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Rochira C, Mazzapicchi A, Tomasello SD, Azzarelli SA, Di Giorgio A, Scardaci F, Argentino V, Amico F. Percutaneous left atrial appendage closure for stroke prevention: current challenges and future perspectives. Clin Res Cardiol 2025:10.1007/s00392-025-02624-5. [PMID: 40014086 DOI: 10.1007/s00392-025-02624-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 02/15/2025] [Indexed: 02/28/2025]
Abstract
Stroke accounts for significant morbidity and mortality worldwide. Accordingly, appropriate prevention is crucial to reduce the global burden of stroke. Percutaneous left atrial appendage closure (LAAC) is a viable approach for preventing cardioembolic stroke in patients with non-valvular atrial fibrillation who have a contraindication to long-term oral anticoagulation due to a non-reversible cause. In the last 2 decades, percutaneous LAAC has become a rapidly evolving field, with multiple devices approved or under clinical development. However, several issues remain, including limited high-quality evidence, late adverse events, and unclear post-procedural antithrombotic therapy. This review offers an up-to-date perspective on percutaneous LAAC, concentrating on current challenges and unmet needs.
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Affiliation(s)
- Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Alessandro Mazzapicchi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "Sant'Orsola", University of Bologna, Bologna, Italy
| | - Salvatore Davide Tomasello
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy.
| | - Salvatore Adriano Azzarelli
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy
| | - Alessandro Di Giorgio
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy
| | - Francesco Scardaci
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy
| | - Vincenzo Argentino
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy
| | - Francesco Amico
- Catheterization Laboratory and Cardiovascular Interventional Unit, Division of Cardiology, Cannizzaro Hospital, University of Catania, Via Antonello Pitagora da Samo 4, Acicastello, 95021, Catania,, Italy
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Potpara T, Grygier M, Haeusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, Potter TD, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Doehner W, Hindricks G, Kovac J, Camm AJ. An International Consensus Practical Guide on Left Atrial Appendage Closure for the Non-implanting Physician: Executive Summary. Thromb Haemost 2024. [PMID: 39657795 DOI: 10.1055/a-2469-4896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2024]
Abstract
Many patients with atrial fibrillation (AF) who are in need of stroke prevention are not treated with oral anticoagulation or discontinue treatment shortly after its initiation. Despite the availability of direct oral anticoagulants (DOACs), such undertreatment has improved somewhat but is still evident. This is due to continued risks of bleeding events or ischemic strokes while on DOAC, poor treatment compliance, or aversion to anticoagulant therapy. Because of significant improvements in procedural safety over the years left atrial appendage closure (LAAC), using a catheter-based, device implantation approach, is increasingly favored for the prevention of thromboembolic events in AF patients who cannot have long-term oral anticoagulation. This article is an executive summary of a practical guide recently published by an international expert consensus group, which introduces the LAAC devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. This practical guide, aligned with published guideline/guidance, is aimed at those non-implanting physicians who may need to refer patients for consideration of LAAC.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, Nephrology Clinic, Monza, Italy and Istituto Auxologico Italiano, University of Milano-Bicocca, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- European Interbalkan Medical Centre, Aristotle University of Thessaloniki, Ippokrateio Hospital of Thessaloniki, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, The Netherlands
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, Centro Cardiologico Monzino, IRCCS, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany; Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, EuDial Working Group of the European Renal Association, Miull General Hospital, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, Italian Society of Nephrology, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine Berlin, Friede Springer Cardiovascular Prevention Center @Charité, Berlin, Germany
| | - Wolfram Doehner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany, Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - A John Camm
- St. George's University of London, London, United Kingdom
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Landmesser U, Skurk C, Tzikas A, Falk V, Reddy VY, Windecker S. Left atrial appendage closure for stroke prevention in atrial fibrillation: current status and perspectives. Eur Heart J 2024; 45:2914-2932. [PMID: 39027946 PMCID: PMC11335376 DOI: 10.1093/eurheartj/ehae398] [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: 09/21/2023] [Revised: 02/18/2024] [Accepted: 06/12/2024] [Indexed: 07/20/2024] Open
Abstract
Atrial fibrillation (AF) is associated with an increased risk of stroke and systemic embolism, and the left atrial appendage (LAA) has been identified as a principal source of thromboembolism in these patients. While oral anticoagulation is the current standard of care, LAA closure (LAAC) emerges as an alternative or complementary treatment approach to reduce the risk of stroke or systemic embolism in patients with AF. Moderate-sized randomized clinical studies have provided data for the efficacy and safety of catheter-based LAAC, largely compared with vitamin K antagonists. LAA device iterations, advances in pre- and peri-procedural imaging, and implantation techniques continue to increase the efficacy and safety of LAAC. More data about efficacy and safety of LAAC have been collected, and several randomized clinical trials are currently underway to compare LAAC with best medical care (including non-vitamin K antagonist oral anticoagulants) in different clinical settings. Surgical LAAC in patients with AF undergoing cardiac surgery reduced the risk of stroke on background of anticoagulation therapy in the LAAOS III study. In this review, we describe the rapidly evolving field of LAAC and discuss recent clinical data, ongoing studies, open questions, and current limitations of LAAC.
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Affiliation(s)
- Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
| | - Apostolos Tzikas
- Second Department of Cardiology, Hippocratic University Hospital, Aristotle University of Thessaloniki Department of Cardiology, Interbalkan Medical Center, Pylaia, Thessaloniki, Greece
| | - Volkmar Falk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charite (DHZC), Hindenburgdamm 30, 12203 Berlin, Germany
- Berlin Institute of Health (BIH), Anna-Louisa-Karsch-Straße 2, 10178 Berlin, Germany
- Friede Springer Cardiovascular Prevention Center@Charité, Hindenburgdamm 30, 12203 Berlin, Germany
- DZHK Partner Site Berlin, Germany
- Department of Cardiothoracic Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, 3010 Bern, Switzerland
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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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Magnocavallo M, Della Rocca DG, Gianni C, Zagrodzky W, Lavalle C, Mohanty S, Chimenti C, Al-Ahmad A, Di Biase L, Horton RP, Natale A. Zero-Contrast Left Atrial Appendage Occlusion and Peridevice Leak Closure in Patients with Advanced Kidney Disease. Heart Rhythm 2022; 19:1013-1014. [DOI: 10.1016/j.hrthm.2022.01.036] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
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Lessons learned from experimental models of cerebrovascular aneurysms to improve endocardial device occlusion of the left atrial appendage. Heart Rhythm O2 2021; 2:423-430. [PMID: 34430948 PMCID: PMC8369292 DOI: 10.1016/j.hroo.2021.06.004] [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] [Indexed: 11/21/2022] Open
Abstract
In patients with atrial fibrillation, left atrial appendage (LAA) occlusion devices represent an alternative to anticoagulation but are associated with residual peridevice leaks (PDLs) and device-related thrombi (DRT). Similarly, cerebrovascular aneurysms can be treated with coil embolization, but pericoil leaks represent a significant limitation. In experimental models of cerebrovascular aneurysms, endothelial denudation achieved independently with (1) embolization with radioactive coils, (2) mechanical removal of the endothelium, or (3) radiofrequency ablation was dramatically effective in preventing or eliminating pericoil leaks. Anatomical, physiological, and blood flow similarities exist between the LAA and saccular aneurysms. Concepts developed in treating aneurysm leaks can be used to treat similar problems in the LAA. Learning from aneurysms, we conceived of a novel technique to denude local endothelium and thus eliminate residual leaks around LAA-occlusion devices. We recently successfully tested this hypothesis in patients with a PDL in a prospective manner in a multicenter study. In this article, we expand on the rationale of the technique developed to close PDLs and potentially also prevent DRTs.
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