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Kotta PA, Nambi V, Misra A, Afshar H, Chelu MG, Nasir K, Abramov D, Khan Minhas AM. Association between neighborhood household income and inpatient atrial fibrillation outcomes. Heart Rhythm 2024:S1547-5271(24)00203-0. [PMID: 38382688 DOI: 10.1016/j.hrthm.2024.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/22/2024] [Accepted: 02/08/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND The impact of socioeconomic status on the clinical outcomes of patients admitted to the hospital for atrial fibrillation (AF) is not well described. OBJECTIVE The purpose of this study was to determine the association between median neighborhood household income (mNHI) and clinical outcomes among patients admitted to the hospital for AF. METHODS We retrospectively analyzed primary AF hospitalizations from the United States National Inpatient Sample between 2016 and 2020. The analyzed sample was divided into quartiles based on the mNHI in the zip code of the patient's residence. The lowest quartile was used as the reference category. Study outcomes included inpatient procedure utilization (ablation, cardioversion, percutaneous left atrial appendage closure), length of stay, cost, mortality, and disposition. Weighted multivariable logistic and linear regression, adjusting for multiple patient and hospital-level characteristics, was performed. RESULTS Patients in the highest mNHI quartile had lower comorbidity burden, lower in-hospital mortality (odds ratio [OR] 0.78; 95% confidence interval [CI] 0.7-0.87; P <.001), lower discharges to care facility (OR 0.86; 95% CI 0.83-0.9; P <.001), shorter length of stay (adjusted mean difference -0.26; 95% CI -0.30 to -0.22; P <.001), higher procedure utilization, and higher health care costs ($12,124 vs $10,018) compared to the lowest mNHI quartile patients. CONCLUSION We identified significantly higher in-hospital mortality and lower procedural/resource utilization in patients living in lower-income neighborhoods compared to higher-income neighborhoods. Further research is needed to better understand the drivers of these disparities and the strategies to improve health care disparities between socioeconomic groups.
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Affiliation(s)
- Prasanti A Kotta
- Baylor College of Medicine, Department of Internal Medicine, Houston, Texas.
| | - Vijay Nambi
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Arunima Misra
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Hamid Afshar
- Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Section of Cardiology, Houston, Texas
| | - Mihail G Chelu
- Baylor College of Medicine, Department of Internal Medicine, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas; Texas Heart Institute at Baylor St. Luke's Medical Center, Houston, Texas
| | - Khurram Nasir
- Houston Methodist DeBakey Heart & Vascular Center, Section of Cardiology, Houston, Texas
| | - Dmitry Abramov
- Loma Linda, University Health, Department of Cardiology, Loma Linda, California
| | - Abdul Mannan Khan Minhas
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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Sylvester CB, Patel V, Ghanta RK, Loor G. Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery. Cardiovasc Drugs Ther 2023; 37:1011-1019. [PMID: 36550349 DOI: 10.1007/s10557-022-07415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.
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Affiliation(s)
- Christopher B Sylvester
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX, USA
| | - Vivek Patel
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Gabriel Loor
- Michael E. DeBakey Department of Surgery, Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX, USA.
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He YG, Yang SH, Xu L, Wang Y, Qin XT, Chen PP, Zhao YJ. The Effect of Peri-Device Leaks on Ischaemic Stroke/Transient Ischaemic Attack/Systemic Embolism after Left Atrial Appendage Closure: A Systematic Review and Meta-Analysis. Cardiology 2023; 148:581-592. [PMID: 37459844 DOI: 10.1159/000532019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 07/10/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a safe and effective method for preventing embolic events in patients with non-valvular atrial fibrillation. However, peri-device leaks (PDLs) are sometimes unavoidable. Controversy exists regarding whether PDLs lead to embolic events. OBJECTIVES This study aimed to explore the association between PDLs and embolic events, including ischaemic stroke, transient ischaemic attacks (TIAs), and systemic embolism (SE). METHODS We conducted a systematic search of the PubMed, Web of Science, MEDLINE, and Cochrane Library databases for studies published up to September 25, 2022, to compare the rate of ischaemic stroke/TIA/SE between the PDL group and the non-PDL group after LAAC. RESULTS Thirteen studies comprising 54,405 patients were included in the meta-analysis. The PDL group detected by transoesophageal echocardiography (TEE) had a significantly higher rate of ischaemic stroke/TIA/SE than the non-PDL group (OR: 1.20, 95% CI: 1.08-1.33, p = 0.0009). However, no difference in ischaemic stroke/TIA/SE was found between the PDL and non-PDL subgroups of the cardiac computed tomography angiography (CCTA) group (OR: 1.12, 95% CI: 0.51-2.50, p = 0.77). CCTA and TEE showed different rates of PDL detection, with the CCTA group having a higher rate of PDL detection (p < 0.0001), especially for trivial leaks. CONCLUSIONS PDL detected by TEE increases the risk of embolic events after LAAC. However, no association was found between PDL and ischaemic stroke/TIA/SE in the CCTA group, which showed a higher rate of PDL detection than TEE, particularly for trivial leaks. In the future, CCTA may be used to explore the relationship between PDL size and ischaemic stroke/TIA/SE.
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Affiliation(s)
- Yin-Ge He
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China,
| | - Shao-Hua Yang
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Liang Xu
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Yan Wang
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Xu-Tan Qin
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Pan-Pan Chen
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
| | - Yu-Jie Zhao
- Department of Cardiology, Zhengzhou No. 7 People's Hospital, Zhengzhou, China
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Lee RJ, Hanke T. The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture). Card Electrophysiol Clin 2023; 15:201-213. [PMID: 37076232 DOI: 10.1016/j.ccep.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.
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Affiliation(s)
- Randall J Lee
- Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143, USA.
| | - Thorsten Hanke
- Department of Cardiovascular Surgery, ASKLEPIOS Klinikum Harburg, Abteilung Herzchirurgie, Eißendorfer Pferdeweg 52, 21075 Hamburg, Germany
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Rozen G, Margolis G, Marai I, Roguin A, Rahamim E, Planer D, Heist EK, Amir O, Tahiroglu I, Ruskin J, Mansour M, Elbaz-Greener G. Left atrial appendage exclusion in atrial fibrillation. Front Cardiovasc Med 2022; 9:949732. [PMID: 36176999 PMCID: PMC9513198 DOI: 10.3389/fcvm.2022.949732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 08/05/2022] [Indexed: 11/13/2022] Open
Abstract
Although oral anticoagulants (OACs) are first-line therapy for stroke prevention in patients with atrial fibrillation (AF), some patients cannot be treated with OACs due to absolute or relative contraindications. Left atrial appendage (LAA) exclusion techniques have been developed over the years as a therapeutic alternative for stroke prevention. In this paper, we review the evolution of surgical techniques, employed as an adjunct to cardiac surgery or as a stand-alone procedure, as well as the recently introduced and widely utilized percutaneous LAA occlusion techniques. Until recently, data on surgical LAAO were limited and based on non-randomized studies. We focus on recently published randomized data which strongly support an add-on surgical LAAO in eligible patients during cardiac surgery and could potentially change current practice guidelines. In recent years, the trans-catheter techniques for LAA occlusion have emerged as another, less invasive alternative for patients who cannot tolerate oral anticoagulation. We review the growing body of evidence from prospective studies and registries, focusing on the two systems which are in widespread clinical use nowadays: the Watchman and Amulet type devices. These data show favorable results for both Watchman and Amulet devices, setting them as an important tool in our arsenal for stroke reduction in AF patients, especially in those who have contraindications for OACs. A better understanding of the different therapeutic alternatives, their specific benefits, and downfalls in different patient populations can guide us in tailoring the optimal therapeutic approach for stroke reduction in our AF patients.
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Affiliation(s)
- Guy Rozen
- Cardiovascular Center, Tufts Medical Center, Boston, MA, United States
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- *Correspondence: Guy Rozen
| | - Gilad Margolis
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Ibrahim Marai
- Division of Cardiovascular Medicine, Baruch Padeh Medical Center, The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Ariel Roguin
- Cardiology Division, Hillel Yaffe Medical Center, Hadera, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Eldad Rahamim
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - David Planer
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Edwin Kevin Heist
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilgar Tahiroglu
- Department of Cardiology, Baku Health Center University, Baku, Azerbaijan
| | - Jeremy Ruskin
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Moussa Mansour
- Cardiac Arrhythmia Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Gabby Elbaz-Greener
- Department of Cardiology, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Lee RJ, Hanke T. The Strengths and Weaknesses of Left Atrial Appendage Ligation or Exclusion (LARIAT, AtriaClip, Surgical Suture). Interv Cardiol Clin 2022; 11:205-217. [PMID: 35361465 DOI: 10.1016/j.iccl.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Left atrial appendage (LAA) epicardial exclusion has been associated with addressing 2 potential deleterious consequences attributed to the LAA, namely, thrombus formation and an arrhythmogenic contributor in advanced forms of atrial fibrillation. With more than 60 years of history, the surgical exclusion of the LAA has been firmly established. Numerous approaches have been used for surgical LAA exclusion including surgical resections, suture ligation, cutting and non-cutting staples, and surgical clips. Additionally, a percutaneous epicardial LAA ligation approach has been developed. A discussion of the various epicardial LAA exclusion approaches and their efficacy will be discussed, along with the salient beneficial affects on LAA thrombus formation, LAA electrical isolation and neuroendocrine homeostasis.
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Affiliation(s)
- Randall J Lee
- Cardiac Electrophysiology, University of California, San Francisco, 500 Parnassus Avenue, Box 1354, San Francisco, CA 94143, USA.
| | - Thorsten Hanke
- Department of Cardiovascular Surgery, ASKLEPIOS Klinikum Harburg, Abteilung Herzchirurgie, Eißendorfer Pferdeweg 52, 21075 Hamburg, Germany
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7
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Bartus K, Kanuri SH, Litwinowicz R, Ali Elbey M, Natorska J, Zabczyk M, Bartus M, Kapelak B, Gopinnathannair R, Garg J, Turagam MK, Malecki MT, Lee RJ, Lakkireddy D. Long Term Impact of Epicardial Left Atrial Appendage Ligation on Systemic Hemostasis: LAA HOMEOSTASIS-2. J Clin Med 2022; 11:1495. [PMID: 35329819 DOI: 10.3390/jcm11061495] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/28/2022] [Accepted: 03/05/2022] [Indexed: 02/04/2023] Open
Abstract
Background: Recent data suggest that epicardial left atrial appendage closure (LAAC) is associated with several short-term neurohormonal effects. However, the long-term effects are currently unknown. Objective: To investigate the effects of percutaneous epicardial left atial appendage (LAA) exclusion using LARIAT on neurohormonal profiles at long-term follow-up. Methods: In a prospective single centre study, 60 patients with long-standing, persistent atrial fibrillation (AF) LARIAT were treated. The major hormones of the adrenergic system, renin-angiotensin-aldosterone system (RAAS), and natriuretic peptides were assessed before the intervention and at regular intervals during the following two years. Results: In patients with epicardial LAAC, atrial natriuretic peptide (ANP) levels were significantly increased from baseline at 24 h and decreased at 7 days, 1 month, and 3 months, while remaining unchanged at 12 and 24 months. Noradrenaline levels were significantly lower at 24 h, 7 days, 1 month, 6 months, 12 months, and 24 months, while epinephrine levels decreased significantly at 1 month, 6 months, 12 months, and 24 months. Plasma renin activity significantly decreased at 7 days, 1 month, 6 months, 12 months, and 24 months, while aldosterone levels significantly decreased at 6 months, 12 months, and 24 months. Endothelin-1 and vasopressin showed a significant increase and decrease, respectively, at 24 h, 7 days, 1 month, 6 months, 12 months, and 24 months. There was also a significant decrease in systolic and diastolic blood pressure at 3 months, 6 months, 1 year, and 2 years after the intervention. Conclusions: Epicardial LAAC in AF patients is associated with persistent neurohormonal changes favouring blood pressure reduction.
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Sabzwari SRA, Mehta NA, Garg L, Racharla L, Kurtz E, Afzal MR, Turagam MK, Lakkireddy D. Safety and efficacy of left atrial appendage closure using an epicardial suture snaring device: Systematic review and current status. J Cardiovasc Electrophysiol 2021; 32:2189-2198. [PMID: 34164881 DOI: 10.1111/jce.15132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/29/2021] [Accepted: 05/31/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The LARIAT epicardial suture snaring device has been fraught with technical challenges and procedural complications. Over time, technique modification and improved operator experience have helped overcome many of these challenges. METHODS AND RESULTS: Studies reporting left atrial appendage epicardial closure over a 12-year period from 2009 to 2020 were evaluated. The primary efficacy outcome evaluated was left atrial appendage closure with residual flow ≤1 mm. Safety outcomes evaluated were periprocedural and long term complications after device placement. Nine studies consisting of 1430 patients were included in this analysis, of which 1386 (97%) underwent successful device placement. The mean age was 69.3 years, with a mean CHADS2 -VASC score of 3.78. Primary efficacy end point was achieved in 95.8% patients immediately after device placement, and in 92.8% patients on long term follow-up. Early procedural complications consisted of pericardial effusion 5.6%, cardiac perforation 2.7%, pericarditis 2.6%, and need for open heart surgery 1.5%. Long term complications consisted of all-cause mortality 2.3%, stroke 1.5%, and left atrial appendage thrombus 2.3%. Reduced complications were noted using micropuncture needles (2.20% vs. 10.14%; p < .0001), a longer duration pericardial drainage, and use of anti-inflammatory medications (1.58% vs. 8.4%). Oral anticoagulation use decreased from 44.7% to 22.9% post device implantation, and to 8.5% on last clinical follow up. CONCLUSIONS The LARIAT device is effective in epicardial closure of the left atrial appendage. Improvement in device techniques such as use of micropuncture needle, prophylactic colchicine, and maintenance of a pericardial drain have helped improve safety over time.
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Affiliation(s)
| | - Nikhil A Mehta
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Lohit Garg
- Department of Electrophysiology, Hospital of the University of Pennsylvania, Pennsylvania, USA
| | - Lekha Racharla
- Department of Cardiology, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Emilee Kurtz
- Department of Internal Medicine, Lehigh Valley Health Network, Allentown, Pennsylvania, USA
| | - Muhammad R Afzal
- Department of Electrophysiology, Ohio State University, Columbus, Ohio, USA
| | - Mohit K Turagam
- Department of Electrophysiology, The Mount Sinai Hospital, New York City, New York, USA
| | - Dhanunjaya Lakkireddy
- Department of Electrophysiology, Overland Park Regional Medical Center, Overland Park, Kansas, USA
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Nentwich K, Ene E, Halbfass P, Berkowitz A, Sonne K, Kerber S, Lee R, Deneke T. Concomitant epicardial left atrial appendage ligation and left atrial ablation of atrial fibrillation: Safety, feasibility and outcome. Indian Pacing Electrophysiol J 2021; 21:75-79. [PMID: 33460777 PMCID: PMC7952894 DOI: 10.1016/j.ipej.2021.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/07/2021] [Accepted: 01/09/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction We present initial results of patients undergoing a combined procedure of epicardial LAA ligation in addition to left atrial ablation for AF. Methods 9 patients were included for additional use of LARIAT as an individual treatment approach for AF. First an epicardial LAA ligation was performed, in the same procedure left atrial ablations consisting of PVI and additional substrate based modifying ablations were performed. Follow–up at 3 months and 12 months was performed. Results There was only 1 minor procedural complication (11%) involving epicardial bleeding and 2 late adverse events of pericardial tamponade and stroke. At the final follow-up (median 20 months) 7 patients were in stable sinus rhythm (78%) and 2 pts had reduced AF burden. Conclusion Concomitant epicardial LAA ligation and ablation is feasible in selected patients with a reasonable risk profile. More prospective data are required to validate the safety and efficacy.
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Affiliation(s)
- Karin Nentwich
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany.
| | - Elena Ene
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Philipp Halbfass
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Arthur Berkowitz
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Kai Sonne
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Sebastian Kerber
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
| | - Randall Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, 500 Parnassus Ave, San Francisco, CA, 94143, USA
| | - Thomas Deneke
- Campus Bad Neustadt, Department Cardiology and Invasive Electrophysiology, von Guttenbergstrasse 11, 97616, Bad Neustadt, Germany
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Litwinowicz R, Burysz M, Mazur P, Kapelak B, Bartus M, Lakkireddy D, Lee RJ, Malec‐Litwinowicz M, Bartus K. Endocardial versus epicardial left atrial appendage exclusion for stroke prevention in patients with atrial fibrillation: Midterm follow‐up. J Cardiovasc Electrophysiol 2020; 32:93-101. [DOI: 10.1111/jce.14802] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/28/2020] [Accepted: 10/09/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Radoslaw Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College John Paul II Hospital Krakow Poland
| | - Marian Burysz
- Department of Cardiac Surgery Regional Specialist Hospital Grudziadz Poland
| | - Piotr Mazur
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College John Paul II Hospital Krakow Poland
| | - Boguslaw Kapelak
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College John Paul II Hospital Krakow Poland
| | - Magdalena Bartus
- Departament of Pharmacology Jagiellonian University Medical College Krakow Poland
| | - Dhanunjaya Lakkireddy
- The Kansas City Heart Rhythm Institute & Research Foundation Overland Park Kansas USA
| | - Randall J. Lee
- Department of Medicine and Cardiovascular Research Institute University of California San Francisco California USA
| | | | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College John Paul II Hospital Krakow Poland
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Abstract
PURPOSE The left atrial appendage (LAA) is believed to be a source for thrombus formation and an ancillary structure involved in the initiation and maintenance of atrial fibrillation (AF). LAA ligation has been proposed as adjunctive therapy for the treatment of AF. This study will determine the feasibility of a percutaneous epicardial approach for LAA ligation. METHODS The pericardium of 5 dogs was accessed via percutaneous subxyphoid approach. A 20F epicardial cannula was inserted into the pericardial space and contrast-injected to visualize the LAA. Under fluoroscopic guidance, a suction cup catheter was inserted and attached to the LAA. A 12F snare device was inserted over the vacuum cup to ligate the LAA. The closure of the LAA was verified with LA angiography, in the first 2 dogs, and ICE in all 5 animals. All animals were sacrificed for post hoc assessment of LAA closure. RESULTS All 5 dogs underwent successful epicardial suture ligation of the LAA. In the first 2 dogs, LA angiography demonstrated complete closure of the LAA. All dogs underwent gross examination of the LAA. Post hoc assessment was notable for a small well-circumscribed hematoma on the LAA, consistent with point of suction cup attachment, as well as complete closure of the entire LAA. No laceration or perforation was noted on the LAA. CONCLUSIONS Exclusion of the LAA via a novel percutaneous epicardial-only approach was successful without complications. This demonstrates the feasibility of this technique in an animal model, and may provide an effective approach for epicardial-only LAA exclusion in humans.
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Affiliation(s)
- José M Sanchez
- Section of Cardiac Electrophysiology, Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adam Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantation, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Randall J Lee
- Section of Cardiac Electrophysiology, Division of Cardiology, University of California, San Francisco, CA, USA.
- , San Francisco, USA.
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Perino AC, Kaiser DW, Lee RJ, Fan J, Askari M, Schmitt SK, Turakhia MP. Incidence and outcomes of patients with atrial fibrillation and major bleeding complications: from the TREAT-AF study. J Interv Card Electrophysiol 2020; 62:133-142. [PMID: 32986177 DOI: 10.1007/s10840-020-00873-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Optimal stroke prevention strategies for patients with atrial fibrillation (AF) who experience a major bleed are poorly defined. We sought to estimate the effectiveness and safety of oral anticoagulation (OAC) represcription after an OAC contraindication. METHODS TREAT-AF is a retrospective cohort study of patients with newly diagnosed AF (2004-2012), treated in the Veterans Health Administration. From this cohort, we identified patients with a contraindication to OAC after AF diagnoses, defined as incident intracranial bleeding, non-intracranial bleeding requiring hospitalization, or unrepaired cerebral aneurysm or aortic dissection. We used multivariate Cox proportional hazards to estimate the association of OAC prescription in the 90 days following OAC contraindication to ischemic stroke and rebleeding. RESULTS Among 167,190 patients with newly diagnosed AF (70 ± 11 years, 1.7% female, CHA2DS2-VASc 2.7 ± 1.7), 19,285 patients (11.5%) had an incident bleed (n = 18,342) or an unrepaired cerebral aneurysm or aortic dissection (n = 943). For OAC-contraindicated patients with a CHA2DS2-VASc ≥2 (N = 16,194), OAC was represcribed in 4075 patients (25%) and was associated with a higher risk of non-intracranial bleeding (HR 1.49; 95% CI 1.37-1.61; p < 0.0001) but no difference in intracranial bleeding. There was a trend toward decreased stroke risk (HR 0.85; 95% CI 0.71-1.02; p 0.09). CONCLUSIONS Development of contraindication to OAC after diagnosis of AF is common (11.5%), with most events requiring hospitalization. OAC reinitiation was associated with non-intracranial bleeding risk, with a trend toward reduced stroke risk. These data suggest that stroke prevention approaches after major bleeding events could be beneficial if bleeding risk can be successfully mitigated.
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Affiliation(s)
- Alexander C Perino
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Daniel W Kaiser
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Randall J Lee
- Department of Medicine and Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Jun Fan
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mariam Askari
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Susan K Schmitt
- Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA
| | - Mintu P Turakhia
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA. .,Veterans Affairs Palo Alto Health Care System, 3801 Miranda Ave - 111C, Palo Alto, CA, 94304, USA. .,Center for Digital Health, Stanford University School of Medicine, Stanford, CA, USA.
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Sonaglioni A, Vincenti A, Lombardo M, Anzà C. Left Atrial Cavity Thrombus and Fatal Systemic Embolization in a Stroke Patient with Nonvalvular Atrial Fibrillation: A Caveat against Left Atrial Appendage Closure for Stroke Prevention. J Cardiovasc Echogr 2020; 30:41-43. [PMID: 32766107 PMCID: PMC7307615 DOI: 10.4103/jcecho.jcecho_46_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 11/04/2019] [Accepted: 01/20/2020] [Indexed: 11/28/2022] Open
Abstract
An 88-year-old male with nonvalvular atrial fibrillation (NVAF) and severe congestive heart failure (HF), was admitted to the Neurological Intensive Care Unit because of the acute onset of aphasia and left hemiplegia. Transthoracic echocardiography revealed a left atrial (LA) cavity thrombus. Its “fatal” distal embolization to abdominal aorta occurred in a few days. These observations should lead to a cautious approach in proposing a percutaneous closure of LA appendage in older NVAF patients, with HF and/or left ventricular dysfunction and larger LA volumes, who are not adequately anticoagulated.
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Affiliation(s)
- Andrea Sonaglioni
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Antonio Vincenti
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Michele Lombardo
- Department of Cardiology, Ospedale San Giuseppe Multimedica, Milan, Italy
| | - Claudio Anzà
- Department of Cardiovascular, Multimedica IRCCS, Milano, Italy
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Litwinowicz R, Filip G, Sobczyk D, Lakkireddy D, Vuddanda VLK, Bartuś M, Kapelak B, Bartuś K. Long-term effect of anticoagulation following left atrial appendage occlusion with the LARIAT device in patients with nonvalvular atrial fibrillation: impact on thromboembolism, bleeding and mortality. Real life data. Postepy Kardiol Interwencyjnej 2020; 16:89-96. [PMID: 32368241 DOI: 10.5114/aic.2020.93916] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 09/16/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction Indications for left atrial appendage occlusion (LAAO) are varied and patients require individual management strategies. However, currently no guidelines exist for postprocedure oral anticoagulation (OAC) after an LAAO procedure. Aim To evaluate the effect of OAC on thromboembolism, bleeding and mortality following the LAAO procedure for patients with AF. Material and methods One hundred and thirty-nine consecutive patients with nonvalvular atrial fibrillation (NVAF) who underwent LAAO with the LARIAT device were followed for at least 40 months. Decisions about OAC and its modifications were individualized based on clinical presentation, patient and physician preferences. Results Following LAAO, 52 (41%) patients did not receive OAC (No-OAC group) and 75 (59%) patients received OAC (OAC group), without any intergroup differences in CHADS2, CHA2DS2-VASc score or other thromboembolic risk factors. The median HAS-BLED score was higher in the OAC-group (median 3 (3-4) vs. 3 (2-4), p = 0.014). During a median follow-up time of 51 (43-57) vs. 55 (48-59) months in the No-OAC group and in the OAC group (p = 0.19) there were no significant differences between groups in ischemic stroke/TIA, 0 (0%) vs. 2 (2.7%), other thromboembolic events, 0 (0%) vs. 1 (1.3%), life-threatening, disabling or major events, 2 (3.7%) vs. 2 (2.7%), or annual mortality rate, 1.9% vs. 0.9%, respectively. Conclusions There is no need for OAC after the LAAO procedure. Omitting OAC after an LAAO procedure in AF patients: (1) has similar stroke prevention rates as patients on OAC, (2) has similar bleeding prevention rates as patients on OAC, (3) has similar safety endpoints and long-term efficacy as patients on OAC.
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16
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Tilz RR, Fink T, Bartus K, Wong T, Vogler J, Nentwich K, Panniker S, Fang Q, Piorkowski C, Liosis S, Gaspar T, Sawan N, Metzner A, Nietlispach F, Maisano F, Lee RJ, Foran JP, Ouyang F, Sievert H, Deneke T, Kuck KH. A collective European experience with left atrial appendage suture ligation using the LARIAT+ device. Europace 2020; 22:924-931. [DOI: 10.1093/europace/euaa004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/23/2019] [Accepted: 01/29/2020] [Indexed: 11/12/2022] Open
Abstract
Abstract
Aims
We report the collective European experience of percutaneous left atrial appendage (LAA) suture ligation using the recent generation LARIAT+ suture delivery device.
Methods and results
A total of 141 patients with non-valvular atrial fibrillation and contraindication to oral anticoagulation (OAC), thrombo-embolic events despite OAC or electrical LAA isolation were enrolled at seven European hospitals to undergo LAA ligation. Patients were followed up by clinical visits and transoesophageal echocardiography (TOE) following LAA closure. Left atrial appendage ligation was completed in 138/141 patients (97.8%). Three patients did not undergo attempted deployment of the LARIAT device due to pericardial adhesion after previous epicardial ventricular tachycardia ablation (n = 1), a pericardial access-related complication (n = 1), and multiple posterior LAA lobes (n = 1). Serious 30-day procedural adverse events occurred in 4/141 patients (2.8%). There were two device-related LAA perforations (1.4%) not resulting in any corrective intervention as the LAA was completely sealed with the LARIAT. Minor adverse events occurred in 19 patients (13.5%), including two pericardial effusions due to procedure-related pericarditis requiring pericardiocentesis. Transoesophageal echocardiography was performed after LAA ligation in 103/138 patients (74.6%) after a mean of 181 ± 72 days. Complete LAA closure was documented in 100 patients (97.1%). Two patients (1.8% of patients with follow-up) experienced a transient ischaemic attack at 4 and 7 months follow-up, although there was no leak observed with TOE. There were two deaths during long-term follow-up which were both not device related.
Conclusion
Initial experience with the LARIAT+ device demonstrates feasibility of LAA exclusion. Further larger prospective studies with longer follow-up are warranted.
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Affiliation(s)
- Roland Richard Tilz
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Thomas Fink
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Tom Wong
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Julia Vogler
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Karin Nentwich
- Clinic for Cardiology II (Interventional Electrophysiology), Cardiovascular Center, Bad Neustadt, Germany
| | - Sandeep Panniker
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Qizhi Fang
- Department of Medicine, Cardiovascular Research Institute and Institute for Regeneration Medicine, University of California, San Francisco, CA, USA
| | - Christopher Piorkowski
- Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Dresden, Germany
| | - Spyridon Liosis
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Thomas Gaspar
- Herzzentrum Dresden GmbH Universitätsklinik an der Technischen Universität Dresden, Dresden, Germany
| | - Noureddin Sawan
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
| | - Andreas Metzner
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
| | | | | | - Randall J Lee
- Department of Medicine, Cardiovascular Research Institute and Institute for Regeneration Medicine, University of California, San Francisco, CA, USA
| | - John P Foran
- Department of Cardiology, Heart Rhythm Centre, Royal Brompton and Harefield Hospitals, London, UK
| | - Feifan Ouyang
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
- Clinic for Cardiology, Fuwai Hospital, The Chinese Academy of Medical Sciences & National Center of Cardiovascular Diseases, Beijing, China
| | - Horst Sievert
- Department of Cardiology, Cardiovascular Center, Frankfurt, Frankfurt, Germany
| | - Thomas Deneke
- Clinic for Cardiology II (Interventional Electrophysiology), Cardiovascular Center, Bad Neustadt, Germany
| | - Karl-Heinz Kuck
- Department of Electrophysiology, University Heart Center Lübeck, Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Ratzeburger Allee 160, 23562 Lübeck, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site, Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology, Asklepios Klinik St. Georg, Hamburg, Germany
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Bartus K, Litwinowicz R, Natorska J, Zabczyk M, Undas A, Kapelak B, Lakkireddy D, Lee RJ. Coagulation factors and fibrinolytic activity in the left atrial appendage and other heart chambers in patients with atrial fibrillation: is there a local intracardiac prothrombotic state? (HEART-CLOT study). Int J Cardiol 2020; 301:103-107. [DOI: 10.1016/j.ijcard.2019.09.053] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
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18
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Left Atrial Appendage Occlusion: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 33:1753-1765. [DOI: 10.1053/j.jvca.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/21/2022]
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20
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Ojo A, Yandrapalli S, Veseli G, Karim M, Aronow WS, Sharma M, Frishman WH, Naidu SS, Jacobson JT, Iwai S. Left Atrial Appendage Occlusion in the Management of Stroke in Patients With Atrial Fibrillation. Cardiol Rev 2020; 28:42-51. [PMID: 30520738 DOI: 10.1097/CRD.0000000000000240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Atrial fibrillation (AF) is associated with a substantially higher risk of thromboembolism, particularly stroke events, resulting in significant morbidity and mortality. Oral anticoagulation (OAC), while effective in reducing embolic events in AF patients, is associated with an increased bleeding risk. Thus, not all patients with AF are candidates for OAC and some are only candidates for OAC in the short term. Of the available nonpharmacologic strategies for the management of AF, left atrial appendage occlusion (LAAO) has emerged as a potential approach for reducing the risk of systemic thromboembolism in AF patients eligible for OAC. LAAO can be achieved either surgically or percutaneously using an epicardial, endocardial, or a combined approach. Although available data are limited, currently available LAAO devices, and those being developed, have shown promise in reducing bleeding risk in AF patients because of the reduced overall need for anticoagulation, while maintaining efficacy in preventing thromboembolism. The optimal device will reduce both embolic and hemorrhagic strokes, and other bleeds, with a high implant success rate and a low complication rate. Until that time, anticoagulation remains the gold standard that these devices strive to surpass, and thus LAAO devices are currently indicated in patients with relative contraindication to OAC therapy.
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Turagam MK, Velagapudi P, Kar S, Holmes D, Reddy VY, Refaat MM, Di Biase L, Al-Ahmed A, Chung MK, Lewalter T, Edgerton J, Cox J, Fisher J, Natale A, Lakkireddy DR. Cardiovascular Therapies Targeting Left Atrial Appendage. J Am Coll Cardiol 2018; 72:448-463. [PMID: 29954658 PMCID: PMC8420938 DOI: 10.1016/j.jacc.2018.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Saibal Kar
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - David Holmes
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiology/Cardiac Electrophysiology and Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Luigi Di Biase
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Amin Al-Ahmed
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James Edgerton
- Department of Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Fisher
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya R Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park Regional Medical Center, Kansas City, Kansas.
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22
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Abstract
The thrombus formed within the LAA is responsible for the vast (about 90%) majority of strokes. Anticoagulation, although effective therapy for stroke prevention is not feasible in a significant minority of patients due to various reasons. Two percutaenous LAA exclusion techniques have been developed in an effort to decrease risk for stroke: endocardial closure/plugging of the LAA (Watchman, Amplatzer devices) and epicardial LAA ligation (LARIAT). The aim of this study is to review the trial data to date for the LARIAT device. The LARIAT suture has been used in more than 4500 patients with high success of LAA complete closure (92-100%), mostly in the patients unable to take anticoagulation and in a small minority as antiarrhythmic option. The LARIAT technique has evolved with a change in pericardial access method that resulted in dramatic improvement of safety. LAA closure performance with LARIAT system seems to be similar to Watchman device, with small leaks during follow-up in 6-24% of the cases, which do not to correlate with thrombo-embolic events. LAA has been proven to play an important triggering role in patients with persistent atrial fibrillation. Small studies had shown that LAA ligation with LARIAT could terminate persistent atrial fibrillation and possible improve ablation success. Ongoing aMAZE randomized trial is studying if LAA ligaiton using LARIAT suture leads to improved atrial fibrillation ablation success. Available data suggests that LAA closure using LARIAT epicardial suture is a good alternative for stroke risk reduction in patients who are unable to be on anticoagulation therapy. LARIAT system might improve success of AF ablation for patients with persistent and long persistent AF, pending the results of the ongoing aMAZE trial.
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Affiliation(s)
- Dan Musat
- Valley Health System of NY and NJ, Paramus, NJ
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Fink T, Schlüter M, Tilz RR, Heeger CH, Lemes C, Maurer T, Reissmann B, Rottner L, Santoro F, Mathew S, Rillig A, Ouyang F, Kuck KH, Metzner A. Acute and long-term outcomes of epicardial left atrial appendage ligation with the second-generation LARIAT device: a high-volume electrophysiology center experience. Clin Res Cardiol 2018; 107:1139-1147. [DOI: 10.1007/s00392-018-1288-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 05/30/2018] [Indexed: 10/14/2022]
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25
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Nielsen-Kudsk JE, Johnsen SP, Wester P, Damgaard D, Airaksinen J, Lund J, De Backer O, Pakarinen S, Odenstedt J, Vikman S, Settergren M, Kongstad O, Rosenqvist M, Krieger DW. Left atrial appendage occlusion versus standard medical care in patients with atrial fibrillation and intracerebral haemorrhage: a propensity score-matched follow-up study. EUROINTERVENTION 2018; 13:371-378. [PMID: 28485276 DOI: 10.4244/eij-d-17-00201] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of this study was to investigate the prognosis in patients with atrial fibrillation (AF) and intracerebral haemorrhage (ICH) having a left atrial appendage occlusion (LAAO) versus patients receiving standard medical therapy. METHODS AND RESULTS A total of 151 patients from the Nordic countries with AF and previous ICH who underwent LAAO using the AMPLATZER Cardiac Plug or the AMPLATZER AMULET were compared to a propensity score-matched group of 151 patients receiving standard medical therapy. The two groups were matched so that their risks for stroke and bleeding were similar (CHA2DS2-VASc and HAS-BLED scores). The standard care patients were identified from the Danish Stroke Registry among 787 patients with AF and ICH. The primary endpoint was a composite of all-cause mortality, ischaemic stroke and major bleeding. Patients with AF and a prior ICH treated with LAAO had a lower risk of the composite outcome as compared to patients treated with standard medical care (events/1,000 years [95% confidence interval]: 53.3 [44.3-64.1] vs. 366.7 [298.2-450.9]; hazard ratio 0.16 [0.07-0.37]). CONCLUSIONS LAAO is suggested to be of major clinical benefit in AF patients having sustained an ICH. These results have to be confirmed in a randomised clinical trial.
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Rajabali A, Badhwar N, Lee RJ. The Role of the Left Atrial Appendage in Stroke and Arrhythmia Provocation. Curr Cardiovasc Risk Rep 2018; 12. [DOI: 10.1007/s12170-018-0576-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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McBride DA, Markman TM, Liang JJ, Santangeli P. Left Atrial Appendage Closure Devices for Stroke Prevention in Patients with Non-Valvular AF. US Cardiology Review 2018. [DOI: 10.15420/usc.2018.6.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The left atrial appendage (LAA) may be involved in offloading atrial pressure during left ventricular systole. As ventricular rate increases, LAA emptying decreases during early diastole causing increased risk of thrombus formation particularly in patients with non-valvular AF (NVAF). The LAA is the site of thrombus formation in more than 90 % of patients with NVAF, so is an important target for thromboembolic prophylaxis in these patients. Anticoagulation therapy is used to treat NVAF, but it has long-term complications and may be contraindicated in some patients. Therefore, alternative strategies to reduce embolic risk in patients with AF have been developed. These include percutaneous, thoracoscopic, and open closure strategies. This study reviews the safety and efficacy of these strategies, comparing these approaches and devices with pharmacological strategies. There is little data to endorse one strategy over another. Given the minimal evidence available, recommendations in support of LAA occlusion remain weak and guidelines have called for more research and coding of endpoints for this emerging technology.
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Turagam M, Atkins D, Earnest M, Lee R, Nath J, Ferrell R, Bartus K, Badhwar N, Rasekh A, Cheng J, Di Biase L, Natale A, Wilber D, Lakkireddy D. Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry. J Cardiovasc Electrophysiol 2017; 28:1433-1442. [DOI: 10.1111/jce.13343] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 07/25/2017] [Accepted: 08/01/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Mohit Turagam
- Division of Cardiovascular Medicine; University of Missouri Hospital and Clinics; Columbia MO USA
| | - Donita Atkins
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Matthew Earnest
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Randall Lee
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Jayant Nath
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | - Ryan Ferrell
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
| | | | - Nitish Badhwar
- Section of Electrophysiology; UCSF Medical Center; San Francisco CA USA
| | - Abdi Rasekh
- Baylor St. Luke's Medical Center; Houston TX USA
| | - Jie Cheng
- Texas Heart Institute; Houston TX USA
| | - Luigi Di Biase
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - Andrea Natale
- St. David's Medical Center; Texas Cardiac Arrhythmia Institute; Austin TX USA
| | - David Wilber
- Division of Cardiovascular Medicine; Loyola University Medical Center; Chicago IL USA
| | - Dhanunjaya Lakkireddy
- Division of Cardiovascular Diseases, Cardiovascular Research Institute; University of Kansas Hospital & Medical Center; Kansas City KS USA
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Vuddanda V, Turagam MK, Lakkireddy D. Left Atrial Appendage Closure: Is the Strategy Enough to Lower Long-Term Stroke Risk? Curr Cardiovasc Risk Rep 2017; 11. [DOI: 10.1007/s12170-017-0555-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Alipour A, Wintgens LIS, Swaans MJ, Balt JC, Rensing BJWM, Boersma LVA. Novel stroke risk reduction in atrial fibrillation: left atrial appendage occlusion with a focus on the Watchman closure device. Vasc Health Risk Manag 2017; 13:81-90. [PMID: 28293114 PMCID: PMC5345987 DOI: 10.2147/vhrm.s89213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Atrial fibrillation (AF) remains an important clinical problem with severe complications such as stroke, which especially harms those with risk factors as calculated by the CHADS2 or CHA2DS2-VASc. Until now, no therapy has proven 100% effective against AF. Since the left atrial appendage (LAA) is the most prominent nonvalvular AF-related thromboembolic source and (novel) oral anticoagulant [(N)OAC] carries the hazard of bleeding, LAA occlusion may be an alternative, especially in patients who are ineligible for (N)OAC therapy. In this review, we discuss several LAA occlusion techniques with a focus on the Watchman device since this device is the most thoroughly studied device of all.
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Affiliation(s)
- Arash Alipour
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Martin J Swaans
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jippe C Balt
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Benno J W M Rensing
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Lucas V A Boersma
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, the Netherlands
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