Left atrial appendage occlusion in ventricular assist device patients to decrease thromboembolic events: A computer simulation study

Left atrial appendage occlusion in patients with cancer

Atrial fibrillation (AF) and malignancy share a complex relationship, significantly complicating patient management. Patients with cancer, particularly those with lung, gastrointestinal, genitourinary, and hematologic malignancies, are at increased risk of AF due to cancer-related hypercoagulability, proinflammatory cytokines, and treatment-related factors. This population faces unique thrombotic and bleeding risks, challenging standard management approaches. Anticoagulation is often complicated by drug-drug interactions with cancer therapies and heightened bleeding risks, including thrombocytopenia and coagulopathy. Left atrial appendage occlusion (LAAO) offers an alternative stroke prevention strategy for patients unable to tolerate long-term anticoagulation. By isolating the left atrial appendage, LAAO reduces thromboembolic risk while minimizing bleeding complications. Indications include patients with elevated stroke risk with contraindications to anticoagulation due to nonreversible causes, such as recurrent bleeding or significant drug interactions. Surgical LAAO may also be considered during cardiac surgery in patients with AF and high thromboembolic risk, with previous studies showing reduced risk of thromboembolic complications. Outcomes of LAAO in cancer patients are generally favorable, with studies showing comparable stroke rates, bleeding risks, and mortality to non-cancer populations. However, malignancy-specific complications, such as device-related thrombus, require further investigation. LAAO provides a promising option for stroke prevention in this complex population, but further research is needed to refine patient selection and optimize outcomes.

Blood flow analysis with computational fluid dynamics in the left atrium after left atrial plication: a prospective study

OBJECTIVE

This study aimed to evaluate blood flow stagnation in an enlarged left atrium (LA) and prove that left atrial plication (LAP) could alleviate the stagnation.

METHODS

Five patients with chronic atrial fibrillation who underwent mitral valve surgery followed by LAP for an enlarged LA with a ≥ 60-mm diameter were included. We performed computational fluid dynamics (CFD) analysis using preoperative and postoperative computed tomography and four-dimensional flow magnetic resonance imaging. Additionally, computer graphics were used to create virtual left atrial appendage resection (LAAR) images. We performed CFD analysis to assess blood flow stagnation in the LA for three groups: preoperative, LAAR, and LAP.

RESULTS

When the average and constant stagnation volumes were both set to 100 preoperatively, the average stagnation volumes of the LAAR and LAP groups were 67.42 ± 18.64 and 35.88 ± 8.20, respectively. The constant stagnation volumes of these groups reduced to 45.01 ± 7.43 and 21.14 ± 7.70, respectively. The LAP group also had significantly lower average and constant stagnation volumes than those in the LAAR group (p = 0.006 and p = 0.033, respectively).

CONCLUSIONS

Blood flow stagnation was noted in the LAA and enlarged LA. CFD analysis revealed that LAP for the enlarged LA improved blood flow stagnation more than the virtual LAAR alone.

CLINICAL TRIAL REGISTRY NUMBER

UMIN000049923.

Evolution of Mechanical Circulatory Support for advanced heart failure

This comprehensive review highlights the significant advancements in Left Ventricular Assist Device (LVAD) therapy, emphasizing its evolution from the early pulsatile flow systems to the cutting-edge continuous-flow devices, particularly the HeartMate 3 (HM3) LVAD. These advancements have notably improved survival rates, reduced complications, and enhanced the quality of life (QoL) for patients with advanced heart failure. The dual role of LVADs, as a bridge-to-transplantation and destination therapy is discussed, highlighting the changing trends and policies in their application. The marked reduction in hemocompatibility-related adverse events (HRAE) with the HM3 LVAD, compared to previous models signifies ongoing progress in the field. Challenges such as managing major infections are discussed, including innovative solutions like energy transfer systems aimed at eliminating external drivelines. It explores various LVAD-associated complications, including HRAE, infections, hemodynamic-related adverse events, and cardiac arrhythmias, and underscores emerging strategies for predicting post-implantation outcomes, fostering a more individualized patient care approach. Tools such as the HM3 risk score are introduced for predicting survival based on pre-implant factors, along with advanced imaging techniques for improved complication prediction. Additionally, the review highlights potential new technologies and therapies in LVAD management, such as hemodynamic ramp tests for optimal speed adjustment and advanced remote monitoring systems. The goal is to automate LVAD speed adjustments based on real-time hemodynamic measurements, indicating a shift towards more effective, patient-centered therapy. The review concludes optimistically that ongoing research and potential future innovations hold the promise of revolutionizing heart failure management, paving the way for more effective and personalized treatment modalities.