Contraindications For Anticoagulation Research Articles

Percutaneous Pharmacological Thrombolysis as an Effective Primary Mode of Management of Thrombosed Prosthetic Arterio-Venous Grafts

Abstract Background Thrombosis of prosthetic arterio-venous graft (PAVG) is the most common cause of failure of using this access for haemodialysis (HD) in end stage kidney disease (ESKD) patients. Many different open surgical and vascular techniques were described to restore the function of thrombosed PAVG. Objectives We wanted to assess the feasibility and patency rates following the continuous thrombolysis infusion using tissue Plasminogen Activator (tPA) followed by angiogram and angioplasty of stenotic segment(s) in thrombosed PAVG. Methods We performed retrospective analysis of prospectively collected data from patients who had a thrombosed AVG from January 2020 to January 2022. Thrombolysis took place maximum 7 days after thrombosis was diagnosed. We have excluded patients who were referred to us more than a week after thrombosis occurred and patients with relative or absolute contraindication for thrombolysis and/or anticoagulation. Results During the two years of the study, there were 58 patients referred to our centre with thrombosed PAVG. We have excluded 28 patients who didn’t fulfill inclusion criteria. We have performed PAVG continuous thrombolysis infusion using tPA till we have achieved reopening of the thrombosed PAVG followed by angiography and angioplasty. All patients had venous anastomosis stenosis while 17 patients had stenosis in the graft and only 5 had a stenosis at the arterial anastomosis. During the period of follow up primary patency was achieved in 80% of our patients while our primary assisted patency was 86.67% Conclusions Endovascular tPA thrombolysis for early thrombosis of prosthetic AVAs is feasible, safe, and is associated with an excellent technical success and very good 12 months patency rate.

Acute haemodynamic changes during left atrial appendage closure

Abstract Purpose Left atrial appendage closure (LAAC) presents an alternative treatment for stroke prevention in atrial fibrillation (AF) in patients with contraindication for long-term anticoagulation. However, even in patients in AF, left atrial appendage plays an important role in reservoir function of left atrium. The purpose of this study was to assess acute hemodynamic effects during LAAC. Methods Consecutive patients indicated for LAAC from January 2022 to October 2023 were enrolled. The invasive hemodynamic measurements were done at the beginning of the procedure after transseptal puncture, and at the end from the procedure after device deployment. Following parameters were measured: systolic, and diastolic blood pressure, and pressure in left atrium (LA), all measurements were done at rest and after 3 minute isometric exercise (handgrip). Results Thirty-two patients were included (age 76,2+7,1 yrs, 22 (69%) males, 23 (72%) permanent AF, left ventricular ejection fraction 52+11,8%). No patients experienced moderate/severe mitral insufficiency, the saline intake during procedure was 738 ml. Isometric exercise significantly increased the LA pressure: the LA pressures (rest/exercise) were 13.7+6.7 mmHg/16.7+8.8 mmHg (p=0.003) at the beginning of the procedure, and 17.0+7.3mmHg/20.0+7.3 mmHg (p=0.005) after device deployment. The LA pressure obtained after device deployment (both rest/exercise) were significantly higher compared to values obtained at the beginning of the procedure. (p=0.003). Conclusions LAAC is associated acute increase of both rest and exercise LA pressure. Whether its acute negative effect remains over time needs further investigation.

Left Atrial Appendage Occlusion in Patients With Anticoagulation Failure vs Anticoagulation Contraindication

BackgroundLeft atrial appendage occlusion (LAAO) provides mechanical cardioembolic protection for atrial fibrillation (AF) patients who cannot use oral anticoagulation therapy (OAT). Patients with a thrombotic event despite OAT are at high risk for recurrence and may also benefit from LAAO. ObjectivesThis study sought to investigate the efficacy of LAAO in AF patients with a thrombotic event on OAT compared to: 1) LAAO in AF patients with a contraindication for OAT; and 2) historical data. MethodsThe international LAAO after stroke despite oral anticoagulation (STR-OAC LAAO) collaboration included patients who underwent LAAO because of thrombotic events on OAT. This cohort underwent propensity score matching and was compared to the EWOLUTION (Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology) registry, which represents patients who underwent LAAO because of OAT contraindications. The primary outcome was ischemic stroke. Event rates were compared between cohorts and with historical data without OAT, yielding relative risk reductions based on risk scores. ResultsAnalysis of 438 matched pairs revealed no significant difference in the ischemic stroke rate between the STR-OAC LAAO and EWOLUTION cohorts (2.5% vs 1.9%; HR: 1.37; 95% CI: 0.72-2.61). STR-OAC LAAO patients exhibited a higher thromboembolic risk (HR: 1.71; 95% CI: 1.04-2.83) but lower bleeding risk (HR: 0.39; 95% CI: 0.18-0.88) compared to EWOLUTION patients. The mortality rate was slightly higher in EWOLUTION (4.3% vs 6.9%; log-rank P = 0.028). Relative risk reductions for ischemic stroke were 70% and 78% in STR-OAC LAAO and EWOLUTION, respectively, compared to historical data without OAT. ConclusionsLAAO in patients with a thrombotic event on OAT demonstrated comparable stroke rates to the OAT contraindicated population in EWOLUTION. The thromboembolic event rate was higher and the bleeding rate lower, reflecting the intrinsically different risk profile of both populations. Until randomized trials are available, LAAO may be considered in patients with an ischemic event on OAT.

Percutaneous left atrial appendage occlusion and risk of stroke, hospitalized bleeding and death in Medicare beneficiaries.

Among patients with atrial fibrillation (AF), a nonpharmacologic option (e.g., percutaneous left atrial appendage occlusion [LAAO]) is needed for patients with oral anticoagulant (OAC) contraindications. Among beneficiaries in the Medicare fee-for-service coverage 20% sample databases (2015-18) who had AF and an elevated CHA2DS2-VASc score, we assessed the association between percutaneous LAAO versus OAC use and risk of stroke, hospitalized bleeding, and death. Patients undergoing percutaneous LAAO were matched to up to five OAC users by sex, age, date of enrollment, index date, CHA2DS2-VASc score, and HAS-BLED score. Overall, 17 156 patients with AF (2905 with percutaneous LAAO) were matched (average ± SD 78 ± 6 years, 44% female). Cox proportional hazards model were used. Median follow-up was 10.3 months. After multivariable adjustments, no significant difference for risk of stroke or death was noted when patients with percutaneous LAAO were compared with OAC users (HRs [95% CIs]: 1.14 [0.86-1.52], 0.98 [0.86-1.10]). There was a 2.94-fold (95% CI: 2.50-3.45) increased risk for hospitalized bleeding for percutaneous LAAO compared with OAC use. Among patients 65 to <78 years old, those undergoing percutaneous LAAO had higher risk of stroke compared with OAC users. No association was present in those ≥78 years. In this analysis of real-world AF patients, percutaneous LAAO versus OAC use was associated with similar risk of death, nonsignificantly elevated risk of stroke, and an elevated risk of bleeding in the post-procedural period. Overall, these results support results of randomized trials that percutaneous LAAO may be an alternative to OAC use for patients with contraindications.

Fibrillatory wave amplitude and thromboembolic risk in non-anticoagulated patients with atrial fibrillation

Background The benefit of oral anticoagulation in atrial fibrillation (AF) is well established for patients at elevated stroke risk, but less clear for those at intermediate risk. We investigated whether analysis of electrocardiogram (ECG) derived fibrillatory waves (F-waves) could help identify patients at risk for stroke and systemic embolism (SSE). Methods The Finnish Cardioversion (FinCV) study included patients not on permanent anticoagulation therapy who underwent cardioversion for an acute AF episode. We identified 739 individuals with a valid ECG and complete follow-up data. The maximum amplitudes of the F-waves in leads II and V1 were manually measured from the pre-procedure ECG. Patients were categorized into fine and coarse F-wave groups. The optimal lead and amplitude threshold for grouping were found in an events per person-years analysis. SSE were identified from the patient medical records until either anticoagulation was prescribed, AF was deemed chronic, the patient had deceased, or the end of follow-up. Results Overall 37 (5.0%) patients suffered SSE during the median follow-up time of 5.4 years (1.9–10.8). Measured from lead V1 the SSE rates per 100 person-years were 1.5 and 0.7 in fine and coarse F-wave groups, respectively. Fine F-waves were observed in 112 (15.2%). Baseline characteristics were similar between the groups. Fine F-wave predicted SSE in a competing risk analysis (SHR 2.34, 95%CI 1.12–4.87, p = .023). Analyses from lead II did not provide significant results. Conclusion Electrocardiographic F-wave amplitude may provide additional information on stroke risk in patients with paroxysmal AF and borderline indications or contraindications for anticoagulation.

Rare Complication of Inferior Vena Cava Filter Implantation

Inferior vena cava filters are a valid option in treating patients with deep vein thrombosis of the lower limbs with contraindication or failure of anticoagulation or in cases of recurrent pulmonary embolism under adequate levels of anticoagulation. It should be recognized that, like any procedure, the implantation of these devices is not without complications, and migration is a rare but potentially severe late complication. The authors present the case of migration of a vena cava filter into the right ventricle in a 54-year-old female patient with a history of arterial hypertension and previous hospitalization for bilateral infrapatellar DVT.

Comparison of different intervention methods to reduce the incidence of venous thromboembolism: study protocol for a cluster-randomized, crossover trial

BackgroundVenous thromboembolism (VTE) remains a priority challenge among orthopedic trauma patients. It is crucial to further improve the prophylaxis against VTE in routine orthopedic treatment. This study aims to compare the efficacy of two low molecular weight heparin (LMWH) regimens and additional intermittent pneumatic compression in preventing VTE among orthopedic trauma patients.Methods and analysisThis is a cluster-randomized crossover clinical study conducted in four hospitals in Shanghai from December 2019 to December 2023. The unit of randomization is orthopedic wards, and each ward will define a cluster. All clusters will implement four diverse intervention measures and one control measure in a given random sequence. Perioperative orthopedic trauma patients aged ≥ 18 years with stable vital signs, Caprini score > 2, and no contraindication of anticoagulation or intermittent pneumatic compression (IPC) devices will be eligible. The sample size will be determined to be 2590, considering cluster effect, period effect, and interactions. We will generally use the intention-to-treat (ITT) at the subject level for each outcome. For the primary outcome of the study, the incidence of VTE will be presented as risk ratio and 95% CIs. Generalized estimating equation (GEE) will be deployed to compare differences and adjust cluster effect, period effect, and interaction among interventions and periods if applicable.DiscussionVTE is a complication that cannot be underestimated after major orthopedic surgery. Early identification, early assessment, and early prevention can significantly reduce the incidence of VTE. Most guidelines recommend both medical and physical prevention, and we hope to demonstrate how they would affect the incidence among perioperative orthopedic patients. We want to explore if there is a difference between the two types of LWMH with or without an IPC device to provide more evidence for future guidelines and prevent more patients from the threat of VTE.Ethics and disseminationThe study received approval from the IRB of the coordinating center and all participating hospitals. Findings will be disseminated through peer-reviewed publications and conference presentations.Trial registrationChiCTR1900027659. Registered on 17 November 2019

P112 CLINICAL OUTCOMES OF LEFT ATRIAL APPENDAGE OCCLUSION WITH CONSCIOUS SEDATION WITHOUT ANESTHESIOLOGIST ON SITE: RESULTS FROM A MULTICENTER RETROSPECTIVE STUDY

Abstract Background Left atrial appendage (LAA) occlusion is an important therapeutic option to prevent cardioembolic stroke in patients with atrial fibrillation (AF) with contraindications for oral anticoagulation (OAC). It is usually performed with transesophageal echocardiography (TOE) under general anesthesia (GA). In this retrospective study we present a multicenter experience of LAA occlusion performed with conscious sedation (CS) without anesthesiologist on site. Methods We collected all the LAA occlusion procedures performed from October 2018 to May 2022. All the included patients underwent the procedure for OAC intolerance mainly due to bleeding with irreversible causes. All the procedures were performed with Watchman or Amulet LAA occluders under TOE and fluoroscopy guidance by two expert interventional cardiologists without anesthesiologist on site. CS was performed with a combination of midazolam and fentanyl. Results One hundred and fifteen patients (age 76.4 ± 7.6 year) with non–valvular AF (median CHA2DS2Vasc 4.4 ± 1.4) were included in the study. CS was performed using midazolam (mean dose 5.9 ± 2.1 mg), adding fentanyl (mean dose 52.8 ± 19.6 mcg) in case of poor tolerance of the procedure despite midazolam. Acute procedural success rate was of 99.2%. One patient suffered a cardiac tamponade, urgent necessity of cardiac surgery and died 5 days after procedure. Two patients (2.6%) had anemia with need for transfusion after interventions. A patient (0.8%) suffered from oropharynx hematoma due to TOE. One case (0,8%) of vascular access site pseudoaneurysm occurred. One case (0.8%) of device thrombosis at 3 months TOE follow–up was reported. One procedure (0.8%) result in large leak device (³5 mm), confirmed at TOE follow–up performed at 3 months follow–up. No thromboembolic complications were reported. One hundred and fourteen (99.2%) patients stopped dual antiplatelet therapy within 12 months. In a follow–up of 10 ± 9 months one case of stroke (0.8%) and one case (0.8%) of transient ischemic attack (TIA) occurred. Conclusion LAA occlusion performed under CS and without the presence of anesthesiologist in cath–lab appear to be safe and effective. It can be an attractive alternative to (GA) because of lower medical staff needed and organizational effort required. In our retrospective study the success rate and the incidence of adverse events appear to be comparable with those of previous studies on the topic of LAA occlusion

The Canadian WATCHMAN Registry for Percutaneous Left Atrial Appendage Closure

BackgroundAccess to left atrial appendage closure (LAAC) in Canada is limited, due to funding restrictions. This work aimed to assess Canadian clinical practice on patient selection, postprocedural antithrombotic therapy, and safety and/or efficacy with WATCHMAN device implantation. MethodsSeven Canadian centres implanting the WATCHMAN device participated in this prospective multicentre, observational registry. All procedures were done under general anesthesia with transesophageal echocardiography guidance. Patients were prospectively followed for 2years. The long-term stroke rate was compared with the expected rate based on the CHA2DS2-VASc score. ResultsA total of 272 patients who underwent LAAC with the WATCHMAN device between December 2013 and August 2019 (mean age: 75.4 years [standard deviation {SD}: 8.75]; male, 63.2%; CHA2DS2-VASc score: 4.35 [SD: 1.64]; HAS-BLED score: 3.55 [SD: 0.94]) were included. Most patients (90.4%) had prior history of bleeding (major, 80.5%; minor, 21.7%). The WATCHMAN device was successfully implanted in 269 patients (98.9%), with a few procedure-related complications, including 5 pericardial effusions requiring drainage (1.8%), and 1 death (0.4%; 22 days post-LAAC from respiratory failure). Post-LAAC antithrombotic therapy included dual antiplatelet therapy in 70.6%, single antiplatelet therapy in 18.4%, and oral anticoagulation in 13.6%. During the follow-up period (mean: 709.7 days [SD: 467.2]), an 81.4% reduction of the ischemic stroke rate occurred, based on the expected rate from the CHA2DS2-VASc score (6.0% expected vs 1.1% observed). Device-related thrombus was detected in 1.8%. ConclusionsThe majority of Canadian patients who underwent LAAC had oral anticoagulation contraindication due to prior bleeding, and most were safely treated with antiplatelet therapy post-LAAC, with a low device-related thrombus incidence. Long-term follow-up demonstrated that LAAC achieved a significant reduction in ischemic stroke rate.

Percutaneous left atrial appendage occlusion in patients with a cardiac implantable electronic device

BackgroundLeft atrial appendage occlusion (LAAO) may be a viable option for stroke prevention in patients with non-valvular atrial fibrillation and a contraindication for oral anticoagulation. No evidence evaluating the safety of this procedure in patients with a cardiac implantable electronic device (CIED) exists. The aim of this study was to evaluate whether CIED function is affected by LAAO and to explore LAAO procedural characteristics and complications in patients with a CIED.MethodsThis single-center cohort study included consecutive patients scheduled for percutaneous LAAO. Patients with a CIED prior to LAAO were selected and compared to the patients without CIED, concerning procedural characteristics and peri-procedural complications. In the group of patients with CIEDs, essential pacemaker integrity parameters were compared before and after the procedure to detect possible micro and macro lead displacements.ResultsThirty-one patients with CIED were scheduled for LAAO (age 73.7 ± 5.4 years, 65% males, CHA2DS2-VASc 4.3 ± 1.5, and HAS-BLED 3.3 ± 1.0). The 245 patients without CIED were younger, and HAS-BLED-score was slightly lower (69.4 ± 8.2 years, p < 0.001; 2.8 ± 1.0, p = 0.022). Patients without CIED more frequently underwent LAAO combined with catheter ablation (p = 0.002). All other procedural characteristics were comparable between both groups. No visible lead displacement was observed on chest X-ray after LAAO. Additionally, no differences in impedance, threshold, or intracardiac sensing in various CIED lead locations were found prior versus post LAAO.ConclusionThis study supports the feasibility and safety of LAAO in patients with a CIED.

Peri- and Post-procedural Anticoagulation with Left Atrial Appendage Occlusion Devices.

In patients with atrial fibrillation and high stroke risk, anticoagulation with direct oral anticoagulants or vitamin K antagonists is the standard of care for stroke prevention. The benefit of anticoagulation is driven by attenuating the risk of thrombus formation in the left atrial appendage. Percutaneous left atrial appendage occlusion offers an alternative therapeutic strategy for stroke prevention in patients with high bleeding risk or contraindications for long-term anticoagulation. This review of the current literature delineates the standard protocols of peri- and post-procedural anticoagulation/antithrombotic therapy after left atrial appendage occlusion, the complications of the procedure, and the risk of device-related thrombosis and of incomplete occlusion of the appendage. Finally,the limitations and gaps in the literature are identified.

The risk-benefit balance of anticoagulant treatment: case report

A 76-year-old female presents at the emergency department with dyspnea and pleuritic, sharp right laterothoracic pain that started suddenly. Her medical history includes stage 2 hypertension, diabetes mellitus type 2, chronic obstructive pulmonary disease stage IV GOLD with home oxygen therapy, chronic pulmonary heart disease, diffuse interstitial lung disease with a previous episode of alveolar hemorrhage, chronic renal disease stage 2, and paroxysmal atrial fibrillation, for which she had a Watchman device implanted, taking into consideration her anticoagulation contraindication due to the previous alveolar hemorrhage episode. The biological findings reveal hypoxemia and hypocapnia, a positive D-dimer test, an inflammatory syndrome, mild hypopotassemia, acute decompensation of chronic renal disease, and a positive urine culture with Enterococcus faecium. Emergency thoracic computed tomography reveals bilateral pulmonary thromboembolism. Immediate parenteral anticoagulation and antibiotic therapy are initiated with favorable evolution. At discharge, concerning the risk-benefit balance of anticoagulation in a senior patient with multiple comorbidities, the anticoagulant therapy is changed to a novel oral anticoagulant for at least three months, with reevaluation needed after that period.

Temporary inferior vena cava filters factors associated with non-removal.

Inferior vena cava filter (IVCF) placement is indicated when there is a deep vein thrombosis and/or a pulmonary embolism and a contraindication of anticoagulation. Due to the increased risk of recurrent deep venous thrombosis when left in place, IVCF removal is indicated once anticoagulant treatment can be reintroduced. However, many temporary IVCF are not removed. We aimed to analyze the removal rate and predictors of filter non-removal in a university hospital setting. We collected all the data of consecutive patients who had a retrievable IVCF inserted at the Saint-Etienne University Hospital (France) between April 2012 and November 2019. Rates of filter removal were calculated. We analyzed patient characteristics to assess factors associated with filter non-removal, particularly in patients without a definitive filter indication. The exclusion of this last category of patients allowed us to calculate an adjusted removal rate. The overall removal rate of IVCF was 40.5% (IC 95% 35.6-45.6), and the adjusted removal rate was 62.9 % (IC 95% 56.6-69.2%). No major complications were noted. Advanced age (p < 0.0001) and cancer presence (p < 0.003) were statistically significant predictors of patients not being requested to make a removal attempt. Although most of the filters placed are for therapeutic indications validated by scientific societies, the removal rate in this setting remains suboptimal. The major factors influencing IVCF removal rate are advanced age and cancer presence. • Most vena cava filters are placed for therapeutic indications validated by scientific societies. • Vena cava filter removal rates in this setting remain suboptimal. • Major factors influencing IVCF removal rate are advanced age and cancer presence.

1081: MUSCLE PAIN IN A PATIENT WITH RECENT SARS-COV-2 INFECTION

Introduction: Thrombosis associated with SARS-CoV-2 infection has been well established. Even patients with mild disease, who are able to treat their symptoms at home without supplemental oxygen, are prone to significant sequelae of the disease process. IVC filters, while once considered a standard treatment for deep vein thrombosis (DVT), have fallen out of favor except when there are absolute contraindications for therapeutic anticoagulation due to increased risk of significant adverse events directly correlating with time in-situ including migration, thrombosis, and tears/dissection of the aorta or associated vessels. Description: A 45 y/o F with h/o insulin dependent DM2 and HTN presented for evaluation of bilateral leg cramps with subjective numbness and abdominal pain in the setting of recent COVID-19 infection treated at home. Her exam was notable for significant quadriceps tenderness and induration bilaterally with diminished distal pulses. Initial lab work was significant for lactic acidosis of 6.1, CK 110, and creatinine 2.2. She was admitted to ICU for oliguric AKI and vasopressor support. Broad autoimmune workup was negative. Her renal function continued to deteriorate eventually prompting kidney replacement therapy. Doppler US revealed bilateral DVT in the femoral and popliteal veins. Her CK was monitored daily given continued concern for rhabdomyolysis. CK was >20,000 by day five. Concern for congestive nephropathy prompted CT with contrast of abdomen, pelvis which showed extensive DVT throughout the visualized femoral and iliac veins, extending superiorly past an IVC filter to the inferior margin of the liver. At this time, the patient confirmed she had an IVC filter placed roughly eight years prior after an MVC. The patient underwent successful catheter-directed thrombolysis. Her symptoms slowly improved during her hospitalization which totaled 33 days. The patient was able to discontinue outpatient hemodialysis after 1.5 months. Discussion: It is imperative to obtain complete history in patients with recent COVID as underlying predisposition for thrombosis can greatly increase their morbidity and mortality even with seemingly mild infection. The combination of two highly pro-thrombotic foci in this patient resulted in multi-system sequelae of large IVC and femoral vein thrombosis.

692 THE USE OF ULTRASOUND ENHANCING AGENTS (UEA) IN THE EVALUATION OF LEFT ATRIAL APPENDAGE (LAA) THROMBUS IN PATIENT CANDIDATE TO PERCUTANEOUS LAA CLOSURE

Abstract Introduction Left atrial appendage closure (LAAC) is an emerging option in patients with atrial fibrillation (AF) and contraindication for oral anticoagulation (OAC) therapy. Patients with left atrial thrombus are usually excluded from this strategy. Therefore, pre-procedural transesophageal echocardiography (TEE) is usually performed for LAA thrombus exclusion. The application of second-generation lipid microspheres ultrasound enhancing agents (UEA) is of growing interest. The following clinical cases reports describe the benefit from UEA implication on subsequent decision-making regarding with LAAC procedure. Case report num.1 an 88-year-old male with history of symptomatic AF and post – traumatic cerebral bleeding was referred to LAAC because of high risk of bleeding in using OAC. Transthoracic echocardiography (TTE) documented a severely dilatated left atrium and preserved left ventricular systolic function. Pre – operative TEE revealed a “chicken wing” shaped LAA with severe spontaneous echo-contrast and sludge effect. Echo-contrast medium “SonoVue” showed an early filling defect with late but complete LAA opacification, excluding thrombus. Of note, ECG-gated cardiac CT (CCT) could not exclude filling defect with certainty. Consecutively, the patient was candidate to LAAC in a short time. Case report num.2 a 75-year-old man with valvular permanent AF and multi-territory ischemic ictus despite being on adequate prophylactic OAC (Warfarin). At TTE a dilated left ventricle with mildly reduced ejection fraction was documented. ECG – gated CCT with delayed phases imaging showed a possible filling defect in LAA, however imaging was suboptimal due to a reverb of voluminous hiatal hernia. TEE revealed a “windstock” shaped LAA with incomplete distal opacification when echo-contrast medium “SonoVue” was used, confirming thrombus. The patient was therefore referred for LAAC procedure with concomitant use of cerebral embolic protection devices (CEPDs). Discussion Transesophageal echocardiography is the test of choice for the exclusion of LAA thrombus. However technical difficulty, spontaneous echo contrast (SEC) and prominent pectinate musculature within the appendage may make the exclusion of LAA thrombus not easy. ECG – gated cardiac CT may be conclusive as well. UEA use is associated with higher diagnostic power for LAA thrombus exclusion and recent study have shown its utility also in terms of LAA sizing. Thus, the most recent guidelines of American Society of Echocardiography mention echo contrast use for the delineation of LAA thrombi and differentiate between them with SEC. Conclusion The use of ultrasound enhancing agents is useful and increases the interpretative confidence in exclusion of LAA thrombus.

Transcatheter Left Atrial Appendage Occlusion: A Multi-Center Real Life Experience

(1) Background: left atrial appendage occlusion (LAAO) is considered an effective and relatively safe treatment for the prevention of thromboembolic events in patients with atrial fibrillation and a contra-indication for anticoagulation. We present a large multicenter real-world experience of transcatheter LAAO implementation in patients with atrial fibrillation who cannot be treated with chronic anti-coagulation; (2) Methods: included were atrial fibrillation patients who underwent transcatheter LAAO between 1 January 2016 and 30 June 2021. The study was conducted using the electronic health record database of Clalit Health Services (CHS). The primary outcomes included hemorrhagic and ischemic stroke following LAAO; (3) Results: included were 389 atrial fibrillation patients. During a median follow-up of 2.1 years, 13% patients had ischemic cerebrovascular accident (CVA), and 4.4% patients had hemorrhagic CVA. While the risk of ischemic stroke increased gradually over time, the risk of hemorrhagic CVA was highest during the first 3 months following the procedure. Moreover, previous ischemic stroke was the only significant predictor for both hemorrhagic and ischemic stroke following LAAO; (4) Conclusions: while the annual performance rate of transcatheter LAAO has increased significantly over the past years, post procedural long-term prognosis remains poor with a substantial risk of both thrombotic and bleeding events.

Inferior vena cava filters in pregnancy: Safe or sorry?

Potential hazards of vena cava filters include migration, tilt, perforation, fracture, and in-filter thrombosis. Due to physiological changes during pregnancy, the incidence of these complications might be different in pregnant women. To evaluate the use and safety of inferior vena cava filters in both women who had an inferior vena cava filter inserted during pregnancy, and in women who became pregnant with an inferior vena cava filter in situ. We performed two searches in the literature using the keywords "vena cava filter", "pregnancy" and "obstetrics". The literature search on women who had a filter inserted during pregnancy yielded 11 articles compiling data on 199 women. At least one filter complication was reported in 33/177 (19%) women and included in-filter thrombosis (n = 14), tilt (n = 6), migration (n = 5), perforation (n = 2), fracture (n = 3), misplacement (n = 1), air embolism (n = 1) and allergic reaction (n = 1). Two (1%) filter complications led to maternal deaths, of which at least one was directly associated with a filter insertion. Filter retrieval failed in 9/149 (6%) women. The search on women who became pregnant with a filter in situ resulted in data on 21 pregnancies in 14 women, of which one (6%) was complicated by uterine trauma, intraperitoneal hemorrhage and fetal death caused by perforation of the inferior vena cava filter. The risks of filter complications in pregnancy are comparable to the nonpregnant population, but could lead to fetal or maternal death. Therefore, only in limited situations such as extensive thrombosis with a contraindication for anticoagulants, inferior vena filters should be considered in pregnant women.

Trends in percutaneous left atrial appendage occlusion and 1-year mortality: a nationwide cohort study

Abstract Background Percutaneous left atrial appendage occlusion (LAAO) is increasingly used for stroke prevention in high-risk patients with atrial fibrillation and contraindication for oral anticoagulation. However, studies evaluating comorbidities and mortality remain scarce. Objectives The aim of this study was to evaluate changes in patient characteristic over time and 1-year risk of death. Methods Using Danish nationwide registers, we included all patients undergoing first-time LAAO between 2013 and 2021. To evaluate changes in patient characteristics, the study population was stratified according to calendar year of LAAO procedure: 2013–2015, 2016–2018, and 2019–2021. Baseline patient characteristics were defined from 10 years prior to date of LAAO procedure. Antithrombotic therapy was defined as claimed prescriptions within 180 days prior to LAAO procedure. Patients were then followed until either emigration, death, one year of full follow-up, or end of study period. Baseline frailty risk was estimated with The Hospital Frailty Risk Score, a validated frailty risk assessment tool based on ICD-10 codes. The 1-year unadjusted risk of death was estimated with the Aalen-Johansen method. Results In total, 1,306 patients underwent LAAO. The number of LAAO increased from 201 procedures in 2013–2015 to 586 in 2019–2021. During follow-up, the age of the patients remained stable (2013–2015: median age: 70 years; 2016–2018: median age 69 years; 2019–2021: median age 69 years). Fewer patients had a history of ischemic stroke (2013–2015: 44.3% vs 2019–2021: 27.6%), hemorrhagic stroke (2013–2015: 32.8% vs 2019–2021: 21.0%), and previous bleeding (2013–2015: 71.1% vs 2019–2021: 59.2%). Median CHA2DS2-VASs score decreased over time (2013–2015: 4 vs 2019–2021: 3) and same trend was found in median HAS-BLED score (2013–2015: 3 vs 2019–2021: 2). In addition, fewer patients were categorized as high frailty risk (2013–2015: 16.9% vs 2019–2021: 8.9%). However, there was an increase in patients with a history of cancer (2013–2015: 11.9% vs 2019–2021: 18.9%). The use of antiplatelet therapy prior to LAAO decreased while the use of oral anticoagulation increased (2013–2015: 50.2% vs 2019–2021: 68.9%) due to a marked increase in non-vitamin K antagonist oral anticoagulants and a decrease in vitamin K antagonists (Figure 1). In total, 88 (7.22%) patients died within one year of LAAO procedure. The 1-year all-cause mortality risk in each period were similar (2013–2015: 7.0%; 2016–2018: 7.1%; 2019–2021: 6.9%). [Figure 2] Conclusion In the years 2013–2021, the annual number of LAAO procedures increased. The age of patients remained stable. Comorbidity burden decreased and fewer patients were at high frailty risk, but the 1-year mortality risks were similar. Our real-life data suggest that profiles of patients undergoing LAAO has changed considerably over time. Funding Acknowledgement Type of funding sources: None.

Percutaneous Treatment Approaches in Atrial Fibrillation: Current Landscape and Future Perspectives.

Atrial fibrillation (AF), the most common sustained arrhythmia in clinical practice, represents a major cause of morbidity and mortality, with an increasing prevalence. Pharmacologic treatment remains the cornerstone of its management through rhythm and rate control, as well as the prevention of thromboembolism with the use of oral anticoagulants. Recent progress in percutaneous interventional approaches have provided additional options in the therapeutic arsenal, however. The use of the different catheter ablation techniques can now lead to long arrhythmia-free intervals and significantly lower AF burden, thus reducing the rate of its complications. Particularly encouraging evidence is now available for patients with persistent AF or concomitant heart failure, situations in which catheter ablation could even be a first-line option. In the field of stroke prevention, targeting the left atrial appendage with percutaneous device implantation may reduce the risk of thromboembolism to lower rates than that predicted with conventional ischemic risk scores. Left atrial appendage occlusion through the approved Watchman or Amplatzer devices is a well-established, efficacious, and safe method, especially in high-ischemic and bleeding risk patients with contraindications for oral anticoagulation.

Left atrial appendage occlusion should be offered only to select atrial fibrillation patients.

Left atrial appendage occlusion should be offered only to select atrial fibrillation patients.