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Liu M, Coburn R, Koriesh A, Wang H, Graff-Radford J, Killu A, Sularz A, Yang EH, Arsanjani R, Pollak P, O'Cochlain F, Vaidya V, Singh G, Simard T, Alkhouli M, Brown RD, Holmes D, Scharf E. The safety and efficacy of left atrial appendage closure devices in patients with non-traumatic intracranial hemorrhage. J Neurol Sci 2025; 473:123490. [PMID: 40252387 DOI: 10.1016/j.jns.2025.123490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2024] [Revised: 03/06/2025] [Accepted: 04/02/2025] [Indexed: 04/21/2025]
Abstract
INTRODUCTION Anticoagulation in patients with atrial fibrillation and a history of intracranial hemorrhage (ICH) presents with challenges when balancing the risk of recurrent bleeding vs ischemic stroke. Left atrial appendage closure (LAAC) devices have shown promise as a minimally invasive method to prevent stroke without long-term anticoagulation. The goal of our study is to evaluate the efficacy of LAAC devices in patients with non-traumatic ICH and intraspinal hemorrhage which has not been well studied. METHODS A retrospective analysis on patients who had a history of atrial fibrillation and ICH/intraspinal hemorrhage was performed. The primary outcome was the development of new hemorrhage or ischemic stroke. Secondary outcomes included procedural complications and mortality. RESULTS 103 patients were included with a mean follow-up time of 1341 ± 764 days. All patients had successful LAAC placement. 7 patients developed periprocedural complications including groin hematoma, stroke, and pericarditis. 43 had a peri-device leak of any size including 3 device related thrombus. 11 patients suffered a new ischemic stroke with an annualized incidence rate of 2.9 % and 6 suffered a recurrent hemorrhage with an annualized incidence rate of 1.6 %. Those who suffered a new stroke were more likely to have a history of prior stroke (p = 0.04) and had a larger peri-device leak (4.3 vs 2.7 mm, p = 0.04). There was no difference in patient characteristics in those who suffered an ICH. CONCLUSION LAAC devices appear to be a safe and effective alternative to anticoagulation in patients with a history of nontraumatic ICH or intraspinal hemorrhage.
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Affiliation(s)
- Michael Liu
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - Ryan Coburn
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - Ahmed Koriesh
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - Han Wang
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - Jonathan Graff-Radford
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - Ammar Killu
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Agata Sularz
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Eric H Yang
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Reza Arsanjani
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Peter Pollak
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Fearghas O'Cochlain
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Vaibhav Vaidya
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Gurpreet Singh
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Trevor Simard
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Mohamad Alkhouli
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Robert D Brown
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
| | - David Holmes
- Mayo Clinic Department of Cardiovascular Medicine, 200 1(st) St. SW, Rochester. MN 55905, United States.
| | - Eugene Scharf
- Mayo Clinic Department of Neurology, 200 1(st) St. SW, Rochester, MN 55905, United States.
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2
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Wallentin L, Lindbäck J, Hijazi Z, Oldgren J, Carnicelli AP, Alexander JH, Berg DD, Eikelboom JW, Goto S, Lopes RD, Ruff CT, Siegbahn A, Giugliano RP, Granger CB, Morrow DA. Biomarker-Based Model for Prediction of Ischemic Stroke in Patients With Atrial Fibrillation. J Am Coll Cardiol 2025; 85:1173-1185. [PMID: 40107814 DOI: 10.1016/j.jacc.2024.11.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2024] [Revised: 11/21/2024] [Accepted: 11/27/2024] [Indexed: 03/22/2025]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) the risk of ischemic stroke is central to recommendations for stroke-prevention treatment. OBJECTIVES The authors evaluated the biomarker-based Age, Biomarkers, Clinical history (ABC)-AF-stroke risk score and developed a modified ABC-AF-istroke risk score for prediction of respectively total and ischemic stroke in patients with AF. METHODS In 26,452 patients with AF assigned to direct oral anticoagulants (DOACs) or warfarin, information on age, clinical history of stroke, and levels of N-terminal pro B-type natriuretic peptide and troponin were used for calculation of the ABC-AF-stroke score and the modified ABC-AF-istroke score. RESULTS During follow-up, there were 756 cases with stroke or systemic embolism (SEE) including 534 with ischemic stroke/SEE. The discrimination of total stroke/SEE was superior for the ABC-AF-stroke score, C-index (0.667 [95% CI: 0.648-0.687]), compared with 0.632 (95% CI: 0.612-0.652) for the ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation) and 0.614 (95% CI: 0.594-0.633) for the CHA2DS2-VASc score (P < 0.001 for both). The results were similar for ischemic stroke/SEE with C-index for ABC-AF-istroke 0.677 (95% CI: 0.654-0.700) compared with 0.642 (95% CI: 0.618-0.666) for the ATRIA and 0.624 (95% CI: 0.601-0.647) for the CHA2DS2-VASc score (P < 0.001 for both). The ABC-AF-stroke scores showed good calibration for total and ischemic stroke. Results were consistent in relevant subgroups. Decision curve analyses showed a net benefit concerning stroke-prevention decision thresholds. CONCLUSIONS The biomarker-based ABC-AF risk scores for the risk of total and ischemic stroke were well calibrated, showed better discrimination than clinical risk scores in predicting total and ischemic stroke, and provided meaningful decision support for stroke-prevention treatments in patients with AF.
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Affiliation(s)
- Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden.
| | - Johan Lindbäck
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Ziad Hijazi
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Jonas Oldgren
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden; Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anthony P Carnicelli
- Cardiology Division, Department of Internal Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - John H Alexander
- Duke Clinical Research Institute, Duke Medicine, Durham, North Carolina, USA
| | - David D Berg
- The TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Shinya Goto
- Department of Medicine, Tokai University School of Medicine, Kanagawa, Japan
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke Medicine, Durham, North Carolina, USA
| | - Christian T Ruff
- The TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Agneta Siegbahn
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden; Department of Medical Sciences, Clinical Chemistry, Uppsala University, Uppsala, Sweden
| | - Robert P Giugliano
- The TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | | | - David A Morrow
- The TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Carneiro HA, Cook A, Belani K, Benzuly K, Knight B. Percutaneous closure of the left atrial appendage after failed surgical closure using a septal occluder device guided by real-time 4-dimensional intracardiac echocardiography. J Interv Card Electrophysiol 2024; 67:1959-1962. [PMID: 38739248 DOI: 10.1007/s10840-024-01824-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Accepted: 05/02/2024] [Indexed: 05/14/2024]
Affiliation(s)
- Herman A Carneiro
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA.
- Bluhm Cardiovascular Institute, Feinberg School of Medicine, Northwestern University, 676 N St Clair Street, Suite 730, Chicago, IL, 60611, USA.
| | - Arianna Cook
- Department of Anesthesiology, Northwestern University, Chicago, IL, USA
| | - Kiran Belani
- Department of Anesthesiology, Northwestern University, Chicago, IL, USA
| | - Keith Benzuly
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Bradley Knight
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, IL, USA
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Oliva A, Ioppolo AM, Chiarito M, Cremonesi A, Azzano A, Miccichè E, Mangiameli A, Ariano F, Ferrante G, Reimers B, Garot P, Amabile N, Mehran R, Condorelli G, Stefanini G, Cao D. Left Atrial Appendage Closure Compared With Oral Anticoagulants for Patients With Atrial Fibrillation: A Systematic Review and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e034815. [PMID: 39119987 PMCID: PMC11963956 DOI: 10.1161/jaha.124.034815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND Percutaneous left atrial appendage closure (LAAC) has been suggested as an alternative to long-term oral anticoagulation for nonvalvular atrial fibrillation, but comparative data remain scarce. We aimed to assess ischemic and bleeding outcomes of LAAC compared with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for the prevention of cardioembolic events in patients with atrial fibrillation. METHODS AND RESULTS Embase and MEDLINE were searched for randomized trials comparing LAAC, VKAs, and DOACs. The primary efficacy end point was any stroke or systemic embolism. Treatment effects were calculated from a network meta-analysis and ranked according to the surface under the cumulative ranking curve. Seven trials and 73 199 patients were included. The risk of the primary end point was not statistically different between LAAC versus VKAs (odds ratio [OR], 0.92 [95% CI, 0.62-1.50]) and LAAC versus DOACs (OR, 1.11 [95% CI, 0.71-1.73]). LAAC and DOACs resulted in similar risk of major or minor (OR, 0.93 [95% CI, 0.61-1.42]) and major bleeding (OR, 0.92 [95% CI, 0.58-1.46]); however, after exclusion of procedural bleeding, bleeding risk was significantly lower in those undergoing LAAC. Both LAAC and DOACs reduced the risk of all-cause death compared with VKAs (LAAC versus VKAs: OR, 0.70 [95% CI, 0.53-0.91]; DOACs versus VKAs: OR, 0.90 [95% CI, 0.85-0.95], respectively). DOACs ranked as the best treatment for stroke or systemic embolism prevention (66.9%) and LAAC for reducing major bleeding (63.9%) and death (96.4%). CONCLUSIONS As a nonpharmacological alternative to oral anticoagulation for atrial fibrillation, LAAC showed similar efficacy and safety compared with VKAs or DOACs. Prospective confirmation from larger studies is warranted.
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Affiliation(s)
- Angelo Oliva
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | | | - Mauro Chiarito
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | - Alberto Cremonesi
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
| | - Alessia Azzano
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
| | - Eligio Miccichè
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
| | | | - Francesco Ariano
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
| | - Giuseppe Ferrante
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | - Bernhard Reimers
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | - Philippe Garot
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques CartierRamsay‐SantéMassyFrance
| | - Nicolas Amabile
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques CartierRamsay‐SantéMassyFrance
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular InstituteIcahn School of Medicine at Mount SinaiNew YorkNYUSA
| | - Gianluigi Condorelli
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | - Giulio Stefanini
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Cardio CenterHumanitas Clinical and Research Hospital IRCCSRozzanoItaly
| | - Davide Cao
- Cardiovascular DepartmentHumanitas Gavazzeni HospitalBergamoItaly
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleMIItaly
- Institut Cardiovasculaire Paris Sud (ICPS), Hôpital Privé Jacques CartierRamsay‐SantéMassyFrance
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Dell'Angela L, Nicolosi GL. Lights and shadows on left atrial appendage occlusion: mind the gap in knowledge and think twice on long-term outcomes. J Cardiovasc Med (Hagerstown) 2024; 25:345-352. [PMID: 38477853 DOI: 10.2459/jcm.0000000000001610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Ischemic stroke prevention represents a crucial concern in health systems, being associated with high morbidity and mortality. Atrial fibrillation is associated with 15-20% of ischemic strokes, in the presence of thrombus in the left atrial appendage in 90% of patients with nonvalvular atrial fibrillation. Oral anticoagulation represents the standard of care. However, left atrial appendage occlusions have been developed for selected patients with nonvalvular atrial fibrillation. With regard to the latter, particularly, some important concerns have been raised on the selection of patients potentially amenable to the procedure, seemingly emphasizing a gap in knowledge, real-life clinical practice, and current management guidelines. In light of the recent evidence regarding the current indications for management of left atrial appendage in presence of nonvalvular atrial fibrillation, the purpose of this critical review is to highlight the blind spots of left atrial appendage occlusion indications, taking into account the evidence-based mid- to long-term outcomes. Apparently, many unsolved concerns and problems are still present, mainly including mid- and long-term device-related potential complications, the possibility of concurrent sources of embolization, ethical and economic issues. Furthermore, larger, well designed, long-term, multicentric, and more inclusive studies, as well as shared/integrated registries are needed, aiming at comparing direct oral anticoagulation with left atrial appendage occlusion in the long run.
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Affiliation(s)
- Luca Dell'Angela
- Cardio-Thoracic and Vascular Department, Cardiology Division, Gorizia & Monfalcone Hospital, ASUGI, Gorizia
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