qizhi Fang
- Department of Medicine, Cardiovascular Research Institute and Institute for Regeneration Medicine, University of California, San Francisco, CA, USA
| | - Christopher Piorkowski
- Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Dresden, Germany
| | - Spyridon Liosis
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Thomas Gaspar
- Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Dresden, Germany
| | - Noureddin Sawan
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | | | - Randall J Lee
- Department of Medicine, Cardiovascular Research Institute and Institute for Regeneration Medicine, University of California, San Francisco, CA, USA
| | - John P Foran
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Clinic for Cardiology, Fuwai Hospital, The Chinese Academy of Medical Sciences & National Center of Cardiovascular Diseases, Beijing, China
| | - Horst Sievert
- Department of Cardiology, Cardiovascular Center, Frankfurt, Frankfurt, Germany
| | - Thomas Deneke
- Clinic for Cardiology II (Interventional Electrophysiology), Cardiovascular Center, Bad Neustadt, Germany
| | - Karl-Heinz Kuck
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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30
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Della Rocca DG, Horton RP, Di Biase L, Bassiouny M, Al-Ahmad A, Mohanty S, Gasperetti A, Natale VN, Trivedi C, Gianni C, Burkhardt JD, Gallinghouse GJ, Hranitzky P, Sanchez JE, Natale A. First Experience of Transcatheter Leak Occlusion With Detachable Coils Following Left Atrial Appendage Closure. JACC Cardiovasc Interv 2020; 13:306-319. [DOI: 10.1016/j.jcin.2019.10.022] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/07/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
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Abstract
PURPOSE OF REVIEW Intracranial hemorrhage remains one of the most feared acute neurological emergencies. However, apart from the acute management, secondary risk factor management and prevention of ischemic events remains ambiguous. We present a thorough review of the current data available regarding management of antithrombotics after intracranial hemorrhage. RECENT FINDINGS The most robust evidence comes from the investigators of the RESTART trial which reassured the safety of resuming antiplatelet therapy after ICH, namely in patients with prior indication and treatment with antithrombotics. We conclude that based on available data, the risk of recurrent ICH is probably too small to exceed the found benefits of antiplatelet therapy in the secondary prevention of ischemic vascular disease.
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32
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Aryana A, d'Avila A. Epicardial approach for cardiac electrophysiology procedures. J Cardiovasc Electrophysiol 2019; 31:345-359. [DOI: 10.1111/jce.14282] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/18/2019] [Accepted: 11/09/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Arash Aryana
- Department of Cardiology and Cardiac ElectrophysiologyMercy General Hospital and Dignity Health Heart and Vascular InstituteSacramento California
| | - André d'Avila
- Cardiac Arrhythmia ServiceHospital SOS CardioFlorianopolis Santa Catarina Brazil
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33
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Karim N, Ho SY, Nicol E, Li W, Zemrak F, Markides V, Reddy V, Wong T. The left atrial appendage in humans: structure, physiology, and pathogenesis. Europace 2019; 22:5-18. [DOI: 10.1093/europace/euz212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 07/12/2019] [Indexed: 01/01/2023] Open
Abstract
Abstract
For many years, the left atrial appendage (LAA) was considered a dormant embryological remnant; however, it is a structurally complex and functional organ that contributes to cardiac haemodynamic changes and volume homeostasis through both its contractile properties and neurohormonal peptide secretion. When dysfunctional, the LAA contributes to thrombogenesis and subsequent increased predisposition to cardioembolic events. Consequently, the LAA has gained much attention as a therapeutic target to lower this risk. In addition, attention has focused on the LAA in its role as an electrical trigger for atrial tachycardia and atrial fibrillation with ablation of the LAA to achieve electrical isolation showing promising results in the maintenance of sinus rhythm. This in-depth review explores the structure, physiology and pathophysiology of the LAA, as well as LAA intervention and their sequelae.
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Affiliation(s)
- Nabeela Karim
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Siew Yen Ho
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Edward Nicol
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Wei Li
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Filip Zemrak
- Barts Heart Centre, St. Bartholomew’s Hospital, Barts Health NHS Trust, London, UK
| | - Vias Markides
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
| | - Vivek Reddy
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York City, NY, USA
| | - Tom Wong
- Department of Cardiology, The Royal Brompton and Harefield NHS Foundation Trust, Imperial College London, Sydney Street, London, UK
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34
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Vuddanda VLK, Turagam MK, Umale NA, Shah Z, Lakkireddy DR, Bartus K, McCausland FR, Velagapudi P, Mansour M, Heist EK. Incidence and causes of in-hospital outcomes and 30-day readmissions after percutaneous left atrial appendage closure: A US nationwide retrospective cohort study using claims data. Heart Rhythm 2019; 17:374-382. [PMID: 31539630 DOI: 10.1016/j.hrthm.2019.09.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (pLAAC) emerged as an option for stroke prevention in patients with atrial fibrillation ineligible for long-term anticoagulation. Real-world data on pLAAC's in-hospital and 30-day readmission measures are limited. OBJECTIVE We sought to report the nationwide incidence of the above outcomes using 2016 claims data. METHODS We used the National Inpatient Sample for in-hospital outcomes and Nationwide Readmissions Database for readmissions. We identified hospitalizations with a primary diagnosis of atrial fibrillation and pLAAC procedure by using International Classification of Diseases, Tenth Revision codes and compared the outcomes mentioned above between the endocardial and epicardial cohorts. Statistical analyses were performed using R 3.3.2. RESULTS Among 5480 pLAAC procedures (endocardial: 5145; epicardial: 335), the in-hospital mortality was 0.3%. Endocardial left atrial appendage closure (LAAC) had lower complications (8.5% vs 25.4%; P < .001) and shorter length of stay median [interquartile range] 1 [1-1] day vs 2 [1-3] days; P < .001) but higher hospitalization cost (24.13 [18.45-30.17] × 1000 dollars vs 21.21 [14.03-27.86] × 1000 dollars; P = .016). The most common complications include pericardial (endocardial vs epicardial: 3% vs 10.4%; P < .001) and renal failure (1.4% vs 6.0%; P = .004). Epicardial LAAC had higher 30-day unplanned readmissions (19.5% vs 8.3%; P = .001), with the most common reason being pericarditis and/or effusion (33.9%). CONCLUSION Endocardial LAAC had lower complications and 30-day readmissions but higher hospitalization cost. Although epicardial LAAC showed higher complications, given recent improvements in its technique, and postprocedural care demonstrated a significant reduction in pericardial complications, more contemporary data comparing these outcomes are needed.
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Affiliation(s)
- Venkat L K Vuddanda
- Department of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mohit K Turagam
- Helmsley Centre for Cardiac Electrophysiology, Mount Sinai Hospital, New York, New York
| | - Nikita A Umale
- Department of Emergency Medicine, Brigham & Women's Hospital, Boston, Massachusetts
| | - Zubair Shah
- Cardiovascular Research Institute, The Kansas University Hospital, Kansas City, Kansas
| | - Dhanunjaya R Lakkireddy
- Division of cardiac electrophysiology, Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, Kansas
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Finnian R McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Poonam Velagapudi
- Division of Cardiovascular Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Moussa Mansour
- Division of Cardiac Electrophysiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - E Kevin Heist
- Division of Cardiac Electrophysiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts.
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35
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Black-Maier E, Piccini JP, Granger CB. Left atrial appendage closure: A therapy uniquely suited for specific populations of patients with atrial fibrillation. J Cardiovasc Electrophysiol 2019; 30:2968-2976. [PMID: 31520437 DOI: 10.1111/jce.14182] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/03/2019] [Accepted: 09/07/2019] [Indexed: 01/26/2023]
Abstract
Atrial fibrillation (AF) is the most common clinically relevant arrhythmia and confers a fivefold increased risk for stroke. Cardioembolic stroke secondary to AF is a devastating event, but is largely preventable with appropriate oral anticoagulation (OAC). The PROTECT and PREVAIL trials demonstrated that the WATCHMAN left atrial appendage closure (LAAC) device in combination with short-term warfarin therapy is noninferior to long-term warfarin with respect to a composite endpoint of stroke, cardiovascular death, and systemic embolism. Importantly, the WATCHMAN confers a significant reduction in life-threatening bleeding compared to OAC. Although direct-acting oral anticoagulant (DOAC) are superior to warfarin in eligible patients, several important AF populations exist in whom left atrial appendage (LAA) closure may be preferable to DOAC. Populations warranting strong consideration of LAAC include patients with contraindications to DOAC, end-stage renal disease, prior intracranial hemorrhage, recurrent gastrointestinal bleeding, and patients undergoing transcatheter aortic valve replacement or left atrial electrical isolation. Device-related thrombosis is an important complication of LAAC, and DOAC may be preferential to warfarin for prevention and treatment of this complication remains unexplored. Prospective clinical trials comparing DOAC to LAAC in these unique populations are either ongoing or needed.
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Affiliation(s)
- Eric Black-Maier
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Christopher B Granger
- Division of Cardiology, Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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36
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Holmes BB, Patel N, Lugo R, Richardson T, Metawee M, Rinke LL, Meisch C, Shoemaker MB, Ellis CR. Clinical predictors of acute hyponatremia following LARIAT ligation of the left atrial appendage. J Cardiovasc Electrophysiol 2019; 30:2501-2507. [PMID: 31515883 DOI: 10.1111/jce.14177] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/30/2019] [Accepted: 08/31/2019] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Hyponatremia commonly follows percutaneous exclusion of the left atrial appendage (LAA) with the LARIAT suture delivery device. The aim of this study was to evaluate for clinical predictors hyponatremia following ligation of the appendage with the LARIAT device. METHODS AND RESULTS A retrospective analysis was conducted on 61 consecutive patients (average age 69.7 ± 9.8 years, 55.7% male) who underwent successful appendage ligation with the LARIAT device. Acute hyponatremia (AH) was defined as a drop in serum sodium (Na) by greater than or equal to 4 mmol/L within 48 hours of ligation while exaggerated acute hyponatremia (EAH) was defined as a drop greater than or equal to 10 mmol/L. Among all patients, there was a significant decrease in [Na] at 24 hours (3.26 ± 2.77 mmol/L) and 48 hours (4.98 ± 3.74 mmol/L). Thirty-two patients (52.4%) had AH while six patients (9.8%) experienced EAH. A body mass index (BMI) of less than 28.4 kg/m2 was associated with AH (P = .037) while a BMI < 25 kg/m2 was associated with EAH (P = .021). A linear regression analysis comparing the maximum sodium decrease to the indexed left atrial (LA) diameter found that for every 1 cm/m2 increase in indexed LA diameter, there was a 2.5 mEq/L decrease in serum sodium (P = .04). CONCLUSIONS Hyponatremia frequently occurs following LAA ligation with the LARIAT device. A low BMI < 25 kg/m2 is associated with a drop in serum sodium of greater than 10 mmol/L while increasing indexed LA diameter predicts any AH. AH is also associated with a significantly lower systolic blood pressure 48 to 72 hours post LAA exclusion with the LARIAT device.
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Affiliation(s)
- Benjamin B Holmes
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Neel Patel
- Section of Cardiovascular Medicine, Wake Forest Baptist Health, Winston Salem, North Carolina
| | - Ricardo Lugo
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis Richardson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mohammed Metawee
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lauren Lee Rinke
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carol Meisch
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Christopher R Ellis
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Turagam MK, Vuddanda V, Verberkmoes N, Ohtsuka T, Akca F, Atkins D, Bommana S, Emmert MY, Gopinathannair R, Dunnington G, Rasekh A, Cheng J, Salzberg S, Natale A, Cox J, Lakkireddy DR. Epicardial Left Atrial Appendage Exclusion Reduces Blood Pressure in Patients With Atrial Fibrillation and Hypertension. J Am Coll Cardiol 2019; 72:1346-1353. [PMID: 30213326 DOI: 10.1016/j.jacc.2018.06.066] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/22/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage exclusion (LAAE) has evolved as an alternative strategy for stroke prevention in atrial fibrillation (AF). Recent observational data have suggested that epicardial LAAE can have substantial impact on arrhythmia burden and hemodynamic profile. OBJECTIVES The authors aimed to study the impact of epicardial versus endocardial LAAE on systemic blood pressure in hypertensive AF patients. METHODS This was a prospective, nonrandomized study comparing 247 patients who underwent epicardial LAAE with 124 patients with endocardial exclusion. Clinical outcomes were measured at 3 months and 1 year. Primary outcome was improvement in systolic blood pressure (SBP) between both groups compared with baseline. Secondary outcome included changes in diastolic pressures (DBP), serum electrolytes, and creatinine. RESULTS There was no significant difference in baseline SBP between epicardial and endocardial groups. SBP was significantly lower in the epicardial group both at 3 months (122 ± 11.8 mm Hg vs. 129.7 ± 8.2 mm Hg; p < 0.001) and 1 year (123 ± 11.6 mm Hg vs. 132.2 ± 8.8 mm Hg; p < 0.001) compared with the endocardial group. An adjusted multivariate linear mixed effects model demonstrated that epicardial LAAE significantly decreased SBP by 7.4 mm Hg at 3 months and by 8.9 mm Hg at 1 year (p < 0.0001). There was a trend toward lower DBP with epicardial LAAE at 3 months by 1.3 mm Hg (p = 0.2) and at 1 year by 1.8 mm Hg (p = 0.09). There was no significant difference in serum electrolytes and creatinine between both groups. CONCLUSIONS In hypertensive AF patients, epicardial LAAE significantly decreases SBP both at 3 and 12 months compared with endocardial exclusion.
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Affiliation(s)
- Mohit K Turagam
- Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Toshiya Ohtsuka
- Department of Cardiovascular Surgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Ferdi Akca
- Heart Center, Catharina Hospital, Eindhoven, the Netherlands
| | - Donita Atkins
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, Kansas
| | - Sudharani Bommana
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park, Kansas
| | | | | | | | | | - Jie Cheng
- Texas Heart Institute, Houston, Texas
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas. https://twitter.com/andreanatalemd
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Ramchand J, Harb SC, Miyasaka R, Kanj M, Saliba W, Jaber WA. Imaging for Percutaneous Left Atrial Appendage Closure: A Contemporary Review. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1643957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Jay Ramchand
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C. Harb
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rhonda Miyasaka
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed Kanj
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Walid Saliba
- Section of Cardiac Pacing and Electrophysiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Wael A. Jaber
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Mohanty S, Gianni C, Trivedi C, Gadiyaram V, Della Rocca DG, MacDonald B, Horton R, Al-Ahmad A, Gibson DN, Price M, Krumerman AK, Palma EC, Di Biase L, Lakkireddy D, Natale A. Risk of thromboembolic events after percutaneous left atrial appendage ligation in patients with atrial fibrillation: Long-term results of a multicenter study. Heart Rhythm 2019; 17:175-181. [PMID: 31400519 DOI: 10.1016/j.hrthm.2019.08.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Percutaneous left atrial appendage (LAA) occlusion with Lariat has emerged as a viable alternative to oral anticoagulation (OAC) to prevent thromboembolic (TE) events in patients with atrial fibrillation. OBJECTIVE We evaluated the long-term TE risk in post-Lariat patients. METHODS Consecutive patients undergoing LAA ligation with the Lariat device at multiple centers with at least 1-year follow-up were included in the analysis. Transesophageal echocardiography (TEE) was performed at 4 weeks, 6 months, and 12 months to assess the completeness of LAA occlusion. OAC was discontinued if 4-week TEE revealed no device-related thrombus and complete closure of the appendage. Patients remained on 81 mg of aspirin per day after discontinuation of the blood thinner. RESULTS A total of 306 patients were included in the study (mean age 68.8 ± 11.0 years; mean CHA2DS2-VASc score 3.6 ± 1.7). Four-week TEE revealed leaks in 81 patients (26.5%); all leaks were less than 5 mm in diameter. At 6-month TEE, spontaneous closure of the leak was demonstrated in 21 patients (25.9%), 26 patients (32%) underwent a successful leak closure procedure, and the remaining 34 (42%) patients were placed on OAC. At the median follow-up period of 15.9 ± 9.2 months, 9 TE events (2.9%) were reported: 7 with persistent leak and 2 without any detectable leaks on 2-dimensional TEE (P < .001). CONCLUSION Complete occlusion of the LAA with the Lariat device was associated with the low rate of TE events at long-term follow-up. However, residual leaks were common after Lariat closure and the stroke rate was significantly higher in patients with incomplete occlusion, even with small leaks.
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Affiliation(s)
- Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Internal Medicine, Dell Medical School, Austin, Texas
| | - Carola Gianni
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Chintan Trivedi
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Varuna Gadiyaram
- Interventional Electrophysiology, Scripps Clinic, San Diego, California
| | | | - Bryan MacDonald
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Amin Al-Ahmad
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas
| | - Douglas N Gibson
- Interventional Electrophysiology, Scripps Clinic, San Diego, California
| | - Matthew Price
- Interventional Electrophysiology, Scripps Clinic, San Diego, California
| | - Andrew K Krumerman
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, New York
| | - Eugen C Palma
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, New York
| | - Luigi Di Biase
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Albert Einstein College of Medicine, Montefiore Medical Center, New York City, New York
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas; Department of Internal Medicine, Dell Medical School, Austin, Texas; Interventional Electrophysiology, Scripps Clinic, San Diego, California; Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio; Division of Cardiology, Stanford University, Stanford, California.
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40
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Understanding Atrial Cardiopathy: an Under-Recognized Contributor to Cardioembolic Stroke. Curr Treat Options Neurol 2019; 21:32. [DOI: 10.1007/s11940-019-0571-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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41
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Price MJ. Device-Related Thrombus After Transcatheter Left Atrial Appendage Closure. JACC Cardiovasc Interv 2019; 12:1015-1017. [PMID: 31103539 DOI: 10.1016/j.jcin.2019.03.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 03/27/2019] [Indexed: 12/27/2022]
Affiliation(s)
- Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California.
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42
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Left Atrial Appendage Occlusion: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 33:1753-1765. [DOI: 10.1053/j.jvca.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/21/2022]
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Tan NY, Yasin OZ, Sugrue A, El Sabbagh A, Foley TA, Asirvatham SJ. Anatomy and Physiologic Roles of the Left Atrial Appendage: Implications for Endocardial and Epicardial Device Closure. Interv Cardiol Clin 2019. [PMID: 29526287 DOI: 10.1016/j.iccl.2017.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The left atrial appendage has been implicated as a major nidus for thrombus formation, particularly in atrial fibrillation. This discovery has prompted substantial interest in the development of left atrial appendage exclusion devices aimed at decreasing systemic thromboembolism risk. Its deceptively simple appearance belies the remarkable complexity that characterizes its anatomy and physiology. We highlight the key anatomic features and variations of the left atrial appendage as well as its relationships with surrounding structures. We also summarize crucial anatomic factors that should be taken into account by the interventional cardiologist when planning for or performing left atrial appendage exclusion procedures.
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Affiliation(s)
- Nicholas Y Tan
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Omar Z Yasin
- Department of Internal Medicine, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Alan Sugrue
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Abdallah El Sabbagh
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Thomas A Foley
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA
| | - Samuel J Asirvatham
- Department of Cardiovascular Diseases, Mayo Clinic Rochester, 200 1st Street Southwest, Rochester, MN 55905, USA.
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Left Atrial Appendage Electrical Isolation as a Target in Atrial Fibrillation. JACC Clin Electrophysiol 2019; 5:407-416. [DOI: 10.1016/j.jacep.2019.02.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 02/25/2019] [Accepted: 02/28/2019] [Indexed: 11/21/2022]
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45
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Left Atrial Appendage Occlusion Guided Only by Transesophageal Echocardiography. Cardiol Res Pract 2019; 2019:1376515. [PMID: 30719340 PMCID: PMC6334355 DOI: 10.1155/2019/1376515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 12/16/2018] [Indexed: 11/17/2022] Open
Abstract
Aims To investigate a new method of left atrial appendage occlusion without fluoroscopy. Methods and Results We performed left atrial appendage occlusion for 14 patients with atrial fibrillation in our hospital. All of the surgeries were completed in a general surgery setting, avoiding fluoroscopy, and in each case, the entire procedure was guided by transesophageal echocardiography (TEE). All of the surgeries were performed through the femoral vein pathway. All operations went smoothly with no serious complications. Postoperative TEE indicated that each device was in a good position, and there was no residual shunt around any of the devices. Conclusions TEE-guided left atrial appendage occlusion is safe and reliable, simplifies the procedure, protects doctors and patients from radiation, and is gradually becoming the mainstream operation for left atrial appendage occlusion. This trial is registered with ChiCTR1800018387.
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46
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Gadiyaram VK, Mohanty S, Gianni C, Trivedi C, Al-Ahmad A, Burkhardt DJ, Gallinghouse JG, Hranitzky PM, Horton RP, Sanchez JE, Della Rocca DG, Di Biase L, Price MJ, Couts L, Gibson D, Natale A. Thromboembolic events and need for anticoagulation therapy following left atrial appendage occlusion in patients with electrical isolation of the appendage. J Cardiovasc Electrophysiol 2019; 30:511-516. [PMID: 30623500 DOI: 10.1111/jce.13838] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 12/27/2018] [Accepted: 12/30/2018] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Electrical isolation of the left atrial appendage (LAA) is an important adjunctive ablation strategy in patients with nonparoxysmal atrial fibrillation (AF). Patients who have impaired LAA contractility following isolation may require long-term oral anticoagulant (OAC) therapy irrespective of their CHADS2 -VASc score. Percutaneous LAA occlusion (LAAO) is a potential alternative to life-long OAC therapy. We aimed to assess the rate of OAC discontinuation and thromboembolic (TE) events following percutaneous LAAO in patients who underwent LAA electrical isolation (LAAI). METHODS This is a retrospective two-center study of patients who underwent percutaneous LAAO following LAAI. Patients with at least 3-month follow-up were included in the study. The antithrombotic therapy and TE events at the time of the last follow-up were noted. RESULTS The LAA was successfully occluded in 162 (with Watchman device in 140 [86.4%] and Lariat in 22 [13.6%]). A total of 32 patients had leaks detected on the 45-day transesophageal echocardiogram (TEE); 21 (15%) Watchman and 11 (50%) Lariat cases (P = 0.0001). Two (one Watchman and one Lariat) of the 32 leaks were more than 5 mm. After the 45-day TEE, 150 (92.6%) patients were off-OAC. No TE events were reported in the 150 patients who stopped the anticoagulants. Four (2.47%) patients experienced stroke following the LAAO (three Watchman and one Lariat) procedure while on-OAC, two of which were fatal. At the median follow-up of 18.5 months, 159 (98.15%) patients were off-anticoagulant. CONCLUSION Up to 98% of patients with LAAI could safely discontinue OAC after undergoing the appendage closure procedure.
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Affiliation(s)
- Varuna K Gadiyaram
- Department of Interventional Electrophysiology, Scripps Clinic, La Jolla, California
| | - Sanghamitra Mohanty
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas.,Dell Medical School, University of Texas, Austin, Texas
| | - Carola Gianni
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Chintan Trivedi
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Amin Al-Ahmad
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - David J Burkhardt
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Joseph G Gallinghouse
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Patrick M Hranitzky
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Rodney P Horton
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | - Javier E Sanchez
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas
| | | | - Luigi Di Biase
- Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas.,Department of Biomedical Engineering, University of Texas, Austin, Texas.,Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York.,Department of Internal Medicine and Cardiology, Department of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy
| | - Matthew J Price
- Department of Interventional Electrophysiology, Scripps Clinic, La Jolla, California
| | - Linda Couts
- Department of Interventional Electrophysiology, Scripps Clinic, La Jolla, California
| | - Douglas Gibson
- Department of Cardiac Electrophysiology, Scripps Clinic, La Jolla, CA
| | - Andrea Natale
- Department of Interventional Electrophysiology, Scripps Clinic, La Jolla, California.,Department of Electrophysiology, St. David's Medical Center, Texas Cardiac Arrhythmia Institute, Austin, Texas.,Dell Medical School, University of Texas, Austin, Texas.,Department of Biomedical Engineering, University of Texas, Austin, Texas.,Department of Electrophysiology, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio.,Division of Cardiology, Stanford University, Stanford, California
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47
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Rocca DGD, Prete AD, Biase LD, Horton RP, Al-Ahmad A, Bassiouny M, Mohanty S, Trivedi C, Romero J, Gianni C, Burkhardt JD, Gallinghouse GJ, Sanchez JE, Versaci F, Natale A. Current Endocardial Approaches for Left Atrial Appendage Closure. ACTA ACUST UNITED AC 2019. [DOI: 10.17925/ejae.2019.5.1.40] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
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49
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Sharma SP, Park P, Lakkireddy D. Left Atrial Appendages Occlusion: Current Status and Prospective. Korean Circ J 2018; 48:692-704. [PMID: 30073807 PMCID: PMC6072669 DOI: 10.4070/kcj.2018.0231] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 07/17/2018] [Indexed: 12/21/2022] Open
Abstract
Stroke continues to be a major cause of morbidity and mortality in atrial fibrillation (AF) patients. Oral anticoagulation (OAC) provides protection against stroke and peripheral embolization in AF but significant proportion of patients could not be started on anticoagulation because of bleeding complications. Left atrial appendage harbors clot in about 90% of nonvalvular AF. The advent of left atrial appendage occlusion (LAAO) techniques has provided these patients with alternative to OAC for stroke prophylaxis. Multiple LAAO devices are currently available with Watchman and Amulet being the most commonly used in clinical practice. Randomized studies are available for Watchman device only. Data on Amplatzer Cardiac Plug, Amulet and Lariat devices are limited by the paucity of randomized data. Long-term data on different LAAO techniques are showing promising results. Device related thrombosis continues to be a serious complication associated with LAAO. Future studies should look into comparative effectiveness between different LAAO techniques, optimal patient selection, risk of complications, and anticoagulant treatment after LAAO. This article aims to provide current available evidence on efficacy and safety of different LAAO devices and future prospective.
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Affiliation(s)
| | - Peter Park
- Kansas City Heart Rhythm Institute, Overland Park, KS, USA
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50
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Turagam MK, Velagapudi P, Kar S, Holmes D, Reddy VY, Refaat MM, Di Biase L, Al-Ahmed A, Chung MK, Lewalter T, Edgerton J, Cox J, Fisher J, Natale A, Lakkireddy DR. Cardiovascular Therapies Targeting Left Atrial Appendage. J Am Coll Cardiol 2018; 72:448-463. [PMID: 29954658 PMCID: PMC8420938 DOI: 10.1016/j.jacc.2018.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Saibal Kar
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - David Holmes
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiology/Cardiac Electrophysiology and Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Luigi Di Biase
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Amin Al-Ahmed
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James Edgerton
- Department of Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Fisher
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya R Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park Regional Medical Center, Kansas City, Kansas.
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