Left Atrial Appendage Closure Research Articles

Incidence and Predictors of Adverse Events Among Patients Awaiting Left Atrial Appendage Closure.

There is a paucity of data regarding the optimal timing of left atrial appendage closure (LAAC) and whether scheduling delays increase the risk for adverse outcomes. This study sought to assess the incidence and predictors of adverse events among patients awaiting LAAC. This single-center retrospective study assessed all patients who underwent LAAC from January 2017 to March 2020. The primary study endpoints were the rate and characteristics of adverse events occurring from the time of initial shared decision to pursue LAAC until the time of LAAC. Adverse events were defined as clinically significant bleeding or anemia, thromboembolic complications, or death. Patients were censored after successful closure or the first adverse event. Two hundred and sixty-five patients underwent LAAC with demographics notable for age 73.5 ± 8.1 years, 98 (37%) females, left ventricular ejection fraction 52.3% ± 10.4%, CHA2DS2-VASc 4.8 ± 1.4, and HAS-BLED 3.2 ± 1.2. Median time from shared decision to insurance approval and insurance approval to LAAC were 18 (IQR 28) and 44 (IQR 40) days, respectively. Seventeen (6%) patients suffered an adverse event, including 15 (88%) cases of bleeding or anemia and 2 (12%) cases of thromboembolism. Multivariate analysis demonstrated that increased time to LAAC (odds ratio [OR] 1.31, 95% confidence interval [CI] [1.15, 1.50], p < 0.001) and higher HAS-BLED score (OR 1.67, CI [1.11, 2.59], p = 0.017) were associated with significantly increased risk for adverse events. Prolonged time to LAAC and higher HAS-BLED score portend an increased risk for adverse events while awaiting LAAC. Expedited closure is warranted in high-risk patients.

Impact of intensive versus nonintensive antithrombotic treatment on device-related thrombus after left atrial appendage closure.

The optimal antithrombotic therapy (AT) after left atrial appendage closure (LAAC) is debated. We assessed the impact of intensive vs nonintensive AT on the incidence of device-related thrombus (DRT) based on whether the device implantation was classified as optimal or suboptimal. This study included patients who underwent successful LAAC in 9 centers. Patients were classified according to the quality of device implantation: optimal (proximal implant without ≥ 3 mm peridevice leak) or suboptimal (distal implant and/or ≥ 3 mm peridevice leak). Postimplant AT was classified as either intensive (dual antiplatelet therapy, anticoagulants, or a combination of both) or nonintensive (no AT or a single antiplatelet therapy). The primary endpoint was the incidence of DRT between the 6th and 12th weeks postprocedure. A total of 1225 patients underwent LAAC, with 757 (61.8%) achieving optimal device implantation and 468 (38.2%) classified as suboptimal. After a median follow-up of 20 months, the incidence of DRT in the optimal implant group was 2.6% with intensive AT and 3.7% with nonintensive AT (P =.38). In the suboptimal implant group, the incidence of DRT increased to 11.2% with intensive AT and 15.5% with nonintensive AT (P = .19). On multivariate analysis, suboptimal implantation (HR, 4.51; 95%CI, 2.70-7.54, P < .001) but not intensive AT (HR, 0,66; 95%CI, 0.40-1.07, P = .09) emerged as an independent predictor of DRT. The incidence of DRT after LAAC was higher in patients with suboptimal device implantation. In patients with optimal implantation, the incidence of DRT was low and similar between nonintensive and intensive AT strategies. Large, randomized trials are warranted to confirm these results.

Impact of Angiographically Detected Residual Trabeculation After Left Atrial Appendage Closure Using the WATCHMAN Device: Insight From the OCEAN-LAAC Registry.

Research on the impact of angiographically detected residual trabeculation after left atrial appendage closure (LAAC) is limited. To investigate the incidence, characteristics, and clinical implications of angiographically detected residual trabeculation after LAAC using the WATCHMAN device. We analyzed 1350 consecutive patients with atrial fibrillation undergoing LAAC using the WATCHMAN device from the OCEAN-LAAC registry, which is a prospective ongoing, multicenter Japanese registry. The inclusion criteria comprised patients who successfully underwent LAAC and whose presence or absence of residual trabeculation can be confirmed using a contrast medium. The clinical outcomes were compared between patients with and without angiographically detected residual trabeculation. Residual trabeculation was angiographically detected in 5.6% (75/1350 patients). At the procedure, the proportion of peri-device leak (PDL) was significantly higher in the residual trabeculation group than in the non-residual trabeculation group (20% vs. 5.1%, p < 0.001). However, the PDL and device-related thrombosis at 45 days and 1 year were comparable between the two groups (37% vs. 23%, p = 0.24; 28% vs. 31%, p = 0.84; 2.1% vs. 1.4%, p = 0.50; 6.9% vs. 6.0%, p = 0.69, respectively). The 3-year cumulative incidence of ischemic stroke, all cardiovascular death, and all-cause death were comparable between the two groups (5.7% vs. 5.5%, log-rank p = 0.96; 7.7% vs. 8.9%, log-rank p = 0.34, 31.4% vs. 22.3%, log-rank p = 0.71, respectively). The angiographically detected residual trabeculation rate was 5.6%, and this population had a significantly higher prevalence of PDL at the procedure. However, the presence of residual trabeculation did not contribute to PDL or device-related thrombosis at follow-up or affect the clinical outcomes.

Delayed Endothelialization of Left Atrial Appendage Closure Device: Discordance Between Computed Tomography and Angioscopy.

Delayed Endothelialization of Left Atrial Appendage Closure Device: Discordance Between Computed Tomography and Angioscopy.

Safety and Efficacy of Left Atrial Appendage Closure Devices: In-Vitro Controlled Simulations and In-Vivo Correlations

The "Left Atrial Appendage Closure (LAAC) Device" is specifically designed to address the problem of stroke prevention in patients with atrial fibrillation (AF). In individuals with AF, the heart's atria (upper chambers) do not beat effectively, allowing blood to pool and potentially form clots, particularly in the left atrial appendage (LAA). These clots can then travel to the brain, causing a stroke. The purpose of the Left Atrial Appendage Closure Device is to mechanically seal off the left atrial appendage, preventing blood clots from forming there and reducing the risk of stroke in patients with atrial fibrillation who are at high risk of stroke but cannot tolerate long-term anticoagulation therapy. Hence Patients with atrial fibrillation frequently develop thrombus in the Left Atrial Appendage (LAA), which significantly increases their risk of stroke. LAA closure devices block the appendage, providing a percutaneous method of lowering this risk. With an emphasis on current developments, this research article examines the history, development effectiveness, delivery &amp; deployment and safety of LAA closure devices via in-vitro simulation testing with controlled conditions.

Left Atrial Appendage Closure With Catheter Ablation vs. Ablation Alone on Outcomes of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction: A Propensity Score-Matched Analysis

Left Atrial Appendage Closure With Catheter Ablation vs. Ablation Alone on Outcomes of Atrial Fibrillation in Heart Failure With Reduced Ejection Fraction: A Propensity Score-Matched Analysis

Left Atrial Appendage Closure after Ablation for Atrial Fibrillation.

Oral anticoagulation is recommended after ablation for atrial fibrillation among patients at high risk for stroke. Left atrial appendage closure is a mechanical alternative to anticoagulation, but data regarding its use after atrial fibrillation ablation are lacking. We conducted an international randomized trial involving 1600 patients with atrial fibrillation who had an elevated score (≥2 in men and ≥3 in women) on the CHA2DS2-VASc scale (range, 0 to 9, with higher scores indicating a greater risk of stroke) and who underwent catheter ablation. Patients were randomly assigned in a 1:1 ratio to undergo left atrial appendage closure or receive oral anticoagulation. The primary safety end point, tested for superiority, was non-procedure-related major bleeding or clinically relevant nonmajor bleeding. The primary efficacy end point, tested for noninferiority, was a composite of death from any cause, stroke, or systemic embolism at 36 months. The secondary end point, tested for noninferiority, was major bleeding, including procedure-related bleeding, through 36 months. A total of 803 patients were assigned to undergo left atrial appendage closure, and 797 to receive anticoagulant therapy. The mean (±SD) age of the patients was 69.6±7.7 years, 34.1% of the patients were women, and the mean CHA2DS2-VASc score was 3.5±1.3. At 36 months, a primary safety end-point event had occurred in 65 patients (8.5%) in the left atrial appendage closure group (device group) and in 137 patients (18.1%) in the anticoagulation group (P<0.001 for superiority); a primary efficacy end-point event had occurred in 41 patients (5.3%) and 44 patients (5.8%), respectively (P<0.001 for noninferiority); and a secondary end-point event had occurred in 3.9% and 5.0% (P<0.001 for noninferiority). Complications related to the appendage closure device or procedure occurred in 23 patients. Among patients who underwent catheter-based atrial fibrillation ablation, left atrial appendage closure was associated with a lower risk of non-procedure-related major or clinically relevant nonmajor bleeding than oral anticoagulation and was noninferior to oral anticoagulation with respect to a composite of death from any cause, stroke, or systemic embolism at 36 months. (Funded by Boston Scientific; OPTION ClinicalTrials.gov number, NCT03795298.).

NEJM at AHA — Left Atrial Appendage Closure after Ablation for Atrial Fibrillation

NEJM at AHA — Left Atrial Appendage Closure after Ablation for Atrial Fibrillation

Temporal trends in the utilization, costs, and outcomes of concomitant left atrial appendage closure across a statewide collaborative

ObjectiveWith the rising incidence of atrial fibrillation, left atrial appendage closure (LAAC) at the time of cardiac surgery remains an important adjunct. The present study characterized trends, associated resource utilization, and potential disparities in the use of left atrial appendage exclusion. MethodsUsing a Society of Thoracic Surgeons regional academic collaborative database, we queried all adult patients undergoing coronary and valve procedures with concomitant LAAC between 2015 and 2021. Trends in LAAC, as well as the technique for closure, were evaluated. Multilevel hierarchical logistic modeling was applied to delineate factors associated with LAAC, accounting for patient and operative characteristics. Generalized linear models were developed to perform risk-adjusted incremental cost analysis. ResultsOf the 8699 patients who met the study criteria, 1377 underwent left atrial appendage closure. Over the study period, the annual rate of LAAC increased from 16.7% to 30.8% (P < .001). LAAC patients were older, but less commonly insulin-dependent diabetics or on dialysis. Female sex, redo, and urgent operative status had lower risk-adjusted odds of LAAC. Although LAAC was associated with longer bypass time, there was no significant association with 30-day mortality or 30-day readmission. LAAC was associated with an incremental increase in adjusted costs by $10,602 (95% confidence interval, $4078-$17,126). ConclusionsRates of LAAC are increasing but less common among female patients, as well as those requiring urgent/emergent interventions. LAAC did not significantly impact short-term mortality. Our results suggest that LAAC may be a high-value intervention among patient populations that have the greatest potential to derive its benefits.

Management of giant left atrial thrombus late after transcatheter mitral valve-in-ring replacement using a transcatheter aortic valve: a case report

BackgroundIn symptomatic high-risk patients with severe mitral valve regurgitation (MR), who are not eligible for surgery, Transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) may be an option, especially when surgical mitral valve repair by annuloplasty has been performed earlier. After TMVR, the appropriate anticoagulation regimen is still matter of debate.Case presentationWe here report on a 78-year-old frail lady with heart failure and atrial fibrillation who underwent surgical reconstruction of the mitral valve nine years ago. Due to high surgical risk and after heart team discussion, TMVR using a transcatheter aortic valve prosthesis (valve-in-ring concept) was performed successfully via the transapical access route. Several months later, an excellent result could be confirmed. Since surgical excision of the left atrial appendage was carried out during first surgery, oral anticoagulation was withdrawn. Two months later, the patient presented with a massive LA thrombus mass and severe stenosis of the mitral valve prosthesis requiring re-do surgery.ConclusionsManagement of anticoagulation in patients with atrial fibrillation and successfully performed LAA excision is still a matter of debate, in particular after transcatheter heart valve implantation in mitral position. TMVR devices may be very thrombogenic. Thus, caution should be used whenever discontinuing oral anticoagulation in these patients. Despite the lack of evidence, withdrawal of anticoagulation should be avoided here, especially in the absence of bleeding complications. Left atrial appendage closure or excision should not influence this decision.

Abstract 4122080: Outcomes of Left Atrial Appendage Occlusion With and Without Concurrent Catheter Ablation for Patients at High Bleeding Risk: A Systematic Review and Meta-analysis

Introduction: The prevalence of non-valvular atrial fibrillation (NVAF) and stroke-related morbidity is rising. First-line therapy remains rate or rhythm control with anticoagulation, with catheter ablation (CA) also considered in suitable candidates. Left atrial appendage closure (LAAC) is increasingly used due to mounting evidence of non-inferiority compared to anticoagulation. Despite improved pre-procedural planning and patient selection reducing complications, adverse outcomes such as pericardial effusion and device-related thrombus occur in about 5% of patients. This study evaluates the outcomes of LAAC with CA versus standalone LAAC in NVAF patients with contraindications to anticoagulation. Methods: We searched PubMed, EMBASE, and Cochrane databases for all cohort studies comparing LAAC with CA to LAAC alone in patients with NVAF. Case series, reviews, and non-English language studies were excluded. The assessed outcomes included device compression rate at implant, device-related thrombosis, pericardial effusion, need for pericardiocentesis, and peri-device leak at 6 weeks. Statistical analysis was performed using Review Manager 5.1.7. Heterogeneity was assessed with I 2 statistics. Results: We included 6 studies with 51,545 patients, of whom 1,221 (2.3%) underwent both procedures. LAAC with CA and standalone LAAC cohorts had similar baseline demographics including age (68, 69 years), percentage of women (48%, 46%), CHA2DS2-VASc score (3.6, 3.7), and HAS-BLED score (3.1, 3.2). LAAC with CA was associated with a reduced incidence of device-related thrombosis (OR=0.18; 95% CI= 0.04-0.89; p=0.04) without an increase in pericardial effusion rates (OR=0.85; 95% CI= 0.48-1.51; p=0.59). There were no significant differences in device compression rates at implant (MD=0.34; 95% CI= -0.77-1.45; p=0.55), the need for pericardiocentesis (OR=1.01; 95% CI= 0.30-3.48; p=0.98), or rates of peri-device leak at 6 weeks (OR=0.61; 95% CI= 0.21-1.78; p=0.37). Conclusion: Concomitant LAAC with CA may reduce rates of device-related thrombosis compared to standalone LAAC without increasing the risk of pericardial effusion or peri-device leak at 6 weeks. These findings support the consideration of combining these procedures in the management of high-risk NVAF patients unable to tolerate anticoagulation.

Abstract 4125076: Catheter Ablation Alone Versus Catheter Ablation With Combined Percutaneous Left Atrial Appendage Closure For Atrial Fibrillation: A Systematic Review and Meta-analysis

Background: Combined catheter ablation (CA) with left atrial appendage closure (LAAC) may produce comprehensive treatment for atrial fibrillation (AF) whereby rhythm control is achieved and stroke risk is reduced without the need for chronic oral anticoagulation. However, the efficacy and safety of this strategy is still controversial. Aim: To investigate the efficacy and safety of a combined CA with LAAC approach to treat AF in patients moderate-to-high-risk for bleeding. Methods: This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Risk of bias was assessed using the Modified Newcastle-Ottawa scale and Cochrane risk of bias tool. Eligible studies reported outcomes in patients with AF who underwent combined CA and LAAC versus CA alone. Studies performing CA without pulmonary vein isolation were excluded. Results: Eight studies comprising 1878 patients were included (2 RCT, 6 observational). Pooled results showed no difference in arrhythmia recurrence (risk ratio [RR] 1.05; 95% confidence interval [CI] 0.84-1.30), stroke or systemic embolism (RR 0.71; 95% CI 0.26-1.94), total procedure time (mean difference 31.45 minutes; 95% CI -5.91-68.81), or major periprocedural complications (RR 1.28; 95% CI 0.28-5.89) when comparing combined CA and LAAC versus CA alone. Conclusion: Combined CA with LAAC for AF is associated with similar rates of arrhythmia free survival, stroke, major periprocedural complications, and procedure time when compared to CA alone. A combined strategy may be as safe and efficacious for patients moderate-to-high-risk for bleeding events to negate the need for chronic oral anticoagulation.

Abstract 4137278: Efficacy and Safety of Left Atrial Appendage Closure Devices in Patients Aged Above 80 Years: A Systematic Review and Meta-Analysis

Background: Limited single-center and observational studies suggest that left atrial appendage occlusion (LAAO) may be a safe alternative in selected elderly patients with AFib. Hypothesis: We hypothesize that patients aged over 80 will have similar rates of complications and the same level of efficacy in stroke prevention as young patients. Aims: This review aims to establish the safety and efficacy of LAAO in octogenarians and nonagenarian patients with AFib. Methods: A systematic search of PubMed, Science Direct, and CENTRAL was performed for studies that reported outcomes comparing octogenarian and nonagenarian patients who underwent LAAo with their younger counterparts. The Review Manager 5.4 software was utilized to conduct a meta-analysis of the outcomes. Results: Seven observational studies consisting of 6,126 patients were included, of whom 1,879 (31%) were ≥80 years old and 4247 (69%) &lt;80 years old. The mean age of the octogenarian and older cohort ranged from 82.3 to 84.5 years, while that of the younger cohort ranged from 68.2 to 75.9 years. The mean follow-up across the studies ranged from one month to five years post-LAAO. Our pooled analysis showed no significant difference in the odds of mortality (OR 1.30; 95% CI [0.49, 3.47]; p = 0.60), all causes of stroke (OR 1.22; 95% CI [0.61, 2.43]; p= 0.57), vascular complications (OR 1.70; 95% CI [0.61,4.73]; p=0.31), and pericardial complications (OR 1.45; 95% CI [0.69, 3.05]; p = 0.33) but a significant difference in the odds of major bleeding events (OR 1.88; 95% CI [1.51, 2.34]; p&lt;0.00001)occurred in patients aged &gt;80 compared to their younger counterparts. Conclusion: This meta-analysis suggests that LAAO in patients aged 80 years and above demonstrates comparable mortality rates, post-procedural complications, and efficacy to those seen in younger patients. The findings support the safety and effectiveness of LAAO as a viable alternative for stroke prevention in very elderly patients, with additional consideration needed for those with increased susceptibility to bleeding events.

First-in-Poland thoracoscopic left atrial appendage closure using Novel AtriClip® PRO-V device in patient with previous heart surgery and LAA thrombus.

First-in-Poland thoracoscopic left atrial appendage closure using Novel AtriClip® PRO-V device in patient with previous heart surgery and LAA thrombus.

Abstract 4143224: Feasibility of Left Atrial Appendage Occlusion with Dual-Seal Technology without Pre-Procedural CT: Early Single-Center Experience

Background: Left Atrial Appendage (LAA) Occlusion with Amulet has shown promising results in achieving complete closure with minimal periprocedural leak. Amulet’s dual-sealed technology and numerous sizing options provide versatility for different LAA morphologies. Pre-procedural CT is routinely recommended for pre-procedural planning. However, this brings risks including use of contrast, risk of renal failure, radiation exposure, and patient inconvenience. Here, we share initial results of our Amulet implantation protocol without pre-procedural CT: 83 cases were reviewed; number of devices used, procedural time, periprocedural bleeding complications, success in coming off oral anticoagulation, and incidences of stroke and embolism were followed. Methods: We followed 83 AF patients who underwent LAA closure with Amulet, implanted with intraprocedural TEE, intracardiac left atrial echocardiography, and intraprocedural angiography. Pre-procedural CT was not used. Patients were followed to assess safety and efficacy of this protocol. Safety endpoints included rates of procedural and bleeding complications. Efficacy endpoints included rates of stroke and embolism, and number of devices used. Results: All 83 procedures were successfully completed with no perioperative procedural complications and no documented leaks on follow-up TEE. Patients had early ambulation with closure. On average, 1.14 devices were used per case: 88% of cases required 1 device, and nine cases required 2 devices; one case required 4 devices to fit as patient was noted to have an interrupted IVC, requiring implantation via right IJV. There were no cases of stroke or embolism following implantation, and all patients were safely able to come off oral anticoagulation. Conclusions: Results demonstrate that Amulet with its dual-sealed technology can be effectively and safely implanted without pre-procedural CT. No perioperative complications were observed. 88% of cases closed with single device usage. No post-procedure leaks were noted on follow-up TEE. Safety endpoints revealed minimal adverse events, with 2 cases of late pericardial effusion managed without long-term consequences. This protocol demonstrated high efficacy, as all patients were successfully able to come off oral anticoagulation with no reported strokes or embolic events. Intraprocedural TEE, intracardiac left atrial echocardiography, and intraprocedural angiography are typically appropriate for periprocedural sizing of the device.

Innovative Surgical Left Atrial Appendage Closure Technique: Early Experience of Inverted Spiral Closure Technique.

Simultaneous closure of the left atrial appendage (LAA) during cardiac procedures has become a common preventive measure against cardiogenic embolic events associated with atrial fibrillation. However, this strategy encounters limitations during minimally invasive mitral valve surgery through a right minithoracotomy because access to the LAA is limited. The use of endocardial sutures for surgical exclusion of the LAA is also well established but has a notable rate of closure failure. We introduced a new surgical LAA closure technique called the inverted spiral closure technique (ISCT). Between July 2020 and August 2021, 26 patients underwent LAA closure with ISCT concomitant to mitral valve surgery in our hospital. Early postoperative outcomes and any stroke or thromboembolic event during the follow-up were evaluated. Transthoracic or transesophageal echocardiography (TEE) was used to assess LAA patency. The ISCT procedure was performed successfully in all cases. No significant persistent flow between the left atrium and LAA was observed on intraoperative TEE. During a median follow-up of 1.1 years, no patients experienced stroke, myocardial infarction, or death. Postoperative echocardiography showed no significant residual flow within the LAA. One patient was incidentally found to have recanalization between the left atrium and LAA several months after surgery on an enhanced computed tomography scan during coronary evaluation. The ISCT can be performed reliably through the same left atriotomy for mitral valve surgery and is a useful and effective technique for surgical LAA exclusion. There are still not enough patients and modalities for postoperative evaluation.

Presence of patent foramen ovale does not increase cerebrovascular event rates in patients with atrial fibrillation following left atrial appendage closure

ObjectiveBoth atrial fibrillation (AF) and patent foramen ovale (PFO) has been associated with occurrences of ischemic stroke. The aim of this study was to investigate whether patients with concomitant AF and PFO were at an increased risk of stroke, and whether PFO closure was necessary for the prevention of stroke in AF patients who underwent left atrial appendage closure (LAAC). MethodWe retrospectively analyzed 614 patients who underwent LAAC at Wuhan Asia Heart Hospital from May 2014 to April 2021. We compared the baseline clinical characteristics and ischemic stroke rates before LAAC, major adverse cardiovascular events (MACEs) and other long-term outcomes between AF patients with and without PFO after LAAC. The predictor for ischemic stroke or TIA after LAAC was analyzed with univariate and multivariable Cox regression, and the long-term cumulative survival rates of AF patients with PFO compared to those without PFO after LAAC were analyzed with the Kaplan–Meier graph. ResultsA total of 614 patients who underwent LAAC and had completed follow-up data were included in our study. Among them, 74 patients were diagnosed with AF with PFO, and 540 with AF without PFO. There was no significant difference between their baseline clinical data, including ischemic stroke rates (p = 0.961). Patients with and without PFO had similar device implantation success rates (98.6 % vs 99.4 %, P = 0.403) and procedure-related complications. During follow-up (medium follow-up period 36.9 months), no significant difference was observed in the incidence of MACEs (8.1 % in PFO group vs 5.7 % in non-PFO group, P = 0.432) or the cumulative ischemic stroke/TIA rates (5.4 % in PFO group vs 4.3 % in non-PFO group, P = 0.554). The Cox multivariable regression analysis indicated that the presence of PFO in patients with AF had no correlation with ischemic stroke or TIA after LAAC implantation (HR 1.685, 95 % CI 0.570–4.978, P = 0.345). The only predictor for ischemic stroke/TIA events after LAAC was major leakage (>5 mm) seen on transesophageal echocardiography (TEE) or left atrial CTA at the 45-day follow-up (HR 10.352, 95 % CI 1.221–87.736, P = 0.032). ConclusionAF patients with PFO are not at increased risk for ischemic stroke or TIA before LAAC. The presence of PFO in AF patients did not affect the success rate and safety of LAAC. The presence of mild PFO is not a viable predictor of stroke events in AF patients who underwent LAAC during long-term follow-up. Major leakage (>5 mm) is associated with a higher ischemic stroke/TIA rate in AF patients who underwent LAAC.

Management strategies to prevent stroke in patients with atrial fibrillation and malignant left atrial appendage

BackgroundPatients with atrial fibrillation and malignant left atrial appendage (LAA) may benefit from LAA closure (LAAC); however, evidence is limited. ObjectiveThe purpose of this study was to determine management strategies and clinical outcomes in patients with atrial fibrillation and malignant LAA. MethodsMalignant LAA was defined as a history of ischemic stroke and/or evidence of LAA thrombus despite continuous oral anticoagulation (OAC) therapy (continuous for ≥3 weeks). We studied 80 patients with malignant LAA treated with LAAC. We compared these patients first against 44 patients with malignant LAA treated with OAC alone and second against 114 patients without malignant LAA who were treated with LAAC for conventional indications. ResultsAmong patients with malignant LAA (first comparison), those treated with LAAC had a higher 1-year cumulative incidence rate of ischemic stroke than did patients treated with OAC alone (6.3% vs 5.3%; log-rank, P = .09) whereas the difference in stroke risk while receiving OAC was comparable (2.7% vs 5.3%; log-rank, P = .84). Furthermore, all disabling stroke events in patients with malignant LAA treated with LAAC occurred only while not receiving OAC. Among patients treated with LAAC (second comparison), those with malignant LAA had a higher 1-year cumulative incidence rate of ischemic stroke (and ischemic stroke due to device-related thrombosis) than did those without malignant LAA (6.3% vs 2.2%; log-rank, P = .009 and 2.2% vs 0%; log-rank, P = .04, respectively). However, these differences in stroke risk were no longer significant while receiving OAC (2.7% vs 1.0%; log-rank, P = .11). ConclusionCombination performing LAAC and continuation of OAC may be options to prevent ischemic stroke in patients with high thromboembolic risk and malignant LAA.

Complex left atrial appendage closure in a multimorbid patient using AVP II occluder: A case report.

Complex left atrial appendage closure in a multimorbid patient using AVP II occluder: A case report.

Left Atrial Appendage Closure in Atrial Fibrillation Patients with Cancer.

Background: There are limited data about left atrial appendage closure (LAAC) in patients with cancer. We therefore sought to compare the outcome after LAAC in patients with vs. without cancer in a multicentre registry. Methods: In this sub-analysis of the prospective Austrian LAAC Registry, we analysed consecutive patients undergoing LAAC to assess the relationship between baseline characteristics and outcome in patients with vs. without cancer. Inverse probability weighting was performed to adjust for differences in baseline characteristics. Results: A total of 486 consecutive patients from 9 centres with a median age of 75 years (IQR 70-79 years; 35.8% female) were included. Fifty-seven patients (11.7%) had a history of cancer. The median CHA2DS2-VASc and HAS-BLED scores were similar in both groups (median [IQR], 4 [4-6] vs. 5 [3-5], p = 0.415; 4 [3-4] vs. 3 [3-4], p = 0.428 in cancer vs. other patients). Cancer patients were significantly older, and anaemia and gastrointestinal bleeding were significantly more common. Major procedural complications occurred in 5.3% vs. 7.0% (p = 0.276) of patients. The cumulative five-year survival rates were 80.7% and 84.8% in cancer vs. other patients (adjusted hazard ratio for death 1.29 [95% CI 0.67-2.48], p = 0.443). There were also no differences in one-year survival (96.1% vs. 94.0%, p = 0.582) and five-year event-free survival (64.9% vs. 74.4%, p = 0.124). Conclusions: In daily clinical practice, LAAC has already been accepted as a treatment option in patients with cancer. This retrospective analysis shows that short-term and adjusted long-term complications are similar in patients with vs. without cancer undergoing LAAC.