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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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Llagostera-Martín M, Cainzos M, Salvatella N, Cubero-Gallego H, Mas-Stachurska A, Sánchez-Carpintero A, Tizón-Marcos H, Calvo-Fernández A, Molina L, Vaquerizo B. Single antiplatelet therapy after left atrial appendage closure in patients with AF: safety and effectiveness. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:150-157. [PMID: 37879431 DOI: 10.1016/j.rec.2023.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/16/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION AND OBJECTIVES The optimal antithrombotic strategy following left atrial appendage closure (LAAC) is poorly defined in patients with nonvalvular atrial fibrillation. We assessed the safety and effectiveness of a single antiplatelet treatment (SAPT) strategy after LAAC in a population at high risk of ischemic and bleeding events. METHODS This single-center, observational, prospective study included a consecutive cohort of patients who underwent LAAC using the LAmbre device (Lifetech Scientific, China) and who were discharged with SAPT. The primary outcome was a composite of stroke, systemic embolism, and device-related thrombosis during follow-up. Secondary endpoints were cardiovascular mortality and major bleeding events (BARC ≥3a). Clinical follow-up was performed at 1, 6, and 12 months and subsequently on an annual basis. Transesophageal echocardiography was performed at 1 and 12 months of follow-up. RESULTS The study comprised 74 patients. The median age was 77 [72-83] years and 43% were women. The cohort exhibited a high prevalence of comorbidities and cardiovascular risk factors. The median CHA2DS2-VASc and HAS-BLED scores were 4 [3-6] and 4 [4-5], respectively. The median length of follow-up was 2.5 years (188 patients-year). During follow-up, device-related thrombosis occurred in 3 patients (4%). Ischemic stroke occurred in 1 patient (1.3%, rate 0.5%/y), representing a 90.9% relative risk reduction compared with the risk predicted by CHA2DS2-VASc. Major bleeding events occurred in 12 patients (16%, 6.4%/y), with a relative risk reduction of 26.4% of that predicted by HAS-BLED. Cardiovascular-related mortality was observed in 2 patients (2.7%). CONCLUSIONS SAPT appears to be a safe and effective treatment following LAAC in patients at high ischemic and hemorrhagic risk. Further studies are needed to confirm our findings.
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Affiliation(s)
| | - Miguel Cainzos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | | | - Héctor Cubero-Gallego
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Aleksandra Mas-Stachurska
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Servicio de Cardiología, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Helena Tizón-Marcos
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Alicia Calvo-Fernández
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Luis Molina
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Departamento de Medicina, Universidad Pompeu Fabra, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
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3
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Amalathasan T, Nagaratnam PA, El Dirani M, Nagaratnam JM, Kholoki S. Should the Left Atrial Appendage Closure (LAAC) Technique Be the Main Form of Stroke Prevention in Patients With Long-Standing Persistent or Permanent Atrial Fibrillation? Cureus 2024; 16:e54256. [PMID: 38496111 PMCID: PMC10944332 DOI: 10.7759/cureus.54256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2024] [Indexed: 03/19/2024] Open
Abstract
Currently, oral anticoagulants are considered the gold standard for stroke prevention in patients with atrial fibrillation. Despite the efficacy of oral anticoagulants in reducing stroke incidence, patients are at risk of developing adverse reactions such as excessive bleeding and bruising, and can also have drug-drug interactions. In the early 2000s, a minimally invasive technique called the left atrial appendage closure emerged as an alternative for stroke prevention in atrial fibrillation patients who could not tolerate oral anticoagulants. Despite the success of the left atrial appendage closure, practitioners still opt for medication therapy and are reluctant to advocate for this procedure. Given the adverse effects of oral anticoagulants, physicians should question if this is the appropriate method of stroke prevention in long-standing persistent or permanent atrial fibrillation patients. This case report investigates an 82-year-old Middle Eastern male in the United States with long-standing persistent atrial fibrillation who underwent a left atrial appendage closure due to recurrent bleeding on oral anticoagulants. In addition, there will be further discussion on the appropriate method of stroke prevention in similar patients.
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Affiliation(s)
| | | | - Mirna El Dirani
- Internal Medicine, Saint James School of Medicine, Chicago, USA
| | | | - Samer Kholoki
- Internal Medicine, La Grange Memorial Hospital, Chicago, USA
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4
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Lucà F, Colivicchi F, Oliva F, Abrignani M, Caretta G, Di Fusco SA, Giubilato S, Cornara S, Di Nora C, Pozzi A, Di Matteo I, Pilleri A, Rao CM, Parlavecchio A, Ceravolo R, Benedetto FA, Rossini R, Calvanese R, Gelsomino S, Riccio C, Gulizia MM. Management of oral anticoagulant therapy after intracranial hemorrhage in patients with atrial fibrillation. Front Cardiovasc Med 2023; 10:1061618. [PMID: 37304967 PMCID: PMC10249073 DOI: 10.3389/fcvm.2023.1061618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 04/14/2023] [Indexed: 06/13/2023] Open
Abstract
Intracranial hemorrhage (ICH) is considered a potentially severe complication of oral anticoagulants (OACs) and antiplatelet therapy (APT). Patients with atrial fibrillation (AF) who survived ICH present both an increased ischemic and bleeding risk. Due to its lethality, initiating or reinitiating OACs in ICH survivors with AF is challenging. Since ICH recurrence may be life-threatening, patients who experience an ICH are often not treated with OACs, and thus remain at a higher risk of thromboembolic events. It is worthy of mention that subjects with a recent ICH and AF have been scarcely enrolled in randomized controlled trials (RCTs) on ischemic stroke risk management in AF. Nevertheless, in observational studies, stroke incidence and mortality of patients with AF who survived ICH had been shown to be significantly reduced among those treated with OACs. However, the risk of hemorrhagic events, including recurrent ICH, was not necessarily increased, especially in patients with post-traumatic ICH. The optimal timing of anticoagulation initiation or restarting after an ICH in AF patients is also largely debated. Finally, the left atrial appendage occlusion option should be evaluated in AF patients with a very high risk of recurrent ICH. Overall, an interdisciplinary unit consisting of cardiologists, neurologists, neuroradiologists, neurosurgeons, patients, and their families should be involved in management decisions. According to available evidence, this review outlines the most appropriate anticoagulation strategies after an ICH that should be adopted to treat this neglected subset of patients.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Furio Colivicchi
- Cardiology Division, San Filippo Neri Hospital, ASL Roma 1, Roma, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | | | - Giorgio Caretta
- Cardiology Unit, Sant'Andrea Hospital, ASL 5 Liguria, La Spezia, Italy
| | | | | | - Stefano Cornara
- Cardiology Division San Paolo Hospital, ASL 2, Savona, Italy
| | | | - Andrea Pozzi
- Cardiology Division, Maria della Misericordia di Udine, Italy
| | - Irene Di Matteo
- De Gasperis Cardio Center, ASST Niguarda Hospital, Milano, Italy
| | - Anna Pilleri
- Cardiology Division, Brotzu Hospital, Cagliari, Italy
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Antonio Parlavecchio
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | - Roberto Ceravolo
- Cardiology Division, Giovanni Paolo II Hospital, Lamezia Terme, Italy
| | - Francesco Antonio Benedetto
- Cardiology Department, Grande Ospedale Metropolitano di Reggio Calabria, GOM, Azienda Ospedaliera Bianchi Melacrino Morelli, Italy
| | | | | | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University, Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, A.O.R.N. Sant'Anna e San Sebastiano, Caserta, Italy
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Reduced- or Half-Dose Rivaroxaban Following Left Atrial Appendage Closure: A Feasible Antithrombotic Therapy in Patients at High Risk of Bleeding? J Clin Med 2023; 12:jcm12030847. [PMID: 36769499 PMCID: PMC9917793 DOI: 10.3390/jcm12030847] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 01/24/2023] Open
Abstract
The optimal antithrombotic strategy after percutaneous left atrial appendage closure (LAAC) has not yet been established. The advisability of administering low-dose direct oral anticoagulation after LAAC to patients at high risk of bleeding is uncertain. Thus, in the present study, we evaluated the safety and effectiveness of reduced-(15 mg) or half-dose rivaroxaban (10 mg) versus warfarin regarding real-world risks of thromboembolism, bleeding, and device-related thrombosis (DRT) after LAAC. Patients with non-valvular atrial fibrillation and HASBLED ≥ 3 who had undergone successful LAAC device implantation from October 2014 to April 2020 were screened and those who had received 10 mg or 15 mg rivaroxaban or warfarin therapy were enrolled. The patients were followed up 45 days and 6 months after LAAC to evaluate outcomes, including death, thromboembolism, major bleeding, and DRT. Of 457 patients with HASBLED ≥ 3 who had undergone LAAC, 115 had received warfarin and 342 rivaroxaban (15 mg: N = 164; 10 mg: N = 178). There were no significant differences in the incidence of thromboembolism or DRT between the warfarin and both doses of rivaroxaban groups (all p > 0.05). The incidence of major bleeding was significantly higher in the warfarin group than in either the reduced- or half-dose rivaroxaban groups (warfarin vs. rivaroxaban 15 mg: 2.6% vs. 0%, p = 0.030; warfarin vs. rivaroxaban 10 mg: 2.6% vs. 0%, p = 0.038). Either reduced- or half-dose rivaroxaban may be an effective and safe alternative to warfarin therapy in patients with LAAC and who are at high risk of bleeding, the risk of thromboembolism being similar and of major bleeding lower for both doses of rivaroxaban.
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Looking for optimal antithrombotic strategy after transcatheter left atrial appendage occlusion: a real-world comparison of different antiplatelet regimens. Int J Cardiol 2023; 371:92-99. [PMID: 36181948 DOI: 10.1016/j.ijcard.2022.09.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Transcatheter left atrial appendage occlusion (LAAO) has emerged as an effective procedure for the prevention of thromboembolic events in non-valvular atrial fibrillation (AF) patients with contraindications to oral anticoagulation. After the procedure, different antithrombotic regimens have been used, in order to prevent device-related thrombus and trying to minimize bleedings. The search for the optimal antithrombotic strategy is still ongoing. We sought to assess efficacy and safety of different antiplatelet therapy (APT) regimens. METHODS We enrolled non-randomized consecutive patients who underwent LAAO at the University Hospital of Parma between 2010 and 2021. Three study groups were identified according to post-procedural APT: long (>1, ≤12 months)-dual APT (DAPT), short (≤ 1 month)-DAPT, lifelong single APT (SAPT). The choice of the APT was left to multidisciplinary team evaluation. The incidence of the primary outcome, a composite of any ischemic or hemorrhagic event, was assessed at follow-up. RESULTS We enrolled a total of 130 patients. Technical success was achieved in 123 (94.6%) patients. After LAAO, 39 [31.7%] patients were discharged on short-DAPT, 35 [28.5%] on long-DAPT and 49 [39.8%] on SAPT. After a median follow-up of 32 months, short-DAPT group had a significantly lower occurrence of the primary outcome (3 [7.7%] vs. 7 [20.0%] in long-DAPT vs. 14 [28.6%] in SAPT, p = 0.049], mainly driven by a lower occurrence of the bleeding endpoint (0 vs. 4 [11.4%] in long-DAPT vs. 9 [18.4%] in SAPT, p = 0.020). Finally, comparison of the Kaplan-Meier curves showed that short-DAPT group had a higher primary endpoint-free survival [p = 0.015] compared to the other groups. CONCLUSION Post-procedural short-DAPT strategy was associated with better outcomes, mainly driven by reduction of major bleedings.
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Kany S, Brachmann J, Lewalter T, Akin I, Sievert H, Zeymer U, Hochadel M, Senges J, Kirchhof P, Lubos E. Influence of severe anemia on procedural safety and one-year outcome after left atrial appendage closure: Insights from a very high-risk cohort. IJC HEART & VASCULATURE 2022; 38:100946. [PMID: 35028410 PMCID: PMC8739449 DOI: 10.1016/j.ijcha.2021.100946] [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] [Received: 10/19/2021] [Revised: 12/05/2021] [Accepted: 12/24/2021] [Indexed: 01/28/2023]
Abstract
Introduction Patients undergoing left atrial appendage closure (LAAC) are often severly anemic and close to the transfusion threshold. The aim was to investigate the prevalence of severe anemia in this cohort and if procedural safety is compromised compared with non-anemic patients. Methods and results Comparison of severly anemic patients (Hb < 80 g/l) vs. non-severly anemic patients in the prospective, multicentre observational LAARGE registry of patients undergoing LAAC. A total of 638 patients (anemia 22.3% vs non-anemic 77.7%) were included. Anemic patients were older (77.1 years ± 7.9 vs 75.6 years ± 7.9, p = 0.014), had more comorbidities, higher CHA2DS2-VASc (4.8 vs 4.4, p = 0.017) and higher HAS-BLED (4.3 vs 3.8, p < 0.001) scores. Implant success was not influenced by anemia (99.3% vs 97.2%). Severe in-hospital (0.7% vs 5.6%, p = 0.01) and overall complications (8.5% vs 13.7%, p = 0.11) were less common in patients with anemia, driven by fewer pericardial effusions. Mortality was higher in anemic patients and associated with an increased hazard ratio, albeit not significantly (16.0% vs 10.3%, HR 1.61 (95%-CI: 0.97–2.67), p = 0.06). In the one-year follow-up, composite outcome of death, stroke or systemic embolism occurred in 22/142 anemic and in 54/496 non-anemic patients with an adjusted HR of 1.04 (95%-CI 0.62–1.73, p = 0.89). Conclusion Severe anemia close to the transfusion threshold is common in patients undergoing LAAC. However, this does not influence in-hospital complications or implant success. One-year mortality is higher in anemic patients, mainly driven by co-morbidities.
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Affiliation(s)
- Shinwan Kany
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Brachmann
- Department of Cardiology, Angiology and Pneumology, Coburg Hospital, Coburg, Germany
| | - Thorsten Lewalter
- Department of Medicine-Cardiology and Intensive Care, Hospital Munich-Thalkirchen, Munich, Germany
| | - Ibrahim Akin
- Department of Cardiology, University Hospital Mannheim, Mannheim, Germany
| | - Horst Sievert
- Cardio Vascular Centre Frankfurt, Frankfurt/Main, Germany
| | - Uwe Zeymer
- Department of Cardiology, Ludwigshafen Hospital, Ludwigshafen, Germany
| | | | - Jochen Senges
- Stiftung für Herzinfarktforschung (IHF), Ludwigshafen, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
| | - Edith Lubos
- Department of Cardiology, University Heart and Vascular Center Hamburg-Eppendorf, Hamburg, Germany
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Aminian A, De Backer O, Nielsen-Kudsk JE, Lam S, Freixa X, Gage R, Diener HC, Schmidt B, Lam SCC, Freixa X, Gage R, Diener HC, Schmidt B. Incidence and clinical impact of major bleeding following left atrial appendage occlusion: insights from the Amplatzer Amulet Observational Post-Market Study. EUROINTERVENTION 2021; 17:774-782. [PMID: 33495144 PMCID: PMC9724974 DOI: 10.4244/eij-d-20-01309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Major bleeding (MB) events are independent predictors of mortality after cardiac interventional procedures. The clinical relevance of MB following left atrial appendage occlusion (LAAO) remains unclear. AIMS This study aimed to investigate the incidence and clinical impact of MB after LAAO in a real-world population at high risk for bleeding and contraindicated to anticoagulation. METHODS The two-year results of the Amplatzer Amulet Observational Post-Market Study were analysed. An independent committee adjudicated MBs according to the Bleeding Academic Research Consortium scale. Cox proportional hazards regression identified variables associated with MB events and mortality. RESULTS The MB rate was 7.2%/year, with a rate of 10.1%/year during year one, decreasing to 4.0%/year over year two. The most common bleeding location was gastrointestinal, accounting for 48% of MBs. Pre-LAAO MB was associated with an increased risk for post-LAAO MB (HR 2.34, 95% CI: 1.37-3.99). The occurrence of post-LAAO MB was associated with increased mortality (37.3% vs 12.7%; p<0.0001), driven mainly by events occurring beyond the periprocedural period. The annualised rate of ischaemic stroke or TIA was similar in patients with and without MB (2.3% vs 3.3%; p=0.446). MB post LAAO was a strong independent predictor of mortality (HR 3.07, 95% CI: 2.15-4.40). CONCLUSIONS In real-world patients at high bleeding risk, MB following LAAO was not uncommon and associated with a significant increase in mortality, without increasing the risk of stroke. ClinicalTrials.gov Identifier: NCT02447081. https://clinicaltrials.gov/ct2/show/NCT02447081.
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Affiliation(s)
- Adel Aminian
- Department of Cardiology, Centre Hospitalier Universitaire de Charleroi, Chaussée de Bruxelles 140, 6042 Charleroi, Belgium
| | - Ole De Backer
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | | | - Simon Lam
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
| | | | - Ryan Gage
- Structural Heart Clinical Affairs, Abbott, St. Paul, MN, USA
| | - Hans-Christoph Diener
- Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty of the University Duisburg-Essen, Essen, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Medizinische Klinik 3 – Kardiologie, Frankfurt, Germany
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9
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Calabrò P, Gragnano F, Niccoli G, Marcucci R, Zimarino M, Spaccarotella C, Renda G, Patti G, Andò G, Moscarella E, Mancone M, Cesaro A, Giustino G, De Caterina R, Mehran R, Capodanno D, Valgimigli M, Windecker S, Dangas GD, Indolfi C, Angiolillo DJ. Antithrombotic Therapy in Patients Undergoing Transcatheter Interventions for Structural Heart Disease. Circulation 2021; 144:1323-1343. [PMID: 34662163 DOI: 10.1161/circulationaha.121.054305] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Contemporary evidence supports device-based transcatheter interventions for the management of patients with structural heart disease. These procedures, which include aortic valve implantation, mitral or tricuspid valve repair/implantation, left atrial appendage occlusion, and patent foramen ovale closure, profoundly differ with respect to clinical indications and procedural aspects. Yet, patients undergoing transcatheter cardiac interventions require antithrombotic therapy before, during, or after the procedure to prevent thromboembolic events. However, these therapies are associated with an increased risk of bleeding complications. To date, challenges and controversies exist regarding balancing the risk of thrombotic and bleeding complications in these patients such that the optimal antithrombotic regimens to adopt in each specific procedure is still unclear. In this review, we summarize current evidence on antithrombotic therapies for device-based transcatheter interventions targeting structural heart disease and emphasize the importance of a tailored approach in these patients.
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Affiliation(s)
- Paolo Calabrò
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Felice Gragnano
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Giampaolo Niccoli
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (G.N.).,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy (G.N.).,Department of Medicine, University of Parma, Italy (G.N.)
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Italy (R. Marcucci.)
| | - Marco Zimarino
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Carmen Spaccarotella
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.)
| | - Giulia Renda
- Institute of Cardiology, University "G. D'Annuzio" of Chieti-Pescara, Italy (M.Z., G.R)
| | - Giuseppe Patti
- Department of Translational Medicine, "Maggiore della Carità" Hospital, University of Eastern Piedmont, Via Solaroli, Novara, Italy (G.P.)
| | - Giuseppe Andò
- Unit of Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy (G.A.)
| | - Elisabetta Moscarella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Massimo Mancone
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Italy (M.M.)
| | - Arturo Cesaro
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli," Naples, Italy (P.C., F.G., E.M., A.C.).,Division of Cardiology, A.O.R.N. "Sant'Anna e San Sebastiano," Caserta, Italy (P.C., F.G., E.M., A.C.)
| | - Gennaro Giustino
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Raffaele De Caterina
- University Cardiology Division, University of Pisa, Pisa University Hospital, Italy; Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Italy (R.D.C.)
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Davide Capodanno
- Cardio-Thoracic-Vascular Department, Centro Alte Specialità e Trapianti, Catania, Italy (D.C.).,Azienda Ospedaliero Universitaria Policlinico "G. Rodolico-San Marco," University of Catania, Italy (D.C.)
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, Lugano, Switzerland (M.V.).,Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, University of Bern, Switzerland (M.V., S.W.)
| | - George D Dangas
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York (G.G., R. Mehran., G.D.D.)
| | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro, Italy (C.S., C.I.).,Mediterranea Cardiocentro, Naples, Italy (C.I.)
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville (D.J.A.)
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10
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Morita S, Malik AH, Kuno T, Ando T, Kaul R, Yandrapalli S, Briasoulis A. Analysis of outcome of 6-month readmissions after percutaneous left atrial appendage occlusion. Heart 2021; 108:606-612. [PMID: 34400473 DOI: 10.1136/heartjnl-2021-319345] [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: 03/14/2021] [Accepted: 07/21/2021] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Percutaneous left atrial appendage occlusion (LAAO) is an alternative strategy for prevention of thromboembolic events in patients with atrial fibrillation and unsuitable for long-term oral anticoagulation. The study aimed to evaluate the causes and timing of readmissions within 6 months following percutaneous LAAO in a real-world setting. METHODS We conducted a retrospective cohort study of percutaneous LAAO performed in the USA between January and June of 2016-2018 using the Nationwide Readmissions Database. RESULTS Overall, 12 446 patients who underwent LAAO were included in the analyses and 3477 patients (28%) were readmitted within 6 months following the interventions. Readmitted patients were more often women (p=0.001). The index hospitalisation was characterised by longer duration of hospital stay (p<0.001) and complicated with acute kidney injury (p<0.001) among readmitted patients compared with those without readmissions. Readmissions within 6 months following the index intervention were mainly due to heart failure (13%) and gastrointestinal bleeding (12%). Characteristics associated with readmissions due to heart failure included previously known heart failure (HR 2.39; 95% CI 1.70 to 3.37), valvular heart disease (HR 1.39; 95% CI 1.05 to 1.84) and chronic kidney disease (HR 1.42; 95% CI 1.03 to 1.94). Readmissions due to gastrointestinal bleeding were associated with diabetes mellitus (HR 1.78; 95% CI 1.25 to 2.53), chronic kidney disease (HR 1.86; 95% CI 1.23 to 2.81) and previous anaemia (HR 2.41; 95% CI 1.54 to 3.77). CONCLUSIONS After percutaneous LAAO, over a quarter of the patients in the USA required rehospitalisation within 6 months, mainly due to heart failure and gastrointestinal bleeding.
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Affiliation(s)
- Sae Morita
- Department of Cardiology, Columbia University Medical Center, New York, New York, USA
| | - Aaqib H Malik
- Department of Cardiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical Center, Bronx, New York, USA
| | - Tomo Ando
- Internal Medicine, Kawasaki Saiwai Hospital, Kawasaki, Japan.,Department of Cardiology, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Risheek Kaul
- Department of Cardiology, Westchester Medical Center Health Network, Valhalla, New York, USA
| | - Srikanth Yandrapalli
- Department of Cardiology, Westchester Medical Center Health Network, Valhalla, New York, USA
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11
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Schmidt B, Bordignon S, Chen S, Chun KRJ. What Does the Future Hold?: Ideal Device, Newer Devices, and More. Card Electrophysiol Clin 2021; 12:125-130. [PMID: 32067642 DOI: 10.1016/j.ccep.2019.11.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Please verify if "pigtail guided" should be "pigtail catheter-guided": Recent design changes for left atrial appendage (LAA) closure devices have led to significant improvement by facilitating the procedural workflow (no need for pigtail guided LAA intubation), moving the workspace from distal LAA to the landing zone (closed distal end design), and improving device stability (different anchor design). The availability of different device types (plug vs disc-lobe design) offers an option to tailor a device type to a patient's anatomy; thereby, sealing results have improved substantially. The issue of device-related thrombus has not been resolved and deserves future research, with the goal of eliminating postprocedural antithrombotic medication without increasing risk for stroke.
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Affiliation(s)
- Boris Schmidt
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Strasse 4, Frankfurt/Main 60431, Germany.
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Strasse 4, Frankfurt/Main 60431, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Strasse 4, Frankfurt/Main 60431, Germany
| | - Kyoung Ryul Julian Chun
- Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Strasse 4, Frankfurt/Main 60431, Germany
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12
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Cruz-González I, Korsholm K, Trejo-Velasco B, Thambo JB, Mazzone P, Rioufol G, Grygier M, Möbius-Winkler S, Betts T, Meincke F, Sandri M, Schmidt B, Schmitz T, Nielsen-Kudsk JE. Procedural and Short-Term Results With the New Watchman FLX Left Atrial Appendage Occlusion Device. JACC Cardiovasc Interv 2020; 13:2732-2741. [DOI: 10.1016/j.jcin.2020.06.056] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/04/2020] [Accepted: 06/30/2020] [Indexed: 01/01/2023]
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13
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Patti G, Sticchi A, Verolino G, Pasceri V, Vizzi V, Brscic E, Casu G, Golino P, Russo V, Rapacciuolo A, Boccuzzi G, Mangieri A, Pagnotta PA, Colombo A. Safety and Efficacy of Single Versus Dual Antiplatelet Therapy After Left Atrial Appendage Occlusion. Am J Cardiol 2020; 134:83-90. [PMID: 32892987 DOI: 10.1016/j.amjcard.2020.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/29/2020] [Accepted: 08/03/2020] [Indexed: 10/23/2022]
Abstract
The optimal antiplatelet strategy after left atrial appendage (LAA) occlusion able to protect from device-related thrombosis, paying the lowest price in terms of bleeding increase, is unclear. In a real-world, observational study we performed a head-to-head comparison of single versus dual antiplatelet therapy (SAPT vs DAPT) in patients who underwent LAA occlusion. We included 610 consecutive patients, stratified according to the type of post-procedural antiplatelet therapy (280 on SAPT and 330 on DAPT). Primary outcome measure was the incidence of the net composite end point including Bleeding Academic Research Consortium classification 3-5 bleeding, major adverse cardiovascular events or device-related thrombosis at 1-year follow-up. The use of SAPT compared with DAPT was associated with similar incidence of the primary net composite end point (9.3% vs 12.7% p = 0.22), with an adjusted hazard ratio (HR) of 0.69, 95% confidence interval 0.41 to 1.15; p = 0.15) at multivariate analysis. However, SAPT significantly reduced Bleeding Academic Research Consortium classification 3-5 bleeding (2.9% vs 6.7%, p = 0.038; adjusted HR 0.37, 0.16 to 0.88; p = 0.024). The occurrence of ischemic events (major adverse cardiovascular events or device-related thrombosis) was not significantly different between the 2treatment strategies (7.8% vs 7.4%; adjusted HR 1.34, 0.70 to 2.55; p = 0.38). In patients who underwent LAA occlusion, post-procedural use of SAPT instead of DAPT was associated with reduction of bleeding complications, with no significant increase in the risk of thrombotic events. These hypothesis-generating findings should be confirmed in a specific, randomized study.
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14
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Zender N, Weise FK, Bordignon S, Herrmann E, Konstantinou A, Bologna F, Nagase T, Chen S, Chun KRJ, Schmidt B. Thromboembolism after electrical isolation of the left atrial appendage: a new indication for interventional closure? Europace 2020; 21:1502-1508. [PMID: 31230078 DOI: 10.1093/europace/euz161] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Accepted: 05/14/2019] [Indexed: 11/14/2022] Open
Abstract
AIMS Left atrial appendage electrical isolation (LAAI) may improve the rhythm outcome in selected patients with atrial fibrillation (AF). Controversy exists if LAAI is associated with an increased rate of thromboembolic complications. We sought to assess the feasibility, efficacy, and safety of interventional left atrial appendage closure (LAAC) in comparison to oral anticoagulation (OAC) after electrical LAAI. METHODS AND RESULTS Weeks after index LAAI using the cryoballoon or a linear maze like ablation strategy patients' left atrial appendage was invasively remapped. In case of persistent LAAI, LAAC was performed. Patients who refused invasive remapping continued OAC. The primary endpoint was composed of any stroke or systemic embolism (SE) and the occurrence of intracardiac thrombus. Secondary endpoints included stroke/SE, major bleeding, and all-cause death. Of 166 patients (51% female; mean age 70 ± 8 years; mean CHAD2S2VASc score 3.4 ± 1.8) after LAAI, 94 patients received LAAC (LAAC group) and 72 continued OAC (no LAAC). After LAAC, 83% of patients received dual antiplatelet therapy for 6 weeks and aspirin thereafter. During a mean follow-up of 778 ± 630 days, 5 and 11 primary endpoint events were observed in the LAAC and no LAAC group, respectively [hazard ratio (HR) 0.27, 95% confidence interval (CI) 0.10-0.75; P = 0.010]. The calculated annual thromboembolic event rates were 6.9% (no LAAC) and 2.3% (LAAC), respectively. Left atrial appendage closure significantly reduced the incidence of stroke and SE (HR 0.31, CI 0.1-0.98; P = 0.04). CONCLUSION After electrical LAAI for rhythm control in AF patients, interventional LAAC was associated with fewer thromboembolic complications when compared with OAC.
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Affiliation(s)
- Niklas Zender
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Felix K Weise
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Stefano Bordignon
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Eva Herrmann
- Department of Medicine, Institute of Biostatistics and Mathematical Modelling, Goethe-University, Frankfurt, Germany
| | - Athanasios Konstantinou
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Fabrizio Bologna
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Takahiko Nagase
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Shaojie Chen
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Kyoung Ryul Julian Chun
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus-Krankenhaus, Wilhelm-Epstein Str. 4, D Frankfurt am Main, Germany
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15
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Kleinecke C, Gloekler S, Meier B. Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation: an update on patient outcomes. Expert Rev Cardiovasc Ther 2020; 18:517-530. [DOI: 10.1080/14779072.2020.1794820] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Caroline Kleinecke
- Cardiology, Internal Medicine Department, Klinikum Lichtenfels, Lichtenfels, Germany
| | - Steffen Gloekler
- Cardiology, Internal Medicine Department, Klinikum Hochrhein, Waldshut-Tiengen, Germany and Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
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16
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Liu XX, Kleinecke C, Busch S, Allakkis W, Mohrez Y, Cheikh-Ibrahim M, Mahnkopf C, Brachmann J, Schnupp S, Gloekler S, Yu J, Ma C. Propensity-matched comparison of antiplatelet versus anticoagulant after left atrial appendage closure with the Watchman. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:1242-1251. [PMID: 32779203 DOI: 10.1111/pace.14032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Optimal antithrombotic therapy following left atrial appendage closure (LAAC) with the Watchman occluder remains uncertain. This study retrospectively compared clinical outcomes of a 3-month dual antiplatelet therapy (DAPT group) and a protocol of anticoagulation plus aspirin for 45 days followed by DAPT for 6 months (ACT group) after LAAC with the Watchman device. METHODS Of two Watchman registries (Coburg and Lichtenfels hospitals, Germany), 220 and 304 consecutive patients with successful LAAC were included. Patients in Coburg hospital received DAPT while they received ACT in Lichtenfels. After a 1:1 propensity score matching, 174 (DAPT) versus 174 (ACT) patients were compared by use of the primary efficacy endpoint of thromboembolic events and cardiovascular/unexplained death, the primary safety endpoint of nonprocedural related major bleeding events at follow-up, and the combined hazard endpoint, a composite of all above-mentioned hazards. RESULTS The mean age 77.5 ± 7.2 (DAPT) versus 77.3 ± 7.1 (ACT) years, CHA2 DS2 -VASc score 4.6 ± 1.5 versus 4.7 ± 1.6, and HAS-BLED score 3.3 ± 0.8 versus 3.3 ± 0.8 were similar. After 12 months, the clinical efficacy (13/174, 7.4% [DAPT] vs 11/174, 6.3% [ACT]; hazard ratio [HR], 0.84; 95% confidence interval [CI], 0.38-1.86; P = .66) and safety (6/174, 3.4% vs 8/174, 4.5%; HR, 0.86; 95% CI, 0.29-2.56; P = .79) as well as the combined hazard endpoint (18/174, 10.3% vs 18/174, 10.3%; HR,1.01; 95% CI, 0.53-1.95; P = .97) were comparable. CONCLUSIONS This study suggests comparable efficacy and safety of 3-month DAPT versus 6 weeks ACT plus aspirin following LAAC with the Watchman.
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Affiliation(s)
- Xiao-Xia Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
| | - Caroline Kleinecke
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany
| | - Sonia Busch
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | - Wasim Allakkis
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | - Yamen Mohrez
- Department of Cardiology, Klinikum Coburg, Coburg, Germany
| | | | | | | | | | - Steffen Gloekler
- Cardiology, Cardiovascular Department, University Hospital of Bern, Bern, Switzerland
| | - Jiangtao Yu
- Department of Cardiology, Helmut-G.-Walther-Klinikum, Lichtenfels, Germany.,Clinic for General Internal Medicine and Cardiology, Marienhof Katholisches Klinikum, Koblenz. Montabaur, Koblenz, Germany
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, PR China
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17
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Glikson M, Wolff R, Hindricks G, Mandrola J, Camm AJ, Lip GYH, Fauchier L, Betts TR, Lewalter T, Saw J, Tzikas A, Sternik L, Nietlispach F, Berti S, Sievert H, Bertog S, Meier B. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion - an update. EUROINTERVENTION 2020; 15:1133-1180. [PMID: 31474583 DOI: 10.4244/eijy19m08_01] [Citation(s) in RCA: 148] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michael Glikson
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
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18
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Osman M, Busu T, Osman K, Khan SU, Daniels M, Holmes DR, Alkhouli M. Short-Term Antiplatelet Versus Anticoagulant Therapy After Left Atrial Appendage Occlusion: A Systematic Review and Meta-Analysis. JACC Clin Electrophysiol 2020; 6:494-506. [PMID: 32439033 PMCID: PMC7988890 DOI: 10.1016/j.jacep.2019.11.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 11/07/2019] [Accepted: 11/14/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this study was to compare bleeding, thromboembolic, device-related thrombus (DRT), and all-cause mortality events between patients treated with short-term oral anticoagulation (OAC) and those treated with short-term antiplatelet therapy (APT) following left atrial appendage occlusion (LAAO). BACKGROUND Short-term OAC is recommended for patients following LAAO. However, in practice many patients receive APT rather than OAC because of excessive bleeding risk. However, the safety and efficacy of APT compared with OAC have been debated. METHODS A search was conducted of databases for studies comparing OAC with APT following LAAO. The outcomes of interest were all-cause stroke, major bleeding, DRT, and all-cause mortality. Noncomparative studies were pooled into a single study to generate comparisons of the studies' outcomes. Effects measure were pooled using the random-effect model. RESULTS A total of 83 studies with 12,326 patients (APT, n = 7,900; OAC, n = 4,151) were included. Mean CHA2DS2-VASc and HAS-BLED scores were 4.1 ± 1.6 and 3.0 ± 1.3, respectively. There were no significance differences between the APT and OAC groups with regard to stroke (risk ratio [RR]: 1.04; 95% confidence interval [CI]: 0.54 to 1.98; p = 0.91; I2 = 31%), major bleeding (RR: 1.12; 95% CI: 0.68 to 1.84; p = 0.65; I2 = 53%), DRT (RR: 1.33; 95% CI: 0.74 to 2.39; p = 0.33; I2 = 36%), and all-cause mortality (RR: 1.29; 95% CI: 0.40 to 4.09; p = 0.18; I2 = 36%). These findings persisted in multiple secondary analyses: 1) excluding studies that reported no events; 2) including comparative studies only; 3) excluding patients who were treated with single APT; and 4) removing one study at a time to assess the effect of each study on the overall effect size. There was also no difference in the studies' endpoints among patients who received different LAAO devices. CONCLUSIONS In a meta-analysis of observational data, there were no differences in the occurrence of stroke, major bleeding DRT, and all-cause mortality in patients treated with short-term OAC or APT following LAAO.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Tatiana Busu
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Khansa Osman
- Michigan Health Specialist, Michigan State University, Flint, Michigan, USA
| | - Safi U Khan
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia, USA
| | - Matthew Daniels
- Division of Cardiovascular Medicine, Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Mohamad Alkhouli
- Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.
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19
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Glikson M, Wolff R, Hindricks G, Mandrola J, Camm AJ, Lip GYH, Fauchier L, Betts TR, Lewalter T, Saw J, Tzikas A, Sternik L, Nietlispach F, Berti S, Sievert H, Bertog S, Meier B, Lenarczyk R, Nielsen-Kudsk JE, Tilz R, Kalarus Z, Boveda S, Deneke T, Heinzel FR, Landmesser U, Hildick-Smith D. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update. Europace 2019; 22:184. [DOI: 10.1093/europace/euz258] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Michael Glikson
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Rafael Wolff
- Integrated Heart Center, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gerhard Hindricks
- Heartcenter Leipzig at Leipzig University and Leipzig Heart Institute, Department of Electrophysiology, Leipzig, Germany
| | | | - A John Camm
- Cardiology Clinical Academic Group Molecular & Clinical Sciences Research Institute, St. George’s University of London, London, United Kingdom
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | - Tim R Betts
- Oxford University Hospitals NHS Foundation Trust, Oxford Biomedical Research Centre, Department of Cardiology, Oxford, United Kingdom
| | - Thorsten Lewalter
- Dept. of Cardiology and Intensive Care, Hospital for Internal Medicine Munich South, Munich, Germany
- Dept. of Cardiology, University of Bonn, Bonn, Germany
| | - Jacqueline Saw
- Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Apostolos Tzikas
- Structural & Congenital Heart Disease, AHEPA University Hospital & Interbalkan European Medical Center, Thessaloniki, Greece
| | - Leonid Sternik
- Cardiac Surgery, Sheba Medical Center, Tel-Hashomer, Israel
| | - Fabian Nietlispach
- Cardiovascular Center Zurich, Hirslanden Klinik im Park, Zurich, Switzerland
| | - Sergio Berti
- Heart Hospital-Fondazione C.N.R. Reg. Toscana G. Monasterio, Cardiology Department, Massa, Italy
| | - Horst Sievert
- CardioVascular Center CVC, Cardiology and Angiology, Frankfurt, Germany
- Anglia Ruskin University, Chelmsford, United Kingdom
- University of California San Francisco, San Francisco, CA, USA
- Yunnan Hospital Fuwai, Kunming, China
| | - Stefan Bertog
- CardioVascular Center CVC, Cardiology and Angiology, Frankfurt, Germany
| | - Bernhard Meier
- Cardiology, Cardiovascular Department, University Hospital Bern, Bern, Switzerland
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20
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Schmidt B, Bordignon S, Chun KJ. Reassuring but not convincing - another registry to support left atrial appendage closure but randomized data remains scarce. IJC HEART & VASCULATURE 2019; 23:100371. [PMID: 31193070 PMCID: PMC6514719 DOI: 10.1016/j.ijcha.2019.100371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 04/28/2019] [Accepted: 04/30/2019] [Indexed: 11/20/2022]
Affiliation(s)
- Boris Schmidt
- Corresponding author at: Cardioangiologisches Centrum Bethanien, AGAPLESION Markus Krankenhaus, Wilhelm-Epstein Str. 4, 60431 Frankfurt/Main, Germany.
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21
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Incidence, Characterization, and Clinical Impact of Device-Related Thrombus Following Left Atrial Appendage Occlusion in the Prospective Global AMPLATZER Amulet Observational Study. JACC Cardiovasc Interv 2019; 12:1003-1014. [DOI: 10.1016/j.jcin.2019.02.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/11/2019] [Accepted: 02/05/2019] [Indexed: 11/18/2022]
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22
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Gasperetti A, Fassini G, Tundo F, Zucchetti M, Dessanai M, Tondo C. A left atrial appendage closure combined procedure review: Past, present, and future perspectives. J Cardiovasc Electrophysiol 2019; 30:1345-1351. [PMID: 31042321 DOI: 10.1111/jce.13957] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/17/2019] [Accepted: 04/23/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND AND OBJECTIVE Atrial fibrillation (AF) represents the most common cardiac arrhythmia worldwide; it poses a great burden in terms of quality of life reduction and yearly stroke risk. Left atrial appendage closure (LAAC) is a stroke prevention strategy that has been proven a viable alternative to antithrombotic regimens in nonvalvular AF patients. LAAC can be performed as a standalone procedure or alongside a concomitant AF transcatheter ablation, in a procedure known as "Combined procedure". Aim of this study is to summarize the scientific evidence backing this combined strategy. METHODS We reviewed the whole Medline indexed combined procedure literature, to summarize all the combined procedure study data. RESULTS Nine published studies regarding combined procedure were found. Data, aims, and scientific rationales were reported and commented. CONCLUSION LAA combined procedure appears to be a safe and effective procedure; a careful patient selection is necessary to maximize its benefit.
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Affiliation(s)
- Alessio Gasperetti
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Gaetano Fassini
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Fabrizio Tundo
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Martina Zucchetti
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Mariantonietta Dessanai
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy
| | - Claudio Tondo
- Heart Rhythm Center is the Department name; IRCCS, Centro Cardiologico Monzino is the name of the hospital, Milano, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
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23
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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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24
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Amoroso NS. Review on Future Targets and Current Trends in Transcatheter Left Atrial Appendage Closure. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0609-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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25
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Nusca A, Bressi E, Colaiori I, Miglionico M, Di Sciascio G. Antiplatelet therapy in valvular and structural heart disease interventions. Cardiovasc Diagn Ther 2018; 8:678-693. [PMID: 30498690 DOI: 10.21037/cdt.2018.06.08] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.
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Affiliation(s)
- Annunziata Nusca
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Edoardo Bressi
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Iginio Colaiori
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Marco Miglionico
- Unit of Cardiac Sciences, Campus Bio-Medico University of Rome, Rome, Italy
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26
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Skurk C, Hartung JJ, Leistner DM, Landmesser U. [Catheter-based atrial appendage closure-current data and future developments]. Internist (Berl) 2018; 59:1028-1040. [PMID: 30182193 DOI: 10.1007/s00108-018-0483-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
In Germany more than 1.6 million patients suffer from atrial fibrillation (AF). Within the next decades this number will substantially increase due to current demographic trends with the increasing average age of the population. When untreated, patients with atrial fibrillation have a five times higher risk for stroke as compared with a control cohort. A potent stroke prevention therapy reducing the risk of stroke by approximately 70-80% is primarily treatment with new oral anticoagulants (NOACs). The risk scores for stroke (CHA2DS2-VASc) and major bleeding (HAS-BLED) in patients with atrial fibrillation share common variables, so that patients with the highest stroke risk often carry a very high bleeding risk. A significant number of patients (ca. 20-30%) are, however, not eligible for long-term anticoagulation, e.g. because of a high bleeding risk. For this population there is an urgent need for alternative stroke prevention strategies, such as catheter-based percutaneous left atrial appendage closure. Current data about the efficiency and safety of this treatment as well as a discussion of ongoing recruitment for randomized studies are discussed in this review.
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Affiliation(s)
- C Skurk
- Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12003, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - J J Hartung
- Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12003, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
| | - D M Leistner
- Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12003, Berlin, Deutschland.,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland.,Berlin Institute of Health (BIH), Berlin, Deutschland
| | - U Landmesser
- Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12003, Berlin, Deutschland. .,Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland. .,Berlin Institute of Health (BIH), Berlin, Deutschland.
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27
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Chen S, Weise FK, Chun KRJ, Schmidt B. Antithrombotic strategies after interventional left atrial appendage closure: an update. Expert Rev Cardiovasc Ther 2018; 16:675-678. [PMID: 30095350 DOI: 10.1080/14779072.2018.1510316] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
INTRODUCTION Interventional left atrial appendage occlusion (LAAO) has emerged as a valid alternative to oral anticoagulation (OAC) therapy for the prevention of ischemic stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). Areas covered: Antithrombotic therapy following interventional LAAO is critical in balancing the risk of thromboembolism and bleeding during the endothelialization of the implanted devices. In this article, the most recent clinical trials are reviewed and the current real-world antithrombotic strategies following LAAO device implantation are discussed. Expert commentary: For patients eligible for OAC and receiving a Watchman device, the most solid scientific evidence exists for warfarin plus aspirin for 45 days followed by dual antiplatelet therapy (DAPT) for 6 months and a lifelong aspirin therapy. In real-world most patients are being treated with DAPT for 3-6 months. Alternatively, the Watchman was approved for 3 months of novel OAC (NOAC) therapy in conjunction with aspirin. For all other devices, DAPT for 1-6 months has been used in the vast majority of cases. Considering major bleeding as the predominant complication following LAAO, evidence suggests that short-term DAPT (6 weeks) or single antiplatelet therapy using aspirin may be a viable option.
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Affiliation(s)
- Shaojie Chen
- a Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main , Frankfurt am Main , Germany
| | - Felix K Weise
- a Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main , Frankfurt am Main , Germany
| | - K R Julian Chun
- a Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main , Frankfurt am Main , Germany
| | - Boris Schmidt
- a Cardioangiologisches Centrum Bethanien (CCB) Frankfurt am Main , Frankfurt am Main , Germany
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28
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Landmesser U, Tondo C, Camm J, Diener HC, Paul V, Schmidt B, Settergren M, Teiger E, Nielsen-Kudsk JE, Hildick-Smith D. Left atrial appendage occlusion with the AMPLATZER Amulet device: one-year follow-up from the prospective global Amulet observational registry. EUROINTERVENTION 2018; 14:e590-e597. [DOI: 10.4244/eij-d-18-00344] [Citation(s) in RCA: 98] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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