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Hozman M, Herman D, Zemanek D, Fiser O, Vrba D, Poloczek M, Varvarovsky I, Obona P, Pokorny T, Osmancik P. Transseptal puncture in left atrial appendage closure guided by 3D printing and multiplanar CT reconstruction. Catheter Cardiovasc Interv 2023; 102:1331-1340. [PMID: 37855202 DOI: 10.1002/ccd.30867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/28/2023] [Accepted: 10/05/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND The presented study investigates the application of bi-arterial 3D printed models to guide transseptal puncture (TSP) in left atrial appendage closure (LAAC). AIMS The objectives are to (1) test the feasibility of 3D printing (3DP) for TSP guidance, (2) analyse the distribution of the optimal TSP locations, and (3) define a CT-derived 2D parameter suitable for predicting the optimal TSP locations. METHODS Preprocedural planning included multiplanar CT reconstruction, 3D segmentation, and 3DP. TSP was preprocedurally simulated in vitro at six defined sites. Based on the position of the sheath, TSP sites were classified as optimal, suboptimal, or nonoptimal. The aim was to target the TSP in the recommended position during the procedure. Procedure progress was assessed post hoc by the operator. RESULTS Of 68 screened patients, 60 patients in five centers (mean age of 74.68 ± 7.64 years, 71.66% males) were prospectively analyzed (3DP failed in one case, and seven patients did not finally undergo the procedure). In 55 patients (91.66%), TSP was performed in the optimal location as recommended by the 3DP. The optimal locations for TSP were postero-inferior in 45.3%, mid-inferior in 45.3%, and antero-inferior in 37.7%, with a mean number of optimal segments of 1.34 ± 0.51 per patient. When the optimal TSP location was achieved, the procedure was considered difficult in only two (3.6%) patients (but in both due to complicated LAA anatomy). Comparing anterior versus posterior TSP in 2D CCT, two parameters differed significantly: (1) the angle supplementary to the LAA ostium and the interatrial septum angle (160.83° ± 9.42° vs. 146.49° ± 8.67°; p = 0.001), and (2) the angle between the LAA ostium and the mitral annulus (95.02° ± 3.73° vs. 107.38° ± 6.76°; p < 0.001), both in the sagittal plane. CONCLUSIONS In vitro TSP simulation accurately determined the optimal TSP locations for LAAC and facilitated the procedure. More than one-third of the optimal TSP sites were anterior.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Dalibor Herman
- Cardiocenter, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - David Zemanek
- Second Department of Internal Medicine, Charles University, Prague, Czech Republic
| | - Ondrej Fiser
- Department of Biomedical Technology, Faculty of Biomedical Engineering, CTU in Prague, Prague, Czech Republic
| | - David Vrba
- Department of Biomedical Technology, Faculty of Biomedical Engineering, CTU in Prague, Prague, Czech Republic
| | - Martin Poloczek
- Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine of Masaryk University, Brno, Czech Republic
| | | | - Peter Obona
- Cardiocenter, University Hospital Nitra, Nitra, Slovakia
| | - Tomas Pokorny
- Department of Biomedical Technology, Faculty of Biomedical Engineering, CTU in Prague, Prague, Czech Republic
| | - Pavel Osmancik
- Cardiocenter, Third Faculty of Medicine, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
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2
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Neurologic complications of atrial fibrillation: Pharmacologic and interventional approaches to stroke prevention. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:143-149. [PMID: 33632432 DOI: 10.1016/b978-0-12-819814-8.00012-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation is a common cardiac arrhythmia that carries a risk of stroke. This is commonly stratified with the CHA2DS2-VASc score. Stroke risk can be reduced with anticoagulants or with interventions to close the left atrial appendage, the most common source of left atrial thrombi. While warfarin has been traditionally used as the only oral anticoagulant available, there are several direct oral anticoagulants that compare favorably with respect to both stroke and bleeding risk in randomized controlled trials. Multiple interventional options exist to close the left atrial appendage, but the Watchman device is the only one that compares favorably with warfarin in randomized controlled trials.
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3
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Obeid S, Nietlispach F, Meier B. Plugs for left atrial appendage occlusion: an overview of available devices. Expert Rev Med Devices 2020; 17:1145-1154. [PMID: 33054430 DOI: 10.1080/17434440.2020.1837621] [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: 10/23/2022]
Abstract
INTRODUCTION Approximately one-third of all ischemic strokes and the ensuing health and economic burden can be attributed to the presence of atrial fibrillation (AF). The global prevalence of AF continues to rise, thus making it by far the most common diagnosed cardiac arrhythmia. Percutaneous left atrial appendage (LAA) occlusion or obliteration has been developed to protect from the occurrence of stroke in patients with nonvalvular AF. AREAS COVERED We address the characteristics and techniques for implantation as well as some clinical registries and randomized trials of the various catheter-based devices for the occlusion of the LAA that are either currently available or in the clinical evaluation stage. EXPERT OPINION Over less than 2 decades, LAA occlusion progressed from being a concept applied in a few specialized centers to a globally recognized procedure implemented in numerous hospitals as part of daily interventional practice. The respective devices are to date safer and easier to deploy than initially. Periprocedural and postprocedural complications will continue to decrease as already evident from prospective randomized trials and registries. Although current indications focus on patients with nonvalvular AF and contraindications for oral anticoagulation, it is all but certain that the future will bring a widening in the spectrum of indications, applicability, and usage of these devices.
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Affiliation(s)
- Slayman Obeid
- Cardiology, Kantonsspital Aarau , Aarau, Switzerland
| | - Fabian Nietlispach
- Cardiovascular Center Zurich, Hirslanden Klinik Im Park , Zurich, Switzerland
| | - Bernhard Meier
- Cardiology, University Hospital Bern , Bern, Switzerland
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Boccuzzi GG, Montabone A, D'Ascenzo F, Colombo F, Ugo F, Muraglia S, De Backer O, Nombela-Franco L, Meincke F, Mazzone P. Cerebral protection in left atrial appendage closure in the presence of appendage thrombosis. Catheter Cardiovasc Interv 2020; 97:511-515. [PMID: 32808741 DOI: 10.1002/ccd.29161] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/21/2020] [Accepted: 07/09/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Presence of thrombus in the left atrial appendage (LAA) remains a severe contraindication to the percutaneous left atrial appendage closure procedure (LAAC), due to increased embolic risk. Recently, the experience developed in cerebral protection device in transcatheter aortic valve implantation (TAVI) procedure was translated in LAAC to address this issue. AIM To evaluate efficacy and safety of Sentinel cerebral protection system (CPS) in supporting LAAC in real-world patient with persistent LAA thrombus. METHODS AND RESULTS The study retrospectively enrolled consecutive patients with non-valvular atrial fibrillation (NVAF) and thrombus in LAA who underwent LAAC supported by Sentinel CPS in seven European high-volume centres. Twenty-seven patients were included with a median age of 69.1 ± 9.7 years old, with median CHA2 DS2 -VASc and HAS-BLEED scores 3 [2-5] and 3 [2.75-4], respectively. Technical and procedural success was achieved in all patients. No periprocedural TIA, stroke, or supra-aortic trunks dissection was recorded. CONCLUSIONS In this multicenter registry, LAAC supported by Sentinel CPS in patients with LAA persistent thrombus seems to be a safe and efficacious treatment.
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Affiliation(s)
| | - Andrea Montabone
- Division of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | - Fabrizio D'Ascenzo
- Città della Scienza e della Salute, Department of Cardiology, University of Turin, Turin, Italy
| | | | - Fabrizio Ugo
- Division of Cardiology, San Giovanni Bosco Hospital, Turin, Italy
| | | | - Ole De Backer
- Interventional Cardiology, The Heart Center-Rigshospitalet, Copenhagen, Denmark
| | | | - Felix Meincke
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Patrizio Mazzone
- Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy
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5
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Häusler KG, Endres M, Landmesser U. [Left atrial appendage occlusion in patients with nonvalvular atrial fibrillation : Present evidence, ongoing studies, open questions]. Med Klin Intensivmed Notfmed 2020; 115:107-113. [PMID: 30483820 DOI: 10.1007/s00063-018-0500-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/18/2018] [Accepted: 07/29/2018] [Indexed: 01/14/2023]
Abstract
About every fifth ischemic stroke is caused by atrial fibrillation. Oral anticoagulation is highly effective in secondary stroke prevention, but a relevant portion of patients with atrial fibrillation is not (permanently) anticoagulated for a variety of reasons. Based on present evidence, no general recommendation can be given for left atrial appendage occlusion in patients with nonvalvular atrial fibrillation. However, left atrial appendage occlusion is a treatment option after severe anticoagulation-related bleeding, if the cause of bleeding is not treatable. Left atrial appendage occlusion is critical in patients with a relative contraindication for oral anticoagulation or lack of adherence to given medication. It seems to be important that further randomized studies confirm a benefit of left atrial appendage occlusion in selected patients with nonvalvular atrial fibrillation. In addition, it is vital to clarify whether discontinuation of antiplatelets is feasible after catheter-based left atrial appendage occlusion, as antiplatelets are associated with a risk of bleeding. Within this review article, we discuss present evidence, gaps of knowledge and provide an overview on ongoing clinical studies. In addition, we summarize the design of the CLOSURE-AF study. This randomized multicenter study will start recruitment soon and is funded by the German Center for Cardiovascular Research e. V.
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Affiliation(s)
- K G Häusler
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland.
- Kompetenznetz Vorhofflimmern e. V., Münster, Deutschland.
| | - M Endres
- Klinik und Poliklinik für Neurologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203, Berlin, Deutschland
- Centrum für Schlaganfallforschung Berlin, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, Berlin, Deutschland
- Deutsches Zentrum für Neurodegenerative Erkrankungen (DZNE), Standort Berlin, Berlin, Deutschland
- Excellence Cluster NeuroCure, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Berliner Institut für Gesundheitsforschung, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - U Landmesser
- Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Berlin, Berlin, Deutschland
- Berliner Institut für Gesundheitsforschung, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
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6
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Abstract
Atrial fibrillation is the most frequent cardiac arrhythmia worldwide, causing approximately 20% of all ischemic strokes. Therefore, oral anticoagulation is recommended in patients with atrial fibrillation with at least a moderate risk of stroke; however, there is a significant proportion of patients who cannot undergo long-term oral anticoagulation. As the left atrial appendage is of major relevance for atrial fibrillation-induced thrombus formation, catheter-based or surgical closure of the left atrial appendage appears to be a promising therapeutic option. Large registry studies including patients with catheter-based left atrial appendage closure have proven its effectiveness and a decreasing procedure-related complication rate. This review article summarizes the current knowledge and introduces major ongoing randomized studies, which will investigate the impact of left atrial appendage closure on stroke prevention. The authors hope that the results of the randomized CLOSURE AF trial, which is funded by the German Center for Cardiovascular Research e. V. and is now recruiting patients in Germany, will help to solve many of the currently prevalent clinical questions.
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Affiliation(s)
- K G Häusler
- Neurologische Klinik und Poliklinik, Universitätsklinikum Würzburg, Josef-Schneider-Str. 11, 97080, Würzburg, Deutschland.
| | - U Landmesser
- Medizinische Klinik für Kardiologie, Charité - Universitätsmedizin Berlin, Hindenburgdamm 30, 12203, Berlin, Deutschland
- Berliner Institut für Gesundheitsforschung, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Standort Berlin, Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Berlin, Deutschland
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7
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Okamoto M, Neuss M, Krimnitz J, Butter C. Technical aspects of a successful transvascular retrieval of an acutely dislodged WaveCrest® left atrial appendage occluder. Catheter Cardiovasc Interv 2019; 94:285-288. [PMID: 31215161 DOI: 10.1002/ccd.28365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 04/29/2019] [Accepted: 05/28/2019] [Indexed: 11/11/2022]
Abstract
Percutaneous left atrial appendage (LAA) closure is an alternative therapy in patients with atrial fibrillation who are not suitable for anticoagulation. However, device embolization is one of the notable complications which inevitably requires catheter or surgical retrieval. In addition to previously reported Watchman® or AMULET® occluder embolization, here we report the first case of a WaveCrest® occluder dislodgement which was successfully removed by transcatheter technique. Instead of using the well-known snaring technique, we used a "wiring and ballooning technique" for retrieval. Considering its specific architecture without having hooks or feet where suitable for grasping, this technique is an option for retrieving WaveCrest® devices.
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Affiliation(s)
- Maki Okamoto
- Department of Cardiology, Heart Center Brandenburg, Bernau, Germany.,Brandenburg Medical School (MHB) Theodor Fontane, Neuruppin, Germany
| | - Michael Neuss
- Department of Cardiology, Heart Center Brandenburg, Bernau, Germany.,Brandenburg Medical School (MHB) Theodor Fontane, Neuruppin, Germany
| | - Juliane Krimnitz
- Department of Cardiology, Heart Center Brandenburg, Bernau, Germany.,Brandenburg Medical School (MHB) Theodor Fontane, Neuruppin, Germany
| | - Christian Butter
- Department of Cardiology, Heart Center Brandenburg, Bernau, Germany.,Brandenburg Medical School (MHB) Theodor Fontane, Neuruppin, Germany
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8
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Zhang H, Tang Z, Han Z, Zeng L, Wang C. Role of real time-three dimensional transesophageal echocardiography in left atrial appendage closure with LACBES ® devices. Exp Ther Med 2019; 17:1456-1462. [PMID: 30680028 DOI: 10.3892/etm.2018.7086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/22/2018] [Indexed: 11/06/2022] Open
Abstract
Catheter-based left atrial appendage closure (LAAC) has recently become an innovative strategy for preventing embolic events in patients with nonvalvular atrial fibrillation (AF). There is limited information on optimal sizing for LAAC with the recently developed LACBES® device. The aim of the present study was to assess the role of real time-three dimensional transesophageal echocardiography (RT-3D TEE) for LACBES® device selection during LAAC. A total of 22 patients with nonvalvular AF and indications for LAAC were enrolled in the study. All patients underwent LAAC with LACBES® devices. TEE was performed in all patients 3 days prior to the procedure, during the procedure, and 3 months and 1 year following the procedure. Interatrial septal puncture, exchange of the sheath and release of the device were performed under the guidance of RT-3D TEE. The LAA ostium and landing zone dimensions measured by RT-3D TEE were better correlated with the device size used for occlusion (r=0.60, P=0.003) than those measured with two dimensional TEE or LAA contrast angiography. There were no clinically significant residual shunts, pericardial effusion or tamponade following occlusion. All patients had the device well-seated and presented no evidence of closure-associated complications during the follow-up. No cases of peri-procedural stroke or mortality were observed during a mean follow-up period of 12 months. In conclusion, RT-3D TEE is a reliable and effective imaging modality to guide LAAC using LACBES® devices in patients with nonvalvular AF at high risk of cardioembolic events.
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Affiliation(s)
- Huili Zhang
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, P.R. China
| | - Zhengde Tang
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, P.R. China
| | - Zhihua Han
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, P.R. China
| | - Lefeng Zeng
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, P.R. China
| | - Changqian Wang
- Department of Cardiology, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai 200011, P.R. China
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Menne MF, Schrickel JW, Nickenig G, Al‐Kassou B, Nelles D, Schmitz‐Rode T, Steinseifer U, De Backer O, Sedaghat A. Mechanical properties of currently available left atrial appendage occlusion devices: A bench‐testing analysis. Artif Organs 2019; 43:656-665. [DOI: 10.1111/aor.13414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/04/2018] [Accepted: 12/10/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Matthias F. Menne
- Institute of Applied Medical Engineering Helmholtz Institute, RWTH Aachen University Aachen Germany
| | - Jan W. Schrickel
- Med. Klinik und Poliklinik II—Kardiologie, Universitätsklinikum Bonn, Rheinische Friedrich‐Wilhelms‐Universität Bonn Bonn Germany
| | - Georg Nickenig
- Med. Klinik und Poliklinik II—Kardiologie, Universitätsklinikum Bonn, Rheinische Friedrich‐Wilhelms‐Universität Bonn Bonn Germany
| | - Baravan Al‐Kassou
- Med. Klinik und Poliklinik II—Kardiologie, Universitätsklinikum Bonn, Rheinische Friedrich‐Wilhelms‐Universität Bonn Bonn Germany
| | - Dominik Nelles
- Med. Klinik und Poliklinik II—Kardiologie, Universitätsklinikum Bonn, Rheinische Friedrich‐Wilhelms‐Universität Bonn Bonn Germany
| | - Thomas Schmitz‐Rode
- Institute of Applied Medical Engineering Helmholtz Institute, RWTH Aachen University Aachen Germany
| | - Ulrich Steinseifer
- Institute of Applied Medical Engineering Helmholtz Institute, RWTH Aachen University Aachen Germany
- Monash Institute of Medical Engineering and Department of Mechanical and Aerospace Engineering Monash University Melbourne Australia
| | | | - Alexander Sedaghat
- Med. Klinik und Poliklinik II—Kardiologie, Universitätsklinikum Bonn, Rheinische Friedrich‐Wilhelms‐Universität Bonn Bonn Germany
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10
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Rillig A, Bellmann B, Skurk C, Leistner DM, Haeusler KG, Lin T, Geran R, Koehler L, Guttmann S, Steffens D, Kasner M, Jakob P, Tscholl V, Roser M, Lenz K, Villringer K, Park JW, Fiebach JB, Landmesser U. Left atrial appendage angiography is associated with the incidence and number of magnetic resonance imaging-detected brain lesions after percutaneous catheter-based left atrial appendage closure. Heart Rhythm 2018; 15:3-8. [PMID: 29304951 DOI: 10.1016/j.hrthm.2017.11.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Percutaneous catheter-based left atrial appendage closure (LAAC) is a procedure being increasingly performed in patients with atrial fibrillation and high bleeding risk. OBJECTIVE The purpose of this study was to evaluate the incidence of magnetic resonance imaging (MRI)-detected acute brain lesions (ABLs) as well as potential changes in neurocognitive function after percutaneous LAAC in patients with atrial fibrillation. METHODS Brain MRI at 3 T was performed within 24 hours before and after LAAC along with neurologic (National Institutes of Health Stroke Scale [NIHSS] score) and cognitive (Montreal Cognitive Assessment [MoCA] test) assessment. Acquired MRI sequences included high-resolution diffusion-weighted imaging as well as fluid-attenuated inversion recovery. RESULTS Successful device implantation was achieved in all 23 patients (age 74.1 ± 10.5 years; 16 male) using the Amulet (n = 18), Occlutech (n = 3), or LAmbre (n = 2) device. Thirty-seven ABLs were detected by MRI in 12 of 23 patients (52%) after LAAC. The number of periprocedural LAA angiographies was significantly higher in patients with ABL than in those without ABL (1.67 ± 0.65 vs 1.18 ± 0.41; P = .048) and was associated with a higher number of ABL (ρ = 0.615; P = .033). Compared to pre-LAAC assessment, post-LAAC MoCA and NIHSS scores revealed similar results. After LAAC, MoCA test (mean 24.1 ± 4.6 vs 23.2 ± 4.6; P = .09) and NIHSS score (mean 1.0 ± 1.7 vs 1.2 ± 1.8; P = .1) were similar between patients with and those without ABL, respectively. CONCLUSION MRI-detected ABLs are commonly observed after percutaneous LAAC. The number of LAA angiographies is significantly associated with the number of ABLs; however, the clinical implications of ABL have yet to be determined.
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Affiliation(s)
- Andreas Rillig
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany.
| | - Barbara Bellmann
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Carsten Skurk
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - David Manuel Leistner
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany; Department of Neurology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Tina Lin
- Heartcare Victoria, Melbourne, Australia
| | - Rohat Geran
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Luzie Koehler
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Selma Guttmann
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Daniel Steffens
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Mario Kasner
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Philipp Jakob
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Verena Tscholl
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Mattias Roser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Klaus Lenz
- Institute for Biometry and Clinical Epidemiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Jai-Wun Park
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany
| | - Ulf Landmesser
- Department of Cardiology, Charité-Universitätsmedizin Berlin, University Hospital, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; Deutsches Zentrum für Herz- und Kreislaufforschung (DZHK), Partner Site Berlin, Germany
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11
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Schellinger PD, Tsivgoulis G, Steiner T, Köhrmann M. Percutaneous Left Atrial Appendage Occlusion for the Prevention of Stroke in Patients with Atrial Fibrillation: Review and Critical Appraisal. J Stroke 2018; 20:281-291. [PMID: 30309224 PMCID: PMC6186917 DOI: 10.5853/jos.2018.02537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Accepted: 09/12/2018] [Indexed: 12/27/2022] Open
Abstract
The authors review the current status of percutaneous left atrial appendage (LAA) occlusion therapy in patients with atrial fibrillation with the goal to prevent ischemic stroke and systemic embolism and to reduce oral anticoagulation associated bleeding. While we cover the historical and also surgical background, and all tested devices, the main focus rests on the single currently U.S. Food and Drug Administration (FDA) approved LAA occluder, the WATCHMAN device, and its approval process. The authors also give a critical appraisal beyond the review of mere facts, trying to put the current data into perspective.
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Affiliation(s)
- Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Sciences Center, Memphis, TN, USA
| | - Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
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12
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Bergmann MW, Betts TR, Sievert H, Schmidt B, Pokushalov E, Kische S, Schmitz T, Meincke F, Stein KM, Boersma LVA, Ince H. Safety and efficacy of early anticoagulation drug regimens after WATCHMAN left atrial appendage closure: three-month data from the EWOLUTION prospective, multicentre, monitored international WATCHMAN LAA closure registry. EUROINTERVENTION 2018; 13:877-884. [PMID: 28606886 DOI: 10.4244/eij-d-17-00042] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIMS While LAA closure has recently been incorporated into both European and US guidelines for stroke prevention, uncertainties regarding post-procedural drug therapy so far limit its adoption. The aim of this analysis is to compare real-world outcome data stratified for the post-procedural drug regimen employed. METHODS AND RESULTS One thousand and five patients were implanted with a WATCHMAN device in the prospective EWOLUTION study at 47 centres; 73.5% of the patients were deemed contraindicated for long-term OAC therapy. Here we report on three-month data including the first follow-up TOE exam for 94% of the study population. Following LAA closure, patients received DAPT, VKA, NOAC, single antiplatelet or no therapy (60.3%, 15.4%, 10.9%, 7% and 6.5%, respectively). Device thrombus (2.6%), stroke (0.4%) and major bleeding SAE (2.6%) rates were low overall and did not vary by post-implantation medication strategy. Patients on NOAC had the lowest bleeding rate, without an increase in device thrombus or stroke rates. CONCLUSIONS LAA closure with the WATCHMAN device is feasible in patients with a relative or absolute contraindication to oral anticoagulation. Neither DAPT nor NOAC therapy leads to a significant increase in device thrombus, stroke or bleeding compared to the standard VKA regimen. Numerically, NOAC therapy had the lowest event rate.
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Menne MF, Schrickel JW, Nickenig G, Al-Kassou B, Nelles D, Schmitz-Rode T, Steinseifer U, Sedaghat A. Mechanical Performance of Two Left Atrial Appendage Occlusion Systems: In Vitro Comparison of Tug Force, Radial Force, Sealing and Deformation. Ann Biomed Eng 2018; 46:1337-1347. [DOI: 10.1007/s10439-018-2057-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/19/2018] [Indexed: 12/28/2022]
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Guérios ÊE, Chamié F, Montenegro M, Saad EB, Brito FSD, Caramori PA, Simões LC, Oliveira FRAD, Giuliano LC, Tavares CMDF. First results of the Brazilian Registry of Percutaneous Left Atrial Appendage Closure. Arq Bras Cardiol 2017; 109:440-447. [PMID: 29069203 PMCID: PMC5729780 DOI: 10.5935/abc.20170150] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 03/29/2017] [Indexed: 12/14/2022] Open
Abstract
Background Left atrial appendage closure (LAAC) is an effective alternative to oral
anticoagulation (OA) for the prevention of stroke in patients with
non-valvular atrial fibrillation (NVAF). Objective To present the immediate results and late outcomes of patients submitted to
LAAC and included in the Brazilian Registry of Percutaneous Left Atrial
Appendage Closure. Methods 91 patients with NVAF, high stroke risk (CHA2DS2VASc
score = 4.5 ± 1.5) and restrictions to OAC (HAS-BLED score = 3.6
± 1.0) underwent 92 LAAC procedures using either the Amplatzer
cardiac plug or the Watchman device in 11 centers in Brazil, between late
2010 and mid 2016. Results Ninety-six devices were used (1.04 device/procedure, including an additional
non-dedicated device), with a procedural success rate of 97.8%. Associated
procedures were performed in 8.7% of the patients. Complete LAAC was
obtained in 93.3% of the successful cases. In cases of incomplete closure,
no residual leak was larger than 2.5 mm. One patient needed simultaneous
implantation of 2 devices. There were 7 periprocedural major (5 pericardial
effusions requiring pericardiocentesis, 1 non-dedicated device embolization
and 1 coronary air embolism without sequelae) and 4 minor complications.
After 128.6 patient-years of follow-up there were 3 deaths unrelated to the
procedure, 2 major bleedings (one of them in a patient with an unsuccessful
LAAC), thrombus formation over the device in 2 cases (both resolved after
resuming OAC for 3 months) and 2 strokes (2.2%). Conclusions In this multicenter, real world registry, that included patients with NVAF
and high thromboembolic and bleeding risks, LAAC effectively prevented
stroke and bleeding when compared to the expected rates based on
CHA2DS2VASc and HASBLED scores for this
population. Complications rate of the procedure was acceptable considering
the beginning of the learning curve of most of the involved operators.
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Affiliation(s)
| | - Francisco Chamié
- Hospital dos Servidores do Estado do Rio de Janeiro, Rio de Janeiro, RJ - Brasil
| | - Márcio Montenegro
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro, RJ - Brasil
| | | | | | - Paulo Avancini Caramori
- Centro de Pesquisa Cardiovasculares do Hospital São Lucas da Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS - Brasil
| | - Luiz Carlos Simões
- Instituto Nacional de Cardiologia (INC - MS), Rio de Janeiro, RJ - Brasil
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Percutaneous Closure of Left Atrial Appendage affects Mid-Term Release of MR-proANP. Sci Rep 2017; 7:9028. [PMID: 28831085 PMCID: PMC5567360 DOI: 10.1038/s41598-017-08999-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/17/2017] [Indexed: 01/05/2023] Open
Abstract
The left atrial appendage (LAA) represents both a predisposing source of thrombus formation and of neuro-humoral haemostasis. This study aims to evaluate changes of biomarker expression before and after successful percutaneous closure of the LAA. Patients with atrial fibrillation and contraindication for oral anticoagulant therapy were enrolled. Blood samples were taken within 24 hours before (T1) and at least 6 months (mid-term) (T2) after successful implantation of LAA occlusion devices. Blood levels of high sensitivity troponin I and T (hsTnI, hsTnT), aminoterminal pro-brain natriuretic peptide (NT-proBNP) and mid-regional pro-atrial natriuretic peptide (MR-proANP) were evaluated at both time points. A total of 42 patients with successful percutaneous LAA closure were included. Median mid-term follow-up was of 183 days. HsTnT, hsTnI and NT-proBNP did not show any significant differences over time. Serum levels of MR-proANP increased significantly between immediate pre-intervention (T1: median = 245.7 pmol/l, IQR 155.8–361.3 pmol/l) and at mid-term follow-up (T2: median = 254 pmol/l, IQR 183.4–396.4 pmol/l) (p = 0.037). These results indicate, that percutaneous LAA closure affects neuro-humoral haemostasis by increasing MR-proANP serum levels at mid-term follow-up.
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Bergmann MW. LAA occluder device for stroke prevention: Data on WATCHMAN and other LAA occluders. Trends Cardiovasc Med 2017; 27:435-446. [PMID: 28461140 DOI: 10.1016/j.tcm.2017.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 03/10/2017] [Accepted: 03/20/2017] [Indexed: 01/01/2023]
Abstract
NOAC therapy has become the standard for stroke prevention in patients with atrial fibrillation. Yet some patients suffer extracranial bleeding events or have other reasons to seek non-pharmacologic stroke protection. LAA occlusion with the WATCHMAN device has been proven safe and effective for such patients and is now recommended in current guidelines for this patient group; other devices also seek approval.
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17
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Majunke N, Eplinius F, Gutberlet M, Moebius-Winkler S, Daehnert I, Grothoff M, Schürer S, Mangner N, Lurz P, Erbs S, Kirsch K, Schuler G, Sandri M. Frequency and clinical course of cerebral embolism in patients undergoing transcatheter left atrial appendage closure. EUROINTERVENTION 2017; 13:124-130. [DOI: 10.4244/eij-d-16-00776] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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Jalal Z, Iriart X, Dinet ML, Selly JB, Tafer N, Renou P, Sibon I, Thambo JB. Extending percutaneous left atrial appendage closure indications using the AMPLATZER™ Cardiac Plug device in patients with persistent left atrial appendage thrombus: The thrombus trapping technique. Arch Cardiovasc Dis 2016; 109:659-666. [DOI: 10.1016/j.acvd.2016.02.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 02/05/2016] [Accepted: 02/09/2016] [Indexed: 11/16/2022]
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Meincke F, Spangenberg T, Kreidel F, Frerker C, Virmani R, Ladich E, Kuck KH, Ghanem A. Rationale of cerebral protection devices in left atrial appendage occlusion. Catheter Cardiovasc Interv 2016; 89:154-158. [PMID: 27762092 DOI: 10.1002/ccd.26677] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/25/2016] [Accepted: 07/02/2016] [Indexed: 11/11/2022]
Abstract
AIMS Aims of this case-series were to assess the feasibility of cerebral protection devices in interventional left atrial appendage occlusion (iLAAO) procedures and to yield insight into the pathomorphological correlate of early, procedural cerebral embolization during iLAAO. METHODS AND RESULTS Five consecutive patients underwent iLLO flanked by the Sentinel CPS® (Claret Medical, Inc., Santa Rosa, CA) cerebral protection system. Placement and recapture of the Sentinel® device as well as the iLAAO were successful and safe in all cases. Histomorphometric analysis of the collected filters showed embolized debris in all patients. Acute thrombus was found in three patients, organizing thrombus in four. Interestingly, two patients had endocardial or myocardial tissue in their filters. CONCLUSIONS Cerebral protection during iLAAO with the Sentinel CPS® device is feasible. Furthermore, this dataset identifies the formation and embolization of thrombus and cardiac tissue as emboligeneic sources and potential future targets to reduce procedural complications. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Felix Meincke
- Department for Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | - Felix Kreidel
- Department for Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Christian Frerker
- Department for Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | | | - Karl-Heinz Kuck
- Department for Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Alexander Ghanem
- Department for Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany.,Medizinische Klinik II, Universitaetsklinikum Bonn, Germany
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Abstract
Patients with nonvalvular atrial fibrillation have a 4- to 5-fold increase in strokes and that rhythm may be responsible for 15% to 20% of all strokes, particularly in the elderly. In this setting, thrombus in the left atrial appendage has been found to be the source of stroke in 90% of cases. Although oral anticoagulants have been found effective in reducing stroke rates, for a variety of issues, they may only be used in 40% to 50% of patients at increased risk for stroke. Given pathophysiology of stroke, site-specific therapy directed at left atrial appendage occlusion has been now studied for stroke prevention, and one device is FDA approved (Watchman). A meta-analysis of 2 randomized clinical trials and 2 registries with this device documented the following: (1) patients receiving the device had significantly fewer hemorrhagic strokes (hazard ratio 0.22,
P
=0.004); (2) a significant reduction in cardiovascular or unexplained death (hazard ratio 0.48,
P
=0.004); (3) more ischemic strokes in the device group; however, when periprocedural events were excluded, the difference was not significant; and (4) a significant reduction in nonprocedural bleeding with the device (hazard ratio 0.51,
P
=0.006) versus control. At present, the only device approved in the United States is indicated in patients with nonvalvular atrial fibrillation with acceptable anatomy who are at increased risk for stroke and would be candidates for anticoagulation in whom there is concern about the risk/benefit ratio for chronic anticoagulation. Unresolved issues include optimal patient selection criteria, the role of devices in patients in whom anticoagulation is contraindicated, and the relative role of novel oral anticoagulants versus the device which has not been tested in randomized trials.
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Affiliation(s)
- David R. Holmes
- From the Mayo Clinic, Rochester, MN (D.R.H.); and Mount Sinai School of Medicine, New York, NY (V.Y.R.)
| | - Vivek Y. Reddy
- From the Mayo Clinic, Rochester, MN (D.R.H.); and Mount Sinai School of Medicine, New York, NY (V.Y.R.)
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Behnes M, Akin I, Sartorius B, Fastner C, El-Battrawy I, Borggrefe M, Haubenreisser H, Meyer M, Schoenberg SO, Henzler T. --LAA Occluder View for post-implantation Evaluation (LOVE)--standardized imaging proposal evaluating implanted left atrial appendage occlusion devices by cardiac computed tomography. BMC Med Imaging 2016; 16:25. [PMID: 27009279 PMCID: PMC4806427 DOI: 10.1186/s12880-016-0127-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 03/15/2016] [Indexed: 12/16/2022] Open
Abstract
Background A standardized imaging proposal evaluating implanted left atrial appendage (LAA) occlusion devices by cardiac computed tomography angiography (cCTA) has never been investigated. Methods cCTA datasets were acquired on a 3rd generation dual-source CT system and reconstructed with a slice thickness of 0.5 mm. An interdisciplinary evaluation was performed by two interventional cardiologists and one radiologist on a 3D multi-planar workstation. A standardized multi-planar reconstruction algorithm was developed in order to assess relevant clinical aspects of implanted LAA occlusion devices being outlined within a pictorial essay. Results The following clinical aspects of implanted LAA occlusion devices were evaluated within the most appropriate cCTA multi-planar reconstruction: (1) topography to neighboring structures, (2) peri-device leaks, (3) coverage of LAA lobes, (4) indirect signs of neo-endothelialization. These are illustrated within concise CT imaging examples emphasizing the potential value of the proposed cCTA imaging algorithm: Starting from anatomical cCTA planes and stepwise angulation planes perpendicular to the base of the LAA devices generates an optimal LAA Occluder View for post-implantation Evaluation (LOVE). Aligned true axial, sagittal and coronal LOVE planes offer a standardized and detailed evaluation of LAA occlusion devices after percutaneous implantation. Conclusions This pictorial essay presents a standardized imaging proposal by cCTA using multi-planar reconstructions that enables systematical follow-up and comparison of patients after LAA occlusion device implantation. Electronic supplementary material The online version of this article (doi:10.1186/s12880-016-0127-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Michael Behnes
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Ibrahim Akin
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Benjamin Sartorius
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Holger Haubenreisser
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Mathias Meyer
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Stefan O Schoenberg
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Thomas Henzler
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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LARIAT: The Endo-Epicardial Technique for Left Atrial Appendage Exclusion. CONTEMPORARY CARDIOLOGY 2016. [DOI: 10.1007/978-3-319-16280-5_14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kebernik J, Jose J, Abdel-Wahab M, Stöcker B, Geist V, Richardt G. Safety and Efficacy of Left Atrial Appendage Closure with the Amplatzer Cardiac Plug in Very High Stroke and Bleeding Risk Patients with Non-Valvular Atrial Fibrillation. Cardiol Ther 2015; 4:167-77. [PMID: 26563411 PMCID: PMC4675748 DOI: 10.1007/s40119-015-0053-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Indexed: 01/05/2023] Open
Abstract
Introduction Limited data exist on the outcomes after left atrial appendage closure (LAAC) with the Amplatzer™ Cardiac Plug (ACP; St. Jude Medical, Minneapolis, MN, USA) in patients with atrial fibrillation (AF) with very high stroke and bleeding risks, the subset expected to benefit most from this procedure. The objective of this study was to report clinical outcomes after LAAC with the ACP device in a very high stroke and bleeding risk cohort of patients with non-valvular AF and contraindications to oral anticoagulation (OAC). Methods LAAC using the ACP device was performed in 96 patients with AF who had median CHA2DS2-VASc and HAS-BLED scores of 5 and 3, respectively. Post-procedure, patients received dual antiplatelet therapy for 6 months. A transesophageal echocardiography (TEE) was scheduled at 6 months. Results Procedural success was 100%. Procedural-related complications occurred in 7.3% (pericardial effusion, 4.2%; thromboembolic events, 2.1%; device embolization, 1.0%). Additional thromboembolic events occurred in three patients during follow-up (92.7% follow-up). After 93.4 patient-years of follow-up, the annual rates of thromboembolic and major bleeding events were 3.2% and 1.1%, respectively. In those with TEE follow-up (70%), complete LAAC with no leaks was observed. Thrombus formation on the device was noted on TEE in two patients. Conclusion LAAC using the ACP device was associated with an acceptable low rate of embolic and bleeding events after a median follow-up of 9 months in a cohort of patients with AF who were amongst the highest stroke and bleeding risks reported so far in LAAC trials. Electronic supplementary material The online version of this article (doi:10.1007/s40119-015-0053-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Julia Kebernik
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany.
| | - John Jose
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany
| | - Mohamed Abdel-Wahab
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany
| | - Björn Stöcker
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany
| | - Volker Geist
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany
| | - Gert Richardt
- Heart Center, Segeberger Kliniken GmbH (Academic Teaching Hospital of the Universities of Kiel, Lübeck, and Hamburg), Bad Segeberg, Germany
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Bösche LI, Afshari F, Schöne D, Ewers A, Mügge A, Gotzmann M. Initial Experience With Novel Oral Anticoagulants During the First 45 Days After Left Atrial Appendage Closure With the Watchman Device. Clin Cardiol 2015; 38:720-4. [PMID: 26467851 DOI: 10.1002/clc.22478] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 09/10/2015] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The use of oral anticoagulation or dual antiplatelet therapy (DAPT) is recommended within the first 45 days after left atrial appendage (LAA) closure using the Watchman device because of incomplete device endothelialization. This study reports for the first time the feasibility of novel oral anticoagulants (NOAC) in these patients. HYPOTHESIS NOAC therapy is safe and effective after LAA closure. METHODS Interventional LAA closure was performed successfully in 45 patients. Of these, 18 patients received NOAC during the first 45 days after implantation and 27 patients received DAPT. Transesophageal echocardiography was conducted 45 days after implantation. The primary study endpoint was abnormal thrombus apposition 45 days after implantation. Secondary study endpoints were death from any cause, major adverse cardiac and cerebrovascular events (MACCE), and major bleedings. RESULTS After 45 days, transesophageal echocardiography revealed no abnormal thrombus apposition. During a follow-up of 417 ± 323 days, 7 patients died. No stroke or transient ischemic attack occurred. Nonfatal myocardial infarction occurred in 1 patient. There was a nonsignificant trend for lower all-cause mortality (P = 0.159) and occurrence of MACCE (P = 0.096) in the NOAC group compared with the DAPT group. Overall, 6 patients suffered from a major bleeding (NOAC, n = 3; DAPT, n = 3). In NOAC group, major bleedings (at day 205, 688, and 736) occurred long after termination of NOAC therapy. There was no significant difference in the frequency of major bleedings in different groups. CONCLUSIONS Our pilot study suggests that NOAC therapy within the first 45 days after interventional LAA closure is safe and effective.
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Affiliation(s)
- Leif I Bösche
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Faegheh Afshari
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Dominik Schöne
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Aydan Ewers
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Andreas Mügge
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
| | - Michael Gotzmann
- Department of Cardiology and Angiology, Bergmannsheil, Ruhr-University Bochum, Bochum, Germany
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Tzikas A. Real World Outcomes of Left Atrial Appendage Occlusion. Interv Cardiol 2015; 10:109-111. [PMID: 29588685 PMCID: PMC5808629 DOI: 10.15420/icr.2015.10.2.109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 04/20/2015] [Indexed: 01/28/2023] Open
Abstract
Percutaneous left atrial appendage occlusion (LAAO) is a device-based therapy for the prevention of stroke in patients with non-valvular atrial fibrillation (AF). Recently, the Watchman device (Boston Scientific, St Paul, MN, US) was approved in the US by the Food and Drug Administration (FDA) based on the results of two randomised clinical trials that evaluated LAAO in patients eligible for oral anticoagulation (OAC) therapy. However, in real-word clinical practice LAAO is typically offered to patients ineligible for OAC therapy, as they appear to have limited treatment options and consequently worse prognosis. Although LAAO has shown favourable clinical outcomes in OAC-ineligible patients in single or multicentre observational studies, these results need to be confirmed in randomised clinical trials.
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27
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Parashar A, Tuzcu EM, Kapadia SR. Cardiac Plug I and Amulet Devices: Left Atrial Appendage Closure for Stroke Prophylaxis in Atrial Fibrillation. J Atr Fibrillation 2015; 7:1236. [PMID: 27957168 DOI: 10.4022/jafib.1236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/20/2015] [Accepted: 04/22/2015] [Indexed: 12/15/2022]
Abstract
Percutaneous left atrial appendage (LAA) occlusion has emerged as an exciting and effective modality for stroke prophylaxis in patients with non-valvular atrial fibrillation who are deemed too high risk for anticoagulation with warfarin or newer anticoagulants. The Amplatzer devices have been used in LAA occlusion for more than a decade, starting with off label use of an atrial septal occluder device for LAA occlusion. This was followed by introduction of a dedicated Amplatzer cardiac plug (ACP) 1 for LAA occlusion, and more recently, the second generation Amulet device, with reported better stability enhancing features, has been introduced. Both these devices are widely used outside the United States, however in the US only the WATCHMAN device has been FDA approved. Unlike the WATCHMAN device, where the evidence is continuously building as the data from two pivotal randomized controlled trials are emerging, most of the evidence for ACP devices is from pooled multicenter registry data. In this article, we review the device design, implantation techniques and the most recently published evidence for both the Amplatzer cardiac plug 1 and the newer Amulet device. Our goal is to summarize the most recent literature and discuss the current role of the Amplatzer devices in the exciting and rapidly growing field of percutaneous LAA occlusion.
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Affiliation(s)
- Akhil Parashar
- Medicine Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - E Murat Tuzcu
- Sones Cardiac Catheterization Laboratories, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Samir R Kapadia
- Sones Cardiac Catheterization Laboratories, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH
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Abstract
Atrial fibrillation is associated with a markedly increased risk of thromboembolic stroke. At present, lifelong antithrombotic therapy with warfarin or a novel oral anticoagulant is indicated for prophylaxis in the majority of patients. Left atrial appendage occlusion devices have been developed as an alternative to these agents, aiming to avoid issues around consistency of anticoagulation, bleeding risk, and drug-related side effects. The best evidence is available for Boston Scientific's WATCHMAN device. The safety and efficacy of WATCHMAN and other similar devices have been questioned, although the increasing body of evidence supports a role in selected settings. A recently updated randomized controlled trial of WATCHMAN (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation [PROTECT-AF]) demonstrates its noninferiority to warfarin and suggests an advantage in terms of functional outcome for patients, with superior net clinical benefit 6 to 9 months after starting treatment. The procedural risk associated with device implantation remains substantial, although improving device design and increasing operator experience means that this should decrease in the future. As the body of data and overall experience around WATCHMAN grow, it may come to be recognized as the best option in selected patients.
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Affiliation(s)
- George Couch
- Bye-Fellow in Pathology, Downing College , Cambridge , UK
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