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Yoon SH, Amoah JK, Galo J, Dallan LAP, Arruda M, Rashid I, Rajagopalan S, Filby SJ. Incidence, progression, and predictors of left atrial appendage sealing after Watchman FLX device implantation with computed tomographic assessment. Catheter Cardiovasc Interv 2024. [PMID: 38662126 DOI: 10.1002/ccd.31044] [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: 09/26/2023] [Revised: 02/13/2024] [Accepted: 03/31/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Limited data exists regarding incidence, progression, and predictors of left atrial appendage (LAA) sealing after transcatheter LAA closure. We aimed to evaluate the incidence, progression, and predictive factors associated with LAA sealing after LAA closure. METHODS This study includes patients who underwent successful LAA closure with Watchman FLX device and had both pre- and postprocedural computed tomography (CT). Postprocedural CT was performed 45 days after LAA closure and used to evaluate residual LAA patency. Patient who had residual LAA patency at 45 days underwent 1-year follow-up CT. RESULTS A total of 105 patients (mean age: 75.2 ± 9.6 years; 53.3% female) who underwent successful LAA closure with Watchman FLX device and had pre- and postprocedural CT at 45 days were included. Residual patency was observed in 35 (33.3%) patients: 21 (20.0%) patients showed complete contrast opacification in LAA (complete LAA patency) while 14 (13.3%) patients showed contrast opacification only in the distal LAA (distal LAA patency). Among patients with residual LAA patency at 45 days, the rate of LAA sealing at 1 year was significantly higher in the distal LAA patency group than in the complete LAA patency group (75.0% vs. 16.7%; p = 0.019). Increased depth oversizing was associated with both distal LAA patency and complete LAA patency. CONCLUSION Postprocedural CT at 45 days detected patent LAA in one-third of patients after LAA closure. LAA sealing was more frequently observed at 1 year among the distal LAA patency group than the complete LAA patency group.
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Affiliation(s)
- Sung-Han Yoon
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Medicine, Division of Structural Heart Disease, Hackensack University Medical Center, Hackensack, New Jersey, USA
| | - Joseph Kofi Amoah
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jason Galo
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Luis Augusto Palma Dallan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mauricio Arruda
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Sanjay Rajagopalan
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Steven J Filby
- Division of Cardiology, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Samaras A, Papazoglou AS, Balomenakis C, Bekiaridou A, Moysidis DV, Patsiou V, Orfanidis A, Giannakoulas G, Kassimis G, Fragakis N, Saw J, Landmesser U, Alkhouli MA, Tzikas A. Residual leaks following percutaneous left atrial appendage occlusion and outcomes: a meta-analysis. Eur Heart J 2024; 45:214-229. [PMID: 38088437 DOI: 10.1093/eurheartj/ehad828] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 10/02/2023] [Accepted: 10/19/2023] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND AND AIMS Residual leaks are not infrequent after left atrial appendage occlusion. However, there is still uncertainty regarding their prognostic implications. The aim of this study is to evaluate the impact of residual leaks after left atrial appendage occlusion. METHODS A literature search was conducted until 19 February 2023. Residual leaks comprised peri-device leaks (PDLs) on transoesophageal echocardiography (TEE) or computed tomography (CT), as well as left atrial appendage patency on CT. Random-effects meta-analyses were performed to assess the clinical impact of residual leaks. RESULTS Overall 48 eligible studies (44 non-randomized/observational and 4 randomized studies) including 61 666 patients with atrial fibrillation who underwent left atrial appendage occlusion were analysed. Peri-device leak by TEE was present in 26.1% of patients. Computed tomography-based left atrial appendage patency and PDL were present in 54.9% and 57.3% of patients, respectively. Transoesophageal echocardiography-based PDL (i.e. any reported PDL regardless of its size) was significantly associated with a higher risk of thromboembolism [pooled odds ratio (pOR) 2.04, 95% confidence interval (CI): 1.52-2.74], all-cause mortality (pOR 1.16, 95% CI: 1.08-1.24), and major bleeding (pOR 1.12, 95% CI: 1.03-1.22), compared with no reported PDL. A positive graded association between PDL size and risk of thromboembolism was noted across TEE cut-offs. For any PDL of >0, >1, >3, and >5 mm, the pORs for thromboembolism were 1.82 (95% CI: 1.35-2.47), 2.13 (95% CI: 1.04-4.35), 4.14 (95% CI: 2.07-8.27), and 4.44 (95% CI: 2.09-9.43), respectively, compared with either no PDL or PDL smaller than each cut-off. Neither left atrial appendage patency, nor PDL by CT was associated with thromboembolism (pOR 1.45 and 1.04, 95% CI: 0.84-2.50 and 0.52-2.07, respectively). CONCLUSIONS Peri-device leak detected by TEE was associated with adverse events, primarily thromboembolism. Residual leaks detected by CT were more frequent but lacked prognostic significance.
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Affiliation(s)
- Athanasios Samaras
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Andreas S Papazoglou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Charalampos Balomenakis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandra Bekiaridou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Institute of Bioelectronic Medicine, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Dimitrios V Moysidis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Patsiou
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Orfanidis
- Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Giannakoulas
- First Department of Cardiology, Faculty of Health Sciences, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Kassimis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Nikolaos Fragakis
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Ulf Landmesser
- Department of Cardiology, Charité Universitätsmedizin, Berlin, Germany
| | | | - Apostolos Tzikas
- Second Department of Cardiology, Faculty of Health Sciences, School of Medicine, General Hospital 'Hippokration', Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece
- European Interbalkan Medical Center, Department of Cardiology, Asklipiou 10, Pylaia, Thessaloniki 57001, Greece
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Haertel F, Lustermann P, Hamadanchi A, Gruen K, Bogoviku J, Aftanski P, Westphal J, Baez L, Franz M, Schulze PC, Moebius-Winkler S. Prognostic Value of Galectin-3 after Left Atrial Appendage Occlusion for Predicting Peri-Device Leakage. Int J Mol Sci 2023; 24:16802. [PMID: 38069127 PMCID: PMC10705923 DOI: 10.3390/ijms242316802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
Echocardiographic detection of residual peri-device leakage (PDL) after percutaneous left atrial appendage occlusion (LAAO) is crucial for managing anticoagulation. Galectin-3, a protein involved in tissue-foreign body interactions, may hold significance in understanding PDL and cardiac tissue remodeling after LAAO. This study aimed to analyze galectin-3 serum levels in relation to PDL using a novel echo-morphological classification. LAAO eligible patients were included in the study. Galectin-3 serum levels were measured before LAAO, at 45 days (45D), and at 6 months (6M) after the procedure. Transesophageal echocardiography was used to assess LAAO success. A new echo-morphological classification categorized the degree of LAAO into three different types (A: homogenous echodensity, indicating completely thrombosed device; B: inhomogeneous echolucencies (<50% of device); and C: partially thrombosed device with echolucencies > 50%). Among 47 patients, complete LAAO was achieved in 60% after 45D and in 74% after 6M. We observed a significant increase and distribution of serum levels of galectin-3 [ng/mL] after 45D among the three types (baseline: 13.1 ± 5.8 ng/mL; 45D: 16.3 ± 7.2 ng/mL (Type A) vs. 19.2 ± 8.6 ng/mL (Type B) vs. 25.8 ± 9.4 ng/mL (Type C); p = 0.031), followed by a drop in galectin-3 for Types A and B after 6M toward and below the baseline levels (6M: 8.9 ± 3.1 ng/mL (Type A) vs. 12.4 ± 5.5 ng/mL (Type B)), whereas Type C persisted in showing elevated galectin-3 levels compared to all other types (6M: 17.5 ± 4.5 ng/mL (Type C); p < 0.01). Increased galectin-3 serum levels after LAAO likely reflect the transition from thrombus formation to fibrotic scar development in the LAA lumen. Successful occlusion is associated with a time-restricted decrease in galectin-3 levels after 6 months, while relevant PDL leads to persistently elevated levels, making galectin-3 a potential predictor of occlusion success.
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Affiliation(s)
- Franz Haertel
- Department of Internal Medicine I, Cardiology, University Hospital Jena, Am Klinikum 1, 07747 Jena, Germany
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Mostafa MR, Eid MM, Abuelazm M, Al-Abdouh A, Najim M, Hassan AR, El-Sakka AA, Renjithal SLM, Malik MA, Mohamed S, Balmer-Swain M, Paul TK, Goldsweig AM. Meta-Analysis of the Outcomes of Peri-Device Leak After Left Atrial Appendage Closure. Am J Cardiol 2023; 204:325-332. [PMID: 37572568 DOI: 10.1016/j.amjcard.2023.07.102] [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: 02/21/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/14/2023]
Abstract
Left atrial appendage closure (LAAC) reduces the risk of thromboembolic stroke in atrial fibrillation. Peri-device leak (PDL) after LAAC may affect the subsequent risk of thromboembolism. We conducted a systematic review and meta-analysis to evaluate the effect of PDL after LAAC. We searched PubMed/Medline, Embase, and Google Scholar for studies reporting outcomes of PDL after LAAC from inception through October 2022. The primary outcome was the composite of stroke, transient ischemic attack (TIA), or systemic embolism (SE). Secondary outcomes included all-cause and cardiovascular mortality, ischemic stroke, TIA, and device-related thrombus. Outcomes were pooled using random-effects models. We used I2 statistics to assess statistical heterogeneity; I2 >50% considered significant heterogeneity. This study included 54,279 patients from 11 studies (6 observational, 2 nonrandomized controlled trials [non-RCTs] primary results, 2 RCT post hoc analyses, and 1 analysis combining 2 RCTs data). PDL was associated with a significant increase in the composite outcome of stroke, TIA, or SE (odds ratio 1.63, 95% confidence interval 1.06 to 2.52, p = 0.03, I2 = 43%) as compared with cases with no PDL. There were no significant differences in all-cause or cardiovascular mortality, ischemic stroke, TIA, or device-related thrombus. In conclusion, PDL after LAAC is associated with an increased risk of thromboembolism (composite stroke, TIA, or SE) without impacting mortality.
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Affiliation(s)
- Mostafa Reda Mostafa
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Magdi Eid
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Mohamed Abuelazm
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Ahmad Al-Abdouh
- Department of Medicine, University of Kentucky, Lexington, Kentucky
| | - Mostafa Najim
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Abdul Rhman Hassan
- Department of Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Amro A El-Sakka
- Department of Medicine, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | | | - Muhammad Ahmed Malik
- Department of Medicine, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Sarah Mohamed
- Department of Medicine, Cairo University School of Medicine, Cairo, Egypt
| | - Mallory Balmer-Swain
- Department Cardiology, Rochester Regional Health, Unity Hospital, Rochester, New York
| | - Timir K Paul
- Department of Cardiovascular Medicine, University of Tennessee at Nashville, Ascension St. Thomas Hospital, Nashville, Tennessee
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, Massachusetts.
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Zhang P, Zhao Y, Sun J, Wang Q, Li W, Zhang R, Chen M, Mo B, Yu Y, Feng X, Liu B, Yu Y, Lu Q, Li Y. Safety and efficacy of ablation for atrial fibrillation in combination with left atrial appendage occlusion in octogenarians. Clin Cardiol 2023; 46:1202-1209. [PMID: 37522390 PMCID: PMC10577539 DOI: 10.1002/clc.24099] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Catheter ablation (CA) combined with left atrial appendage occlusion (LAAO) is a feasible approach for atrial fibrillation (AF) patients. Its role in octogenarians with AF is unclear. HYPOTHESIS In AF patients over 80 years, CA combined with LAAO is a feasible way in restoring sinus rhythm and preventing stroke. METHODS This is a single-center retrospective study. Patients who underwent CA and LAAO in a single procedure between March 2018 and December 2020 were included. Efficacy endpoints included procedural success rate, AF recurrence rate, and thromboembolic events. Safety endpoints included pericardial effusion/cardiac tamponade, device-related thrombus (DRT), all-cause death, and major bleeding. RESULTS Five hundred and five patients (mean age 69.5 ± 7.7 years; 230 [45.5%] female) were included, with 46 (9.1%) patients aged ≥80 years old (octogenarian group). Prevalence of paroxysmal AF (25 [54.3%] vs. 207 [45.1%], p < 0.001) and CHA2DS2VASc score (4.1 ± 1.3 vs. 3.1 ± 1.4, p < 0.0001) were higher in octogenarian patients. There were six cases (1.2%) of pericardial effusion (all in nonoctogenarian patients). At 3 months postprocedure, 437 patients underwent TEE/CT. Thirty-two (80%) octogenarian patients and 308 (77.6%) nonoctogenarian patients had no peri-device leak. After a mean follow-up of 26.9 ± 9.1 months, AF was documented in 10 (21.7%) patients in octogenarian group and in 103 (22.4%) patients in nonoctogenarian group (p = 0.99). The annual thromboembolic risk was 2.1% and 0.8% in the octogenarian group and nonoctogenarian group, respectively. Death occurred in 16 nonoctogenarian patients. One major bleeding was recorded in the octogenarian group. CONCLUSIONS The combination of CA and LAAO in a single procedure is a feasible treatment option in octogenarians with comparable efficacy and safety profile.
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Affiliation(s)
- Peng‐Pai Zhang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yan Zhao
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Jian Sun
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Qun‐Shan Wang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Wei Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Rui Zhang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Mu Chen
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Bin‐Feng Mo
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi Yu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Xiang‐Fei Feng
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Bo Liu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi‐Chi Yu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Qiu‐Fen Lu
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
| | - Yi‐Gang Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiao Tong UniversitySchool of MedicineShanghaiChina
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6
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Agasthi P, Pujari SH. Peri- and Post-procedural Anticoagulation with Left Atrial Appendage Occlusion Devices. Heart Int 2023; 17:54-59. [PMID: 37456348 PMCID: PMC10339453 DOI: 10.17925/hi.2023.17.1.54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.
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Affiliation(s)
- Pradyumna Agasthi
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sai Harika Pujari
- Department of Cardiovascular Diseases, Mayo Clinic Arizona, Phoenix, AZ, USA
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7
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Kadian M, Kok CY, Ravindran D, Passam F, Pasalic L, Kizana E. Focal Anticoagulation by Somatic Gene Transfer: Towards Preventing Cardioembolic Stroke. Heart Lung Circ 2023:S1443-9506(23)00509-7. [PMID: 37316436 DOI: 10.1016/j.hlc.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/05/2023] [Indexed: 06/16/2023]
Abstract
Cardioembolic stroke (CS) has emerged as a leading cause of ischaemic stroke (IS); distinguished by thrombi embolising to the brain from cardiac origins; most often from the left atrial appendage (LAA). Contemporary therapeutic options are largely dependent on systemic anticoagulation as a blanket preventative strategy, yet this does not represent a nuanced or personalised solution. Contraindications to systemic anticoagulation create significant unmedicated and high-risk cohorts, leaving these patients at risk of significant morbidity and mortality. Atrial appendage occlusion devices are increasingly used to mitigate stroke risk from thrombi emerging from the LAA in patients ineligible for oral anticoagulants (OACs). Their use, however, is not without risk or significant cost, and does not address the underlying aetiology of thrombosis and CS. Viral vector-based gene therapy has emerged as a novel strategy to target a spectrum of haemostatic disorders, achieving success through the adeno-associated virus (AAV) based therapy of haemophilia. Yet, thrombotic disorders, such as CS, have had limited exploration within the realm of AAV gene therapy approaches-presenting a gap in the literature and an opportunity for further research. Gene therapy has the potential to directly address the cause of CS by localised targeting of the molecular remodelling that serves to promote thrombosis.
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Affiliation(s)
- Megha Kadian
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; The University of Sydney, Sydney, NSW, Australia; Faculty of Medicine, The University of Queensland, St Lucia, Qld, Australia
| | - Cindy Y Kok
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Dhanya Ravindran
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Freda Passam
- Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The Heart Research Institute, Charles Perkins Centre, Sydney, NSW, Australia
| | - Leonardo Pasalic
- Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia; Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Sydney, NSW, Australia
| | - Eddy Kizana
- The Centre for Heart Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Westmead Clinical School, The University of Sydney, Sydney, NSW, Australia; Department of Cardiology, Westmead Hospital, Sydney, NSW, Australia.
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8
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Sievert K, Asmarats L, Arzamendi D. Left Atrial Appendage Occlusion Strengths and Weaknesses of the Lobe-Only Occluder Concept in Theory and in Practice. Card Electrophysiol Clin 2023; 15:193-200. [PMID: 37076231 DOI: 10.1016/j.ccep.2023.01.007] [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: 04/21/2023]
Abstract
Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design. This review highlights the potential features and benefits of the single-lobe devices.
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Affiliation(s)
- Kolja Sievert
- CardioVascular Center Frankfurt (CVC), St. Catherine Hospital, Seckbacher Landstraße 65, 60389 Frankfurt am Main, Germany
| | - Lluis Asmarats
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Dabit Arzamendi
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).
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9
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Nestelberger T, Alfadhel M, McAlister C, Saw J. Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long? Card Electrophysiol Clin 2023; 15:157-168. [PMID: 37076228 DOI: 10.1016/j.ccep.2023.01.004] [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: 04/21/2023]
Abstract
Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures.
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Affiliation(s)
- Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Vancouver General Hospital, Basel, British Columbia, Canada; University of British Columbia, 2775 Laurel Street, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
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Wong I, Tzikas A, Søndergaard L, De Backer O. The Strengths and Weaknesses of the LAA Covering Disc Occluders-Conceptually and in Practice. Card Electrophysiol Clin 2023; 15:183-192. [PMID: 37076230 DOI: 10.1016/j.ccep.2023.01.013] [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: 04/21/2023]
Abstract
Endocardial left atrial appendage (LAA) occluders with a covering disc encompass a wide range of devices that share the common feature of a distal anchoring "body" and proximal covering "disc" design. This unique design feature has potential advantages in certain complex LAA anatomies and challenging clinical scenarios. The current review article summarizes the different features of established and novel devices, preprocedural imaging updates, intraprocedural technical considerations, and postprocedural follow-up issues specific to this category of LAA occluders.
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Affiliation(s)
- Ivan Wong
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Apostolos Tzikas
- European Interbalkan Medical Centre & AHEPA University Hospital, Asklipiou 10, Thessaloniki 57001, Greece
| | - Lars Søndergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark.
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11
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Shabtaie SA, Tan NY, Ward RC, Lewis BR, Yang EH, Holmes DR, Herrmann J. Left Atrial Appendage Occlusion in Patients With Atrial Fibrillation and Cancer. JACC CardioOncol 2023; 5:203-212. [PMID: 37144110 PMCID: PMC10152198 DOI: 10.1016/j.jaccao.2022.10.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 03/09/2023] Open
Abstract
Background The prevention of stroke in patients with atrial fibrillation (AF) and cancer is challenging because patients are at increased bleeding and thrombotic risk. Objectives The authors sought to assess left atrial appendage occlusion (LAAO) as a safe and effective strategy for reducing stroke at no increased bleeding risk in cancer patients with AF. Methods We reviewed patients with nonvalvular AF who underwent LAAO at Mayo Clinic sites from 2017 to 2020 and identified those who had undergone prior or current treatment for cancer. We compared the incidence of stroke, bleeding, device complications, and death with a control group who underwent LAAO without malignancy. Results Fifty-five patients were included; 44 (80.0%) were male, and the mean age was 79.0 ± 6.1 years. The median CHA2Ds2-VASc score was 5 (Q1-Q3: 4-6), with 47 (85.5%) having a prior bleeding event. Over the first year, ischemic stroke occurred in 1 (1.4%) patient, bleeding complications in 5 (10.7%) patients, and death in 3 (6.5%) patients. Compared with controls who underwent LAAO without cancer, there was no significant difference in ischemic stroke (HR: 0.44; 95% CI: 0.10-1.97; P = 0.28), bleeding complication (HR: 0.71; 95% CI: 0.28-1.86; P = 0.19), or death (HR: 1.39; 95% CI: 0.73-2.64; P = 0.32). Conclusions Within our cohort, LAAO in cancer patients was achieved with good procedural success and offered a reduction in stroke at no increased bleeding risk similar to noncancer patients.
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Affiliation(s)
- Samuel A. Shabtaie
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicholas Y. Tan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert C. Ward
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley R. Lewis
- Department of Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric H. Yang
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, USA
| | - David R. Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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12
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Alkhouli M, De Backer O, Ellis CR, Nielsen-Kudsk JE, Sievert H, Natale A, Lakkireddy D, Holmes DR. Peridevice Leak After Left Atrial Appendage Occlusion: Incidence, Mechanisms, Clinical Impact, and Management. JACC Cardiovasc Interv 2023; 16:627-642. [PMID: 36990553 DOI: 10.1016/j.jcin.2022.12.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 11/11/2022] [Accepted: 12/05/2022] [Indexed: 03/31/2023]
Abstract
Left atrial appendage occlusion is an increasingly adopted stroke prevention strategy in patients with atrial fibrillation. However, peridevice leaks after the procedure are not infrequent and have recently been shown to confer a higher risk for subsequent ischemic events. In this paper, the authors review the available research on the frequency, mechanisms, clinical significance, and management of peridevice leak after percutaneous left atrial appendage occlusion.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine Rochester, Minnesota, USA.
| | - Ole De Backer
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | | | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin, Texas, USA
| | | | - David R Holmes
- Department of Cardiology, Mayo Clinic School of Medicine Rochester, Minnesota, USA
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13
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Li S, Dong J, Luo J, Wang G, Xie D, Zhou L. Comparison of different quantitative evaluation protocols for peri-device leak detection using cardiac computed tomography angiography after left atrial appendage closure. Int J Cardiovasc Imaging 2023; 39:659-666. [PMID: 36329328 PMCID: PMC9947090 DOI: 10.1007/s10554-022-02748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
This study seeks to propose and compare different quantitative evaluation methods for identifying patients with peri-device leak (PDL) using cardiac computed tomography angiography (CCTA). Patients who had undergone left atrial appendage (LAA) closure and both transesophageal echocardiography (TEE) and CCTA were enrolled. Hounsfield units (HU) were measured in the proximal and distal regions of the left atrial appendage (p-LAA, d-LAA) on the CCTA, and the average of the two was determined (a-LAA). The relative HU ratios of the LAA to the center of the left atrium (LA) were calculated (p-LAA/c-LA, d-LAA/c-LA, a-LAA/c-LA). The area under the curve (AUC) for the LAA HU and the LAA/LA HU ratio were analyzed and compared. Fifty-one patients were included in this study. Pairwise comparisons showed a statistically significant difference (p = 0.029) in diagnostic performance between the d-LAA (AUC = 0.868) and a-LAA (AUC = 0.972). There were no significant differences between the a-LAA and p-LAA (p = 0.549) or between the d-LAA and p-LAA (p = 0.053). At the optimal cutoff for a-LAA of 115.5 HU, the sensitivity was 100%, the specificity was 88%. At the optimal cutoff for p-LAA of 109 HU, the sensitivity was 100%, the specificity was 84%. The LAA/LA HU ratio did not exhibit better diagnostic performance than HU attenuation in the LAA (p > 0.05). The a-LAA > 115.5 is useful in identifying PDL. Due to its convenience and intuitiveness, p-LAA > 109.0 can also be used as an alternative protocol for a-LAA.
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Affiliation(s)
- Shiqi Li
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Jing Dong
- Department of Echocardiography, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Jie Luo
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Gaofeng Wang
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006 China
| | - Dujiang Xie
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
| | - Ling Zhou
- Department of Cardiology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210006, China.
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14
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Kowalewski M, Wańha W, Litwinowicz R, Kołodziejczak M, Pasierski M, Januszek R, Kuźma Ł, Grygier M, Lesiak M, Kapłon-Cieślicka A, Reczuch K, Gil R, Pawłowski T, Bartuś K, Dobrzycki S, Lorusso R, Bartuś S, Deja MA, Smolka G, Wojakowski W, Suwalski P. Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study. BMJ Open 2022; 12:e063990. [PMID: 36130748 PMCID: PMC9494590 DOI: 10.1136/bmjopen-2022-063990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA2DS2-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile. METHODS AND ANALYSIS Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well. ETHICS AND DISSEMINATION Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences. TRIAL REGISTRATION NUMBER NCT05144958.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Radoslaw Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Michalina Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
| | - Michal Pasierski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Rafal Januszek
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Marek Grygier
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Krzysztof Reczuch
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Wrocław, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Tomasz Pawłowski
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stanislaw Bartuś
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Andrzej Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
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15
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Alkhouli M, Du C, Killu A, Simard T, Noseworthy PA, Friedman PA, Curtis JP, Freeman JV, Holmes DR. Clinical Impact of Residual Leaks Following Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JACC Clin Electrophysiol 2022; 8:766-778. [PMID: 35387751 PMCID: PMC9233062 DOI: 10.1016/j.jacep.2022.03.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 02/28/2022] [Accepted: 03/02/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Data on the impact of residual peri-device leak after left atrial appendage occlusion (LAAO) are limited. OBJECTIVES The goal of this study was to explore the association of peri-device leak with adverse clinical events. METHODS The National Cardiovascular Data Registry LAAO Registry was queried to identify patients undergoing LAAO between January 1, 2016, and December 31, 2019. Patients were classified according to leak size on echocardiography at 45 ± 14 days (0 mm, no leak; >0-5 mm, small leak; and >5 mm, large leak). RESULTS A total of 51,333 patients were included, of whom 37,696 (73.4%) had no leak, 13,258 (25.8%) had small leaks, and 379 (0.7%) had large leaks. The proportion of patients on warfarin at 45 days was higher in the large vs small or no leak cohorts (44.9% vs 34.4% and 32.4%, respectively; P < 0.001). At 6 and 12 months, anticoagulant utilization decreased but remained more frequent in patients with large leaks. Thromboembolic and bleeding events were uncommon in all groups. However, compared with patients with no leak, those with small leaks had slightly higher odds of stroke/transient ischemic attack/systemic embolization (adjusted HR: 1.152; 95% CI: 1.025-1.294), major bleeding (HR: 1.11; 95% CI: 1.029-1.120), and any major adverse events (HR: 1.102; 95% CI: 1.048-1.160). There were no significant differences in adverse events between patients with large leaks and patients with small or no leaks. CONCLUSIONS Small (>0-5 mm) leaks after LAAO were associated with a modestly higher incidence of thromboembolic and bleeding events; large leaks (>5 mm) were not associated with adverse events, although higher proportions of these patients were maintained on anticoagulation. Newer devices with improved seal might mitigate the events associated with residual leaks.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Chengan Du
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ammar Killu
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Trevor Simard
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Paul A Friedman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James V Freeman
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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16
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Korsholm K, Jensen JM, Nørgaard BL, Nielsen-Kudsk JE. Temporal changes and clinical significance of peridevice leak following left atrial appendage occlusion with Amplatzer devices. Catheter Cardiovasc Interv 2022; 99:2071-2079. [PMID: 35582829 PMCID: PMC9541112 DOI: 10.1002/ccd.30178] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/05/2022] [Accepted: 03/13/2022] [Indexed: 12/05/2022]
Abstract
Background The natural history of peridevice leak (PDL) following left atrial appendage occlusion (LAAO) is unknown. This study sought to investigate changes of PDL from 2 until 12 months after LAAO, using cardiac computed tomography (CT), and to assess the potential association between persistent PDL and clinical outcomes Methods Single‐center observational study of Amplatzer LAAO implants between 2010 and 2017 (n = 206). Patients with 2 and 12 months cardiac CT were included in the study (n = 153). Images were blindly analyzed. PDL was characterized by frequency and size at the device disc, lobe, and left atrial appendage contrast patency. Patients were followed for the composite outcome of ischemic stroke, transient ischemic attack, systemic embolism, or all‐cause death. Median follow up from LAAO was 3.1 (2.3–4.3) years. Results Contrast patency was present in 101 (66%) and 72 (47%) (p < 0.001) at 2 and 12 months, respectively. PDL was identified at the disc in 103 (67%) patients at 2 months versus 93 (61%) at 12 months (p = 0.08), and at the lobe in 29 (19%) at both time points. PDL area at the disc did not change significantly over time, ∆ area: −8.95 mm (95% confidence interval [CI]: −18.9; 1.01) p = 0.08. Permanent atrial fibrillation was independently associated with persistent PDL. Persistent versus no PDL was associated with a 62% worse clinical outcome, however not statistically significant, hazard ratio (HR): 1.62 (95% CI: 0.9–2.93), p = 0.11. Conclusion Persistent PDL was frequently observed following LAAO with Amplatzer devices. The PDL frequency and size appeared unchanged between 2 and 12 months. Persistent PDL was not significantly associated with worse clinical outcomes, yet this needs further delineation in future studies.
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Affiliation(s)
- Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jesper M Jensen
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Bjarne L Nørgaard
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
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17
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Cardiac Rehabilitation in Atrial Fibrillation Patients With Left Atrial Appendage Occlusion. J Cardiopulm Rehabil Prev 2022; 42:266-271. [DOI: 10.1097/hcr.0000000000000693] [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: 11/27/2022]
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18
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Sievert K, Asmarats L, Arzamendi D. Left Atrial Appendage Occlusion Strengths and Weaknesses of the Lobe-Only Occluder Concept in Theory and in Practice. Interv Cardiol Clin 2022; 11:195-203. [PMID: 35361464 DOI: 10.1016/j.iccl.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design. This review highlights the potential features and benefits of the single-lobe devices.
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Affiliation(s)
- Kolja Sievert
- CardioVascular Center Frankfurt (CVC), St. Catherine Hospital, Seckbacher Landstraße 65, 60389 Frankfurt am Main, Germany
| | - Lluis Asmarats
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain
| | - Dabit Arzamendi
- Department of Cardiology, Hospital de la Santa Creu I Sant Pau, Sant Antoni Maria Claret 167, Barcelona 08025, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).
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19
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Nestelberger T, Alfadhel M, McAlister C, Saw J. Follow Up imaging After Left Atrial Appendage Occlusion-Something or Nothing and for How Long? Interv Cardiol Clin 2022; 11:159-170. [PMID: 35361461 DOI: 10.1016/j.iccl.2021.11.008] [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] [Indexed: 06/14/2023]
Abstract
Routine postprocedural imaging with transesophageal echocardiography or cardiac computed tomography angiography is the most commonly used imaging modality for follow-up surveillance usually performed 1 to 6 months after the procedure. Imaging enables recognition of well-suited and sealed devices in the left atrial appendage as well as of potential harmful complications such as peri-device leaks, device-related thrombus, and device embolization, which may lead to further surveillance observation with recurrent imaging, reinitiation of oral anticoagulants, or additional interventional procedures.
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Affiliation(s)
- Thomas Nestelberger
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland; Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Mesfer Alfadhel
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Cameron McAlister
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada
| | - Jacqueline Saw
- Division of Cardiology, Vancouver General Hospital, University of British Columbia, 2775 Laurel Street, Level 9, Vancouver, BC V5Z1M9, Canada; Vancouver General Hospital, Basel, British Columbia, Canada; University of British Columbia, 2775 Laurel Street, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.
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20
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Wong I, Tzikas A, Søndergaard L, De Backer O. The Strengths and Weaknesses of the LAA Covering Disc Occluders-Conceptually and in Practice. Interv Cardiol Clin 2022; 11:185-194. [PMID: 35361463 DOI: 10.1016/j.iccl.2021.11.010] [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] [Indexed: 06/14/2023]
Abstract
Endocardial left atrial appendage (LAA) occluders with a covering disc encompass a wide range of devices that share the common feature of a distal anchoring "body" and proximal covering "disc" design. This unique design feature has potential advantages in certain complex LAA anatomies and challenging clinical scenarios. The current review article summarizes the different features of established and novel devices, preprocedural imaging updates, intraprocedural technical considerations, and postprocedural follow-up issues specific to this category of LAA occluders.
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Affiliation(s)
- Ivan Wong
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Apostolos Tzikas
- European Interbalkan Medical Centre & AHEPA University Hospital, Asklipiou 10, Thessaloniki 57001, Greece
| | - Lars Søndergaard
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Ole De Backer
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark.
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21
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Hamadanchi A, Ijuin S, Haertel F, Bekfani T, Westphal J, Franz M, Moebius-Winkler S, Schulze PC. A Novel Echocardiographic-Based Classification for the Prediction of Peri-Device Leakage Following Left Atrial Appendage Occluder Implantation. J Clin Med 2022; 11:jcm11041059. [PMID: 35207334 PMCID: PMC8877112 DOI: 10.3390/jcm11041059] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/21/2022] [Accepted: 02/12/2022] [Indexed: 02/05/2023] Open
Abstract
(1) Background: The assessment of residual peri-device leakages (PDL) after left atrial appendage occlusion (LAAO) remains crucial for post-procedural management. Our study aimed to verify a novel echocardiographic classification for the prediction of PDL. (2) Methods: Echocardiographic data of 72 patients who underwent percutaneous LAAO were evaluated. All echo images were analyzed by two independent investigators using standard analysis software (Image-Arena IA-4.6.4.44 by TomTec®, Munich, Germany). A total number of 127 studies was evaluated. Forty-four patients had baseline studies, at 45 days and at 6 months post-implantation. We propose a morphological classification of LAA devices based on the amount of echodensity inside the devices into three types: type A showing complete homogenous thrombosis, type B incompletely thrombosed device with inhomogeneous echo-free space <50% of device, and type C with partially thrombosed device in which the echo free space was >50% of device in various planes, which we called the “ice-cream cone” sign. Each type was matched to the degree of PDL and clinical outcome parameters. (3) Results: Patients with type C had the highest percentage of PDL at 45 days follow-up (type A: 24%, type B: 31%, type C 100% PDL, p < 0.001) and at 6 months follow-up (type A: 7%, type B: 33%, type C 100% PDL, p < 0.001). Notably, device size in patients with PDL was larger than that in patients without PDL at 6 months follow-up (25.6 ± 3.5 mm vs. 28.7 ± 3.4 mm, p = 0.004). Device size in patients with type C appearance was the largest of the three types (type A: 25.9 ± 3.6 mm, type B: 25.8 ± 3.4 mm, type C 29.8 ± 3.0 mm, type A vs. C; p = 0.019; type B vs. C, p = 0.007). (4) Conclusions: In conclusion, PDL are common post-LAAO, and their frequency is underestimated and under-recognized. PDL are much more common in patients with larger LAA ostial sizes and likely lower longitudinal compression. Type C appearance of the LAAO devices (“ice-cream cone sign”) has a high positive predictive value for PDL. Further studies are needed for better delineation of the clinical importance of this proposed classification.
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Affiliation(s)
- Ali Hamadanchi
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
- Correspondence: ; Tel.: +49-3641-9-32-46-45; Fax: +49-3641-9-32-41-02
| | - Shun Ijuin
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
- Department of Cardiology, National Hospital Organization Kagoshima Medical Center, Kagoshima 892-0853, Japan
| | - Franz Haertel
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
| | - Tarek Bekfani
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Magdeburg, Otto von Guericke-University, 39120 Magdeburg, Germany;
| | - Julian Westphal
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
| | - Marcus Franz
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
| | - Sven Moebius-Winkler
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
| | - P. Christian Schulze
- Division of Cardiology, Angiology and Intensive Medical Care, Department of Internal Medicine I, University Hospital Jena, Friedrich-Schiller-University, 07747 Jena, Germany; (S.I.); (F.H.); (J.W.); (M.F.); (S.M.-W.); (P.C.S.)
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Piayda K, Sievert K, Della Rocca D, Adeola O, Alkhouli M, Yoo D, Benito-González T, Cruz-González I, Galea R, Skurk C, De Backer O, Nielsen-Kudsk J, Grygier M, Beaty E, Newton J, Pérez de Prado A, Räber L, Gibson D, Van Niekerk C, Ellis C, Horton R, Natale A, Grundwald I, Zeus T, Sievert H. Safety and feasibility of peri-device leakage closure after LAAO: an international, multicentre collaborative study. EUROINTERVENTION 2021; 17:e1033-e1040. [PMID: 34219662 PMCID: PMC9724933 DOI: 10.4244/eij-d-21-00286] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Residual peri-device leakage (PDL) is frequent after left atrial appendage occlusion (LAAO). Little is known about management strategies, procedural aspects and outcomes of interventional PDL closure. AIMS The aim of this study was to assess the safety and feasibility of PDL closure after LAAO. METHODS Fifteen centres contributed data on baseline characteristics, in-hospital and follow-up outcomes of patients who underwent PDL closure after LAAO. Outcomes of interest included acute success and complication rates and long-term efficacy of the procedure. RESULTS A total of 95 patients were included and a cumulative number of 104 leaks were closed. The majority of PDLs were detected within 90 days (range 41-231). Detachable coils were the most frequent approach (42.3%), followed by the use of the AMPLATZER Vascular Plug II (29.8%) and the AMPLATZER Duct Occluder II (17.3%). Technical success was 100% with 94.2% of devices placed successfully within the first attempt. There were no major complications requiring surgical or transcatheter interventions. During follow-up (96 days [range 49-526]), persistent leaks were found in 18 patients (18.9%), yielding a functional success rate of 82.7%, although PDLs were significantly reduced in size (pre-leak sizemax: 6.1±3.6 mm vs post-leak sizemax: 2.5±1.3 mm, p<0.001). None of the patients had a leak >5 mm. Major adverse events during follow-up occurred in 5 patients (2 ischaemic strokes, 2 intracranial haemorrhages, and 1 major gastrointestinal bleeding). CONCLUSIONS Several interventional techniques have become available to achieve PDL closure. They are associated with high technical and functional success and low complication rates.
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Affiliation(s)
- Kerstin Piayda
- Cardiovascular Center (CVC) Frankfurt, Frankfurt, Germany
| | - Kolja Sievert
- Cardiovascular Center (CVC) Frankfurt, Frankfurt, Germany
| | | | | | | | | | | | | | - Roberto Galea
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | - Marek Grygier
- Poznan University of Medical Sciences, Poznan, Poland
| | - Elijah Beaty
- Wake Forest Baptist Health, Winston-Salem, NC, USA
| | | | | | - Lorenz Räber
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | | | | | - Rodney Horton
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA,Scripps Health, La Jolla, CA, USA
| | | | - Tobias Zeus
- University Hospital Düsseldorf, Düsseldorf, Germany
| | - Horst Sievert
- CardioVascular Center (CVC) Frankfurt, Seckbacker Landstraβe 65, 60389 Frankfurt, Germany. E-mail:
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Sleiman JR, Lewis AJ, Perez EJ, Asher CR, Cubeddu RJ. Cardioform Septal Occluder for the Closure of a Peri-Device Leak After Initial Watchman Implantation. Cureus 2021; 13:e15439. [PMID: 34113525 PMCID: PMC8177093 DOI: 10.7759/cureus.15439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/29/2022] Open
Abstract
Left atrial appendage occlusion has become a safe and effective alternative for stroke-risk reduction among patients with non-valvular atrial fibrillation (AF). Although complete closure is ideal, residual peri-device leaks (PDL) are not uncommon and have been associated with an increased residual risk of stroke. PDL closure has been proposed as an alternate strategy to allow for the safe discontinuation of oral anticoagulation. We describe the safety and feasibility of successful PDL closure using a non-fenestrated Cardioform (Gore Medical, Flagstaff, Arizona) septal occluder after initial Watchman (Boston Scientific, Marlborough, Massachusetts) implantation.
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24
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Jang SJ, Wong SC, Mosadegh B. Leaks after Left Atrial Appendage Closure: Ignored or Neglected? Cardiology 2021; 146:384-391. [PMID: 33735867 DOI: 10.1159/000513901] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 12/12/2020] [Indexed: 11/19/2022]
Abstract
Left atrial appendage (LAA) closure has recently been approved as an alternative management for stroke prevention in patients with chronic atrial fibrillation who have difficulties with long-term oral anticoagulation. The various shapes and sizes of LAA and orientation of the atrial ostium may contribute to the incomplete LAA closure from circular design devices and orientation of the non-steerable delivery catheter. Incomplete closure of LAA leads to a high-velocity blood flow through the peri-device gap, resulting in peri-device leak (PDL). Residual leaks are frequently diagnosed after LAA closure procedures, regardless of closure methods. There is a controversy in the clinical significance of the leaks, particularly about its association with thromboembolic events. PDL <5 mm was not associated with any increase of risk for thromboembolism. Current literatures with small study population have not been sufficient to clarify the role of the leaks after LAA closure. Nevertheless, management of severe leaks has been a challenging concern for cardiologists. Leaks after epicardial LAA closures are at the neck of the incompletely closed LAA and have shown to increase the risk of thromboembolism. Percutaneous closure of the leaks after LAA closure has been attempted with good safety and success, but long-term safety and efficacy remains unclear. Further large long-term studies which aim to assess the role of leaks or PDLs in predicting thromboembolic events and management strategies are warranted.
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Affiliation(s)
- Sun-Joo Jang
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA
| | - S Chiu Wong
- Greenberg Cardiology Division, Weill Cornell Medicine, New York, New York, USA
| | - Bobak Mosadegh
- Dalio Institute of Cardiovascular Imaging, New York Presbyterian Hospital and Weill Cornell Medicine, New York, New York, USA,
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25
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He B, Jiang LS, Hao ZY, Wang H, Miao YT. Combination of ablation and left atrial appendage closure as "One-stop" procedure in the treatment of atrial fibrillation: Current status and future perspective. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:1259-1266. [PMID: 33629763 PMCID: PMC8359309 DOI: 10.1111/pace.14201] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 02/18/2021] [Accepted: 02/21/2021] [Indexed: 12/19/2022]
Abstract
Atrial fibrillation (AF), the most common arrhythmia, is a major cause of stroke and systemic embolism. Left atrial appendage closure (LAAC) has been proved to be noninferior to traditional Vitamin K antagonists (VKAs) as well as novel oral anticoagulants (NOACs), which is becoming an important alternative to prevent stroke in non‐valvular AF. Catheter‐based AF ablation (CA) is recommended to be a standard of care in patients with AF refractory to drug therapy due to a better rhythm control and improvement of life quality than antiarrhythmic drugs. Theoretically, the one‐stop combination with LAAC and CA tends to bring more benefits in patients with AF, as it not only relieves symptoms, but also reduces the risk of stroke significantly. However, several important questions still need to be considered in the combination procedure although quite a few attempts have already been made in clinical practice. This review provides a comprehensive update on the concept, technique, perioperative management, benefits and other critical issues of the “one‐stop” procedure.
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Affiliation(s)
- Ben He
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Li-Sheng Jiang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Zi-Yong Hao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Hao Wang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Yu-Tong Miao
- Department of Cardiology, Shanghai Chest Hospital, Shanghai Jiaotong University, Shanghai, China
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26
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Alkhouli M, Holmes DR. Remaining Challenges With Transcatheter Left Atrial Appendage Closure. Mayo Clin Proc 2020; 95:2244-2248. [PMID: 33012352 PMCID: PMC7528944 DOI: 10.1016/j.mayocp.2020.07.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 06/19/2020] [Accepted: 07/10/2020] [Indexed: 01/01/2023]
Abstract
Left atrial appendage closure has emerged as a feasible stroke prevention strategy in selected patients with nonvalvular atrial fibrillation. Since its commercial approval in the United States in 2015, the use of percutaneous left atrial appendage closure has witnessed a substantial growth. However, certain issues remain unresolved with the technology. Knowledge of these issues, their significance, and the current and future efforts to resolve them is key for proper informed decision making by physicians and patients.
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Affiliation(s)
- Mohamad Alkhouli
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| | - David R Holmes
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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27
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Zhang X, Jin Q, Kong D, Jiang Y, Chen S, Chen D, Hou CR, Zhang L, Pan C, Zhou D, Ge J. Comparison of fluoroscopy and transesophageal echocardiogram for intra-procedure device surveillance assessment during implantation of Watchman. Int J Cardiol 2020; 324:72-77. [PMID: 32882298 DOI: 10.1016/j.ijcard.2020.08.070] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/01/2020] [Accepted: 08/19/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate intraprocedural assessments using transesophageal echocardiography (TEE) and fluoroscopy during left atrial appendage occlusion (LAAO) with the WATCHMAN device. METHOD A total of 208 patients with non-valvular atrial fibrillation (AF) undergoing LAAO were included in this study[101 standard procedures (retrospective cohort) and 107 with fluoroscopy-alone approach (prospective cohort). Individual device position, anchoring, compression and peri-device leak (PDL) were successively analyzed based on TEE and fluoroscopy in the retrospective cohort to summarize detailed fluoroscopic assessments for prospective application. Clinical outcomes were assessed between two cohorts. RESULTS For retrospective cohort, TEE and fluoroscopy agreed on device position and anchoring. Compression upon fluoroscopy was well correlated with 2D-TEE (r = 0.908) and the difference in overall detection of PDL was not statistically significant between two imaging modalities (p = 0.304). For the prospective cohort with fluoroscopy-guidance alone, implantation success was similar to that of the retrospective cohort (98.13% vs 100%, p = 0.498). The incidence rate of major clinical adverse events was relatively higher in prospective cohort during hospitalization and follow-up but did not reach significant difference (5.61% vs 1.98%; 0.99% vs 0.93%, p > 0.05). Moreover, the prospective group presented with shorter procedural duration, shorter in-hospital stay and lower total hospitalization cost than retrospective group. CONCLUSION LAAO performed by experienced operators in large volume centers is feasible under fluoroscopy guidance. However, there is still a trend in favor of TEE for greater procedural safety and more complete LAA seal. We suggest that this minimalist approach could be proposed in cases with contraindication to general anesthesia and/or TEE.
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Affiliation(s)
- Xiaochun Zhang
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qinchun Jin
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dehong Kong
- Shanghai Institution of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yingying Jiang
- Shanghai Institution of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shasha Chen
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dandan Chen
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cody R Hou
- College of Biological Sciences, University of Minnesota Twin Cities, Minneapolis, MN, USA
| | - Lei Zhang
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cuizhen Pan
- Shanghai Institution of Cardiovascular Disease, Shanghai Institute of Medical Imaging, Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Daxin Zhou
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Junbo Ge
- Shanghai Institution of Cardiovascular Disease, Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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28
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Caliskan E, Eberhard M, Falk V, Alkadhi H, Emmert MY. Incidence and characteristics of left atrial appendage stumps after device-enabled epicardial closure. Interact Cardiovasc Thorac Surg 2020; 29:663-669. [PMID: 31504552 DOI: 10.1093/icvts/ivz176] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/11/2019] [Accepted: 06/26/2019] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES High success rates for left atrial appendage (LAA) exclusion with the AtriClip (Atricure, USA) device have been reported in the literature. This study evaluated the presence and characteristics of residual LAA stumps after AtriClip LAA exclusion using postoperative short- and long-term computed tomography angiography (CTA). METHODS In this retrospective analysis, 43 of 291 consecutive patients undergoing cardiac surgery with concomitant LAA occlusion using the AtriClip device were identified with available postoperative short- and long-term follow-up by CTA. LAA patency and the absence or the size of a present residual LAA stump were assessed on 2-dimensional multiplanar reconstructions, on maximum intensity projection images and on volume-rendered 3-dimensional computed tomography reconstructions. Based on current recommendations, the threshold for a significant LAA stump length was defined <10 mm. RESULTS The LAA was successfully occluded in all 43 patients (100%) as confirmed by intraoperative transoesophageal echocardiography and CTA imaging with a mean follow-up duration of 7.1 ± 0.8 years post-implant. The absence of blood flow in the excluded LAA was confirmed in all cases. In 31 of 43 patients (72%), no residual stump (0 mm) was observed creating a smooth endocardial surface, CTA revealed residual LAA stumps in 11/43 patients (26%) with a length <10 mm and a significant residual stump with a depth of >10 mm (12 mm) in 1 patient (2%). The mean length, width and depth of the residual stumps were 5.8 ± 2.1, 4.4 ± 1.2 and 7.3 ± 2.3 mm, respectively. CONCLUSIONS This study investigated the incidence of residual stump formation (>10 mm) after LAA closure with the AtriClip device based on CTA imaging data obtained during short- and long-term follow-up. While no LAA stump was detectable in the majority of patients, a non-significant LAA stump (<10 mm) was present in 26% of cases, indicating a favourable LAA occlusion profile for the AtriClip device. However, although a LAA stump length <10 mm is currently considered clinically safe, this definition needs further attention in future studies with regards to its potential clinical implications.
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Affiliation(s)
- Etem Caliskan
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
| | - Matthias Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,ETH Zurich, Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Maximilian Y Emmert
- Clinic for Cardiovascular Surgery, University Hospital Zurich, University of Zurich, Zurich, Switzerland.,Department of Cardiovascular Surgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiothoracic and Vascular Surgery, German Heart Institute Berlin, Berlin, Germany
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29
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Alkhouli M. Management of Peridevice Leak After LAAO. JACC Cardiovasc Interv 2020; 13:320-322. [DOI: 10.1016/j.jcin.2019.10.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 10/29/2019] [Indexed: 12/21/2022]
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30
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Wilkins B, Fukutomi M, De Backer O, Søndergaard L. Left Atrial Appendage Closure: Prevention and Management of Periprocedural and Postprocedural Complications. Card Electrophysiol Clin 2019; 12:67-75. [PMID: 32067649 DOI: 10.1016/j.ccep.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Left atrial appendage closure (LAAC) is noninferior to oral vitamin K antagonist therapy for the reduction of nonvalvular atrial fibrillation-related stroke risk. Currently, the procedure is most widely accepted in patients who cannot tolerate oral anticoagulants. This patient population is generally comorbid, making any reduction in procedural complications paramount. LAAC has important complications described in the periprocedural and postprocedural periods. The prevention and management of complications regarding vascular access, transseptal puncture, pericardial effusion, device embolization, stroke, air embolusperidevice leak, device-related thrombus and device erosion/ late pericardial effusion are discussed.
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Affiliation(s)
- Ben Wilkins
- Department of Cardiology, Heart Center, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Motoki Fukutomi
- Department of Cardiology, Heart Center, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Ole De Backer
- Department of Cardiology, Heart Center, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark
| | - Lars Søndergaard
- Department of Cardiology, Heart Center, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, Copenhagen 2100, Denmark.
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31
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Alkhouli M, Chaker Z, Clemetson E, Alqahtani F, Al Hajji M, Lobban J, Sengupta PP, Raybuck B. Incidence, Characteristics and Management of Persistent Peri-Device Flow after Percutaneous Left Atrial Appendage Occlusion. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2019. [DOI: 10.1080/24748706.2019.1663381] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Mohamad Alkhouli
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Zakieh Chaker
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Emily Clemetson
- Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Fahad Alqahtani
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Mohammed Al Hajji
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - John Lobban
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Partho P. Sengupta
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Bryan Raybuck
- Division of Cardiology, Department of Medicine, West Virginia University, Morgantown, West Virginia, USA
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Ciobotaru V, Combes N, Martin CA, Marijon E, Maupas E, Bortone A, Bruguière E, Thambo JB, Teiger E, Pujadas-Berthault P, Ternacle J, Iriart X. Left atrial appendage occlusion simulation based on three-dimensional printing: new insights into outcome and technique. EUROINTERVENTION 2019. [PMID: 29537376 DOI: 10.4244/eij-d-17-00970] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to assess the predictive value of simulation based on 3D-printed models before left atrial appendage occlusion (LAAO) for peri-device leaks (PDL) and the impact on procedural outcomes compared to conventional imaging. METHODS AND RESULTS Seventy-six patients referred for LAAO with double disc device underwent construction of a 3D-printed LA model using flexible photopolymer resin. An implant simulation was performed retrospectively in Group 1 (55 patients), blinded to implanted device size, and prospectively in Group 2 (21 patients). In Group 1, an off-axis device position occurred in 14 patients (25%) and the incidence of PDL was 27% (15 patients); mismatch between model and device size was the best predictor (area under the curve 0.88, CI: 0.77-0.99). When using 3D simulation prospectively, mean prosthesis number per patient (1.05±0.21 vs. 1.20±0.52, p=0.04) and incidence of leaks (5% vs. 27%, p<0.01) were reduced compared to conventional imaging alone, as well as fluoroscopy time (19 mins [13.4-23] vs. 13.5 mins [11.1-15], p=0.012) and total fluoroscopy dose (7,291 [1,811-12,734] vs. 1,978 (1,548-4,800) mGy·cm2, p=0.029). CONCLUSIONS 3D-printed patient-specific adaptive and flexible LA models improve LAAO double disc device sizing. This can potentially reduce procedure time and the number of prostheses employed per patient.
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33
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de Backer O, Rosseel L, Søndergaard L. Are we too simple in planning complex structural interventions? The potential role of cardiac computed tomography to prepare for percutaneous left atrial appendage closure. EUROINTERVENTION 2019; 15:e213-e215. [PMID: 31186221 DOI: 10.4244/eijv15i3a38] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Ole de Backer
- The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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34
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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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35
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Holmes DR, Alkhouli M, Reddy V. Left Atrial Appendage Occlusion for The Unmet Clinical Needs of Stroke Prevention in Nonvalvular Atrial Fibrillation. Mayo Clin Proc 2019; 94:864-874. [PMID: 30962008 DOI: 10.1016/j.mayocp.2018.09.025] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/29/2018] [Accepted: 09/11/2018] [Indexed: 12/29/2022]
Abstract
Oral anticoagulation is the dominant strategy for stroke prevention in patients with nonvalvular atrial fibrillation. However, lifelong oral anticoagulation is associated with major issues including inappropriate dosing, nonadherence, and adverse effects. Therefore, efforts have been made to develop site-specific therapy aimed to occlude the left atrial appendage, the anatomical site accountable for more than 90% of nonvalvular atrial fibrillation-related ischemic strokes. This review focuses on the growing literature to put into perspective the risk-balance ratio of left atrial appendage occlusion.
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Affiliation(s)
- David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | - Mohamad Alkhouli
- Division of Cardiology, West Virginia University School of Medicine, Morgantown
| | - Vivek Reddy
- Department of Medicine, Division of Cardiology, Helmsley Electrophysiology Center, Mount Sinai Medical Center, New York, NY
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36
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Alkhouli M, Chaker Z, Al-Hajji M, Sengupta PP. Management of Peridevice Leak Following Left Atrial Appendage Occlusion. JACC Clin Electrophysiol 2018; 4:967-969. [DOI: 10.1016/j.jacep.2018.02.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 02/22/2018] [Indexed: 11/26/2022]
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37
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Affiliation(s)
- Bernhard Meier
- From the Cardiovascular Department, University Hospital of Bern, Switzerland
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