Left Atrial Appendage Occlusion Research Articles

Abstract 16504: Hospital Frailty Risk Score (HFRS) Predicts Adverse Events in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty and its association with adverse events are well-known in transcatheter aortic valve replacement. However, this association has not been well-studied in patients undergoing Left Atrial Appendage Closure (LAAC). Hypothesis: Frailty predicts adverse events in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from the 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Multivariate regression and receiver operating characteristic (ROC) analyses were used to assess the relationship between the HFRS and MAE. Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included, and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Frail patients were older and had a more significant proportion of women. Rates of MAE were significantly greater in frail patients (4% vs. 9.7%; p<0.001). Increasing Hospital Frailty Risk Score was associated with a greater risk of in-hospital MAE. The AUC - ROC was 0.63 (Figures: A and B). Conclusions: HFRS predicts adverse events after LAAC. HFRS could be implemented in hospital information systems to facilitate the identification of at-risk patients.

Abstract 16630: Economic Impact of Frailty in Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure (LAAC) With WATCHMAN Device

Introduction: Frailty is associated with significant morbidity and mortality in older adults. Currently, standard practice after percutaneous left atrial appendage closure involves monitoring patients overnight and discharging them the following day. Hypothesis: Frailty predicts increased hospital cost and length of stay (LOS) in patients undergoing elective LAAC with WATCHMAN device. Methods: Patients aged ≥65 years who underwent elective LAAC with WATCHMAN device were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. Multivariate regression analysis was used to assess the relationship between the HFRS and hospital cost hospitalization (≥90 centile) and prolonged LOS (>72 hours). Results: 28,050 patients (Age = 77.3 ± 6.4 years; Female = 42.6%) were included. Median hospitalization cost was $24,500 (inter-decile range: $14,000-37,100) and median LOS was 1 day (inter-decile range: 1-2 days) and 4.7% experienced in-hospital MAE. Frail patients (HFRS score ≥ 5) constituted 12.5% of the cohort. Increasing Hospital Frailty Risk Score was associated with a greater risk of high-cost hospitalization and LOS > 72 hours (Figure). Conclusions: Increasing frailty is a significant predictor of increased hospital cost and LOS in elective LAAC. This effect is independent of age and in-hospital MAE.

Abstract 14182: Outcomes From Left Atrial Appendage Occlusion Utilizing the Watchman FLX versus Watchman 2.5: A Systematic Review and Meta-Analysis

Introduction: Left atrial appendage occlusion with the Watchman device has been shown to be noninferior to oral anticoagulation in preventing strokes in patients with atrial fibrillation. The Watchman FLX device was designed to overcome many of the limitations of the Watchman 2.5. Hypothesis: The Watchman FLX will have better short- and long-term safety and efficacy relative to the Watchman 2.5. Methods: We performed an extensive literature search and systematic review of studies that compared the short- and/or long-term safety and efficacy of the Watchman FLX versus Watchman 2.5. Risk ratio 95% confidence intervals (CI) were measured using the Mantel-Haenszel method for dichotomous variables, where a RR<1.0 favors the FLX group. Results: Seven studies with a total of 2315 patients were included, of which 24.0% (n=555) had the FLX and 76.0% (n=1760) had the 2.5 implanted. There were no statistically significant differences in procedural complications or device-related thrombosis, but significantly less peri-device leak at follow-up, as shown in Figure 1. There were no statistically significant differences in pericardial effusion/tamponade (MD 0.54; 95% CI 0.09-3.25) or device embolization (MD 0.44; 95% CI 0.05-4.14). No statistically significant differences were seen in major bleeding (MD 1.06; 95% CI 0.55-2.05), transient ischemic attack, stroke or systemic embolism (MD 0.31; 95% CI 0.08-1.20) or all-cause mortality (MD 1.65; 95% CI 0.76-3.57) at follow-up. Conclusion: Based on the results of this meta-analysis, the Watchman FLX appears to be as safe as the Watchman 2.5, but with lower rates of peri-device leak.

Abstract 15554: Three-Year Incidence of Pacemaker Implantation in Patients With Atrial Fibrillation and Sinus Node Dysfunction Receiving Ablation versus Antiarrhythmic Drugs

Introduction: Around one in five patients with atrial fibrillation (AF) has a diagnosis of sinus node dysfunction (SND). Hypothesis: There will be lower incidence of pacemaker implantation (PPM) among patients with AF and SND who undergo catheter ablation (CA) compared to anti-arrhythmic drugs (AAD). Methods: Data were collected from 2014-2022 utilizing Optum Clinformatics database, an administrative claims database for commercially insured and Medicare Advantage beneficiaries in the United States. Adult patients with concomitant AF and SND, and prior history of taking at least one AAD were identified and classified into CA or AAD cohort based for subsequent treatment. Patients were excluded if they had a prior history of PPM, implantable cardiac defibrillator, catheter or surgical ablation, AV nodal ablation, valvular procedure, left atrial appendage occlusion, or high grade/complete heart block. Inverse probability treatment weighting technique was applied to balance sociodemographic and clinical comorbid characteristics between the cohorts. Weighted Cox regression model was used to evaluate the differential risk of incident PPM. Sub-analyses were performed by AF type (paroxysmal and persistent AF). Results: There were 1,206 patients in AAD cohort and 1,624 patients in CA cohort. Incidence rate (per 1,000 person-year) of PPM was 55.8 (95% CI 47.1-64.5) for CA cohort and 117.8 (95% CI 101.7-133.9) for AAD cohort and the 3-year cumulative incidence of PPM was 23.1% (95% CI 20.0%-26.2%) and 13.8% (95% CI 11.6%-15.9%), respectively. Weighted Cox regression model indicated that CA had 43% lower risk of incident PPM compared to AADs (hazard ratio [HR] 0.57; 95% CI 0.46-0.71). Those with paroxysmal AF (HR 0.48; 95% CI 0.34-0.69) had lower need for PPM compared to persistent AF (HR 0.57; 95% CI 0.40-0.81). Conclusions: Patients with AF and SND treated with CA were observed to have significantly lower risk of incident pacemaker implantation compared to those who had AAD.

Abstract 15616: Decline in Temporal Trends of Medicare Physician Reimbursement for Cardiovascular Procedures

Introduction: Utilization of cardiac procedures are common among Medicare beneficiaries and projected to increase over time. Temporal trends of physician fee reimbursement for CV procedures have not been studied. Methods: Cross-sectional study was conducted for national payment amounts that were extracted from Centers for Medicare & Medicaid Services (CMS) Physician Fee Schedule Look-Up Tool using Current Procedural Terminology (CPT) codes. Study time period ranged from 2013 through 2023. CPT codes were analyzed for coronary (percutaneous coronary intervention, coronary artery bypass graft), valvular (surgical aortic, mitral, tricuspid repair/replacement), and structural (transcatheter aortic valve replacement, mitral transcatheter edge-to-edge repair, left atrial appendage occlusion) procedures. All prices were adjusted for inflation to January 2023 US dollars. Primary outcomes were unadjusted and adjusted mean percentage changes (annual and total over 10-year period) and compound annual growth rates for each CV procedure. Results: From 2013 to 2023, mean total unadjusted percentage changes ranged from -0.54% to -21.78%; which decreased further after adjusting for inflation, ranging from -21.07% to -39.83%. The decline was seen in all studied CV procedures. Annual rates (mean and compound) were -3% for most procedures after adjusting for inflation. Conclusions: Our findings suggest a declining trend in physician reimbursement for CV procedures by Medicare, which may adversely influence access to procedures, affect commercial insurance pricing/coverage, and inform trainees and practicing CV physicians of current financial situation. Emphasis needs to be placed on value-based payment model for sustainable and efficient CV care.

Abstract 16107: Post-Cardioversion Device-Related Thrombus in a Patient With Left Atrial Appendage Occlusion Device on Apixaban

Introduction and Importance: Current guidelines recommend against pre-procedural transesophageal echocardiogram (TEE) prior to cardioversion in atrial fibrillation patients compliant with oral anticoagulants for at least 3 weeks. The relevance of these guidelines remain unclear in those undergoing repeat cardioversion. Case Presentation: 66-year-old male with a history of atrial fibrillation and an implanted left atrial appendage occlusion device(LAAO), compliant with apixaban, presented with dyspnea and lightheadedness. He was cardioverted into sinus rhythm 10 days prior to symptom onset with TEE unremarkable for thrombus. Vitals were remarkable for tachycardia and electrocardiogram revealed that the patient converted back into atrial fibrillation. Patient was then scheduled for cardioversion. At the patient’s request, a TEE was obtained which revealed a new thrombus in the left atrium located on his WATCHMAN device. Cardioversion was canceled and patient was admitted for coumadin initiation with lovenox bridge along with neurological monitoring due to increased stroke risk. Clinical Discussion: Restoration of sinus rhythm after cardioversion can lead to thrombus formation due to atrial stunning, a transitory dysfunction of the atrial appendage and atrium.Atrial stunning occurs immediately after cardioversion and can persist for several weeks. Time-span of preceding atrial fibrillation, presence of structural cardiovascular disease, and atrial size impact severity of atrial stunning and duration of anticoagulation needed.While anticoagulation decreases the risk of thrombus formation, it does not completely eliminate it, especially in those with increased stroke risk factors. Conclusion: Atrial fibrillation patients are susceptible to thrombus formation after cardioversion.Further studies should be done to assess the need for routine TEE after cardioversion in those with increased risk for stroke on anticoagulants or who have LAAO.

Abstract 17596: Association of Racial-Ethnic Disparities and Frailty on Adverse Outcomes in Geriatric Patients Undergoing Elective Percutaneous Left Atrial Appendage Closure With Watchman Device

Introduction: Use of left atrial appendage closure (LAAC) has become more widespread in the geriatric population. Frailty, a geriatric syndrome, is associated with significant morbidity and mortality. Hypothesis: Race/Ethnicity influences frailty status and may differentially impact adverse outcomes in elective LAAC procedure. Methods: Patients aged ≥65 years who underwent elective LAAC were identified using ICD-10 procedure code 02L73DK from 2016-2018 HCUP-NIS Database. Hospital Frailty Risk Score (HFRS) was calculated for each patient based on 109 ICD-10 diagnosis codes and classified into non-frail (HFRS < 5) and frail (HFRS score ≥ 5) groups. Charlson comorbidity index (CCI) was used to assess comorbidity burden. In-hospital major adverse event (MAE) was defined as the composite of mortality, stroke (ischemic or hemorrhagic) or TIA, bleeding or transfusion, vascular complications, myocardial infarction, systemic embolization, and pericardial effusion or tamponade requiring pericardiocentesis or surgery. Outcome was in-hospital MAE. Multivariate regression analysis was used to assess the association of race/ethnicity and frailty on MAE. Results: 27,155 patients (Age = 77.3 ± 6.4 years; Female = 42.4%, White: 88%, Black: 3.4%, Hispanic:5.2%, Other: 3.4%) were included. Overall, the prevalence of frailty was 12.5% (White:12.4%, Black: 13.7%, Hispanic: 11.8%, Other: 13%). Overall, in-hospital MAE was 4.7%, with increased rates in frail patients (4% vs.9.6%; p<0.001). Rates of in-hospital MAE were frail-White: 9.3%, frail-Black: 8%, frail-Hispanic:20.6%, and frail-Other: 4.2% (p<0.001). On multivariate analysis, frail-White and frail-Hispanic patients were at increased risk of in-hospital MAE compared to non-frail patients (Figure). Conclusion: Further research is needed to highlight disparities by race/ethnicity and to identify potentially modifiable factors to mitigate adverse events in frail geriatric population undergoing LAAC.

Abstract 15986: Very Rare Case of a Interatrial Thrombus Following Watchman Device Placement

Introduction: Device related thrombus (DRT) is a known complication of left atrial appendage closure (LAAC). We present a case of a thrombus at the interatrial septum following LAAC detected eight months after the procedure. Case: Eighty-six years old woman with a history of coronary artery disease s/p percutaneous coronary intervention with drug eluting stent to right coronary artery in 2016, heart failure with preserved ejection fraction, atrial fibrillation (AF) s/p 27mm Watchman device placement (on aspirin only) due to recurrent episodes of hematuria, hypertension, hyperlipidemia, chronic kidney disease presented to the hospital with complaints of right flank pain. Initial labs were unremarkable except for anemia, hemoglobin of 10g/dl. Computed tomography (CT) abdomen and pelvis showed an incidental finding of new mass like filling defect within the left atrium. Transthoracic echocardiogram (TTE) showed mobile mass 1.7 x 1.6 cm attached to the interatrial septum on the left atrial side.(Figure 1.A) Low dose apixaban was started. Follow up transesophageal echocardiogram (TEE) in four months interval showed the thrombus attached to the interatrial septum had slightly reduced in size to 1.5 x 0.9 cm, but an additional large thrombus measuring 2.5 x 1.3 cm was seen on top of the Watchman device (Figure 1.B) and Apixaban was increased to full dose. Discussion: Incidence of DRT after LAAC is 3.74% with most cases occurring in the first year after LAAC. Exposed and incompletely endothelialized device are foci for DRT. Iatrogenic pericardial effusion, hypercoagulable state, deep implant, renal insufficiency, non-paroxysmal AF are some of the factors increasing the risk of device related thrombus. Most cases of DRT described are attached to the device. In our case, a large interatrial thrombus was identified incidentally which likely formed at the site of septal puncture during device insertion which highlights the importance of follow up echocardiogram at intervals.

Abstract 11705: Events of Device Failure in Elderly Patients Undergoing Watchman Device Insertion in the United States

Introduction: Watchman device implant reduces various cardio-cerebral events in patients with left atrial appendage. As there is a lack of data on device failure among the elderly undergoing this procedure, we aim to provide a perspective via the 2016-2020 National Inpatient Sample(NIS). Methods: Watchman procedures in patients ages ≥60 years, with a history of atrial fibrillation or flutter, were examined for our study from the NIS. Events of device failure were considered, and variables that may influence such events were studied via logistic regression models. Results: We found 85190 procedures for Watchman device insertion conducted in the United States, and 510 (0.6%) cases reported an event of device failure. Procedures at rural centers reported higher odds of device failure than urban teaching centers (1.3% of rural center procedures vs. 0.6% of urban teaching hospital procedures, aOR 2.970, 95% CI 1.965 -4.488, p<0.01). Meanwhile, patients with a history of CKD (aOR 0.565, p<0.01), hypertension (aOR 0.500, p<0.01), and peripheral vascular diseases (aOR 0.513, p=0.012) showed reduced odds. Several complications were also noted among those with device failure, as 20 cases (3.9% ) had acute kidney injury, 45 patients (8.8%) developed cardiac tamponade, 70 cases (13.7%) had pericardial effusion, and 20 cases (3.9%) necessitated mechanical ventilation. The mean CHA 2 DS 2 -VASc score among patients with device failure was 4.65 (vs. 4.68, p=0.029), and the mean Charlson Comorbidity Index score was 1.42 (vs 1.65, p<0.01). Patients with device failure had a more expensive stay (mean hospital charge $144936 vs. $122504). Conclusions: Device failure was a rare but severe complication involving 0.6% of procedures in our analysis. Many comorbidities influenced events of device failure. As our study found a higher incidence among procedures done in rural centers, further studies to screen and assess the patients and monitor their condition may help improve the outcomes.

Abstract 12649: Harnessing Ambulatory Monitoring Data to Improve Prediction of Heart Failure

Introduction: Despite growing evidence that atrial fibrillation (AF) burden impacts clinical outcomes, few clinical risk scores incorporate individual-level arrhythmia characteristics. We analyzed predictors of hospitalization for heart failure (HF) in patients using both clinical history and ambulatory cardiac monitoring data. Methods: We evaluated patients who underwent Zio XT ambulatory monitoring in the US (2014-2020). The monitoring data were linked with clinical data from Centers for Medicare and Medicaid Services. Patients on anticoagulation or anti-arrhythmic therapy and those with evidence of sustained VT, known ventricular fibrillation/flutter, prior ablation, prior left atrial appendage occlusion, or cardiac arrest in the prior year were excluded. We randomly divided our dataset into a 70% training dataset and 30% testing dataset. Predictive models were generated using LASSO Cox regression for variable selection in the training dataset and evaluated on testing dataset among ambulatory ECG variables and the components of CHA 2 DS 2 -VASC. Results: Among 224,682 patients in the training dataset, 4,021 (1.8%) were hospitalized for HF within 1 year. A model that included components of the CHA 2 DS 2 -VASC and all ECG variables (excluding multicollinear variables) had greater discrimination and calibration for HF hospitalization (C-statistic 0.85 [0.84-0.86]), compared with the CHA 2 DS 2 -VASC score alone (C-statistic 0.73 [0.72-0.74], Figure ). ECG findings with the greatest predictive value were the presence of premature ventricular couplets (HR 1.54 [1.43-1.65]) and presence of AF (HR 1.53 [1.35-1.72]). Conclusion: A model that incorporates both ECG variables from ambulatory monitoring data and the components of the CHA 2 DS 2 -VASC provides better discrimination for the risk of HF hospitalization compared with the CHA 2 DS 2 -VASC risk score alone. Premature ventricular couplets and AF are highly associated with HF hospitalization.

Abstract 13662: Novel Morphological Classification of Left Atrial Appendage Using 3-Dimensional Printer -Rock, Paper and Scissors-

Background: Left atrial appendage (LAA) of Asians is generally larger and more complicated than that of non-Asians. Whereas the four classifications from previous reports are widely used in the world, different physicians have different point of views in the real-world practice. Purpose: To identify the relationship between morphological features of LAA and cardioembolic stroke in Japanese patients. Methods: All left atrial appendage closure (LAAC) cases in our institution performed between February 2020 and April 2023 were retrospectively analyzed. The three-dimensional printing of LAA was generated from cardiovascular computed tomography imaging data. The shapes of the LAA were classified into 3 morphological types: (1) The LAA with bi lobe was defined as “Scissors” type; (2) The one with complicated peripheral branches was “Paper” type; (3) The simple one was “Rock” type. We examined the relationship between the risk of cardioembolic stroke and the morphological features of the LAA. Results: The cohort consisted of 93 consecutive patients (age, 75±1 years; male gender, 72%; the size of WATCHMAN device, 29±0 mm). There were 41 (44%) patients who had a history of cardioembolic stroke (27% vs. 41% vs. 58%; Rock vs. Scissors vs. Paper types, p-value = 0.0466). In the multivariate analysis, the Paper type is the potential risk factor of cardioembolic stroke (p-value < 0.01) (Table1.2). Conclusions: The morphological features of LAA by three-dimensional printing was significantly related to cardioembolic stroke in this population. Physicians should pay attention to anticoagulant therapy management and proactively consider LAAC in LAA with complicated peripheral branches.

Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis.

Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I2 = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I2 = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04). ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

Utilization and short-term outcomes of percutaneous left atrial appendage occlusion in patients with cancer

BackgroundPercutaneous left atrial appendage occlusion (LAAO) has been rapidly evolving since FDA’s approval in 2015 and has become more of a same-day-discharge procedure. Cancer patient with atrial fibrillation/flutter (AF) population can benefit from the procedure but the in-hospital outcomes and readmission data were rarely studied.ObjectivesWe investigated the utilization, in-hospital and readmission outcomes in cancer patients with AF who underwent LAAO.MethodsData were derived from the National Inpatient Sample and National Readmissions Database from 2016 to 2019. Patients with primary diagnosis of AF admitted for LAAO (ICD-10 code 02L73DK) were grouped by cancer as a secondary diagnosis. We assessed in-hospital mortality, length of stay, total hospital charges, and complications. Thirty-day readmission rates were compared.ResultsLAAO was performed in 60,380 patients with AF and 3% were cancer patients. There were no differences in in-hospital mortality and total hospital charges; however, cancer patients tended to have longer hospital stay (1.59 ± 0.11 vs. 1.32 ± 0.02, p = 0.013). Among complications, cancer patients had higher rates in open or percutaneous pericardial drainage (adjusted odds ratio [aOR] 2.38; 95% confidence interval [CI] 1.19–4.76) and major bleeding events (aOR 7.07; 95% CI 1.82–27.38). There was no statistical significance of 30-day readmission rates between patients with and without cancer (10.0% vs. 9.1%, p = 0.34). The most common readmission reason in cancer patients was gastrointestinal bleeding.ConclusionsLAAO is a promising procedure in cancer patients complicated by AF with contraindication to anticoagulation. Readmission rate is comparable between patients with and without cancer.

Delayed coronary artery stenosis: a rare complication of the left atrial clipping device.

A clipping device may impinge on the coronary artery following left atrial appendage occlusion during cardiac surgery, causing rare cardiac ischaemia perioperatively. This report highlights a case of delayed severe coronary artery stenosis resulting in ventricular fibrillation 2 months after cardiac surgery with the implantation of a left atrial clipping device. Following a percutaneous coronary intervention, the patient underwent clip removal surgery. Postoperative three-dimensional heart model verification revealed that the base of the left atrial appendage was more dorsal than usual, thereby increasing the potential risk of the clip impinging on the coronary artery. We should remember that this rare complication can occur after left atrial clipping, either in the early postoperative period or later.

The Left Atrial Appendage and Atrial Fibrillation—A Contemporary Review

In patients with atrial fibrillation, the left atrial appendage may serve as the site of thrombus formation due to stasis that occurs within the appendage because of its shape and trabeculations. Although thrombus formation can be reduced by using anticoagulants, this may be contraindicated in some patients. The need for a better alternative treatment prompted the study of left atrial appendage occlusion for thromboembolism prophylaxis. Due to this, procedures that excise or occlude the left atrial appendage have gained attention because of their ability to prevent thromboembolic events. This article provides a comprehensive review of the left atrial appendage and its associated procedures’ clinical utility.

Antiplatelet Agent Use After Stroke due to Intracerebral Hemorrhage.

This focused update about antiplatelet agents to reduce the high risk of major adverse cardiovascular events after stroke due to spontaneous (nontraumatic) intracerebral hemorrhage (ICH) complements earlier updates about blood pressure-lowering, lipid-lowering, and oral anticoagulation or left atrial appendage occlusion for atrial fibrillation after ICH. When used for secondary prevention in people without ICH, antiplatelet agents reduce the risk of major adverse cardiovascular event (rate ratio, 0.81 [95% CI, 0.75-0.87]) and might increase the risk of ICH (rate ratio, 1.67 [95% CI, 0.97-2.90]). Before 2019, guidance for clinical decisions about antiplatelet agent use after ICH has focused on estimating patients' predicted absolute risks and severities of ischemic and hemorrhagic major adverse cardiovascular event and applying the known effects of these drugs in people without ICH to estimate whether individual ICH survivors in clinical practice might be helped or harmed by antiplatelet agents. In 2019, the main results of the RESTART (Restart or Stop Antithrombotics Randomized Trial) randomized controlled trial including 537 survivors of ICH associated with antithrombotic drug use showed, counterintuitively, that antiplatelet agents might not increase the risk of recurrent ICH compared to antiplatelet agent avoidance over 2 years of follow-up (12/268 [4%] versus 23/268 [9%]; adjusted hazard ratio, 0.51 [95% CI, 0.25-1.03]; P=0.060). Guidelines in the United States, Canada, China, and the United Kingdom and Ireland have classified the level of evidence as B and indicated that antiplatelet agents may be considered/reasonable after ICH associated with antithrombotic agent use. Three subsequent clinical trials have recruited another 174 participants with ICH, but they will not be sufficient to determine the effects of antiplatelet therapy on all major adverse cardiovascular events reliably when pooled with RESTART. Therefore, ASPIRING (Antiplatelet Secondary Prevention International Randomized Study After Intracerebral Hemorrhage) aims to recruit 4148 ICH survivors to determine the effects of antiplatelet agents after ICH definitively overall and in subgroups.

DAPT Is Comparable to OAC Following LAAC With WATCHMAN FLX: A National Registry Analysis.

Left atrial appendage occlusion (LAAO) is an approved alternative for stroke prevention in atrial fibrillation for patients with an "appropriate rationale" to avoid long-term oral anticoagulation (OAC). Many patients undergoing LAAO are at high risk of bleeding. This study sought to investigate whether dual antiplatelet therapy (DAPT) is a safe alternative to OAC (direct oral anticoagulation [DOAC] or warfarin) with aspirin after LAAO. Using National Cardiovascular Data Registry LAAO registry data, patients undergoing Watchman FLX (Boston Scientific) implantation (August 5, 2020-September 30, 2021) were included in 1:1 propensity-matched analyses comparing discharge medication regimens (DAPT, DOAC/aspirin, or warfarin/aspirin). A composite endpoint (death, stroke, major bleeding, and systemic embolism), its components, and device-related thrombus between discharge and 45days were evaluated. In 49,968 patients implanted with the Watchman FLX during the study period, the mean age was 77 years, and 40% were women. Postimplant DOAC/aspirin was prescribed in 24,497 patients, warfarin/aspirin in 3,913, and DAPT in 4,155. DAPT patients had more comorbid conditions than patients receiving OAC/aspirin. After propensity score matching, the 45-day composite endpoint rates were similar among the groups (DAPT=3.44% vs DOAC/aspirin: 4.06%; P = 0.13 and DAPT=3.23% vs warfarin/aspirin: 3.08%; P = 0.75). Death, stroke, and device-related thrombus were also similar; major bleeding was slightly increased in DOAC/aspirin patients (DAPT=2.48% vs DOAC/aspirin=3.25%; P = 0.04 and DAPT=2.25% vs warfarin/aspirin=2.22%; P = 0.93). In a large registry, DAPT had a similar safety profile compared with current Food and Drug Administration-approved postimplant drug regimens of OAC with aspirin following LAAO with the Watchman FLX. Shared decision making for nonpharmacologic stroke prevention should include a discussion of postprocedure medical therapy options.

Comparison of intracardiac vs. transesophageal echocardiography for "one-stop" procedures of combined radiofrequency catheter ablation and left atrial appendage closure with the Watchman device in the treatment of atrial fibrillation.

This study aimed to assess the efficacy and safety of "one-stop" procedures that combined radiofrequency catheter ablation and left atrial appendage closure (LAAC) with the Watchman device under the guidance of intracardiac echocardiography (ICE) vs. transesophageal echocardiography (TEE) in patients with atrial fibrillation. In this study, we prospectively enrolled patients who underwent "one-stop" procedures under the guidance of ICE (n = 193, 109 men, 65.02 ± 8.47 years) or TEE (n = 109, 69 men, 64.23 ± 7.75 years) between January 2021 and October 2022. Intraprocedural thrombus formation in the left atrial appendage (LAA) was observed in 3 (1.46%) patients in the ICE group and 15 (11.63%) patients in the TEE group (P < 0.05) before LAAC. Total fluoroscopy time and dose in the ICE group were less than those in the TEE group. The total "one-stop" turnaround time and LAAC procedure time in the ICE group were significantly shorter than those in the TEE group (P < 0.05). Postoperative esophagus discomfort, nausea and vomiting, and hypotension were more often seen in the TEE group (P < 0.001). There was no significant difference in matched cases between ICE and fluoroscopy measurements (P = 0.082). The TEE results related to LAAC and clinical events were similar between the two groups during the follow-up (P > 0.05). The ICE-guided "one-stop" procedure was safe and feasible with less radiation exposure, shorter turnaround time, and fewer complications and intraoperative thrombus formations than the TEE group. ICE offered accurate measurements in the LAA dimension during LAAC. Echocardiography during the "one-stop" procedures was necessary to rule out the intraoperative thrombus.

Device-Related Thrombus After Left Atrial Appendage Occlusion: Clinical Impact, Predictors, Classification, and Management.

Despite the unprecedented advances in the left atrial appendage occlusion field, device-related thrombus (DRT) remains an unresolved issue with the therapy. This paper aims to provide a state-of-the-art review of the literature on the incidence, clinical impact, predictors and management of DRT and propose a novel classification of DRT and hypoattenuated thickening.

Left atrial appendage occlusion techniques for open heart surgery and for minimally invasive thoracotomy.

Left atrial appendage occlusion techniques for open heart surgery and for minimally invasive thoracotomy.