Nonprocedural bleeding after left atrial appendage closure versus direct oral anticoagulants: A subanalysis of the randomized PRAGUE-17 trial

INTRODUCTION

Observational studies have shown low bleeding rates in patients with atrial fibrillation (AF) treated by left atrial appendage closure (LAAC); however, data from randomized studies are lacking. This study compared bleeding events among patients with AF treated by LAAC and nonvitamin K anticoagulants (NOAC).

METHODS

The Prague-17 trial was a prospective, multicenter, randomized trial that compared LAAC to NOAC in high-risk AF patients. The primary endpoint was a composite of a cardioembolic event, cardiovascular death, and major and clinically relevant nonmajor bleeding (CRNMB) defined according to the International Society on Thrombosis and Hemostasis (ISTH).

RESULTS

The trial enrolled 402 patients (201 per arm), and the median follow-up was 3.5 (IQR 2.6-4.2) years. Bleeding occurred in 24 patients (29 events) and 32 patients (40 events) in the LAAC and NOAC groups, respectively. Six of the LAAC bleeding events were procedure/device-related. In the primary intention-to-treat analysis, LAAC was associated with similar rates of ISTH major or CRNMB (sHR 0.75, 95% CI 0.44-1.27, p = 0.28), but with a reduction in nonprocedural major or CRNMB (sHR 0.55, 95% CI 0.31-0.97, p = 0.039). This reduction for nonprocedural bleeding with LAAC was mainly driven by a reduced rate of CRNMB (sHR for major bleeding 0.69, 95% CI 0.34-1.39, p = .30; sHR for CRNMB 0.43, 95% CI 0.18-1.03, p = 0.059). History of bleeding was a predictor of bleeding during follow-up. Gastrointestinal bleeding was the most common bleeding site in both groups.

CONCLUSION

During the 4-year follow-up, LAAC was associated with less nonprocedural bleeding. The reduction is mainly driven by a decrease in CRNMB.

Left Atrial Appendage Closure versus Non-Warfarin Oral Anticoagulation in Atrial Fibrillation: 4-Year Outcomes of PRAGUE-17

BACKGROUND

The PRAGUE-17 trial demonstrated that left atrial appendage closure (LAAC) was non-inferior to non-warfarin oral anticoagulants (NOAC) for preventing major neurological, cardiovascular or bleeding events in high-risk patients with atrial fibrillation (AF).

OBJECTIVE

To assess the pre-specified long-term (4-year) outcomes in PRAGUE-17.

METHODS

PRAGUE-17 was a randomized non-inferiority trial comparing percutaneous LAAC (Watchman or Amulet) with NOACs (95% apixaban) in non-valvular AF patients with a history of cardioembolism, clinically-relevant bleeding, or both CHA₂DS₂-VASc > 3 and HASBLED > 2. The primary endpoint was a composite of cardioembolic events (stroke, transient ischemic attack, or systemic embolism), cardiovascular death, clinically-relevant bleeding, or procedure/device-related complications (LAAC group only). The primary analysis was modified intention-to-treat (mITT).

RESULTS

We randomized 402 AF patients (201 per group, age 73.3±7.0 years, 65.7% male, CHA₂DS₂-VASc 4.7+1.5, HASBLED 3.1+0.9). After 3.5 years median follow-up (1,354 patients-years), LAAC was non-inferior to NOAC for the primary endpoint by mITT (subdistribution hazard ratio[sHR] 0.81, 95% CI 0.56-1.18; p=0.27; p for non-inferiority=0.006). For the components of the composite endpoint, the corresponding sHRs (and 95% CIs) were 0.68 (0.39-1.20; p=0.19) for cardiovascular death, 1.14 (0.56-2.30; p=0.72) for all-stroke/TIA, 0.75 (0.44-1.27; p=0.28) for clinically-relevant bleeding, and 0.55 (0.31-0.97; p=0.039) for non-procedural clinically-relevant bleeding. The primary endpoint outcomes were similar in the per-protocol [sHR 0.80 (95% CI 0.54-1.18), p=0.25] and on-treatment [sHR 0.82 (95% CI 0.56-1.20), p=0.30] analyses.

CONCLUSION

In long-term follow-up of PRAGUE-17, LAAC remains non-inferior to NOACs for preventing major cardiovascular, neurological or bleeding events. Furthermore, non-procedural bleeding was significantly reduced with LAAC.

Interventional left atrial appendage closure vs novel anticoagulation agents in patients with atrial fibrillation indicated for long-term anticoagulation (PRAGUE-17 study)

Atrial fibrillation (AF), with a prevalence of 1% to 2%, is the most common cardiac arrhythmia. Without antithrombotic treatment, the annual risk of a cardioembolic event is 5% to 6%. The source of a cardioembolic event is a thrombus, which is usually formed in the left atrial appendage (LAA). Prevention of cardioembolic events involves treatment with anticoagulant drugs: either vitamin K antagonists or, recently, novel oral anticoagulants (NOAC). The other (nonpharmacologic) option for the prevention of a cardioembolic event involves interventional occlusion of the LAA.

OBJECTIVE

To determine whether percutaneous LAA occlusion is noninferior to treatment with NOAC in AF patients indicated for long-term systemic anticoagulation.

STUDY DESIGN

The trial will be a prospective, multicenter, randomized noninferiority trial comparing 2 treatment strategies in moderate to high-risk AF patients (ie, patients with history of significant bleeding, or history of cardiovascular event(s), or a with CHA₂DS₂VASc ≥3 and HAS-BLED score ≥2). Patients will be randomized into a percutaneous LAA occlusion (group A) or a NOAC treatment (group B) in a 1:1 ratio; the randomization was done using Web-based randomization software. A total of 396 study participants (198 patients in each group) will be enrolled in the study. The primary end point will be the occurrence of any of the following events within 24months after randomization: stroke or transient ischemic attack (any type), systemic cardioembolic event, clinically significant bleeding, cardiovascular death, or a significant periprocedural or device-related complications.

CONCLUSION

The PRAGUE-17 trial will determine if LAA occlusion is noninferior to treatment with NOAC in moderate- to high-risk AF patients.

Intermediate filament proteins in echinoderm coelomocytes

The presence and organization of intermediate filament (IF) proteins in petaloid coelomocytes from two species of echinoderms, the sea urchin Strongylocentrotus droehachiensis and the sea cucumber Cucumaria frondosa, were studied. Two monoclonal antibodies (IFA and Ah6) and one polyclonal antibody (W3-1) that together recognize invertebrate as well as vertebrate IF proteins were used to probe coelomocytes by immunofluorescence and immunoblotting methods. All three antibodies cross-reacted with a single Mr 68,000 sea urchin lamin, as well as two putative lamin isoforms of approximately Mr 70,000 and 68,000 in sea cucumber coelomocytes. Both IFA and Ah6 labeled granular material in the cytoplasm of sea urchin coelomocytes; by contrast, IFA labeling revealed a striking network of reticular material irregularly arrayed within the central regions of the sea cucumber coelomocyte cytoplasm. In addition, foci of Ah6-positive material were present in coelomocyte nuclei from both species. Comparison of immunoblotting patterns among whole cell and isolated nuclear preparations suggest that the cytoplasmic IF-like material is composed of Mr 46,000 and 58,000 polypeptides, while Mr 215,000 and 185,000 proteins are candidates for the immunoreactive nuclear foci. Further study of the functions of these non-filamentous arrays of IF proteins may furnish valuable insights into the evolution of IF function within vertebrate cells, particularly with respect to certain cytoplasmic and nuclear regulatory functions with which IF proteins have been speculated to be involved.

Neuronal differentiation of NT2/D1 teratocarcinoma cells is accompanied by a loss of lamin A/C expression and an increase in lamin B1 expression

Nuclear lamins are prominent elements of the nuclear matrix and are expressed in cell type-specific and differentiation state-specific patterns. A few observations have indicated that nervous tissue may display unusual patterns of lamin expression, in that some neurons appear to lack A-type lamins, which are generally prominently expressed in terminally differentiated, postmitotic cells. To investigate lamin expression patterns during the differentiation of a teratocarcinoma cell line into neurons, NT2/D1 cells were induced to differentiate with retinoic acid treatment. Lamin expression and organization during differentiation in vitro were examined by quantitative immunofluorescence and immunoblotting methods. Undifferentiated NT2/D1 cells were all strongly labeled with an anti-lamin B1 antibody, but displayed marked variation in A/C lamin immunoreactivity. After differentiation, neuronal nuclear envelopes were significantly more strongly labeled by anti-lamin B1 antibody than those of undifferentiated cells, but completely lacked A/C lamin immunoreactivity. In contrast, nonneuronal cells displayed a slight reduction in B1 lamin immunoreactivity, along with a distinct increase in A/C lamin levels. The loss of lamin A/C expression in NT2/D1 neurons is contrary to the pattern normally observed in most somatic cell types during early development and indicates that the nuclear matrix of some neurons, along with certain neuroendocrine and hematopoietic cells, is uniquely specialized in this regard.

Chlorpropham [isopropyl N-(3-chlorophenyl) carbamate] disrupts microtubule organization, cell division, and early development of sea urchin embryos

The herbicide CIPC [N-(3-chlorophenyl) carbamate] has been shown to disrupt microtubule organization in plants, apparently by interfering with the functioning of the microtubule organizing center. Very few studies have examined the effects of CIPC on animal cell microtubules and centrosomes, however, and the effects of this cytoskeletal disrupting agent on fertilization and early development have not been studied in detail. To address these questions, fertilized sea urchin eggs were cultured in the presence of CIPC until the prism stage, and perturbations in the cytoskeleton and development were examined. It was found that Lytechinus pictus embryos are sensitive to micromolar amounts of CIPC, and that a characteristic set of cytoskeletal and developmental deficits is produced as a result of exposure to this herbicide. Mitotic spindles were truncated and randomly oriented within zygotes and blastomeres, and cytokinesis was compromised, resulting in the production of blastomeres of various sizes and ploidy. Interestingly, in spite of these cytoskeletal and nuclear alterations, spindle poles at fourth cleavage retained their ability to interact with the plasma membrane in a manner similar to that normally characterizing the unequal division of macromeres and micromeres. CIPC treatment resulted in unequal cell divisions at atypical times, and skeletal spicule formation in these embryos was abnormal. These results indicate that CIPC may pose a significant health risk during mammalian embryogenesis; in addition, it may be a useful tool with which to study microtubule and centrosomal functioning during animal cell division-especially in those cell types that exhibit stereotypic patterns of cell division during early development.

Confocal microscopic observation of cytoskeletal reorganizations in cultured shark rectal gland cells following treatment with hypotonic shock and high external K+

The dogfish shark (Squalus acanthias) rectal gland (SRG) cell has served as a model experimental system for investigating the relationship between the actin cytoskeleton and cell volume regulation. Previous reports employing conventional fluorescence microscopy of tissue slices have shown that cells exposed to high external K+ and hypotonically-induced cell swelling displayed a fading of F-actin staining intensity, particularly at the basolateral cell borders. However, spectroscopic measurement of the F-actin present in similarly treated rectal gland slices failed to demonstrate a net change in F-actin amount. In an effort to resolve the structural reorganizations of F-actin which may be occurring during high K+ and hypotonic shock treatments, we have used cultured SRG cells in conjunction with confocal microscopic immunocytochemical localization techniques to examine actin filament, microtubule, and cytokeratin filament dynamics under these two experimental conditions. The results reveal that F-actin in control cells exists in an array of parallel linear bundles (which do not appear to be stress fiber-like given their lack of staining for myosin II or alpha-actinin) that is reorganized to a punctate pattern in hypotonic shock and a dense meshwork in high K+. The linear bundle pattern of F-actin returns in cells undergoing regulatory volume decrease. Quantitative western blotting of F-actin in SRG cell detergent extracted cytoskeletons indicates no significant difference in the relative amounts of F-actin present in control, hypotonic shocked, or high K+ cells. Anti-tubulin and anti-cytokeratin labeling of the treated SRG cells suggest that these other major cytoskeletal elements are not significantly altered by the treatments. Taken together, our results reinforce the concept that there is an association between the structural organization of the actin cytoskeleton and cell volume regulation in the SRG epithelial cells.

Recruitment of maternal material during assembly of the zygote centrosome in fertilized sea urchin eggs

Spindle poles of sea urchin embryos contain centrosomal material derived from maternal as well as paternal sources. To examine how maternal centrosomal material becomes recruited into spindle poles during the first cell cycle, fertilized sea urchin eggs were fixed and labeled with an anti-centrosomal antibody at sequential timepoints after insemination. Immunolabeling patterns demonstrate that the unfertilized egg contains small foci of immunoreactive material dispersed throughout the cytoplasm. Shortly after insemination, the diffuse foci coalesce to form a dense aggregate close to the sperm nucleus. Subsequently, centrosomal material spreads over the surface of the zygote nucleus and becomes partitioned into two masses during spindle pole formation. The involvement of the cytoskeleton in the translocation and targeting of maternal centrosomal material through the first cell cycle was examined by treating eggs with cytoskeletal disrupting agents, a general kinase inhibitor, and by re-inseminating fertilized eggs. These experiments indicate that the initially diffuse centrosomal material is transported centripetally to the sperm nucleus by the sperm aster and the centrosomal material is subsequently sequestered around the zygote nucleus by a microtubule-mediated mechanism. Remarkably, 6-dimethylaminopurine treatment shifted the targeting of maternal centrosomal material from the sperm nucleus to the female pronucleus; upon recovery, some of these zygotes formed spindle poles that flanked only the maternal chromosomes.

Conserved expression of a B-type nuclear lamin in different tissues of the sea urchin

To study patterns of lamin expression in sea urchins, monoclonal and polyclonal antibodies were used to probe 2-D immunoblots of Strongylocentrotus purpuratus and Lytechinus pictus embryos and adult tissues. Three major charge isoforms of a single M(r) 70,000 lamin are common to different tissues of S. purpuratus, and are accompanied by two-to-four more variable minor charge variants. L. pictus expresses and M(r) 70,000 lamin that is distinct from that of S. purpuratus in pI, yet displays essentially the same pattern of major and minor charge isoforms. The results demonstrate that the single lamin gene product so far identified in sea urchin embryos appears to be constitutively expressed in most cells, and that three major charge isoforms are common to these different cell types.

Molecular characterization and expression patterns of a B-type nuclear lamin during sea urchin embryogenesis

Developmentally regulated, tissue-specific patterns of nuclear lamin expression occur during vertebrate embryogenesis, but little is known regarding lamin ontogeny during the early development of other phyla. cDNA clones encoding a lamin from the sea urchins Strongylocentrotus purpuratus and Lytechinus variegatus have been identified, and the full coding region from the former has been sequenced. The predicted amino acid sequence indicates that this echinoderm lamin is more closely related to vertebrate B-type lamins than to dipteran fly and nematode lamins--the only other invertebrate lamins sequenced to date. Monoclonal and polyclonal antibodies to sea urchin lamin demonstrate that nuclei of unfertilized eggs and embryos exhibit relatively faint immunoreactivity until the differentiation of primary mesenchymal cells, the nuclear envelopes of which become strongly and selectively labeled by anti-lamin antibodies. Northern blots reveal stage-specific fluctuations in a single 4-kb lamin message during early development and, together with immunoblotting data, suggest that the increase in mesenchymal cell nuclear envelope immunoreactivity is due to a quantitative increase in a single type of lamin. These observations demonstrate that, similar to vertebrates, cell differentiation in invertebrates can be accompanied by a change in lamin expression patterns.

Spindle pole centrosomes of sea urchin embryos are partially composed of material recruited from maternal stores

The spindle poles of fertilized sea urchin eggs have commonly been modeled as being derived from the centrosomes of the fertilizing spermatozoon. Boveri's theory of fertilization, proposed at the turn of the century, states that the maternal centrosome is suppressed or inactivated during oogenesis and that the sperm centrosome is functionally dominant. In support of this proposal, more recent studies have shown that the sperm imports a determinant that is involved in centrosomal replication. Examination of sea urchin zygotes immunofluorescently labeled with a new anti-centrosomal antibody by quantitative confocal laser-scanning microscopy shows, however, that spindle pole centrosomes are not exclusively paternal structures, but additionally contain material derived from maternal pools. Furthermore, this maternal centrosomal material is divided among daughter blastomeres during cleavage. It therefore appears that although the sperm centrosome plays a dominant role in organizing the spindle poles, much of the centrosomal material within the spindle poles of the zygote is actually recruited from preexisting egg cytoplasmic stores. These data indicate that centrosomes of sea urchin embryos are biparentally derived, composite organelles.

Three-dimensional imaging of fertilization and early development

The field of biological microscopy has recently enjoyed major technical advances, exemplified by the development of field-emission low-voltage scanning electron microscopes and laser scanning confocal light microscopes. In addition, computer processing of microscopical data is revolutionizing the way morphological information is imaged. In this paper, we illustrate methods by which this new technology can be used to examine events in fertilization and early development in three dimensions. Different types of specimen preparation protocols, using both echinoderm and mammalian gametes and embryos, are evaluated for their ability to preserve accurately the three-dimensional organization of these specimens for imaging by both low-voltage scanning electron microscopy and laser scanning confocal light microscopy.

Differential behavior of centrosomes in unequally dividing blastomeres during fourth cleavage of sea urchin embryos

The fourth cleavage in sea urchin embryos is unequal and represents an initial step in cell differentiation: vegetal blastomeres divide to produce micromeres, which are precursors of the skeletogenic mesenchyme, and macromeres. The mitotic spindles of these unequally dividing cells are peripherally located and lie orthogonal to the vegetal pole plasma membrane; the aster of the micromere pole is closely apposed to the plasmalemma and presents a characteristic flattened profile. In order to investigate the role of centrosomes in the generation of the asymmetric vegetal spindle at fourth cleavage, structural dynamics of centrosomes in both equally and unequally dividing blastomeres were compared using immunofluorescence methods. Quantitation of immunofluorescence and three-dimensional reconstruction techniques demonstrate that micromere centrosomes differ from macromere centrosomes in two respects: (1) micromere spindle poles contain less centrosomal material than macromere poles, and (2) micromere centrosomes undergo a specific filiform elongation during late anaphase and telophase. The behavior of micromere centrosomes suggests that a unique spindle pole event, involving interactions of the microtubular cytoskeleton, centrosome and cell cortex, occurs during the process of unequal cleavage of vegetal blastomeres.

Ultrastructure of the intercalated body, a novel organelle associated with fluid forming cells in the organ of Corti

The intercalated body is a newly discovered organelle in the inner and outer spiral sulcus cells of the mouse organ of Corti. The organelle was found in the cochleas of 14-day and older intact mice and in organs in culture of corresponding ages. The organelle consists of a stack of interconnected cisternae of endoplasmic reticulum and of membrane bound rodlets that are intercalated between, and run parallel to, the cisternae. The cisternal membranes are predominantly smooth, but some may display ribosomes. Most rodlets are from 1 to 2 microns long, about 0.1 micron wide, and contain electron dense material. Mitochondria are commonly associated with or incorporated into the organelle. Some electron micrographs suggest that the rodlets may originate from modified mitochondria. It is our impression that the formation of the organelle begins with the apposition of cisternae and mitochondria. Cisternal-associated mitochondria appear to constrict, elongate, and lose their inner membranes. In both the intact animal and in culture, the cells of the inner and outer spiral sulci display microvilli, apical junctional complexes, lateral intercellular spaces containing interdigitating cell processes, and appear to be involved in fluid formation. Moreover, in culture, the cells of inner and outer spiral sulci as well as some cells proliferating in the outgrowth zone participate in fluid formation, producing large fluid pockets. All these cells commonly contain intercalated bodies. It is possible that in the intact animal, as in culture, intercalated bodies may play a role in fluid regulation in the immediate vicinity of the hair cells.

Herpesvirus group antibodies in children with Hodgkin's disease

During the period of three years ((1972-1974), serum samples from 60 patients (children and adolescents) with lympho-hematopoietic system diseases were examined for antibodies to all four human herpesviruses. Among these were 26 active Hodgkin's disease (AHD) patients and 6 HD patients with a minimum five years' remission. Simultaneously matched controls (age, sex) of AHD patients were examined. Antibody levels against the viral capsid antigen of Epstein-Barr virus (EBV/VCA) in AHD patients were significantly higher, with overrepresentation of higher titres (greater than or equal to 1:160), than in matched controls. The lowest EBV/VCA antibody titres were in the leukemia-non-Hodgkin's lymphoma patients. We could not prove any significant relationship between cytomegalovirus or herpes simplex virus type 1 antibody titres and AHD or any other disease of lympho-hematopoietic system. The varicella-zoster virus antibody titres in AHD patients were significantly higher than in matched controls. No significant differences in antibodies against EBV/VCA and the other human herpes viruses between the evolution and remission period of AHD patients could be detected. No differences in EBV/VCA antibody titres were observed between the healthy school-children aged 10 to 15 years who were and who were not in contact with a HD patient.