Nonrheumatic Atrial Fibrillation Research Articles

Abstract 14558: Causes and Predictors of Short-Term Readmissions Following Percutaneous Left Atrial Appendage Closure Procedure in Patients With and Without Rheumatic Mitral Valve Disease

Introduction: Atrial fibrillation (AF) is the most common cardiac arrhythmia, characterized by erratic heart beats. AF increases the risk of thromboembolic events particularly stroke. Percutaneous left atrial appendage closure (LAAC) is an alternative option to prevent embolic stroke in patients with AF who have contraindication to anticoagulants. Up to our knowledge, this is the first National Readmission Database (NRD) study to elucidate the difference in readmission rates between rheumatic vs non-rheumatic AF patients who underwent LAAC. Methods: We utilized the Nationwide Readmissions Database (NRD) between the years 2016-2020. The study involved hospitalizations with rheumatic mitral valve disease (R-MVD) and non-rheumatic mitral valve disease (NR-MVD) who underwent LAAC using ICD-10 diagnostic codes. We deemed this as the index admission. We excluded patients less than 18 years old and October-December hospitalizations from 90-day readmission analysis, due to lack of adjoining period to assess readmission. Results: Among 9,150 patients with mitral valve disease who underwent LAAC in their index hospitalizations, 9,122 were discharged alive. 4,200 patients (45.8%) were readmitted in 90-days. R-MVD 90-day readmission rate compared to NR-MVD (52.3% vs 40.7% respectively, p<0.001). The most common cause of readmission in both groups was atrial fibrillation, 96% of total readmissions in R-MVD and 97% of total readmissions in NR-MVD group. This was followed by “accidental puncture and laceration of a digestive system organ or structure” in 0.3% of R-MVD group vs “mitral valve insufficiency” in 0.7% of NR-MVD readmission causes. Figure 1 shows the Forest plot of multivariate analysis of independent factors associated with readmissions. Conclusion: Among AF patients who underwent LAAC with or without history of mitral valve rheumatic heart disease, those with history of R-MVD had significantly higher 90-day readmission rate.

Effect of mitral regurgitation in stroke risk in patients with nonrheumatic atrial fibrillation

Abstract Background Atrial fibrillation (AF) carries a thrombotic risk related to blood stasis produced in left atrium. In patients with rheumatic valve disease and AF, the presence of severe mitral regurgitation (MR) has been shown to reduce the risk of atrial thrombosis and stroke. In patients without rheumatic disease, the results are controversial. Purpose Our objective is to analyze the association between mitral regurgitation and the incidence of stroke. Methods We analyzed data from the retrospective registry CardioCHUVI-AF, which includes 15,720 patients with AF (excluding mechanical prostheses or rheumatic valvular disease) in the Vigo area, from 2014 to 2018. We grouped the patients according to the MR grades: grade 0–2 (15,194 patients) and grades 3–4 (526 patients). We performed propensity score matching analysis obtaining 2 groups of 511 patients. We analyzed the association between MR and stroke with a competitive risk model, being death the competitive event. Results During a median follow-up of 4.90 years (IQR 2.85–4.93), 859 (5.5%) patients suffered a stroke. The stroke incidence rate was 1.30 per 100 person-years (95% CI: 1.21–1.39), with no differences between the MR groups. In the univariate analysis, no relationship was observed between the MR grades and stroke (sHR 1.12, 95% CI: 0.79–1.60, P=0.530). After the propensity score matching analysis no significant association was observed between the MR grades and stroke (sHR 0.93, 95% CI: 0.57–1.53, P=0.775) (Figure 1 and 2). This same relationship was evaluated by subgroups of interest: oral anticoagulation, prior heart failure, left ventricular ejection fraction <40%, aortic valve disease, and left atrial dilatation, with results consistent with the overall sample (Figure 2). Conclusions In our large registry of patients with AF, we did not find a protective effect of significant mitral regurgitation (grades 3–4) on the risk of stroke. Funding Acknowledgement Type of funding sources: None.

Effect of mitral regurgitation on stroke risk in patients with non-rheumatic atrial fibrillation

Atrial fibrillation (AF) carries a thrombotic risk related to blood stasis in the left atrium. In patients with rheumatic valve disease and AF, the presence of severe mitral regurgitation (MR) has been shown to reduce the risk of atrial thrombosis and stroke. However, in patients without rheumatic disease, the results are controversial. To analyse the association between MR and the incidence of stroke in patients with non-rheumatic AF. We analysed data from the retrospective CardioCHUVI-AF registry, which includes 15,720 patients with AF (without mechanical prostheses or rheumatic valvular disease) in the Vigo area of Spain, during 2014-2018. We grouped the patients according to MR grades: 0-2 (n=15,194) and 3-4 (n=526). We performed univariate and multivariable competitive risk analyses to analyse the association between MR and stroke, with death as the competitive event. During a median (interquartile range [IQR]) follow-up of 4.9 (2.8-4.9) years, 859 patients (5.5%) suffered a stroke. The stroke incidence was 1.3 per 100 person-years (95% confidence interval [95% CI]: 1.2-1.4), with no difference between the MR groups. In univariate analysis, no relationship was observed between MR grade and stroke (subdistribution hazard ratio [sHR]: 1.12, 95% CI: 0.79-1.60; P=0.53); likewise after multivariable analysis (sHR: 0.98, 95% CI: 0.68-1.41; P=0.90). This same relationship was evaluated in subgroups of interest (patients with and without: oral anticoagulation, CHA2DS2-VASc≥2, prior heart failure, aortic valve disease, left ventricular ejection fraction≤40%, and moderate-severe left atrial dilation), with results consistent with the overall population. In our large registry of patients with non-rheumatic AF, we did not find a protective effect of grade 3-4 MR on the risk of stroke.

Mitral regurgitation attenuates thrombotic risk in nonrheumatic atrial fibrillation: a new CHA2DS2-VASc score risk modifier?

Abstract Funding Acknowledgements Type of funding sources: None. Background/Introduction: Atrial fibrillation (AF) carries a thrombotic risk related to left atrial blood stasis. Many risk scores, such as the CHA2DS2-VASc score, have been developed to guide physicians in initiating anticoagulant therapy. However, the risk prediction with these models is modest at best (C-statistic = 0.6). The presence of mitral regurgitation (MR) has been shown to reduce thrombotic risk in patients with rheumatic AF. In nonrheumatic AF, direct evidence of a lower thrombotic risk in patients with MR is still controversial. Purpose The current study assessed the effect of MR on thrombotic risk in nonrheumatic AF patients. Methods The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus (LAAT) and/or left atrial spontaneous echo contrast (LASEC) grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transoesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA2DS2-VASc score. The independent predictors of atrial thrombosis were assessed by stepwise multiple logistic regression analysis. Results A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA2DS2-VASc score was 3.0 (IQR 2.0-4.0). Atrial thrombosis (LAAT and/or LASEC grade >2) was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p for trend = 0.03) (Figure 1). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios (ORs) of 0.51 (95% CI 0.31-0.84) and 0.24 (95% CI 0.11-0.49), respectively. The other independent predictors of atrial thrombosis were: the CHA2DS2-VASc score with an adjusted OR of 1.25 (95% CI 1.10-1.42), poor left ventricular ejection fraction (LVEF, <40%) with an adjusted OR of 4.08 (95% CI 2.56-6.50), and large left atrial volume index (LAVI, >37 ml/m²) with an adjusted OR of 1.90 (95% CI 1.19-3.03) (Figure 1, upper right corner). The C-statistic of the regression model increased significantly (p = 0.0003) from 0.62 to 0.75 by adding MR grade, LVEF, and LAVI to the univariate CHA2DS2-VASc score model. The protective effect of MR was present across all levels of the CHA2DS2-VASc score and the presence of moderate-severe MR in patients with an intermediate CHA2DS2-VASc score (2-3) lowered the atrial thrombotic risk to the level of patients with a low CHA2DS2-VASc score (0-1). Conclusion Our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF, independent of the CHA2DS2-VASc risk score. Moderate to severe MR can therefore be considered a new risk modifier of the CHA2DS2-VASc score, which might help refine the indication of anticoagulants in AF patients. Abstract Figure 1. Thrombotic risk per MR grade.

Effect of Mitral Regurgitation on Thrombotic Risk in Patients With Nonrheumatic Atrial Fibrillation: A New CHA2DS2-VASc Score Risk Modifier?

The current study assessed the effect of mitral regurgitation (MR) on thrombotic risk in nonrheumatic atrial fibrillation (AF). AF carries a thrombotic risk related to left atrial blood stasis. The prevalence of atrial thrombosis, defined as the presence of left atrial appendage thrombus and/or left atrial spontaneous echo contrast grade >2, was determined in 686 consecutive nonrheumatic AF patients without (adequate) anticoagulation scheduled for transesophageal echocardiography before electrical cardioversion and was related to the severity of MR adjusted for the CHA2DS2-VASc score. A total of 103 (15%) patients had severe MR, 210 (31%) had moderate MR, and 373 (54%) had no-mild MR; the median CHA2DS2-VASc score was 3.0 (interquartile range 2.0 to 4.0). Atrial thrombosis was observed in 118 patients (17%). The prevalence of atrial thrombosis decreased with increasing MR severity: 19.9% versus 15.2% versus 11.6% for no-mild, moderate, and severe MR, respectively (p value for trend = 0.03). Patients with moderate and severe MR had a lower risk of atrial thrombosis than patients with no-mild MR, with adjusted odds ratios of 0.51 (95% confidence interval 0.31 to 0.84) and 0.24 (95% confidence interval 0.11 to 0.49), respectively. The protective effect of MR was present across all levels of the CHA2DS2-VASc risk score and the presence of moderate-severe MR in patients with an intermediate CHA2DS2-VASc score (2 to 3) lowered the atrial thrombotic risk to the level of patients with a low CHA2DS2-VASc score (0 to 1). In conclusion, our data show that the presence of MR attenuated the atrial thrombotic risk by more than 50% in patients with nonrheumatic AF.

Beneficial effect of left atrial appendage closure during cardiac surgery: a meta-analysis of 280585 patients.

In non-rheumatic atrial fibrillation (AF), left atrial appendage (LAA) is thought to be the source of embolism in 90% of the strokes. Thus, as recent clinical trials have shown the non-inferiority of percutaneous LAA closure (LAAc) in comparison to medical treatment, and despite a IIb recommendation in the latest guidelines for concomitant surgical LAAc, we sought to investigate the beneficial effect of LAAc in the surgical population. A meta-analysis model was performed comparing studies including any cardiac surgery with or without concomitant surgical LAAc reporting stoke/embolic events and/or mortality, from inception to January 2019. Twenty-two studies (280585 patients) were included in the model. Stroke/embolic events both in the perioperative period [relative risk (RR) 0.66, 95% confidence interval (CI) 0.53-0.82; P = 0.0001] and during follow-up of >2 years (RR 0.67, 95% CI 0.51-0.89; P < 0.005) were significantly reduced in patients who underwent surgical LAAc (RR 0.71, 95% CI 0.58-0.87; P = 0.001). Regarding the rate of preoperative AF, LAAc showed protective effect against stroke/embolic events in studies with >70% preoperative AF (RR 0.64, 95% CI 0.53-0.77; P < 0.00001) but no benefit in the studies with <30% of preoperative AF (RR 0.77, 95% CI 0.46-1.28; P = 0.31). Postoperative mortality was also significantly lower in surgical patients with LAAc at the mid- and long-term follow-up. (RR 0.72, 95% CI 0.67-0.78; P < 0.00001; I2 = 0%). Based on these findings, concomitant surgical LAAc is associated with lower rates of embolic events and stroke in the postoperative period in patients with preoperative AF and also improves postoperative mortality in the mid- and long-term follow-up.

Retraction to: Long-term Oral Anticoagulation Reduces Bone Mass in Patients with Previous Hemispheric Infarction and Nonrheumatic Atrial Fibrillation.

HomeStrokeVol. 50, No. 8Retraction to: Long-term Oral Anticoagulation Reduces Bone Mass in Patients with Previous Hemispheric Infarction and Nonrheumatic Atrial Fibrillation Free AccessRetractionPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessRetractionPDF/EPUBRetraction to: Long-term Oral Anticoagulation Reduces Bone Mass in Patients with Previous Hemispheric Infarction and Nonrheumatic Atrial Fibrillation Originally published22 Jul 2019https://doi.org/10.1161/STR.0000000000000199Stroke. 2019;50:e245This article is retracted byLong-term Oral Anticoagulation Reduces Bone Mass in Patients with Previous Hemispheric Infarction and Nonrheumatic Atrial FibrillationThe Editors of Stroke are retracting the following article, “Long-term Oral Anticoagulation Reduces Bone Mass in Patients with Previous Hemispheric Infarction and Nonrheumatic Atrial Fibrillation,” (Stroke. 1997;28:2390–2394. doi: 10.1161/01.STR.28.12.2390).An expression of concern was published on April 22, 2019, to alert readers that the American Heart Association | American Stroke Association was communicating with the institution regarding the allegations made about the article.1 An investigation by the Futase Social Insurance Hospital has determined that the study was not approved by the institutional review board, which was not established during the study period. Therefore, the editors are retracting the article.[original article URL: https://www.ahajournals.org/doi/10.1161/01.STR.28.12.2390]

036 The impact of a clinical support tool on stroke key performance indicators

IntroductionAdherence to key performance indicators (KPIs) in stroke care is associated with better outcomes.1–6 The complexity in management of acute strokes, however, has created barriers towards delivering best care with plateauing of KPIs as measured by The National Stroke Foundation Clinical Audit.We examined the impact on stroke KPIs in our local health district of a web-based decision support stroke platform which provides clinicians with up-to-date information about the patient’s management flagging potential areas for improvement, allowing treatment to be optimised in real time.MethodsSix months following the introduction of the platform we performed a retrospective analysis of Electronic medical records of patients admitted to Gosford hospital with acute stroke between June 2018 and September 2018 assessing access to the stroke unit as well as being discharged on appropriate secondary prophylactics, including antihypertensives and correct antithrombotic therapy. Patients whose direction of care was palliative and patients with documented contraindication to secondary prophylactics were excluded.ResultsOver four months, 136 patients presented with acute ischaemic stroke and 11 patients had a haemorrhagic stroke. 49 ischaemic stroke patients had atrial fibrillation. Stroke unit access was higher following its introduction in 2018 compared to 2017 (97% vs 76%, respectively). Similar findings were noted for patients with atrial fibrillation who received oral anticoagulants on discharge (90% vs 50%) and patients discharged on antihypertensives (95% vs 80%).ConclusionUse of a clinical support platform in managing acute stroke is an intervention that improves stroke care.ReferencesUrimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. European Stroke Journal 2017;2(4):287–307. https://doi.org/10.1177/2396987317735426Sandercock P, Gubitz G, Foley P. Antiplatelet therapy for acute ischaemic stroke. Cochrane Database Syst Rev 2003;2: CD000029. Google ScholarKwan J, Sandercock P. In-hospital care pathways for stroke. Cochrane Database Syst Rev2004;4: CD002924. Google ScholarSaxena R, Koudstaal PJ. Anticoagulants for preventing stroke in patients with nonrheumatic atrial fibrillation and a history of stroke or transient ischemic attack. Cochrane Database Syst Rev 2004;4: CD000187. Google ScholarGoyal M, Menon BK, van Zwam WH. Endovascular thrombectomy after large-vessel ischaemic stroke: a meta-analysis of individual patient data from five randomised trial. Lancet 2016;387:1723–1731. Google Scholar | Crossref | Medline | ISIMiddleton S, McElduff P, Ward J. Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC): a cluster randomised controlled trial. Lancet 2011;378:1699–1706. Google Scholar | Crossref | Medline | ISI

A Long-Term Cost-Effectiveness Analysis Comparing Radiofrequency Catheter Ablation with Antiarrhythmic Drugs in Treatment of Chinese Patients with Atrial Fibrillation.

Radiofrequency catheter ablation (RFCA) is widely used to treat atrial fibrillation (AF) in China. We aimed to determine the long-term cost effectiveness of RFCA versus antiarrhythmic drugs (AADs) in treating AF from the perspective of third-party payers. The model was structured as a 12-month decision tree leading to a Markov model that simulated the follow-up treatment outcomes and costs with time horizons of 8, 15, and 20years. Comparators were standard-of-care AADs. Clinical parameters captured normal sinus rhythm, AF, stroke, post-stroke, intracranial hemorrhage (ICH), gastrointestinal bleeding, post-ICH, and death. The risk of operative death, procedural complications, and adverse drug toxicity were also considered. The model output was quality-adjusted life-years (QALYs) and incremental cost per QALY gained. RFCA incurred more costs than the AADs but resulted in more QALYs gained than did AADs. The incremental cost per QALY gained with RFCA versus AADs was ¥66,764, ¥36,280, and ¥29,359 at 8, 15, and 20years, respectively. The sensitivity analyses showed that the results were most sensitive to the changes in RFCA cost and CHADS2 score (clinical prediction rule for assessing the risk of stroke in patients with non-rheumatic AF). Compared with AADs, RFCA significantly improves clinical outcomes and QALYs among patients with paroxysmal or persistent AF. From the Chinese payer's perspective, RFCA is a cost-effective therapy over long-term horizons.

Percutaneous devices for left atrial appendage occlusion: A contemporary review.

Patient with atrial fibrillation (AF) are at risk of developing stroke with the left atrial appendage (LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF, some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion (LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device. Watchman is the most common and only Food and Drug Administration (FDA) approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.

Oral anticoagulation and left atrial thrombi resolution in nonrheumatic atrial fibrillation or flutter: A systematic review and meta-analysis.

Oral anticoagulation (OAC) is prescribed for left atrial thrombi (LAT) in nonrheumatic atrial fibrillation (AF) and/or atrial flutter (AFL). The study objective was to review the existing evidence regarding LAT resolution in nonrheumatic AF and/or AFL with OAC agents. Data sources included PubMed, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) between January 1, 1991 and February 10, 2017. English-language studies that assessed LAT resolution with OAC agents in subjects with nonrheumatic AF and/or AFL, by serial transesophageal echocardiography, and with follow-up times ≥ 3weeks and<1 year, were selected. Study quality was assessed using recommendations adapted from the Agency for Healthcare Research and Quality. Pooled LAT resolution rates were evaluated for vitamin K antagonist (VKA) studies and low risk of bias warfarin studies. The pooled LAT resolution rate of 619 subjects from 16 VKA studies was 63.7% (95% confidence interval [CI], 53.3%-72.9%). The pooled LAT resolution rate of 94 subjects from four studies that specified warfarin use, exclusion of prior long-term therapeutic OAC, and target international normalized ratio (INR) ≥ 2.0 and/or average achieved INR ≥ 2.0 was 79.3% (95% CI, 69.8%-86.4%). Two studies in direct-acting oral anticoagulants (DOACs) reported LAT resolution rates of 89.5% (17 of 19) for dabigatran and 41.5% (22 of 53) for rivaroxaban. Warfarin is the most studied initial OAC agent for treating LAT in nonrheumatic AF and/or AFL with a resolution rate of nearly 80%. Further studies in DOACs are warranted.

A role of microRNA in the pathogenesis of ischemic stroke

Ischemic stroke (IS) is one of the leading causes of death and disability worldwide. Among all the causes of IS, cardioembolic stroke (CEI) accounts for up to 40%. Based on the literature data, modern ideas about the role and location of cardiac diseases in the pathogenesis of CEI are presented. The leading cause of CEE is non-rheumatic atrial fibrillation. Numerous attempts to study and prove the genetic nature of the development of IS led to the discovery of new markers - micribonucleic acids (microRNAs), the regulators of gene expression, that inhibit mRNA translation and play a key role in the pathogenesis of IS. This review summarizes the current knowledge of microRNAs, their ability to simultaneously regulate several target genes, and their significance as potential diagnostic and prognostic biomarkers in IS.

Co-existence of ischemic stroke in Rheumatic and non-rheumatic atrial Fibrillation in a tertiary care teaching hospital of Western Nepal

Background &amp; Objectives: Stroke is a major public health burden worldwide leading to long-term morbidity and even mortality. Atrial fibrillation (AF) is the most common sustained arrhythmia and is an independent factor to increase risk of ischemic stroke. The risk of stroke further enhanced in rheumatic atrial fibrillation and affects younger population of developing countries. The study has aimed to find out frequency of co-existence of stroke in AF and secondarily to look for age distribution of stroke and risk factors of AF.Materials &amp; Methods: A retrospective analysis of trans-thoracic echocardiographic records of patients from 1st June 2009 to 31st June 2016 was done. Data were collected in a pre-structured proforma and analyzed.Results: Among 15767 echocardiographies, 577 (3.65%) cases were recorded to have atrial fibrillation. Mean age 65(±15) years ranging from 14 to 100 years. Rheumatic heart disease was the second most common cause of atrial fibrillation after hypertension. The co-existence of ischemic stroke was seen in 87(15.07%) cases with male to female ratio of 1:1.3. The proportion of stroke in rheumatic Atrial fibrillation was 21(18.75%) which was higher than in non-Rheumatic atrial fibrillation 66(14.2%).Conclusion: Rheumatic heart disease is contributing as second most common cause of atrial fibrillation after hypertension, nearly one fourth of total stroke and most common (93%) cause of stroke below the age of 45 years. Preventive strategies aimed at health awareness about rheumatic fever, screening programs at community level, early detection and treatment for hypertension and Rheumatic heart disease can contribute in reduction of stroke burden.

Safety and efficacy of catheter-based left atrial appendage closure in patients with contraindications for long-term anticoagulation.

Percutaneous left atrial appendage closure (LAAC) and the role of postinterventional anticoagulation often evokes controversy in daily practice. This study aimed to evaluate LAAC in patients with non-rheumatic atrial fibrillation, high thromboembolic risk and contraindications for long-term anticoagulation in a clinical scenario. Between 2010-2015, LAAC was attempted in 118 patients (47 women). Devices were successfully implanted in 95% (Watchman™ device: N.=97; Amplatzer™ Cardiac Plug/Amulet: N.=14; Amplatzer PFO Occluder: N.=1). Mean age was 75±8.35 years. Mean HAS-BLED and CHA2DS2VASc scores were 4.3 and 4.9, respectively. Median follow-up was 447 days (IQR: 183-789 days). The primary safety endpoint was defined as major bleeding according to the International Society on Thrombosis and Hemostasis. The combined efficacy endpoint included ischemic strokes, transitory ischemic attacks (TIA) and systemic embolisms. Procedural complication rate was 3.4%. After successful intervention, either a therapy with anticoagulants (N.=62) or dual antiplatelet therapy (DAPT, N.=50) was prescribed temporarily. Medication was reduced if implantation proved satisfying in a 6-week follow-up transesophageal echocardiography, which was the case in 79% of these patients. During follow-up, one patient suffered a TIA (0.6%/year). No other efficacy event was observed. Eleven major bleedings occurred (6.6%/year): one each under DAPT plus phenprocoumon, DAPT plus rivaroxaban, acetylsalicylic acid (ASA) plus rivaroxaban, two under DAPT, two under ASA plus low molecular weight heparin, and four under ASA only. In the present study, catheter-based LAA occlusion prevented thromboembolisms with high efficacy. Major bleedings were however common in patients with, but also without anticoagulation, independent from time course.

Left atrial appendage occlusion with the Amplatzer Cardiac Plug could improve survival and prevent thrombo-embolic and major bleeding events in atrial fibrillation patients with increased bleeding risk.

Literature suggests a beneficial effect of percutaneous left atrial appendage occlusion (LAAO) to prevent thrombo-embolic events in patients with non-rheumatic atrial fibrillation (AF). We compared outcome of LAAO versus ‘suboptimal standard’ treatment in AF patients with high bleeding risk. Patients with sufficient follow-up data (n = 125) who underwent LAAO with the Amplatzer Cardiac Plug (ACP) were selected from the Belgian ACP database. AF patients who survived intracranial haemorrhage were recruited from the Leuven Neurosurgical Registry (LNR, n = 113). After propensity score adjustment, the outcome of both groups was compared for the combined end point (death, stroke, transient ischaemic attack, systemic emboli, and major bleeding event). The LAAO group did not differ from the LNR group for mean age and gender (74 ± 7 versus 75 ± 10 years, P = 0.29; female 39% versus 48%, P = 0.18). However, the CHA2DS2-VASc and HAS-BLED scores were both higher in the LAAO group (4.8 ± 1.7 versus 3.9 ± 1.7, P = 0.0001; 3.5 ± 1.4 versus 3.2 ± 1.4, P = 0.036). After propensity score adjustment, the risk for the primary end point was significantly higher for the LNR group (HR 2.012, 95% CI 1.113-3.638). LAAO with ACP seems to improve the combination of survival and the prevention of thrombo-embolic and major bleeding events in patients with atrial fibrillation and increased bleeding risk.

Dealing With the Left Atrial Appendage for Stroke Prevention: Devices and Decision-Making.

Left atrial appendage (LAA) device occlusion represents a major evolution in stroke prevention for atrial fibrillation (AF). Left atrial appendage device occlusion is now a proven strategy which provides long-term thromboembolic stroke prevention for patients with non-rheumatic AF. Evidence supports its benefit as an alternative to long-term anticoagulation while mitigating long-term bleeding risks and improving cardiovascular mortality. The therapy offers expanded options to physicians and patients negotiating stroke prevention (both primary and secondary prevention), but a good understanding of the risks and benefits is required for decision-making. This review aims to summarise the evolution of LAA device occlusion therapy, current knowledge in the field and a snapshot of current status of the therapy in clinical practice in Australia and around the world.

PM176 Effect of Mitral Regurgitation in Non-Rheumatic Atrial Fibrillation Patients Taking and not Taking Warfarin on Stroke and Bleeding

PM176 Effect of Mitral Regurgitation in Non-Rheumatic Atrial Fibrillation Patients Taking and not Taking Warfarin on Stroke and Bleeding

Left atrial appendage occlusion with the Amplatzer Cardiac Plug could improve survival and prevent thrombo-embolic and major bleeding events in atrial fibrillation patients with increased bleeding risk

Aims Literature suggests a beneficial effect of percutaneous left atrial appendage occlusion (LAAO) to prevent thrombo-embolic events in patients with non-rheumatic atrial fibrillation (AF). We compared outcome of LAAO versus ‘suboptimal standard’ treatment in AF patients with high bleeding risk.Methods and results Patients with sufficient follow-up data (n = 125) who underwent LAAO with the Amplatzer Cardiac Plug (ACP) were selected from the Belgian ACP database. AF patients who survived intracranial haemorrhage were recruited from the Leuven Neurosurgical Registry (LNR, n = 113). After propensity score adjustment, the outcome of both groups was compared for the combined end point (death, stroke, transient ischaemic attack, systemic emboli, and major bleeding event). The LAAO group did not differ from the LNR group for mean age and gender (74 ± 7 versus 75 ± 10 years, P= 0.29; female 39% versus 48%, P= 0.18). However, the CHA2DS2-VASc and HAS-BLED scores were both higher in the LAAO group (4.8 ± 1.7 versus 3.9 ± 1.7, P= 0.0001; 3.5 ± 1.4 versus 3.2 ± 1.4, P= 0.036). After propensity score adjustment, the risk for the primary end point was significantly higher for the LNR group (HR 2.012, 95% CI 1.113-3.638).Conclusion LAAO with ACP seems to improve the combination of survival and the prevention of thrombo-embolic and major bleeding events in patients with atrial fibrillation and increased bleeding risk.

Persistent atrial fibrillation after radiofrequency ablation: considerations in treating rheumatic mitral valve disease patients

Atrial fibrillation (AF) in patients with rheumatic heart disease (RHD) results from hemodynamic consequences of valvular or myocardial heart disease and from direct tissue injury of the atrial myocardium by the underlying inflammatory process [1]. About 60% of patients with rheumatic valve disease develop AF. Several studies have clearly demonstrated a low probability of sinus rhythm recovery in patients with preoperative AF undergoing valve surgery for RHD [2,3]. Atrial fibrillation persistence is associated with worse clinical outcomes that include functional status, exercise capacity, quality of life and overall survival. A retrospective analysis was performed on a total of 793 patients who underwent mitral valve replacement with or without tricuspid valve repair [4]. At a mean follow-up of 8.6 ± 2.4 years of patients with preoperative AF, survival was 88.7%, compared with 96.6% in patients with preoperative sinus rhythm (p = 0.002). Several technical approaches and different energy sources have been employed to restore sinus rhythm in patients undergoing valve surgery. The proper way to verify success after an AF ablation procedure is controversial; continuous rhythm monitoring should be the gold standard of follow-up, but very few studies use it, thus results reported in literature are not easily comparable. It is conceivable that in patients followed with periodic ECG evaluation asymptomatic AF recurrences may occur, thus the true effectiveness might remain unknown. The surgical results of the maze procedure for AF associated with rheumatic mitral valve disease have been known to be less effective than for lone or nonrheumatic AF [5]. Preoperative patients characteristics (age, NYHA functional class at the time of surgery, type of prosthetic valve, proportion of paroxysmal and persistent AF, duration of the arrhythmia), concomitant surgical procedures (including vagal denervation) other than the modalities of success rate evaluation at followup, may explain the large variability (55–80%) of results reported in literature [6–9]. In a recent paper, our group demonstrated in patients undergoing radiofrequency (RF) ablation associated with mitral valve surgery that an increased left atrial area (HR: 1.07 per unit increase; 95% CI: 1.01–1.13) and rheumatic etiology of valve disease (HR: 4.52; 95% CI: 1.65–12.4) were significantly associated with the risk of persistence of AF at hospital discharge [10]. Less than 20% with atrial diameter greater than 55 mm and rheumatic mitral disease recovered sinus rhythm. At 6-year follow-up persistent sinus rhythm (SR) and overall survival in patients with rheumatic mitral valve disease in comparison with degenerative mitral (mitral valve prolapse) who underwent RF ablation and valve surgery were, respectively, 58 and 64%, and 84 and 90%. Persistent atrial fibrillation after radiofrequency ablation: considerations in treating rheumatic mitral valve disease patients

Figure-of-eight artifact after successful percutaneous closure of left atrial appendage

An 80-year-old man with non-rheumatic atrial fibrillation underwent transcatheter occlusion of left atrial appendage (LAA) with the Amplatzer™ Cardiac Plug (ACP) device due to warfarin contraindications. A 28mm ACP device was chosen based on LAA morphology, transesophageal echocardiography (TEE) measurements, and operator experience. After device deployment, sufficient anchoring was confirmed by pulling and releasing the delivery catheter under fluoroscopic and TEE surveillance. The final result was excellent without significant residual leak or pericardial effusion.