Prognostic value of chronic kidney disease in patients undergoing left atrial appendage occlusion

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Optimizing Imaging Techniques for Left Atrial Appendage Closure: Insights and Emerging Directions

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia in adults and is associated with significant morbidity and mortality, including an increased risk of stroke, heart failure, dementia, and recurrent hospitalizations. As life expectancy rises, both the incidence and prevalence of AF continue to grow. Stroke prevention remains a cornerstone of AF management, with oral anticoagulation being the primary strategy to reduce thromboembolic risk. However, despite their advantages, direct oral anticoagulants do not completely eliminate the risk of bleeding complications. For patients in whom anticoagulation is contraindicated, poorly tolerated, or ineffective at preventing AF-related stroke, interventional alternatives have gained traction. The left atrial appendage (LAA), a primary site of thrombus formation in AF, can be occluded through a catheter-based procedure known as left atrial appendage closure (LAAC) or left atrial appendage occlusion (LAAO). This review aims to provide imaging specialists with a comprehensive understanding of their role in LAAC, underscoring the importance of a multidisciplinary approach to enhance patient selection, procedural success, and long-term efficacy.

Cardiac Amyloidosis With Right Atrial Appendage Thrombus Detected After Left Atrial Appendage Occlusion

BACKGROUND

Left atrial appendage occlusion (LAAO) is a valuable alternative therapy to anticoagulants for stroke prevention, and a representative study has demonstrated a high rate of anticoagulant discontinuation after LAAO.

CASE SUMMARY

LAAO was performed on an 88-year-old woman with cardiac amyloidosis (CA). Although anticoagulant therapy was discontinued after LAAO, a follow-up image showed a thrombus in the right atrial appendage (RAA) incidentally. Anticoagulation was resumed, and no clinical events were detected during a 1-year follow-up.

DISCUSSION

Although LAAO is an effective treatment for stroke prevention in patients with CA, this condition is associated with an increased risk of intracardiac thrombus. Therefore, discontinuation of anticoagulant therapy after LAAO should be approached by keeping in mind the possibility of RAA thrombus.

TAKE-HOME MESSAGES

LAAO can be effective in CA, yet anticoagulation discontinuation must be individualized, keeping in mind the possibility of RAA thrombus in high-risk patients.

Safety and efficacy of atrial fibrillation ablation in kidney transplant patients

INTRODUCTION

Managing atrial fibrillation in kidney transplant patients poses a challenge for both nephrologists and cardiologists. Data regarding the safety and efficacy of catheter ablation in this patient's cohort is scarce.

METHODS AND RESULTS

In this two-center prospective study, we included all consecutive kidney transplant patients who underwent atrial fibrillation ablation between April 2017 and March 2022. A 1:3 propensity score matching created a control group of non-transplant AF patients undergoing ablation. We included 16 kidney transplant patients and 48 matched controls. Ablation was successful in all patients. The periprocedural complication rate (6.3% in the kidney transplant group vs. 6.3% in the control group, p value = 1) did not differ between the two groups. One transplant patient experienced graft dysfunction after a complication. At 18 months, AF recurrence-fee rates were 69% in the transplant group and 70.1% in controls (p = 0.95). By the last follow-up, all transplant patients had discontinued antiarrhythmic drugs, while 19.6% of the patients in the control group were treated with antiarrhythmic drugs (p = 0.09). Kidney function in the transplant group remained stable (eGFR 32 [23.8, 40.5] ml/min/1.73 m2 before vs. 34 [29.8, 38] ml/min/1.73 m2 at last follow up, p = 0.93).

CONCLUSIONS

This study demonstrates that catheter ablation is a viable option for treating AF in kidney transplant patients, with comparable outcomes to non-transplanted individuals. Discontinuing antiarrhythmic drugs reduces drug interaction risks, but minimizing procedural complications remains critical to preserving graft function.

Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Hemodialysis: An International, Multicentric Registry

BACKGROUND

The net benefit of oral anticoagulation in patients with end-stage renal disease on hemodialysis (HD) is uncertain. In recent years, left atrial appendage closure (LAAC) has emerged as an alternative to oral anticoagulation; however, there is scant evidence of LAAC in patients on HD.

OBJECTIVES

This study aimed to assess the feasibility and safety of LAAC in patients on HD.

METHODS

In an international multicenter registry, patients' baseline characteristics and procedural and follow-up data were recorded from all patients on HD with atrial fibrillation who underwent LAAC.

RESULTS

A total of 147 patients from 9 centers were included. The mean age was 72.6 ± 10.4 years; the mean CHA2DS2-VASc-score was 4.6 ± 1.5, and the mean HAS-BLED-score was 4.7 ± 1.1. Antithrombotic treatment regimens prior to implantation were notably diverse, encompassing more than 12 distinct combinations. Technical successful LAA at first procedure was achieved in 144 of 147 (98%) patients and major complications were observed in 4.7% (7 of 149 procedures). The median follow-up was 427 days (Q1-Q3: 184-797 days), no device-related thrombi were detected, and peridevice leaks ≥5 mm were 1.7% at first imaging control. The most common post-implantation antithrombotic therapy was single antiplatelet therapy with 165.9 patient-years (py). During follow-up of 222.9 py, the annual stroke rate was 0.9%, reflecting an 88% relative risk reduction (P < 0.001) compared to historical data. Similarly, the annual rate of major bleeding was 4.5%, signifying a 55% relative risk reduction (P = 0.023). Throughout follow-up, 29 deaths (19.9%) were recorded.

CONCLUSIONS

LAAC in end-stage renal disease patients on HD demonstrated an acceptable safety profile, coupled with a notably low incidence of strokes. This was paralleled by low bleeding rates.

Lower rate of major bleeding in very high risk patients undergoing left atrial appendage occlusion: A propensity score-matched comparison with direct oral anticoagulant

BACKGROUND

Long-term oral anticoagulation is the mainstay therapy for thromboembolic (TE) prevention in patients with atrial fibrillation. However, left atrial appendage occlusion (LAAO) could be a safe alternative to direct oral anticoagulants (DOACs) in patients with a very high TE risk profile.

OBJECTIVE

The purpose of this study was to compare the safety and efficacy of LAAO vs DOACs in patients with atrial fibrillation at very high stroke risk (CHA2DS2-VASc [congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category] score ≥ 5).

METHODS

Data from patients with CHA2DS2-VASc score ≥ 5 were extracted from a prospective multicenter database. To attenuate the imbalance in covariates between groups, propensity score matching was used (covariates: CHA2DS2-VASc and HAS-BLED [hypertension, abnormal renal or liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol] scores), which resulted in a matched population of 277 patients per group. The primary end point was a composite of cardiovascular death, TE events, and clinically relevant bleeding during follow-up.

RESULTS

Of 2381 patients, 554 very high risk patients were included in the study (mean age 79 ± 7 years; CHA2DS2-VASc score 5.8 ± 0.9; HAS-BLED score 3.0 ± 0.9). The mean follow-up duration was 25 ± 11 months. A higher incidence of the composite end point was documented with DOACs compared with LAAO (14.9 events per 100 patient-years in the DOAC group vs 9.4 events per 100 patient-years in the LAAO group; P = .03). The annualized clinically relevant bleeding risk was higher with DOACs (6.3% vs 3.2%; P = .04), while the risk of TE events was not different between groups (4.1% vs 3.2%; P = .63).

CONCLUSION

In high-risk patients, LAAO had a similar stroke prevention efficacy but a significantly lower risk of clinically relevant bleeding when compared with DOACs. The clinical benefit of LAAO became significant after 18 months of follow-up.

Assessment of left atrial function provides incremental value: the left atrial volumetric/mechanical coupling index in patients with chronic kidney disease

Background

Heart failure is a common cause of adverse cardiovascular outcomes in patients with chronic kidney disease (CKD). Left atrial (LA) characteristics are thought to be involved in the development of heart failure. However, LA assessment is complex. Though a variety of parameters have been defined, there is no single parameter that best defines LA function. Pilot data indicate that left atrial volumetric/mechanical coupling index (LACI) may be useful, but data with CKD are lacking.

Aim

The objective of this study was to define LACI in a cohort of patients with CKD and to assess its value in evaluating LA function and predicting heart failure.

Methods

A cohort of patients with CKD was enrolled at our hospital between 2021 and 2023. Follow-up was performed for heart failure. LACI is a volumetric to mechanical coupling index, calculated as the ratio of the LA volume index to the tissue-Doppler myocardial velocity at atrial contraction. Spearman's rank correlation or Pearson's correlation was used to calculate the correlation between LACI and echocardiographic/hemodynamic variables. Receiver operating characteristic curve (ROC) analysis was utilised to derive the area under the curve (AUC) for LACI, LVGLS, LASr, LASct and LASI for the detection of heart failure. Kaplan-Meier survival curves were employed to compare clinical outcomes based on LACI thresholds. A multivariable logistic regression analysis was employed to assess the relationship between risk factors and elevated LACI. Cox proportional hazards regression was used to identify risk factors for heart failure.

Results

LACI showed a positive correlation with NT-proBNP, CK-MB, LAVI, E/e' and LASI (r = 0.504, 0.536, 0.856, 0.541 and 0.509, p < 0.001); and a negative correlation with LASr (r = -0.509, p < 0.001). On the ROC analysis for the determination of heart failure, the AUC of LACI was comparable to those of LVGLS (0.588 vs. 509, p = 0.464), LASr (0.588 vs. 0.448, p = 0.132), LASct (0.588 vs. 0.566, p = 0.971) and LASI (0.588 vs. 0.570, p = 0.874). The cardiovascular risk factors increased by LACI were age, BMI, diabetes, triglycerides, LA size, LASr, LASI, E/A, E/e' and EF (p < 0.05). During a median follow-up of 16 months (range, 6-28 months), the event-free survival curves demonstrated a higher risk of heart failure in the group with LACI > 5.0 (log-rank test: P < 0.001). LACI > 5.0 was an independent predictor of heart failure [OR: 0.121, 95% CI (0.020-0.740), p = 0.022].

Conclusion

LACI may prove to be a valuable tool for assessing LA function in patients with CKD, and could be integrated into the routine assessment of LA for the purpose of prognostic assessment and clinical decision-making in patients with CKD.

Incidence and predictors of 2-year mortality following percutaneous left atrial appendage occlusion in the EWOLUTION trial

AIMS

Sufficient survival time following left atrial appendage occlusion (LAAO) is essential for ensuring the efficacy and cost-effectiveness of this strategy for stroke prevention. Understanding prognostic factors for early mortality after LAAO could optimize patient selection. In the current study, we perform an in-depth analysis of 2-year mortality after LAAO, focusing particularly on potential predictors.

METHODS AND RESULTS

The EWOLUTION registry is a real-world cohort comprising 1020 patients that underwent LAAO. Endpoint definitions were pre-specified, and death was categorized as cardiovascular, non-cardiovascular, or unknown origin. Mortality rates were calculated from Kaplan-Meier estimates. Baseline characteristics significantly associated with death in univariate Cox regression analysis were incorporated into the multivariate analysis. All multivariate predictors were included in a risk model. Two-year mortality rate was 16.4% [confidence interval (CI): 14.0-18.7%], with 50% of patients dying from a non-cardiovascular cause. Multivariate baseline predictors of 2-year mortality included age [hazard ratio (HR) 1.05, CI: 1.03-1.08, per year increase], heart failure (HR 1.73, CI: 1.24-2.41), vascular disease (HR 1.47, CI: 1.05-2.05), valvular disease (HR 1.63, CI: 1.15-2.33), abnormal liver function (HR 1.80, CI: 1.02-3.17), and abnormal renal function (HR 1.58, CI: 1.10-2.27). Mortality rate exhibited a gradual rise as the number of risk factors increased, reaching 46.1% in patients presenting with five or six risk factors.

CONCLUSION

One in six patients died within 2 years after LAAO. We identified six independent predictors of mortality. When combined, this model showed a gradual increase in mortality rate with a growing number of risk factors, which may guide appropriate patient selection for LAAO.

CLINICAL TRIAL REGISTRATION

The original EWOLUTION registry was registered at clinicaltrials.gov under identifier NCT01972282.

In-hospital safety outcomes of left atrial appendage occlusion in octogenarians and nonagenarians

AIMS

Data on safety outcomes of left atrial appendage occlusion (LAAO) in elderly patients are limited. This study aimed to compare the outcomes of LAAO between octogenarians (age 80-89) and nonagenarians (age ≥90) vs. younger patients (age ≤79).

METHODS AND RESULTS

We conducted a retrospective cohort study using the National Inpatient Sample database to identify patients hospitalized for LAAO from 2016 to 2020 and to compare in-hospital safety outcomes in octogenarians and nonagenarians vs. younger patients. The primary outcome was a composite of in-hospital all-cause mortality or stroke. Secondary outcomes included procedural complications, length of stay (LOS), and total costs. Outcomes were determined using logistic regression models. Among 84 140 patients hospitalized for LAAO, 32.9% were octogenarians, 2.8% were nonagenarians, and 64.3% were ≤79 years of age. Over the study period, the volume of LAAO increased in all age groups (all Ptrend < 0.01). After adjustment for clinical and demographic factors, octogenarians and nonagenarians had similar odds of in-hospital all-cause mortality or stroke [adjusted odds ratio (aOR) 1.41, 95% confidence interval (CI) 0.93-2.13 for octogenarians; aOR 1.69, 95% CI 0.67-3.92 for nonagenarians], cardiac tamponade, acute kidney injury, major bleeding, and blood transfusion, in addition to similar LOS and total costs compared with younger patients (all P > 0.05). However, octogenarians and nonagenarians had higher odds of vascular complications compared with younger patients (aOR 1.47, 95% CI 1.08-1.99 for octogenarians; aOR 1.60, 95% CI 1.18-2.97 for nonagenarians).

CONCLUSION

Octogenarians and nonagenarians undergoing LAAO have a similar safety profile compared with clinically similar younger patients except for higher odds of vascular complications.

Percutaneous Left Atrial Appendage Closure in Patients with Non-Valvular Atrial Fibrillation and End-Stage Renal Disease on Hemodialysis: A Case Series

Non-valvular atrial fibrillation (NVAF) is the most common cardiac arrhythmia in the general population, and its prevalence increases among patients with chronic kidney disease (CKD) undergoing hemodialysis. This population presents high risk of both hemorrhagic and thrombotic events, with little evidence regarding the use of oral anticoagulation treatment (OAT) and multiple complications arising from it; however, stroke prevention with percutaneous left atrial appendage closure (LAAC) is an alternative to be considered. We retrospectively describe the safety and efficacy of percutaneous LAAC in eight patients with NVAF and CKD on hemodialysis during a 12-month follow-up. The mean age was 78.8 years (range 64-86; SD ± 6.7), and seven patients were male. The mean CHA2DS2-VASC and HAS-BLED scores were high, 4.8 (SD ± 1.5) and 3.8 (SD ± 1.3), respectively. Seventy-five percent of the patients were referred for this intervention due to a history of major bleeding, with gastrointestinal bleeding being the most common type, while the remaining twenty-five percent of the patients were referred because of a high risk of bleeding. The percutaneous LAAC procedure was successfully completed in 100% of the patients, with complete exclusion of the appendage without complications or leaks exceeding 5 mm. There was one death not related to the procedure four days after the intervention. Among the other seven patients, no deaths, cardioembolic events or major bleeding were reported during the follow-up period. In our sample, percutaneous LAAC appears to be a safe and effective alternative to anticoagulation in patients with NVAF and CKD on hemodialysis.

Three-dimensional intracardiac echocardiography for left atrial appendage sizing and percutaneous occlusion guidance

AIMS

Left atrial appendage (LAA) imaging is critical during percutaneous occlusion procedures. 3D-intracardiac echocardiography (ICE) features direct visualization of LAA from multiple cross-sectional planes at a time. We aimed at reporting procedural success of 3D-ICE-guided LAA occlusion and the correlation between pre-procedural transoesophageal echocardiography (TEE) and intraprocedural 3D-ICE for LAA sizing.

METHODS AND RESULTS

Among 274 patients undergoing left atrial appendage occlusion (LAAO) with a Watchman FLX, periprocedural ICE guidance was achieved via a commercially available 2D-ICE catheter (220 patients) or a novel (NUVISION™) 3D-ICE one (54 patients). Primary endpoint was a composite of procedural success and LAA sealing at follow-up TEE. Secondary endpoint was a composite of periprocedural device recapture/resizing plus presence of leaks ≥ 3 mm at follow-up TEE. 3D-ICE measurements of maximum landing zone correlated highly with pre-procedural TEE reference values [Pearson's: 0.94; P < 0.001; bias: -0.06 (-2.39, 2.27)]. The agreement between 3D-ICE-based device selection and final device size was 96.3% vs. 79.1% with 2D-ICE (P = 0.005). The incidence of the primary endpoint was 98.1% with 3D-ICE and 97.3% with 2D-ICE (P = 0.99). 2D-ICE patients had a trend towards a higher incidence of periprocedural device recapture/redeployment (31.5% vs. 44.5%; P = 0.09). The secondary endpoint occurred in 31.5% of 3D-ICE patients vs. 45.9% of 2D-ICE ones (P = 0.065).

CONCLUSION

Intracardiac echocardiography-guided LAAO showed a very high success, with no major adverse events. A very high level of agreement for LAA sizing was found between pre-procedural TEE and periprocedural 3D-ICE. 3D-ICE performed significantly better than 2D-ICE for FLX size selection and may provide better guidance during device deployment.