Percutaneous left atrial appendage occlusion in a frail, high-risk, octogenarian patient population, after having undergone transcatheter aortic valve implantation

Background

Percutaneous left atrial appendage occlusion (LAAO) represents an alternative stroke prevention method in patients with atrial fibrillation and an increased bleeding risk, chronic kidney disease or contraindications to oral anticoagulants. Aim of our study was to evaluate the feasibility and safety of percutaneous LAAO in high-risk, frail patients having undergone transcatheter aortic valve implantation (TAVI).

Methods

Thirty-one patients having undergone TAVI and scheduled for LAAO were prospectively included in our study.

Results

Implantation was successful in 29 of 31 cases (93.5%).There were no patients that developed a major acute cardiovascular event, stroke, or device dislocation/embolization. There was a single case of major bleeding (3.2%) and 3 cases of acute kidney injury (9.7%). At 3 months, no patients experienced a stroke, one patient had a device-related thrombus (3.4%), one patient showed a significant peri-device leak, and one patient had a persistent iatrogenic atrial septal defect.

Conclusions

Our study shows that percutaneous LAAO may represent a feasible alternative strategy for stroke prevention, that can be safely performed in high-risk, multimorbid patients with high bleeding risk or contraindications to oral anticoagulation.

Single- or dual-antiplatelet therapy after transcatheter aortic valve replacement: A protocol of systematic review and meta-analysis

BACKGROUND

The evidence related to bleeding and thromboembolic events after transcatheter aortic valve replacement (TAVR) compared single antiplatelet therapy (SAPT) with dual antiplatelet therapy (DAPT) treatment are inconsistent. Moreover, there are some limitations such as small sample size and the risk of bias in existing studies. We will conduct a comprehensive systematic review and meta-analysis to explore the safety and efficacy of SAPT or DAPT after TAVR.

METHODS

A comprehensive literature search of PubMed, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials will be searched to retrieve studies involving SAPT versus DAPT after TAVR. Two investigators will independently select studies, extract data, and assess the quality of the included study. Any disagreement will be resolved by the third investigator. The study will use a random-effects model to pool the results of all studies and use the relative risk and 95% confidence intervals to summarize individual trial outcomes and estimate pooled effect. The study will use the Grading of Recommendations Assessment, Development, and Evaluation to assess the certainty of evidence.

RESULTS

This study will provide high-quality evidence for treatment of TAVR in terms of effectiveness and safety.

CONCLUSION

This systematic review aims to provide evidence for treatment of TAVR in different antiplatelet therapies.

REGISTRATION

The systematic review and meta-analysis is registered in the OSF REGISTRIES (10.17605/OSF.IO/Q42TE) international prospective register.

Low-Dose Acetylsalicylic Acid in Chronic Subdural Hematomas: A Neurosurgeon's Sword of Damocles

Background: The possible influence of different antithrombotic drugs on outcome after neurosurgical treatment of chronic subdural hematoma (CSDH) is still unclear. Nowadays, no randomized clinical trials are available. A metanalysis including 24 studies for a total of 1,812 pooled patients concluded that antiplatelets and anticoagulations present higher risk of recurrences. On the other hand, several studies highlighted that antithrombotic suspension, timing of surgery, and resumption of these drugs are still debated, and patients taking these present higher risk of thromboembolic events with no excess risk of bleed recurrences or worse functional outcome. Our assumption is that the real hemorrhagic risk related to antithrombotic drug continuation in CSDH may be overrated and the thromboembolic risk for discontinuation underestimated, especially in patients with high cardiovascular risk.

Methods: A comprehensive literature review with the search terms “acetylsalicylic acid” and “chronic subdural x” was performed. Clinical status, treatment, time of drug discontinuation, complications (in particular, rebleeding or thromboembolic events), and clinical and radiological outcome at follow-up were evaluated.

Results: Five retrospective studies were selected for the review, three of them reporting specifically low-dose acetylsalicylic intake and two of them general antithrombotic drugs for a total of 1,226 patients. Only two papers reported the thromboembolic rate after surgery; in one paper, it is not even divided from other cardiac complications.

Conclusion: The literature review does not clarify the best management of low-dose acetylsalicylic in CSDH patients, in particular, concerning the balance between thromboembolic event rates and rebleeding risks. We do believe that CSDH precipitates the worsening of comorbidities with a resulting increased mortality. Further studies clearly evaluating the thromboembolic events are strongly needed to clarify this topic.

In this perspective paper, we discuss the difficult choice of low-dose acetylsalicylic acid (LDAA) management in patients suffering from chronic subdural hematoma (CSDH). The balance between hemorrhagic and thromboembolic risks often represents a sword of Damocles for neurosurgeons, especially when dealing with patients with high cardiovascular risk. No guidelines are currently available, and a survey by Kamenova et al. showed that most neurosurgeons discontinue LDAA treatment for at least 7 days in the perioperative period of surgical evacuation of CSDH, even though recent studies show that early LDAA resumption might be safe. Thrombosis prophylaxis is administered by only 60%, even though patients with CSDH are at high risk of developing thromboembolic complications. We would like to bring attention to this controversial issue.