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Tsuda T, Hayashi K, Kato T, Kusayama T, Nakagawa Y, Nomura A, Tada H, Usui S, Sakata K, Kawashiri MA, Fujino N, Yamagishi M, Takamura M. Hypertrophic Cardiomyopathy Predicts Thromboembolism and Heart Failure in Patients With Nonvalvular Atrial Fibrillation - A Prospective Analysis From the Hokuriku-Plus AF Registry. Circ J 2023; 87:1790-1797. [PMID: 37866911 DOI: 10.1253/circj.cj-23-0418] [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] [Indexed: 10/24/2023]
Abstract
BACKGROUND The prognostic effect of concomitant hypertrophic cardiomyopathy (HCM) on adverse events in patients with atrial fibrillation (AF) has not been evaluated in a multicenter prospective cohort study in Japan.Methods and Results: Using the Hokuriku-Plus AF Registry, 1,396 patients with nonvalvular AF (1,018 men, 72.3±9.7 years old) were assessed prospectively; 72 (5.2%) had concomitant HCM. During a median follow-up of 5.0 years (interquartile range 3.5-5.3 years), 79 cases of thromboembolism (1.3 per 100 person-years) and 192 of heart failure (HF) (3.2 per 100 person-years) occurred. Kaplan-Meier analysis revealed that the HCM group had a significantly greater incidence of thromboembolism (P=0.002 by log-rank test) and HF (P<0.0001 by a log-rank test) than the non-HCM group. The Cox proportional hazards model demonstrated that persistent AF (adjusted hazard ratio 2.98, 95% confidence interval 1.56-6.21), the CHA2DS2-VASc score (1.35, 1.18-1.54), and concomitant HCM (2.48, 1.16-4.79) were significantly associated with thromboembolism. Conversely, concomitant HCM (2.81, 1.72-4.43), older age (1.07, 1.05-1.10), lower body mass index (0.95, 0.91-0.99), a history of HF (2.49, 1.77-3.52), and lower left ventricular ejection fraction (0.98, 0.97-0.99) were significantly associated with the development of HF. CONCLUSIONS Concomitant HCM predicts the incidence of thromboembolism and HF in AF patients.
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Affiliation(s)
- Toyonobu Tsuda
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Kenshi Hayashi
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Takeshi Kato
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Takashi Kusayama
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Yoichiro Nakagawa
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Akihiro Nomura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Soichiro Usui
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | - Kenji Sakata
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | - Noboru Fujino
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
| | | | - Masayuki Takamura
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences
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Das S, Lorente-Ros M, Wu L, Mehta D, Suri R. Safety of left atrial appendage closure in heart failure patients. J Cardiovasc Electrophysiol 2022; 33:2578-2584. [PMID: 36125496 DOI: 10.1111/jce.15682] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 08/14/2022] [Accepted: 09/01/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Left atrial appendage closure (LAAC) is an intervention aimed at stroke prevention in nonvalvular atrial fibrillation (AF). There is a three-fold increased risk of stroke in patients with concomitant presence of AF and heart failure (HF). While anticoagulation is effective, only 60% receive it. We aimed at studying the safety of LAAC in HF patients using a national all-payer database. METHODS We queried the National Inpatient Sample for the year 2016-2018 for WATCHMAN device insertion using ICD 10 procedure codes. We divided the study population into HF and non-HF groups. Outcomes were compared using appropriate statistical tests, p< .05 was considered significant. RESULTS 34 385 LAAC procedures were identified of which 8530 (24.8%) were done in patients with HF. The mean (SD) age of the study population was 76 (7.9) years and 42% were female. There was no difference in mean age between HF and non-HF groups. Our findings indicate that there is no difference in inpatient mortality and cardiac complications between the HF and non-HF groups. However, noncardiac complications including acute kidney injury and respiratory failure were higher in the HF group. CONCLUSION LAAC appears to be a safe procedure in patients with HF. The study is limited by a short follow up period and long-term follow-up is required before definitive conclusions can be made.
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Affiliation(s)
- Subrat Das
- Department of Cardiology, Westchester Medical Center, Valhalla, New York, USA
| | - Marta Lorente-Ros
- Department of Medicine, Mount Sinai Morningside-West, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lingling Wu
- Divison of Cardiovascular Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Davendra Mehta
- Department of Cardiology, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ranjit Suri
- Department of Cardiology, Mount Sinai Morningside, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Large Device-Related Thrombus Detected following Symptoms of Transient Ischemic Attack. Case Rep Cardiol 2021; 2021:9195984. [PMID: 34858666 PMCID: PMC8632399 DOI: 10.1155/2021/9195984] [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: 09/19/2021] [Revised: 10/24/2021] [Accepted: 11/11/2021] [Indexed: 12/03/2022] Open
Abstract
As an independent risk factor for stroke, atrial fibrillation has been shown to be associated with a fivefold increase in the cause of embolic stroke in comparison to healthy individuals without atrial fibrillation. This risk may be compounded by other factors; however, the main probable cause of stroke leading from atrial fibrillation is thrombus formation in the left atrial appendage. In patients for whom anticoagulation is contraindicated, left atrial appendage occlusion has become a leading alternative option for therapeutic prevention of thromboembolism and stroke in patients with this condition. Unfortunately, these devices (particularly the WATCHMAN) have been associated with a 3-6% incidence of intracardiac thrombus development postimplantation. Some risk factors for the development of device-related thrombus are high platelet count, permanent atrial fibrillation, resistance to clopidogrel, and prior transient ischemic attack or stroke. Despite following an anticoagulant regimen, thrombus formation was reported in 5.6% of participants of a randomized clinical trial, and further analysis showed that some of these patients continued to develop either ischemic stroke or thromboembolism five years later as compared to patients without initial thrombus development. We present a case of an elderly male with prior history of stroke and transient ischemic attack who developed a large device-related thrombus five months following WATCHMAN FLX™ implantation. Currently, there are no specific recommendations on the management of this rare complication; however, we discuss possible consideration of initially prolonging anticoagulation therapy following implantation for high-risk individuals, as there is an increased possibility for thrombus formation in this population. Management options should continue to be studied for therapeutic benefit in streamlining postprocedural therapy and improve future outcomes in the use of left atrial appendage occlusion devices, as well as continual thrombus prevention.
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto S, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 guideline on non-pharmacotherapy of cardiac arrhythmias. J Arrhythm 2021; 37:709-870. [PMID: 34386109 PMCID: PMC8339126 DOI: 10.1002/joa3.12491] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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De Backer O, Hafiz H, Fabre A, Lertsapcharoen P, Srimahachota S, Foley D, Sondergaard L. State-of-the-art preclinical testing of the OMEGA TM left atrial appendage occluder. Catheter Cardiovasc Interv 2021; 97:E1011-E1018. [PMID: 33034944 DOI: 10.1002/ccd.29331] [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: 07/12/2020] [Revised: 09/14/2020] [Accepted: 10/02/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to present a new approach of thorough preclinical testing of a novel left atrial appendage (LAA) occluder device. BACKGROUND The development of a safe and effective LAA occluder has been shown to be challenging. METHODS The novel OMEGATM LAA occluder (Eclipse Medical, Ireland) was tested in a porcine model and three-dimensional (3D) human LAA models - this as a prelude to its first-in-human use. RESULTS In a first series of in-vivo experiments, the OMEGATM LAA occluder was shown to have a satisfactory device biocompatibility in a porcine model. The design of the OMEGATM device was further refined and optimized following three more series of in-vivo experiments. The second generation OMEGATM device was designed with thinner wires, leading to a profile reduction. Based on in-vitro testing of different OMEGATM device sizes implanted at different depths in human three-dimensional (3D) LAA models, it could be determined that (1) the landing zone should be measured at a median depth of 12 mm from the LAA ostium; (2) the distal self-retaining inverted cup should have 10%-25% compression to minimize device embolization risk; and (3) the disc should be slightly inverted, i.e. pulled into the LAA, to promote complete LAA occlusion. The combined in-vivo and in-vitro testing resulted in an optimized pre-procedural planning of the first-in-human case treated with the OMEGATM device. CONCLUSIONS This series of carefully planned in-vivo and in-vitro experiments allowed demonstration of the safety and efficacy of the OMEGATM LAA occluder. This approach of thorough preclinical testing of medical devices may reduce the risk of complications in first-in-human cases and may become the standard approach for device development and preclinical testing in the future.
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Affiliation(s)
- Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hussein Hafiz
- Department of Cardiology, Beaumont Hospital, Dublin, Ireland
| | - Aurelie Fabre
- Department of Histopathology, St Vincent's University College Hospital, Dublin, Ireland
| | | | | | - David Foley
- Department of Cardiology, Beaumont Hospital, Dublin, Ireland
| | - Lars Sondergaard
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Nogami A, Kurita T, Abe H, Ando K, Ishikawa T, Imai K, Usui A, Okishige K, Kusano K, Kumagai K, Goya M, Kobayashi Y, Shimizu A, Shimizu W, Shoda M, Sumitomo N, Seo Y, Takahashi A, Tada H, Naito S, Nakazato Y, Nishimura T, Nitta T, Niwano S, Hagiwara N, Murakawa Y, Yamane T, Aiba T, Inoue K, Iwasaki Y, Inden Y, Uno K, Ogano M, Kimura M, Sakamoto SI, Sasaki S, Satomi K, Shiga T, Suzuki T, Sekiguchi Y, Soejima K, Takagi M, Chinushi M, Nishi N, Noda T, Hachiya H, Mitsuno M, Mitsuhashi T, Miyauchi Y, Miyazaki A, Morimoto T, Yamasaki H, Aizawa Y, Ohe T, Kimura T, Tanemoto K, Tsutsui H, Mitamura H. JCS/JHRS 2019 Guideline on Non-Pharmacotherapy of Cardiac Arrhythmias. Circ J 2021; 85:1104-1244. [PMID: 34078838 DOI: 10.1253/circj.cj-20-0637] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Akihiko Nogami
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Haruhiko Abe
- Department of Heart Rhythm Management, University of Occupational and Environmental Health, Japan
| | - Kenji Ando
- Department of Cardiology, Kokura Memorial Hospital
| | - Toshiyuki Ishikawa
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University
| | - Katsuhiko Imai
- Department of Cardiovascular Surgery, Kure Medical Center and Chugoku Cancer Center
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kaoru Okishige
- Department of Cardiology, Yokohama City Minato Red Cross Hospital
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Morio Shoda
- Department of Cardiology, Tokyo Women's Medical University
| | - Naokata Sumitomo
- Department of Pediatric Cardiology, Saitama Medical University International Medical Center
| | - Yoshihiro Seo
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | - Hiroshi Tada
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, University of Fukui
| | | | - Yuji Nakazato
- Department of Cardiovascular Medicine, Juntendo University Urayasu Hospital
| | - Takashi Nishimura
- Department of Cardiac Surgery, Tokyo Metropolitan Geriatric Hospital
| | - Takashi Nitta
- Department of Cardiovascular Surgery, Nippon Medical School
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine
| | | | - Yuji Murakawa
- Fourth Department of Internal Medicine, Teikyo University Hospital Mizonokuchi
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine
| | - Takeshi Aiba
- Division of Arrhythmia, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Koichi Inoue
- Division of Arrhythmia, Cardiovascular Center, Sakurabashi Watanabe Hospital
| | - Yuki Iwasaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Nippon Medical School
| | - Yasuya Inden
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Kikuya Uno
- Arrhythmia Center, Chiba Nishi General Hospital
| | - Michio Ogano
- Department of Cardiovascular Medicine, Shizuoka Medical Center
| | - Masaomi Kimura
- Advanced Management of Cardiac Arrhythmias, Hirosaki University Graduate School of Medicine
| | | | - Shingo Sasaki
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine
| | | | - Tsuyoshi Shiga
- Department of Cardiology, Tokyo Women's Medical University
| | - Tsugutoshi Suzuki
- Departments of Pediatric Electrophysiology, Osaka City General Hospital
| | - Yukio Sekiguchi
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | - Kyoko Soejima
- Arrhythmia Center, Second Department of Internal Medicine, Kyorin University Hospital
| | - Masahiko Takagi
- Division of Cardiac Arrhythmia, Department of Internal Medicine II, Kansai Medical University
| | - Masaomi Chinushi
- School of Health Sciences, Faculty of Medicine, Niigata University
| | - Nobuhiro Nishi
- Department of Cardiovascular Therapeutics, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences
| | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Hitoshi Hachiya
- Department of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital
| | | | | | - Yasushi Miyauchi
- Department of Cardiovascular Medicine, Nippon Medical School Chiba-Hokusoh Hospital
| | - Aya Miyazaki
- Department of Pediatric Cardiology, Congenital Heart Disease Center, Tenri Hospital
| | - Tomoshige Morimoto
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Hiro Yamasaki
- Department of Cardiology, Faculty of Medicine, University of Tsukuba
| | | | | | - Takeshi Kimura
- Department of Cardiology, Graduate School of Medicine and Faculty of Medicine, Kyoto University
| | - Kazuo Tanemoto
- Department of Cardiovascular Surgery, Kawasaki Medical School
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Garot P, Iriart X, Aminian A, Kefer J, Freixa X, Cruz-Gonzalez I, Berti S, Rosseel L, Ibrahim R, Korsholm K, Odenstedt J, Nielsen-Kudsk JE, Saw J, Sondergaard L, De Backer O. Value of FEops HEARTguide patient-specific computational simulations in the planning of left atrial appendage closure with the Amplatzer Amulet closure device: rationale and design of the PREDICT-LAA study. Open Heart 2020; 7:openhrt-2020-001326. [PMID: 32763967 PMCID: PMC7412609 DOI: 10.1136/openhrt-2020-001326] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Optimal preprocedural planning is essential to ensure successful device closure of the left atrial appendage (LAA). DESIGN The PREDICT-LAA study is a prospective, international, multicentre, randomised controlled trial (ClinicalTrials.gov NCT04180605). Two hundred patients eligible for LAA closure with an Amplatzer Amulet device (Abbott, USA) will be enrolled in the study. Patients will be allocated to a computational simulation arm (experimental) or standard treatment arm (control) using a 1:1 randomisation. For patients randomised to the computational simulation arm, preprocedural planning will be based on the analysis of cardiac computed tomography (CCT)-based patient-specific computational simulations (FEops HEARTguide, Ghent, Belgium) in order to predict optimal device size and position. For patients in the control arm, preprocedural planning will be based on local practice including CCT analysis. The LAA closure procedure and postprocedural antithrombotic therapy will follow local practice in both arms. The primary endpoint of the study is incomplete LAA closure and device-related thrombus as assessed at 3 months postprocedural CCT. Secondary endpoints encompass procedural efficiency (number of devices used, number of repositioning, procedural time, radiation exposure, contrast dye), procedure-related complications within 7 days postprocedure and a composite of all-cause death and thromboembolic events at 12 months. CONCLUSION The objective of the PREDICT-LAA study is to test the hypothesis that a preprocedural planning for LAA closure with the Amplatzer Amulet device based on patient-specific computational simulations can result in a more efficient procedure, optimised procedural outcomes and better clinical outcomes as compared with a standard preprocedural planning. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04180605).
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Affiliation(s)
- Philippe Garot
- Department of Cardiology, Institut Cardiovasculaire Paris Sud, Massy, Île-de-France, France
| | - Xavier Iriart
- Pediatric and Congenital Cardiology, University Hospital of Bordeaux, Pessac, MS, France
| | - Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Charleroi, Hainaut, Belgium
| | - Joelle Kefer
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Xavier Freixa
- Cardiovascular Institute, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Ignacio Cruz-Gonzalez
- Department of Cardiology, Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Sergio Berti
- Cardiology Unit, Fondazione CNR Regione Toscana, Massa, Italy
| | - Liesbeth Rosseel
- Department of Cardiology, University Hospital Galway, Galway, Ireland
| | - Reda Ibrahim
- Department of Cardiology, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Kasper Korsholm
- Department of Cardiology, Aarhus Universitetshospital Skejby, Aarhus, Denmark
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
| | | | - Jaqueline Saw
- Department of Cardiology, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
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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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Short-Term Apixaban for Documented Left Atrial Appendage Thrombus in High-Risk Atrial Fibrillation Patients Undergoing Left Atrial Appendage Occlusion. TH OPEN 2020; 4:e351-e353. [PMID: 33145476 PMCID: PMC7603420 DOI: 10.1055/s-0040-1718585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 09/07/2020] [Indexed: 10/29/2022] Open
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Mahmood E, Matyal R, Mahmood F, Xu X, Sharkey A, Chaudhary O, Karani S, Khabbaz K. Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery. Circulation 2020; 142:20-28. [PMID: 32489114 DOI: 10.1161/circulationaha.119.044642] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. METHODS We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. RESULTS In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). CONCLUSIONS LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
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Affiliation(s)
- Eitezaz Mahmood
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Internal Medicine, North Shore University Hospital, Manhasset, NY (E.M.)
| | - Robina Matyal
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Xinling Xu
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aidan Sharkey
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Omar Chaudhary
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sadia Karani
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal Khabbaz
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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11
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Jiang Y, Li F, Li D, Cheng Y, Jia Y, Fu H, Pu X, Hu H, Jiang J, Zeng R. Efficacy and safety of catheter ablation combined with left atrial appendage occlusion for nonvalvular atrial fibrillation: A systematic review and meta-analysis. Pacing Clin Electrophysiol 2019; 43:123-132. [PMID: 31721242 DOI: 10.1111/pace.13845] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 10/31/2019] [Accepted: 11/11/2019] [Indexed: 02/05/2023]
Abstract
Atrial fibrillation (AF) is currently the most prevalent arrhythmia in clinical practice, with stroke being one of its major complications. Combining catheter ablation and percutaneous left atrial appendage occlusion (LAAO) into a "one-stop" intervention could reduce stroke incidence in selected high-risk patients and, at the same time, relieve AF symptoms in a single procedure. This meta-analysis analyzed the efficacy and safety of catheter ablation combined with LAAO for nonvalvular AF. PubMed, EMBASE, and the Cochrane Library were searched from inception to April 2019 to identify relevant citations. Efficacy indexes were procedural success, AF recurrence, stroke/transient ischemic attacks (TIA), and device-related thrombus (DRT). Safety indexes were all-cause death, major hemorrhagic complications, and pericardial effusion/cardiac tamponade. The incidence rate of events (ratio of events to patients) and 95% confidence interval (CI) were calculated as summary results. A forest plot was constructed to present pooled rates. Eighteen studies (two randomized controlled trials and 16 observational studies) were included. The results showed that one-stop intervention has significant efficacy and safety, with procedural success of .98 (95% CI, .97-1.00), AF recurrence of .24 (95% CI, .15-.35), stroke/TIA of .01 (95% CI, .00-.01), DRT of .00 (95% CI, .00-.01), all-cause mortality of .00 (95% CI, .00-.00), cardiac/neurological mortality of .00 (95% CI, .00-.00), major hemorrhagic complications of .01 (95% CI, .00-.02), and pericardial effusion/cardiac tamponade of .01 (95% CI, .00-.01). A single procedure with catheter ablation and LAAO in AF is a feasible strategy with significant efficacy and safety.
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Affiliation(s)
- Ying Jiang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Fanghui Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Dongze Li
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China.,Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, People's Republic of China
| | - Yisong Cheng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yu Jia
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China.,Department of Emergency Medicine, Laboratory of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People's Republic of China.,Disaster Medical Center, Sichuan University, Chengdu, People's Republic of China
| | - Hua Fu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Xiaobo Pu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Hongde Hu
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jian Jiang
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Rui Zeng
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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12
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Comparison of echocardiographic and fluoroscopic sizing of the left atrial appendage prior to percutaneous closure. J Interv Card Electrophysiol 2019; 58:157-161. [PMID: 31728875 DOI: 10.1007/s10840-019-00643-7] [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: 07/31/2019] [Accepted: 10/07/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Sizing of the left atrial appendage (LAA) ostium prior to occlusion (LAAO) is routinely performed with transesophageal echocardiography (TEE). We sought to compare the utility of sizing via fluoroscopy to TEE for percutaneous LAAO. METHODS We retrospectively evaluated all patients undergoing percutaneous LAAO at our institution from April 2015 through January 2018 (n = 195). We evaluated baseline characteristics, maximum measured ostium size (for both TEE and fluoroscopy), and differences in measured size to device size for both techniques. RESULTS Of the total cohort, 185 (95%) had both intraoperative TEE and fluoroscopic images available for analysis and were included in the final analysis. The mean age was 74 years and 64% were male. Hypertension was present in 89%, diabetes in 30%, and stroke in 32% of patients. The mean ejection fraction was 51%. The most common LAA morphology was "wind sock" (52%). Measured ostial diameter on fluoroscopy was larger compared with TEE (2.04 ± 3.43 mm larger on fluoroscopy, p < 0.001). Ostium diameter on TEE was more closely correlated to the size of the device implanted compared with fluoroscopy (0.76 vs. 0.61, p = 0.001). CONCLUSIONS Fluoroscopy results in larger estimated LAA ostium diameter compared with TEE. Despite this, TEE was more strongly correlated to operator choice in device sizing, which may reflect practice patterns. Because compression of the ostium on the device is necessary for long-term procedural success, under-sizing may lead to a higher rate of leaks. Prospective evaluation of the utility of routine fluoroscopic sizing compared with TEE is warranted.
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13
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Whiteman S, Saker E, Courant V, Salandy S, Gielecki J, Zurada A, Loukas M. An anatomical review of the left atrium. TRANSLATIONAL RESEARCH IN ANATOMY 2019. [DOI: 10.1016/j.tria.2019.100052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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14
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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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15
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Jia D, Zhou Q, Song HN, Zhang L, Chen JL, Liu Y, Kong B, He FZ, Wang YJ, Yang YT. The value of the left atrial appendage orifice perimeter of 3D model based on 3D TEE data in the choice of device size of LAmbre™ occluder. Int J Cardiovasc Imaging 2019; 35:1841-1851. [PMID: 31134413 DOI: 10.1007/s10554-019-01627-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/13/2019] [Indexed: 11/28/2022]
Abstract
Preoperative optimal selection of the occluder size is crucial in percutaneous left atrial appendage (LAA) occlusion, and the maximal width of the LAA orifice is the main reference index, however it can not fully meet the practical operation requirements. We retrospectively analyzed three-dimensional (3D) transesophageal echocardiography (TEE) and computed tomography (CT) imaging dataset of the 41 patients who underwent LAA occlusion with LAmbre™ system. The LAA orifice parameters were overall evaluated to determine their role in device size selection. Eight LAA 3D models of the four cases who had been replaced their device during the procedure based on TEE and CT were printed out to verify the optimal parameter decision strategy. There was a significant concordance of the results between 3D TEE and CT in the LAA orifice evaluation. The correlations between the perimeter and maximal width measurements by 3D TEE and the closure disk of the device were stronger than that between the area measurements and the closure disk (r = 0.93, 0.95, 0.86, respectively and p < 0.001 all), and the result was similar to that by CT (r = 0.92, 0.93, 0.84, respectively and p < 0.001 all). The ratios of the maximal width to the minimal width of the four cases were all > 1.4, however the rest 37 cases were all ≤ 1.4. Based on the comprehensive assessment of the LAA orifice perimeter and maximal width of the 3D printed models, the experiments were all succeed just for one try. The LAA orifice perimeter of 3D printed model based on 3D TEE may help in choosing the optimal device size of LAmbre™, especially for the LAA with flater ostial shape.
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Affiliation(s)
- Dan Jia
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China.
| | - Hong-Ning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Lan Zhang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jin-Ling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yu Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Bin Kong
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fa-Zhi He
- Computer Science and Technology School, Wuhan University, Wuhan, China
| | - Yi-Jia Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yuan-Ting Yang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University, Wuhan, China
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16
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Nadel J, Subbiah R, Jacobs N, Muller DWM, Gunalingam B. Successful left atrial appendage closure in a patient with prior patent foramen ovale occlusion. HeartRhythm Case Rep 2019; 5:183-186. [PMID: 30997330 PMCID: PMC6453555 DOI: 10.1016/j.hrcr.2018.11.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- James Nadel
- Department of Cardiology, St. Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia
| | - Rajesh Subbiah
- Department of Cardiology, St. Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, NSW, Australia
| | - Neil Jacobs
- Department of Cardiology, St. Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia
| | - David W M Muller
- Department of Cardiology, St. Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, Sydney, NSW, Australia
| | - Brendan Gunalingam
- Department of Cardiology, St. Vincent's Hospital, Darlinghurst, Sydney, NSW, Australia
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17
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Feng XF, Zhang PP, Sun J, Wang QS, Li YG. Feasibility and Safety of Left Atrial Appendage Closure Using the LAmbre Device in Patients with Nonvalvular Atrial Fibrillation with or Without Prior Catheter Ablation. Int Heart J 2019; 60:63-70. [DOI: 10.1536/ihj.18-070] [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] [Indexed: 11/18/2022]
Affiliation(s)
- Xiang-Fei Feng
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Peng-Pai Zhang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Qun-Shan Wang
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University
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18
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Use of 3-Dimensional Models to Optimize Pre-Procedural Planning of Percutaneous Left Atrial Appendage Closure. JACC Cardiovasc Interv 2019; 10:1067-1070. [PMID: 28521927 DOI: 10.1016/j.jcin.2017.02.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 02/23/2017] [Indexed: 11/19/2022]
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19
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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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20
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Rajwani A, Nelson AJ, Shirazi MG, Disney PJS, Teo KSL, Wong DTL, Young GD, Worthley SG. CT sizing for left atrial appendage closure is associated with favourable outcomes for procedural safety. Eur Heart J Cardiovasc Imaging 2018; 18:1361-1368. [PMID: 28013284 DOI: 10.1093/ehjci/jew212] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 09/16/2016] [Indexed: 11/12/2022] Open
Abstract
Aims We evaluated the utility of computerized tomography (CT) with respect to sizing work-up for percutaneous left atrial appendage (LAA) closure, and implications for procedural safety and outcomes. Methods and results Contrast-enhanced multi-detector CT was routinely conducted to guide sizing for LAA closure in addition to transoesophageal echocardiography (TOE). Procedural safety and efficacy were prospectively assessed. Across 73 consecutive cases there were no device-related procedural complications, and no severe leaks. Systematic bias in orifice sizing by TOE vs. CT was significant on retrospective analysis (bias -3.0 mm vs. maximum diameter on CT; bias -1.1 mm vs. mean diameter on CT). Importantly, this translated to an altered device size selection in more than half of all cases, and median size predicted by CT was one interval greater than that predicted by TOE (27 mm vs. 24 mm). Of particular note, gross sizing error by TOE vs. CT was observed in at least 3.4% of cases. Degree of discrepancy between TOE and CT was correlated with LAA orifice eccentricity, orifice size, and left atrial volume. Mean orifice size by CT had the greatest utility for final Watchman device-size selection. Conclusions In this single-centre registry of LAA closure, routine incorporation of CT was associated with excellent outcomes for procedural safety and absence of major residual leak. Mean orifice size may be preferable to maximum orifice size. A particular value of CT may be the detection and subsequent avoidance of gross sizing error by 2D TOE that occurs in a small but important proportion of cases.
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Affiliation(s)
- Adil Rajwani
- Department of Cardiology, Royal Perth Hospital, 197 Wellington Street, Perth, WA 6000, Australia.,Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Adam J Nelson
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
| | - Masoumeh G Shirazi
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
| | - Patrick J S Disney
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia
| | - Karen S L Teo
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
| | - Dennis T L Wong
- MonashHeart and Department of Medicine, Monash University, Melbourne, VIC 3168, Australia
| | - Glenn D Young
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
| | - Stephen G Worthley
- Department of Cardiology, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, SA 5000, Australia
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21
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Fiorilli PN, Anwaruddin S, Zhou E, Shah R. Catheterization Laboratory: Structural Heart Disease, Devices, and Transcatheter Aortic Valve Replacement. Anesthesiol Clin 2018; 35:627-639. [PMID: 29101953 DOI: 10.1016/j.anclin.2017.07.008] [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: 11/29/2022]
Abstract
The cardiac catheterization laboratory is advancing medicine by performing procedures on patients who would usually require sternotomy and cardiopulmonary bypass. These procedures are done percutaneously, allowing them to be performed on patients considered inoperable. Patients have compromised cardiovascular function or advanced age. An anesthesiologist is essential for these procedures in case of hemodynamic compromise. Interventionalists are becoming more familiar with transcatheter aortic valve replacement and the device has become smaller, both contributing to less complications. Left atrial occlusion and the endovascular edge-to-edge mitral valve repair devices were approved. Although these devices require general anesthesia, an invasive surgery and cardiopulmonary bypass machine are not necessary for deployment.
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Affiliation(s)
- Paul N Fiorilli
- Interventional Cardiology, Cardiovascular Division, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Saif Anwaruddin
- Transcatheter Valve Program, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Elizabeth Zhou
- Adult Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Ronak Shah
- Adult Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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22
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Piccini JP, Sievert H, Patel MR. Left atrial appendage occlusion: rationale, evidence, devices, and patient selection. Eur Heart J 2018; 38:869-876. [PMID: 27628431 DOI: 10.1093/eurheartj/ehw330] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Accepted: 07/11/2016] [Indexed: 02/06/2023] Open
Abstract
Atrial fibrillation (AF) is a worldwide epidemic associated with significant morbidity and mortality, often due to disabling or fatal thromboembolic stroke. Oral anticoagulation is highly effective at preventing ischaemic stroke and improving all-cause survival in patients with non-valvular AF. Despite the efficacy of oral anticoagulation, many patients are not treated due to either absolute or perceived contraindications to therapy, including bleeding. Left atrial appendage (LAA) closure has emerged as a mechanical alternative to pharmacologic stroke prevention. Initial and mid-term clinical trial data suggest that LAA closure is safe, with less intracranial bleeding, and a net clinical benefit that appears to be non-inferior to oral anticoagulation. However, concern remains over the possible increased risk of ischaemic stroke in long-term follow-up. Careful patient selection for LAA closure is paramount. Patients with prior intracranial bleeding or recurrent serious bleeding who are not eligible for long-term oral anticoagulation are typical candidates for LAA closure; however, other populations may benefit as well, such as patients with end-stage renal disease. Clinical investigation and randomized trials are needed to clarify the best methods of LAA occlusion, optimal pharmacologic strategies in the short-term after LAA closure, and to identify patient populations who will derive the most benefit from LAA occlusion. In this article, we review the rationale for LAA closure, the currently available devices and their evidence base, patient selection, challenges in management, and future directions for LAA closure science.
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Affiliation(s)
- Jonathan P Piccini
- Duke Center for Atrial Fibrillation, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Horst Sievert
- CardioVascular Center Frankfurt, Sankt Katharinen Hospital, Frankfurt, Germany
| | - Manesh R Patel
- Duke Center for Atrial Fibrillation, Durham, NC, USA.,Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
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23
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Abstract
PURPOSE OF REVIEW Atrial fibrillation (AF), the most common sustained arrhythmia, is a major cause of stroke and systemic embolism, and is increasing in prevalence. Device closure of the left atrial appendage (LAA) represents a non-pharmacologic approach to stroke prevention in AF patients. This review presents the rationale for LAA closure (LAAC), describes current transcatheter approaches to LAAC, and summarizes the current evidence for LAAC for stroke prevention, highlighting the main randomized trials and the most recent data available. RECENT FINDINGS Meta-analysis of randomized clinical trials demonstrates similar rates of all-cause stroke with transcatheter LAAC compared with vitamin K antagonist therapy and significantly less bleeding with LAAC after cessation of mandated post-procedure pharmacology. Recent prospective observational studies, including those evaluating outcomes after commercial approval in the USA, show significantly improved procedure safety compared with earlier experiences. LAAC appears to be an attractive alternative strategy for stroke prevention in AF patients, particularly in those who can take short-term oral anticoagulation (OAC), but are not optimal candidates for long-term OAC. Recent data suggests the procedure can be safely performed in patients with contraindications to OAC. Further, robust studies are needed to evaluate safety and efficacy in OAC-contraindicated patients, to compare outcomes with non-vitamin K antagonist OACs, and to explore the relative safety and efficacy of different LAAC devices.
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Affiliation(s)
- Ricardo Kosturakis
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA, 92037, USA
| | - Matthew J Price
- Division of Cardiovascular Diseases, Scripps Clinic, 9898 Genesee Avenue, AMP-200, La Jolla, CA, 92037, USA.
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24
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Streb W, Mitręga K, Podolecki T, Szymała M, Leopold-Jadczyk A, Kukulski T, Kalarus Z. Two-dimensional versus three-dimensional transesophageal echocardiography in percutaneous left atrial appendage occlusion. Cardiol J 2018; 26:687-695. [PMID: 29512094 DOI: 10.5603/cj.a2018.0019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 12/10/2017] [Accepted: 01/22/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Real-time three-dimensional transesophageal echocardiography (RT3D TEE) enables better visualization of the left atrial appendage (LAA) and may be superior to real-time two-dimensional transesophageal echocardiography (RT2D TEE) for LAA occlusion (LAAO). The aim of this study was to assess inter- and intra-observer variability of RT2D TEE and RT3D TEE measurements of LAA, and to assess the accordance of RT2D TEE and RT3D TEE with appropriate occluder selection. METHODS Transesophageal echocardiography was performed in 40 patients during LAAO. RT2D TEE and RT3D TEE measurements of the ostium and landing zone were performed independently by two echocardiographers. The appropriate choice of occluder was confirmed with fluoroscopic criteria. After the procedures, RT2D TEE and RT3D TEE evaluation were repeated separately by the same echocardiographers. RESULTS The mean ostium diameters by RT2D TEE obtained by the two observers were 23.6 ± 4.2 vs. 24.8 ± 5.2 (p = 0.04), and the mean landing zone diameters were 17.7 ± 4.4 vs. 19.4 ± 3.9 (p < 0.01). In the case of RT3D TEE, the ostium diameters were 29.6 ± 5.3 vs. 29.4 ± 6.4 (p = not significant [NS]) and the landing zone diameters were 21.4 ± 3.8 vs. 21.6 ± 3.9 (p = NS). Intra-observer differences were absent in the case of RT3D TEE. The comparison of RT2D TEE vs. RT3D TEE analyses performed by the same echocardiographer revealed significant differences in the ostium and landing zone measurements (both p < 0.01). Agreement between the suggested device size was better for RT3D TEE (weighted kappa was 0.62 vs. 0.28, respectively). CONCLUSIONS The results obtained with RT3D TEE showed significantly larger dimensions of the ostium and the landing zone. RT3D TEE showed lesser inter- and intra-observer variability and better agreement with the implanted device.
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Affiliation(s)
- Witold Streb
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland.
| | - Katarzyna Mitręga
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
| | - Tomasz Podolecki
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
| | - Magdalena Szymała
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
| | - Anna Leopold-Jadczyk
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
| | - Tomasz Kukulski
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
| | - Zbigniew Kalarus
- 1st Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Silesian Center for Heart Diseases, Curie-Sk lodowskiej 9, 41-800 Zabrze, Poland
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25
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Lim YM, Kim JS, Kim TH, Uhm JS, Shim CY, Joung B, Hong GR, Lee MH, Jang YS, Pak HN. Delayed left atrial appendage contrast filling in computed tomograms after percutaneous left atrial appendage occlusion. J Cardiol 2017; 70:571-577. [DOI: 10.1016/j.jjcc.2017.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/05/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
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26
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Affiliation(s)
- Lluis Asmarats
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
| | - Josep Rodés-Cabau
- From the Quebec Heart and Lung Institute, Laval University, Quebec City, Canada
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27
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Akodad M, Garot P. [Left atrial appendage closure and embolic events]. Ann Cardiol Angeiol (Paris) 2017; 66:441-446. [PMID: 29106834 DOI: 10.1016/j.ancard.2017.10.003] [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: 10/18/2022]
Abstract
Atrial fibrillation (AF) is frequent and responsible for embolic events. Currently, the gold standard to prevent such embolic events is anticoagulant therapy with vitamin K antagonist (VKA) or direct oral anticoagulant in nonvalvular AF. Recently, left atrial appendage closure was proposed as an alternative to anticoagulant inpatient with high embolic risk and contraindication to anticoagulant therapy. Data from randomized trials were consistent with a non-inferiority of left atrial appendage closure in comparison to VKA in terms of stroke and cardiovascular death. However, despite improvements in procedure results and complications reduction, this invasive strategy has to be performed with optimal security as this strategy is a preventive treatment in high-risk patients. These improvements may allow an extension of indications of left atrial appendage closure to lower profile risk patients as an alternative to anticoagulant. Indeed, anticoagulant is a risky therapy with hemorrhagic events and observance is a real issue in an asymptomatic population. Finally, there is a lack of data in recent literature comparing left atrial appendage closure to direct oral anticoagulant, widely used in daily practice, as well as cost-effectiveness of this procedure in comparison to anticoagulant.
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Affiliation(s)
- M Akodad
- Service Angio, institut cardiovasculaire Paris-Sud (ICPS), hôpital Jacques Cartier, Ramsay-Generale de santé, Massy, France
| | - P Garot
- Service Angio, institut cardiovasculaire Paris-Sud (ICPS), hôpital Jacques Cartier, Ramsay-Generale de santé, Massy, France.
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Song H, Zhou Q, Zhang L, Deng Q, Wang Y, Hu B, Tan T, Chen J, Pan Y, He F. Evaluating the morphology of the left atrial appendage by a transesophageal echocardiographic 3-dimensional printed model. Medicine (Baltimore) 2017; 96:e7865. [PMID: 28930824 PMCID: PMC5617691 DOI: 10.1097/md.0000000000007865] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The novel 3-dimensional printing (3DP) technique has shown its ability to assist personalized cardiac intervention therapy. This study aimed to determine the feasibility of 3D-printed left atrial appendage (LAA) models based on 3D transesophageal echocardiography (3D TEE) data and their application value in treating LAA occlusions.Eighteen patients with transcatheter LAA occlusion, and preprocedure 3D TEE and cardiac computed tomography were enrolled. 3D TEE volumetric data of the LAA were acquired and postprocessed for 3DP. Two types of 3D models of the LAA (ie, hard chamber model and flexible wall model) were printed by a 3D printer. The morphological classification and lobe identification of the LAA were assessed by the 3D chamber model, and LAA dimensions were measured via the 3D wall model. Additionally, a simulation operative rehearsal was performed on the 3D models in cases of challenging LAA morphology for the purpose of understanding the interactions between the device and the model.Three-dimensional TEE volumetric data of the LAA were successfully reprocessed and printed as 3D LAA chamber models and 3D LAA wall models in all patients. The consistency of the morphological classifications of the LAA based on 3D models and cardiac computed tomography was 0.92 (P < .01). The differences between the LAA ostium dimensions and depth measured using the 3D models were not significant from those measured on 3D TEE (P > .05). A simulation occlusion was successfully performed on the 3D model of the 2 challenging cases and compared with the real procedure.The echocardiographic 3DP technique is feasible and accurate in reflecting the spatial morphology of the LAA, which may be promising for the personalized planning of transcatheter LAA occlusion.
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Affiliation(s)
- Hongning Song
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Qing Zhou
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Lan Zhang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Qing Deng
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Yijia Wang
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Bo Hu
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Tuantuan Tan
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Jinling Chen
- Department of Ultrasound Imaging, Renmin Hospital of Wuhan University
| | - Yiteng Pan
- Computer Science and Technology School, Wuhan University, Wuhan, China
| | - Fazhi He
- Computer Science and Technology School, Wuhan University, Wuhan, China
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29
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Berte B, Jost CA, Maurer D, Fäh-Gunz A, Pillois X, Naegeli B, Pfyffer M, Sütsch G, Scharf C. Long-term follow-up after left atrial appendage occlusion with comparison of transesophageal echocardiography versus computed tomography to guide medical therapy and data about postclosure cardioversion. J Cardiovasc Electrophysiol 2017; 28:1140-1150. [DOI: 10.1111/jce.13289] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 06/18/2017] [Accepted: 06/23/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Benjamin Berte
- Cardiovascular Center; Klinik Im Park; Zürich Switzerland
| | | | - Dominik Maurer
- Cardiovascular Center; Klinik Im Park; Zürich Switzerland
| | - Anja Fäh-Gunz
- Cardiovascular Center; Klinik Im Park; Zürich Switzerland
| | | | | | - Monica Pfyffer
- Cardiovascular Center; Klinik Im Park; Zürich Switzerland
| | - Gabor Sütsch
- Herzzentrum; Hirslanden Clinic; Zürich Switzerland
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Chow DH, Bieliauskas G, Sawaya FJ, Millan-Iturbe O, Kofoed KF, Søndergaard L, De Backer O. A comparative study of different imaging modalities for successful percutaneous left atrial appendage closure. Open Heart 2017; 4:e000627. [PMID: 28761682 PMCID: PMC5515183 DOI: 10.1136/openhrt-2017-000627] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 04/20/2017] [Accepted: 05/09/2017] [Indexed: 12/05/2022] Open
Abstract
Objectives Accurate sizing of the left atrial appendage (LAA) is essential when performing percutaneous LAA closure. This study aimed to compare different LAA imaging modalities and sizing methods in order to obtain successful LAA closure. Background Percutaneous LAA closure is an increasingly used treatment strategy to prevent stroke in patients with atrial fibrillation. LAA sizing has typically been done by 2D-transoesophageal echocardiography (TEE). Methods Patients who had a preprocedural TEE and preprocedural and postprocedural multislice CT (MSCT) were identified. Preprocedural measurements of LAA ostia and landing zones by 2D-TEE, MSCT and angiography were collected and analysed for those patients with successful LAA closure - i.e. with no contrast leakage at 3-month follow-up MSCT. Results The study population (n=67) had a mean CHA2DS2-VASc score of 3.0 and HAS-BLED score of 2.7. Fifty-eight patients (87%) were identified to have successful LAA closure. Based on MSCT, 48 LAA sizings (83%) resulted in a correct LAA closure device size selection, whereas with 2D-TEE sizing, only 33 measurements (57%) would have resulted in a correct device size selection (p<0.01). Using adapted Bland-Altman method, MSCT-based perimeter-derived mean diameter was shown to be the best parameter to guide LAA device size selection for ‘closed-end’ devices (Amulet, WatchmanFLX), whereas the maximal diameter was the best parameter for the ‘open-end’ Watchman device. Conclusions Preprocedural MSCT-based LAA closure device size selection proves to be a more accurate method than conventional 2D-TEE-based sizing. Depending on the LAA closure device design, perimeter-derived mean diameter or maximal diameter could be the better sizing method.
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Affiliation(s)
- Danny Hf Chow
- The Heart Center Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | - Fadi J Sawaya
- The Heart Center Rigshospitalet University Hospital, Copenhagen, Denmark
| | | | - Klaus F Kofoed
- The Heart Center Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Lars Søndergaard
- The Heart Center Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Ole De Backer
- The Heart Center Rigshospitalet University Hospital, Copenhagen, Denmark
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Park YA, Kim JS, Pak HN. Delayed Sealing of WATCHMAN Device Shunt. INTERNATIONAL JOURNAL OF ARRHYTHMIA 2017. [DOI: 10.18501/arrhythmia.2017.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Alipour A, Wintgens LIS, Swaans MJ, Balt JC, Rensing BJWM, Boersma LVA. Novel stroke risk reduction in atrial fibrillation: left atrial appendage occlusion with a focus on the Watchman closure device. Vasc Health Risk Manag 2017; 13:81-90. [PMID: 28293114 PMCID: PMC5345987 DOI: 10.2147/vhrm.s89213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Atrial fibrillation (AF) remains an important clinical problem with severe complications such as stroke, which especially harms those with risk factors as calculated by the CHADS2 or CHA2DS2-VASc. Until now, no therapy has proven 100% effective against AF. Since the left atrial appendage (LAA) is the most prominent nonvalvular AF-related thromboembolic source and (novel) oral anticoagulant [(N)OAC] carries the hazard of bleeding, LAA occlusion may be an alternative, especially in patients who are ineligible for (N)OAC therapy. In this review, we discuss several LAA occlusion techniques with a focus on the Watchman device since this device is the most thoroughly studied device of all.
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Affiliation(s)
- Arash Alipour
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jippe C Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Benno J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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Akin I, Nienaber CA. Left atrial appendage occlusion: A better alternative to anticoagulation? World J Cardiol 2017; 9:139-146. [PMID: 28289527 PMCID: PMC5329740 DOI: 10.4330/wjc.v9.i2.139] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 11/20/2016] [Accepted: 12/01/2016] [Indexed: 02/06/2023] Open
Abstract
Non-valvular atrial fibrillation is associated with a significantly increased risk of embolic stroke due to blood clot forming predominantly in the left atrial appendage (LAA). Preventive measures to avoid embolic events are permanent administration of anticoagulants or surgical closure of the LAA. Various clinical trials provide evidence about safety, effectiveness and therapeutic success of LAA occlusion using various cardiac occluder devices. The use of such implants for interventional closure of the LAA is likely to become a valuable alternative for stroke prevention, especially in patients with contraindication for oral anticoagulation as safety, clinical benefit and cost-effectiveness of LAA occlusion has recently been demonstrated.
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Affiliation(s)
- Ibrahim Akin
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
| | - Christoph A Nienaber
- Ibrahim Akin, Medical Faculty Mannheim, University Heidelberg, 68167 Mannheim, Germany
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Morphologic Assessment of the Left Atrial Appendage in Patients with Atrial Fibrillation by Gray Values–Inverted Volume-Rendered Imaging of Three-Dimensional Transesophageal Echocardiography: A Comparative Study with Computed Tomography. J Am Soc Echocardiogr 2016; 29:1100-1108. [DOI: 10.1016/j.echo.2016.08.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Indexed: 01/07/2023]
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35
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Safavi-Naeini P, Rasekh A. Where We Stand on Left Atrial Appendage Closure for Stroke Prevention in Atrial Fibrillation. Tex Heart Inst J 2016; 43:320-3. [PMID: 27547142 DOI: 10.14503/thij-16-5811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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36
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Percutaneous closure of the left atrial appendage for stroke prevention in atrial fibrillation: an alternative to lifelong anticoagulation? Crit Care Nurs Q 2016; 38:371-84. [PMID: 26335216 DOI: 10.1097/cnq.0000000000000081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Atrial fibrillation is an important risk factor for thromboembolic stroke and it significantly increases the risk of stroke. The left atrial appendage (LAA) is the most common site of thrombus formation in nonvalvular atrial fibrillation, and the recent applications of percutaneous LAA closure devices offer a promising alternative for patients who are unable to tolerate lifelong anticoagulation. Critical care nurses who understand the procedures and are familiar with the various devices used for LAA closure will be well prepared to provide optimum care and appropriate education for these patients.
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37
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Heersink D, Murdoch D, Humphries J, Walters DL. Left Atrial Appendage Closure Device Implantation After Percutaneous Atrial Septal Defect Closure. JACC Cardiovasc Interv 2016; 9:e95-6. [PMID: 27131442 DOI: 10.1016/j.jcin.2016.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/11/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Damion Heersink
- Department of Cardiology, Prince Charles Hospital, Chermside, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia
| | - Dale Murdoch
- Department of Cardiology, Prince Charles Hospital, Chermside, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia.
| | - Julie Humphries
- Department of Cardiology, Prince Charles Hospital, Chermside, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia
| | - Darren L Walters
- Department of Cardiology, Prince Charles Hospital, Chermside, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia
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38
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Jain T, Shah J, Shah S, Modi S. Heart within a Heart. J Cardiovasc Ultrasound 2016; 24:60-3. [PMID: 27081446 PMCID: PMC4828416 DOI: 10.4250/jcu.2016.24.1.60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Revised: 12/09/2015] [Accepted: 02/01/2016] [Indexed: 12/03/2022] Open
Abstract
Device based closure of the left atrial appendage (LAA) has emerged as a viable approach for stroke prevention in atrial fibrillation (AF) patients with contraindications to chronic oral anticoagulation. One of the most feared complications is device related thrombus formation. We present a 66-year-old male with chronic AF who developed a life-threatening intracranial bleed on oral anti-coagulation. He subsequently underwent LAA closure using an Amplatzer muscular ventricular septal defect closure device for stroke prevention. However, he was found to have a large thrombus attached to the device a year later. We present a review of the various LAA closure devices, importance of periodic surveillance via echocardiography and management options to prevent this complication. Also, the case highlights the importance of contrast-enhance echocardiography in diagnosis of LAA closure device thrombus.
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Affiliation(s)
- Tarun Jain
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Jainil Shah
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI, USA
| | - Sunay Shah
- Department of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | - Shalini Modi
- Department of Cardiology, Henry Ford Hospital, Detroit, MI, USA
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Albers GW, Bernstein RA, Brachmann J, Camm J, Easton JD, Fromm P, Goto S, Granger CB, Hohnloser SH, Hylek E, Jaffer AK, Krieger DW, Passman R, Pines JM, Reed SD, Rothwell PM, Kowey PR. Heart Rhythm Monitoring Strategies for Cryptogenic Stroke: 2015 Diagnostics and Monitoring Stroke Focus Group Report. J Am Heart Assoc 2016; 5:e002944. [PMID: 27068633 PMCID: PMC4943268 DOI: 10.1161/jaha.115.002944] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University, Stanford, CA
| | - Richard A Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Johannes Brachmann
- Hospital Klinikum Coburg, Teaching Hospital of the University of Würzburg, Coburg, Germany
| | - John Camm
- Cardiovascular and Cell Sciences Research Institute, St. George's University of London and Imperial College, London, UK
| | - J Donald Easton
- Department of Neurology, University of California San Francisco, Sandler Neurosciences Center, San Francisco, CA
| | - Peter Fromm
- Center for Cardiovascular Health, South Nassau Communities Hospital, Oceanside, NY
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Isehara, Japan
| | | | - Stefan H Hohnloser
- Division of Clinical Electrophysiology, Department of Cardiology, J.W. Goethe University, Frankfurt, Germany
| | - Elaine Hylek
- Boston University School of Medicine, Boston, MA
| | - Amir K Jaffer
- Department of Medicine, Rush University Medical Center, Chicago, IL
| | - Derk W Krieger
- Faculty of Health and Medical Science, University of Copenhagen, Denmark German Neuroscience Center, Dubai Healthcare City, Dubai, UAE
| | - Rod Passman
- Bluhm Cardiovascular Institute, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jesse M Pines
- Office for Clinical Practice Innovation, George Washington University, Washington, DC
| | - Shelby D Reed
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neurosciences, University of Oxford, UK
| | - Peter R Kowey
- Division of Cardiovascular Diseases, Lankenau Heart Institute, Wynnewood, PA Department of Medicine, Jefferson Medical College, Philadelphia, PA
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Abstract
PURPOSE OF REVIEW Patients with atrial fibrillation and heart failure experience an increased morbidity and mortality from the hemodynamic consequences of atrial fibrillation and an increased stroke risk. Consequently, there has been increased attention to procedural alternatives to pharmacologic rhythm control and anticoagulation for stroke prevention. This review aims to evaluate the evidence for atrial fibrillation ablation and left atrial appendage closure in heart failure patients. RECENT FINDINGS Several randomized control trials and systematic reviews demonstrate the safety and efficacy of atrial fibrillation ablation in patients with heart failure and left ventricular systolic dysfunction. In multiple trials, these patients have shown clinical benefit from atrial fibrillation ablation including improved left ventricular systolic function, quality of life, and clinical heart failure symptoms. The evidence of clinical benefit of atrial fibrillation ablation in heart failure patients with preserved ejection fraction remains limited. Only a handful of randomized controlled trials have been performed evaluating left atrial appendage closure, and there is insufficient data regarding the safety and efficacy of these procedures in heart failure patients. SUMMARY Atrial fibrillation ablation in heart failure patients remains well tolerated with an overall efficacy comparable to atrial fibrillation ablation in patients without heart failure. There is consistent evidence for the clinical benefit of atrial fibrillation ablation in heart failure patients with left ventricular systolic dysfunction and limited evidence for atrial fibrillation ablation in heart failure patients with preserved ejection fraction. Currently, there is insufficient data regarding the safety and efficacy of left atrial appendage closure devices in heart failure patients.
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Chung H, Jeon B, Chang HJ, Han D, Shim H, Cho IJ, Shim CY, Hong GR, Kim JS, Jang Y, Chung N. Predicting Peri-Device Leakage of Left Atrial Appendage Device Closure Using Novel Three-Dimensional Geometric CT Analysis. J Cardiovasc Ultrasound 2015; 23:211-8. [PMID: 26755929 PMCID: PMC4707306 DOI: 10.4250/jcu.2015.23.4.211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 11/30/2015] [Accepted: 11/30/2015] [Indexed: 11/04/2022] Open
Abstract
Background After left atrial appendage (LAA) device closure, peri-device leakage into the LAA persists due to incomplete occlusion. We hypothesized that pre-procedural three-dimensional (3D) geometric analysis of the interatrial septum (IAS) and LAA orifice can predict this leakage. We investigated the predictive parameters of LAA device closure obtained from baseline cardiac computerized tomography (CT) using a novel 3D analysis system. Methods We conducted a retrospective study of 22 patients who underwent LAA device closure. We defined peri-device leakage as the presence of a Doppler signal inside the LAA after device deployment (group 2, n = 5) compared with patients without peri-device leakage (group 1, n = 17). Conventional parameters were measured by cardiac CT. Angles θ and φ were defined between the IAS plane and the line, linking the LAA orifice center and foramen ovale. Results Group 2 exhibited significantly better left atrial (LA) function than group 1 (p = 0.031). Pre-procedural θ was also larger in this group (41.9° vs. 52.3°, p = 0.019). The LAA cauliflower-type morphology was more common in group 2. Overall, the patients' LA reserve significantly decreased after the procedure (21.7 mm3 vs. 17.8 mm3, p = 0.035). However, we observed no significant interval changes in pre- and post-procedural values of θ and φ in either group (all p > 0.05). Conclusion Angles between the IAS and LAA orifice might be a novel anatomical parameter for predicting peri-device leakage after LAA device closure. In addition, 3D CT analysis of the LA and LAA orifice could be used to identify clinically favorable candidates for LAA device closure.
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Affiliation(s)
- Hyemoon Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.; Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - Byunghwan Jeon
- Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - Hyuk-Jae Chang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.; Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - Dongjin Han
- Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - Hackjoon Shim
- Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - In Jeong Cho
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.; Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
| | - Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung-Sun Kim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yangsoo Jang
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.; Severance Biomedical Science Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Namsik Chung
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.; Yonsei-Cedar Sinai Integrative Cardiovascular Imaging Research Center, Seoul, Korea
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Alipour A, Swaans MJ, van Dijk VF, Balt JC, Post MC, Bosschaert MA, Rensing BJ, Reddy VY, Boersma LV. Ablation for Atrial Fibrillation Combined With Left Atrial Appendage Closure. JACC Clin Electrophysiol 2015; 1:486-495. [DOI: 10.1016/j.jacep.2015.07.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 07/08/2015] [Accepted: 07/16/2015] [Indexed: 10/22/2022]
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43
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Sohaib SMA, Fox KF. A meta-analysis of left atrial appendage closure for stroke prevention in atrial fibrillation-adding to the debate but elements remain unresolved. J Thorac Dis 2015; 7:E226-9. [PMID: 26380784 DOI: 10.3978/j.issn.2072-1439.2015.08.03] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 07/30/2015] [Indexed: 11/14/2022]
Affiliation(s)
- Syed Mohammad Afzal Sohaib
- 1 Department of Cardiology, Imperial College Healthcare NHS Trust & National Heart & Lung Institute, Imperial College London, Hammersmith Hospital, London, W12 0HS, UK ; 2 Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, W12 0HS, UK
| | - Kevin F Fox
- 1 Department of Cardiology, Imperial College Healthcare NHS Trust & National Heart & Lung Institute, Imperial College London, Hammersmith Hospital, London, W12 0HS, UK ; 2 Department of Cardiology, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, W12 0HS, UK
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Kudenchuk PJ. New approaches to managing nonvalvular atrial fibrillation: what are the thromboembolic implications? J Thromb Thrombolysis 2015; 39:345-52. [DOI: 10.1007/s11239-015-1181-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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45
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Gloekler S, Shakir S, Doblies J, Khattab AA, Praz F, Guerios Ê, Koermendy D, Stortecky S, Pilgrim T, Buellesfeld L, Wenaweser P, Windecker S, Moschovitis A, Jaguszewski M, Landmesser U, Nietlispach F, Meier B. Early results of first versus second generation Amplatzer occluders for left atrial appendage closure in patients with atrial fibrillation. Clin Res Cardiol 2015; 104:656-65. [PMID: 25736061 DOI: 10.1007/s00392-015-0828-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/17/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Transcatheter left atrial appendage (LAA) occlusion has been proven to be an effective treatment for stroke prophylaxis in patients with atrial fibrillation. For this purpose, the Amplatzer cardiac plug (ACP) was introduced. Its second generation, the Amulet, was developed for easier delivery, better coverage, and reduction of complications. AIM To investigate the safety and efficacy of first generation versus second generation Amplatzer occluders for LAA occlusion. METHODS Retrospective analysis of prospectively collected data from the LAA occlusion registries of the Bern and Zurich university hospitals. Comparison of the last consecutive 50 ACP cases versus the first consecutive 50 Amulet cases in patients with non-valvular atrial fibrillation. For safety, a periprocedural combined endpoint, which is composed of death, stroke, cardiac tamponade, and bailout by surgery was predefined. For efficacy, the endpoint was procedural success. RESULTS There were no differences between the two groups in baseline characteristics. The percentage of associated interventions during LAA occlusion was high in (78% with ACP vs. 70% with Amulet p = ns). Procedural success was similar in both groups (98 vs. 94%, p = 0.61). The combined safety endpoint for severe adverse events was reached by a similar rate of patients in both groups (6 vs. 8%, p = 0.7). Overall complication rate was insignificantly higher in the ACP group, which was mainly driven by clinically irrelevant pericardial effusions (24 vs. 14%, p = 0.31). Death, stroke, or tamponade were similar between the groups (0 vs. 2%, 0 vs. 0%, or 6 vs. 6%, p = ns). CONCLUSION Transcatheter LAA occlusion for stroke prophylaxis in patients with atrial fibrillation can be performed with similarly high success rates with first and second generations of Amplatzer occluders. According to this early experience, the Amulet has failed to improve results of LAA occlusion. The risk for major procedural adverse events is acceptable but has to be taken into account when selecting patients for LAA occlusion, a preventive procedure.
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Affiliation(s)
- Steffen Gloekler
- Cardiology, Cardiovascular Department, Bern University Hospital, Bern, Switzerland
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