Watchman Left Atrial Appendage Occlusion Research Articles

Procedure Volume and Outcomes With WATCHMAN Left Atrial Appendage Occlusion.

Procedure volumes are associated with outcomes for many cardiovascular procedures, leading to guidelines on minimum volume thresholds for certain procedures; however, the volume-outcome relationship with left atrial appendage occlusion is poorly understood. As such, we sought to determine the relationship between hospital and physician volume and WATCHMAN left atrial appendage occlusion procedural success overall and with the new generation WATCHMAN FLX device. We performed an analysis of WATCHMAN procedures (January 2019 to October 2021) from the National Cardiovascular Data Registry LAAO Registry. Three-level hierarchical generalized linear models were used to assess the adjusted relationship between procedure volume and procedural success (device released with peridevice leak <5 mm, no in-hospital major adverse events). Among 87 480 patients (76.2±8.0 years; 58.8% men; mean CHA2DS2-VASc score, 4.8±1.5) from 693 hospitals, the procedural success rate was 94.2%. With hospital volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (odds ratio [OR], 0.66 [CI, 0.57-0.77]) and Q2 (OR, 0.78 [CI, 0.69-0.90]) but not Q3 (OR, 0.95 [CI, 0.84-1.07]). With physician volume Q4 (greatest volume) as the reference, the likelihood of procedural success was significantly less among Q1 (OR, 0.72 [CI, 0.63-0.82]), Q2 (OR, 0.79 [CI, 0.71-0.89]), and Q3 (OR, 0.88 [CI, 0.79-0.97]). Among WATCHMAN FLX procedures, there was attenuation of the volume-outcome relationships, with statistically significant but modest absolute differences of only ≈1% across volume quartiles. In this contemporary national analysis, greater hospital and physician WATCHMAN volumes were associated with increased procedure success. The WATCHMAN FLX transition was associated with increased procedural success and less heterogeneity in outcomes across volume quartiles. These findings indicate the importance of understanding the volume-outcome relationship for individual left atrial appendage occlusion devices.

Same-day discharge after left atrial appendage occlusion: Is ICE-guided LAAO ready for prime time?

Key Points Single center study demonstrates the safety of same day discharge in intracardiac echocardiography guided watchman left atrial appendage occlusion. The study also reported that female sex, older age and longer procedure duration are predictors of non‐same day discharge. Standardization of intracardiac echocardiography for left atrial appendage closure devices is imperative before mainstream adoption.

Risk of device-related thrombosis following short-term oral anticoagulation with low-dose dabigatran versus warfarin after Watchman left atrial appendage occlusion.

Percutaneous left atrial appendage occlusion (LAAO) provides an alternative for poor candidates for long-term oral anticoagulation (OAC). To prevent device-related thrombosis (DRT), OAC should be continued for the first 45 days to allow complete endothelialization post-LAAO implantation. Whereas, evidence is limited on the feasibility and safety of direct oral anticoagulants (DOACs) used after LAAO. This was a retrospective observational single-center study of AF patients undergoing LAAO with a Watchman device and receiving either low-dose dabigatran (110mg twice daily) or warfarin in the peri- and post-procedural period for 45 days. Transesophageal echocardiography was scheduled to perform at 6 weeks, 6 months, and 12 months after the procedure to assess the stability of the device and to detect DRT. Incidence of thromboembolic and bleeding events were also evaluated during the follow-up period. There were a total of 84 patients who successfully underwent Watchman implantation, with 38 patients (45.2%) receiving low-dose dabigatran and 46 patients (54.8%) using warfarin post-LAAO. Peri-procedural complications occurred in 10 patients, with 3 patients in the dabigatran group and 7 patients in the warfarin group (7.9% vs. 15.2%, p = 0.30). During the 12-month follow-up, 1 patient experienced major bleeding and 16 patients suffered minor bleeding in the warfarin group, while 5 patients treated with dabigatran had minor bleeding (34.8% vs. 13.2%, p = 0.02). Besides, 6 DRT (15.8%) were detected in dabigatran groups, and the incidence was higher than in the warfarin group (15.8% vs. 2.2%, p = 0.03). No DRT-related ischemic events were found. This study suggested that short-term low-dose dabigatran (110 mg twice daily) could significantly decrease the risk of bleeding compared with warfarin at the expense of increased risk of DRT post-LAAO. Therefore, low-dose dabigatran should be used with caution for post-implant anticoagulation of LAAO. Further studies are urgently needed on the feasibility and safety of DOACs post-LAAO.

B-PO03-155 OUTCOMES OF LEFT ATRIAL APPENDAGE OCCLUSION WITH WATCHMAN IN CONTEMPORARY CLINICAL PRACTICE COMPARED WITH CLINICAL TRIALS: A POOLED ANALYSIS OF PROTECT-AF, PREVAIL, AND THE NCDR LAAO REGISTRY

The PROTECT-AF and PREVAIL trials established Watchman left atrial appendage occlusion (LAAO) as an alternative to warfarin for stroke protection in atrial fibrillation. In clinical practice, LAAO is often performed in patients who cannot tolerate long-term anticoagulation and have more cardiac and non-cardiac comorbidities. To compare outcomes of LAAO and control patients from PROTECT-AF and PREVAIL with LAAO patients from the NCDR LAAO Registry. We performed propensity matched analyses, matching up to 5 registry patients with each trial patient. Follow-up was censored at 425 days. The Kaplan Meier method was used to estimate event rates. Cox proportional hazards models, using registry patients as the reference group, were used to compare risk for ischemic stroke, hemorrhagic stroke, systemic embolism, and mortality. Of 38,285 patients enrolled in the LAAO Registry between 1/2016 and 12/2018; 4,874 were matched to 1,059 trial patients (701 LAAO, 362 warfarin). In adjusted analyses, the risk of ischemic stroke in trial patients randomized to LAAO was significantly higher than registry patients (2.7% vs. 0.9%; HR 2.69, p=0.0004); trial patients randomized to warfarin had a similar rate of ischemic stroke compared to registry patients (1.1%; HR 0.91, p=0.85). Risk of hemorrhagic stroke in trial warfarin patients were significantly higher compared with registry patients (1.4% vs. 0.3% HR 3.58, p=0.0156); trial LAAO patients had a similar risk compared with the registry patients (0.3%, HR 0.74, p=0.69). Systemic embolism was rare in all groups (registry patients 0.4%, trial warfarin patients 0.0%, trial LAAO patients 0.3%, p>0.05). Mortality was lower in trial LAAO patients than registry patients (3.0% vs. 4.7%; HR 0.57, p=0.016) but there were no differences compared to trial warfarin patients (4.1%; HR 0.66, p=0.12). In clinical practice, patients undergoing LAAO experience a lower risk of ischemic stroke, a similar risk of hemorrhagic stroke, and a higher risk of death in the 425 days after implant compared with LAAO patients in randomized trials. These results highlight the value of a national registry in understanding the adoption of technology and assessing procedural outcomes in contemporary practice.

Use of Direct Oral Anticoagulation Therapy Following Implantation of the Watchman Left Atrial Appendage Occlusion Device

ABSTRACT Background: Previously, the standard of care following left atrial appendage occlusion (LAAO) with the Watchman device (Boston Scientific) was 45 days of warfarin and aspirin followed by dual antiplatelet therapy (DAPT) for a total of 6 months and lifelong aspirin thereafter. The recommendation has recently been updated to include post-implantation oral anticoagulation, but there remains a lack of data supporting the use of direct oral anticoagulation (DOAC) therapy. Methods: This was a single-center retrospective analysis of patients undergoing LAAO between 2016 to 2019. Transesophageal echocardiogram (TEE) was conducted at 45 days post implantation. We reported outcomes for patients receiving warfarin with aspirin, DOAC with aspirin, and DOAC alone. Device thrombosis, device leak, transient ischemic attack (TIA)/stroke, major bleeding, and death were evaluated at 45 days and 1 year follow-up. Results: In total, 213 patients were evaluated, where 61 received warfarin/ASA, 81 received DOAC/ASA, and 71 received DOAC alone. At 45 days follow-up TEE, device thrombus was visualized in 2 (3.3%) patients on warfarin/ASA, one (1.2%) patient on DOAC/ASA, and 4 (5.6%) patients on DOAC (P = 0.34). Rates of device leak at 45 days were similar between the groups, from 7.0% to 8.3% (P > 0.99). Major bleeding event rates were similar at 45 days (P = 0.86) and 1 year (P = 0.50). There were no TIA/strokes at both 45 days and 1 year follow-up. At 45 days, one patient on warfarin/ASA died. Conclusion: The use of DOAC with and without aspirin has safety and efficacy outcomes post Watchman implantation similar to outcomes of warfarin and aspirin. Abbreviations: LAAO: left atrial appendage occlusion; DRT: device-related thrombosis; DAPT: dual antiplatelet therapy; DOAC: direct oral anticoagulant; CVA: cerebrovascular accident (i.e., transient ischemic attack [TIA] and stroke); CAD: coronary artery disease; ASA: aspirin; TEE: transesophageal echocardiogram; GI: gastrointestinal

Detection of Leak From Left Atrial Appendage Occlusion Using Dielectric Imaging.

Peri-device leak (PDL) following left atrial appendage occlusion (LAAO) may lead to an increased risk of thrombosis. However, current modalities for PDL detection, such as trans-esophageal echo (TEE) and cardiac CT do not provide quantitative measures of PDL. to use dielectric imaging (DI) to measure PDL from a Watchman (WM) LAAO device. A conductivity contrast agent is injected into the left atrium (LA) through the WM delivery system, while making DI measurements. Recordings are analyzed with a two-compartment model and the flow from the left atrial appendage (LAA) characterized by a "% clearance / beat" (CPB) parameter. With ethics approval, four dogs (26 ± 1.8 kg) were anesthetized and ventilated. Body-surface electrodes were placed and impedance data continuously acquired. WM devices (0-35% oversized) were introduced and placed into the LAA. During the study, the WM was either fully or partial deployed. At each deployment level, 10mL of conductivity contrast was injected through the WM delivery sheath. At twenty-two deployment conditions, Doppler-flow TEE measurements were made, and compared to the DI-based value. In all cases, CPB values correctly predicted the TEE-based assessment of PDL (100% sensitivity/specificity). The TEE leak size also corresponded to CPB values with a correlation of r = 0.914 (p 0.001). Using DI signals, the leak flow from the WM LAAO can be measured and yields comparative results to TEE for detection of PDL. The DI method requires no other imaging modality or ionizing radiation and iodine contrast agent injection.

Cryoballoon Ablation and Bipolar Voltage Mapping in Patients With Left Atrial Appendage Occlusion Devices

Left atrial appendage occlusion is utilized as a second line therapy to long-term oral anticoagulation in appropriately selected patients with atrial fibrillation (AF). We examined the feasibility of cryoballoon (CB) pulmonary vein isolation (PVI) subsequent to Watchman device implantation. The study prospectively identified patients with Watchman devices (>90 days old) who underwent CB-PVI ablation between 2018 and 2019. Twelve consecutive patients (male 50%; mean age 71 ± 9 years; CHA2DS2-VASc score 3.4 ± 1.1) underwent CB-PVI procedures after Watchman device implantation (mean 182 ± 82 days). Acute PVI was achieved in 100% of patients. All patients had evidence of complete (n = 9) or partial (n = 3) endothelialization of the surface of the Watchman device with conductive tissue properties demonstrated during electrophysiologic testing. There were no major procedure-related complications including death, stroke, pericardial effusion, device dislodgment, device thrombus, or new or increasing peri-device leak. Mean peri-device leak size (45-day postimplant: 0.06 ± 0.09 mm vs Post-PVI: 0.04 ± 0.06 mm; p = 0.61) remained unchanged. Two patients had recurrence of AF after the 90-day blanking period (13.2 ± 6.6 months). One patient underwent a redo ablation procedure for recurrent AF. This pilot study suggests the potential feasibility of CB-PVI ablation in patients with chronic Watchman left atrial appendage occlusion devices. Larger prospective studies are needed to confirm the clinical efficacy and safety of this approach.

CRT-600.34 Are There Gender Disparities in Presentation and Left Atrial Anatomy in Adults With Atrial Fibrillation Undergoing Watchman Left Atrial Appendage Occlusion?

Left atrial appendage (LAA) occlusion has become the mainstay for treatment in adults with atrial fibrillation (AF) and a high bleeding risk. While accurate device sizing is critical for successful LAA occlusion and optimal clinical outcomes, it is unknown whether gender impacts LAA anatomy and

Initial anticoagulation experience with standard-dose rivaroxaban after Watchman left atrial appendage occlusion

Warfarin is now recommended as the standard anti-thrombotic regimen to allow complete endothelialization over the Watchman device post percutaneous left atrial appendage occlusion (LAAO). However, the need for frequent monitoring, narrow therapeutic range, dietary restrictions and multiple drug interactions associated with warfarin have contributed to increasing uptake of non-vitamin K oral anticoagulants (NOACs) worldwide. At present, the feasibility and safety of NOACs instead of warfarin post-LAAO is lacking. Patients who underwent successful Watchman device implantation between October 1, 2016 and September 30, 2017 were enrolled in a retrospective database. And only patients who received rivaroxaban in the periprocedural period were included in this study. Transesophageal echocardiography (TEE) follow-up was scheduled at 6 weeks, at 6 months, and at 12 months post-implantation to detect device-related thrombosis (DRT) or peri-device leak. Meanwhile, thromboembolic and bleeding events were also evaluated at the time of follow-up. Totally, 57 Watchman devices were successfully implanted and 10 patients who were allocated to rivaroxaban at the dosage of 20 mg once daily were included. During the follow-up, none of the patients using rivaroxaban experienced DRT, peri-device leak, thromboembolic complications and major bleeding events, except for 2 patients who suffered minor bleeding during the 6 weeks follow-up. This study suggests that a short course of standard-dose rivaroxaban following Watchman LAAO is associated with low incidence of thrombotic complications and bleeding events, and might be a feasible alternative regimen in Chinese. Further randomized trials and large sample of real-world studies are needed to validate our finding.

Evaluating Real-World Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology: Final 2-Year Outcome Data of the EWOLUTION Trial Focusing on History of Stroke and Hemorrhage.

Left atrial appendage occlusion with WATCHMAN has emerged as viable alternative to vitamin K antagonists in randomized controlled trials. Evaluating real-life clinical outcomes in atrial fibrillation patients receiving the WATCHMAN left atrial appendage closure technology was designed to collect prospective multicenter outcomes of thromboembolic events, bleeding, and mortality for patients implanted with a WATCHMAN in routine daily practice. One thousand twenty patients with a WATCHMAN implant procedure were prospectively followed in 47 centers. Left atrial appendage occlusion indication was based on the European Society of Cardiology guidelines. Follow-up and imaging were performed per local practice up to a median follow-up of 2 years. Included population was old (age 73.4±8.9 years), at high risk for stroke (311 prior ischemic stroke/transient ischemic attack and 153 prior hemorrhagic stroke) and bleeding (318 prior major bleeding), with CHA2DS2-VASc score ≥5 in 49%, hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, Labile international normalized ratio, elderly, drugs/alcohol concomitantly ≥3 in 40% and oral anticoagulation contraindication in 72%. During follow-up, 161 patients (16.4%) died, 22 strokes were observed (1.3/100 patient-years, 83% reduction versus historic data), and 47 major nonprocedural bleeding events (2.7/100 patient-years, 46% reduction versus historic data). Stroke and bleeding rates were consistently lower than historic data in those with prior ischemic (-76% and -41%) or hemorrhagic (-81% and 67%) stroke and prior bleeding (-85% and -30%). Lowest bleeding rates were seen in patients with early discontinuation of dual antiplatelet therapy. Patients with early discontinuation of antithrombotic therapy showed lower bleeding rates, while they were highest for those with prior bleeding. Device thrombus was observed in 34 patients (4.1%) and was not correlated to drug regimen during follow-up ( P=0.28). During the complete 2-year follow-up of Evaluating Real-Life Clinical Outcomes in Atrial Fibrillation Patients Receiving the WATCHMAN Left Atrial Appendage Closure Technology, patients with a WATCHMAN left atrial appendage occlusion device had consistently low rates of stroke and nonprocedural bleeding, although most were contraindicated to oral anticoagulation and used only single antiplatelet therapy or nothing. URL: https://clinicaltrials.gov . Unique identifier: NCT01972282.

COMPARING ANTI-COAGULATION STRATEGIES IN PATIENTS UNDERGOING WATCHMAN IMPLANTATION: INCIDENCE OF PERIPROCEDURAL AND 45-DAY THROMBOSIS AND BLEEDING

Various anticoagulation strategies are employed in patients undergoing implantation of the Watchman left atrial appendage occlusion (LAAO) device. It is unknown whether choice of anticoagulation regimen influences periprocedural and short-term incidence of bleeding and thrombosis. We sought to

Usable implantation depth for watchman left atrial appendage occlusion is greater with appendage angiography than transesophageal echocardiography

To compare left atrial appendage (LAA) angiography to transesophageal echocardiography (TEE) for assessing usable LAA depth. TEE is typically employed for procedural measurement of LAA ostial diameter and depth. Since angiography enhances distal LAA anatomy, we sought to compare angiography to TEE for determining usable LAA depth. Seventy five Watchman device cases were retrospectively evaluated. Two independent cardiologists measured intraoperative LAA ostial diameter and depth at standard 0°, 45°, 90°, and 135° TEE omniplane views and in the right anterior oblique (RAO) 30°, caudal (CAUD) 30° angiographic view. The average age and CHA2 DS2 VASc score were 74 (±7.2) years and 4.6 (±1.3), respectively. The average ostial diameter and depth (mm) by TEE were 0°: 19.6 and 26.5; 45°: 17.5 and 26.6; 90°: 18.3 and 25.1; 135°: 19.5 and 23.3. The ostial diameter and depth (mm) by RAO 30° CAUD 30° angiography were 21.1 and 29.7. This angiographic view corresponds to a TEE view between 90° and 135°. In comparison to angiography, TEE 90° underestimated the LAA ostial diameter by 2.9 ± 3.7 mm (P < 0.001) and by 1.9 ± 4.0 mm at TEE 135° (P < 0.01); Pearson's r 0.53 angiography/TEE 90° and 0.50 angiography/TEE 135°. More importantly, TEE 90° underestimated the true usable LAA depth by 5.4 ± 5.8 mm (P < 0.001) and by 7.3 ± 6.1 mm at TEE 135° (P < 0.001); Pearson's r 0.39 angiography/TEE 90° and 0.30 angiography/TEE 135°. Compared to TEE, LAA angiography provides additional depth information and may be particularly valuable when patients have insufficient depth for Watchman by TEE measures.

ACHIEVING LOW RADIATION EXPOSURE AND CONTRAST USAGE WITHOUT COMPROMISING SAFETY AND EFFICACY DURING WATCHMAN LEFT ATRIAL APPENDAGE OCCLUSION DEVICE IMPLANT

The study demonstrates the safety, feasibility and effectiveness of a comprehensive approach to minimize fluoroscopy and contrast use during Watchman left atrial closure device implantation.Background. The introduction of Watchman left atrial appendage occlusion device (WM) has provided an effective alternative to anticoagulation for patients with a high risk of cerebrovascular accidents (CVA) and high risk of bleeding and who are unable to take long-term anticoagulation therapy. Since its introduction, WM has been implanted more than 50,000 times worldwide. While the implant procedure is relatively safe, it involves the use of fluoroscopy and contrast and, as such, poses some associated risk to patient safety. The adoption of procedural techniques which reduce fluoroscopy exposure and contrast use have the potential to provide clinical patient benefit without compromising safety or efficacy. Aim To demonstrate that WM implant can be performed with minimal exposure to both ionizing radiation and IV contrast without compromising safety or efficacy.Methods. A retrospective chart review of all 75 consecutive Watchman implantations by a single operator at a single center between December 2015 and December 2017. Every effort to optimize the WM implant procedure and minimize radiation and contrast exposure was incorporated as implant techniques evolved. Contrast and radiation exposure data were collected and analyzed year-over-year.Results. Charts from 75 consecutive cases were reviewed with all cases at index procedure (100%), and included the majority of patients presenting in paroxysmal AF (63%). Baseline patient characteristics were consistent across years. Procedural characteristics also were consistent over time. The median absorbed radiation dose was low (75 mGy in 2015) and did not change significantly over time. Similarly, the median fluoroscopy time used after the initial case was low (2.8 minutes) and did not vary. 73 of 75 (97%) of procedures resulted in successful implantation. There were no procedural complications; notably, no cases resulted in stroke, death, pericardial effusion, vascular accidents or device embolization.Conclusion.The current generation of WM can be successfully implanted using low fluoroscopy and contrast without compromising safety or efficacy using the techniques described.

Catheter Ablation for Atrial Fibrillation in Patients With Watchman Left Atrial Appendage Occlusion Device: Results from a Multicenter Registry.

There have been an increasing number of atrial fibrillation (AF) patients with Watchman left atrial appendage occlusion (LAAO) device, requiring catheter ablation (CA) for maintenance of normal sinus rhythm. In this study, we describe our experience with the feasibility and safety of CA in patients with a preexisting Watchman LAAO device. This was a retrospective multicenter AF registry of 60 patients with Watchman LAAO device who underwent CA for AF. Baseline clinical and procedural characteristics of the included subjects were retrieved from review of medical records and were analyzed. The mean age was 72.7 ± 4.9 years and the mean CHADS2 score was 2.3 ± 0.6. All patients had successful pulmonary vein isolation (PVI). The left atrial appendage (LAA) was electrically active in 34 (56%) while reentrant tachycardia and AF triggers were seen in 17 (28%) patients. Electrical isolation was attempted in these 17 patients with only 10 achieving complete LAA isolation. Repeat imaging showed new peri-device leaks in 30% (12/40) patients, while new significant peri-device leaks (≥5 mm) were noted in 10% (10/40) of patients after RFA, respectively, requiring continuation of oral anticoagulation. There were a higher proportion of patients with severe peri-device leaks (≥5 mm) after LAA isolation. However, >50% of those leaks sealed off on follow-up transesophageal echocardiogram. AF ablation is a feasible and safe in patients with preexisting Watchman LAAO device. Electrical isolation of the LAA could be difficult and when attempted can result in increased risk of short-term peri-device leak and recurrence of AT/AF in almost all patients.

Assessment of Chronic Watchman Left Atrial Appendage Occlusion by Cardiac Computed Tomography Angiography

Background: No studies have assessed longitudinal imaging of Watchman® left atrial appendage (LAA) occlusion beyond 12 months. We sought to assess appearances of the Watchman® device and completeness of LAA occlusion based on cardiac CT angiography in patients with chronic implants. Methods: A retrospective analysis of images from cardiac CT scans was performed in patients with a Watchman® implanted ≥2 years prior. Patients were imaged with Somatom Definition Flash CT scanners using 0.5–0.8mm axial slice thickness. Three-phase contrast left atrial imaging, or a CT Coronary Angiography protocol was employed. Image review was on InteleviewerPACS using axial reconstruction. Prior TOE imaging results were also analysed. Results: Twenty-four patients were imaged at a mean time of 44±13 months (range 24–72) post Watchman® implant. Watchman® device integrity was intact in all. Total occlusion of the LAA was identified in 11/24. Contrast opacification of the LAA distal to the device was noted in 13/24. Partial occlusion (non-opacification of portions of LAA) was noted in 7/13 varying from 25–90% volume. Comparison with prior TOE results found that in 16 patients with complete occlusion on TOE, 9 were later identified to have total occlusion and 7 had incomplete occlusion on CT. Of 7 patients with peri-device leak on TOE, 2 had total occlusion and 5 had incomplete occlusion on CT. Conclusions: In this study a 46% complete occlusion rate was found in chronic Watchman® implants based on Cardiac CT angiography. Early post-implant TOE imaging predicted long-term complete occlusion in only 58% of patients.

Left Atrial Appendage Occlusion Device and Novel Oral Anticoagulants Versus Warfarin for Stroke Prevention in Nonvalvular Atrial Fibrillation: Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Nonvalvular atrial fibrillation is the most common arrhythmia. Patients with nonvalvular atrial fibrillation are at increased risk of stroke; therefore, we evaluated the efficacy and safety of different approaches to prevent this major complication. We conducted electronic database searches of phase III randomized controlled trials. The groups were novel oral anticoagulants, Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke or systemic embolism, and all-cause mortality. Safety outcome was major bleeding and procedure-related complications. A subgroup analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each outcome. Seven randomized controlled trials (n=73,978) were included. There was a significant difference favoring novel oral anticoagulants for systemic embolism (OR, 0.84; 95% CI, 0.72-0.97; P=0.01), all-cause mortality (OR, 0.89; 95% CI, 0.84-0.94; P<0.001), and safety outcomes (OR, 0.79; 95% CI, 0.65-0.97; P=0.026) compared with warfarin. No difference was seen between DEVICE and warfarin for efficacy end points; however, DEVICE had more complications (OR, 1.85; 95% CI, 1.14-3.01; P=0.012). In the elderly (6 randomized controlled trials, n=30,699), systemic embolism was favored with novel oral anticoagulants over warfarin (OR, 0.77; 95% CI, 0.68-0.87; P≤0.001). No evidence of significant publication bias was found. Novel oral anticoagulants is superior to warfarin for stroke prevention in nonvalvular atrial fibrillation. This benefit was also observed in the elderly population. DEVICE is a reasonable noninferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.

Atrial Fibrillation Through the Years

Information about a real patient is presented in stages (boldface type) to an expert clinician (Dr Valentin Fuster), who responds to the information, sharing his reasoning with the reader (regular type). A discussion by the authors follows. A 61-year-old man presents with 2 weeks of exertional dyspnea. Pertinent medical history includes hypertension, nephrolithiasis, and internal hemorrhoids. He takes no medications and has no known drug allergies. His father died after a myocardial infarction at 57 years of age. He formerly smoked 1 pack of cigarettes daily for 15 years but ceased tobacco use 10 years before presentation. He ingests 2 glasses of alcohol weekly and denies illicit drug use. His caffeine intake is limited. He is an architect and is married, with healthy children. On physical examination, his temperature is 98.0°F, blood pressure is 130/85 mm Hg bilaterally, pulse is irregular at 130 beats per minute, and respiratory rate is 18 breaths per minute with an oxygen saturation of 97% while breathing room air. He is a slender white man in no distress. His jugular venous pressure is elevated at 14 cm H 2 O. There is no thyromegaly, and the carotid upstrokes are brisk, without bruits. Cardiovascular examination reveals a rapid and irregular heart rhythm with variation in the intensity of the first heart sound. The point of maximal impulse is not displaced. The remainder of the chest and abdominal examination is within normal limits. The extremities are warm and show mild pitting edema. Laboratory testing is significant for normal renal function and electrolytes, but a hemogram reveals a mild thrombocytopenia of 90 000 platelets/μL. ECG demonstrates atrial fibrillation (AF) with an average ventricular rate of 123 bpm ( Figure 1 ). Figure 1. The 12-lead ECG showing atrial fibrillation with a rapid ventricular rate. Dr Valentin Fuster : This is a …

2012: A Year In Review

Here's a look at some of the milestones and highlights of the year 2012 in Journal of Visualized Experiments (JoVE). At the start of 2012, JoVE reached a major milestone by publishing our 1500th article. In this publication, in JoVE Bioengineering, Yu et al. described a method for analyzing the free radical composition of cigarette smoke. This method simulated cigarette puffing with a single-port smoking device, and combined it with electron spin resonance (ESR) spectroscopy to measure the degree to which antioxidant compounds can scavenge free radicals in cigarette smoke. A possible outcome of this research is the creation of less harmful cigarettes. JoVE Bioengineering also contained the most-viewed article of 2012. Owczarczak et al. described a method for hacking a standard inkjet printer, loading ink cartridges with a cell-suspension bioink, and printing lines of live cells onto glass slides. The thermal inkjet printing process creates temporary pores in the cell membrane, visualized by the incorporation of fluorescently labeled actin monomers. This concept, called bioprinting, has many potential applications in cell and tissue engineering. Also in 2012, JoVE Bioengineering featured a protocol by Hsia et al. for isolating and purifying spider silk protein, spinning it into fibers, and assessing the fiber strength. This protocol for laboratory-scale production of spider silk, which is stronger than tensile steel, can potentially be extended to large-scale manufacturing. In JoVE Clinical and Translational Medicine, we featured a number of articles related to stroke, one of which. In one article, Mobius-Winkler et al. demonstrated placement of the WATCHMAN left atrial appendage occlusion device from Boston Scientific. This device is designed to prevent strokes by trapping clots within the left atrial appendage of the heart before they exit. Our authors demonstrated how to insert the guide wire through the femoral artery into the heart, advance the device into the left atrium, and deploy the device in the left atrial appendage. Another article focused on stroke, Hamel et al. described the use of a driving simulator to study how patients compensate for visual field defects following stroke. By analyzing the compensatory gaze behavior of patients as they navigated through virtual driving courses with varying degrees of complexity, our authors see great potential for the use of driving simulators in stroke rehabilitation. In JoVE Immunology and Infection, we published an article by Keyel et al. describing the real-time kinetics of immune cell responses to bacterial toxins using live cell microscopy. Combined with high-speed 3D confocal microscopy, this technique can also visualize the cellular repair response. Also in JoVE Immunology and Infection, we featured an article by Yap et al. describing methods for diagnosing helminth infections in children. Helminths are parasitic worms that can infect the intestinal tract of humans and animals, and may be distinguished based on their morphology. The same article demonstrated how to measure the impact of helminth infections on physical fitness in children, which is a measure of overall health. In JoVE Neuroscience, we featured a method by Hoffmann et al., who used tiny headphones to alter the auditory feedback in songbirds, and analyzed the computational and neurophysiological basis of vocal learning in birds when they adjust their singing in response to altered acoustic signals. Also in JoVE Neuroscience, we moved from birds to bees with a method that assesses associative and non-associative tactile learning in honeybees. This method, by Mujagic et al., allowed bees to scan different metal surfaces with their antennae, then conditioned them to expect sugar water when their antennae touched particular surfaces, and analyzed the corresponding changes in antennal movement. In 2012, we launched a brand-new section: JoVE Applied Physics, which features articles on subjects ranging from plasma physics to material science. The Applied Physics section also contained JoVE's 2000th video article, filmed in a synchrotron radiation facility, where Borisenko et al. showed how to determine the electronic structure of complex materials using angle-resolved photoemission spectroscopy. In the JoVE General section, we published an article by Artioli et al. demonstrating the use of a portable gas analyzer to measure oxygen consumption during complex exercise - such as judo. By analyzing oxygen consumption and collecting blood for measuring plasma lactate concentration, this method can determine the relative contributions of different energy systems to specific aspects of complex exercise. Finally, JoVE followed Dolhi et al. to a permanently ice-covered saline lake in Antarctica. There, scientists drilled through the ice to study single-celled microorganisms called protists that live in the harsh conditions of Antarctica. This Year in Review was just a brief glimpse of a few of over 600 video articles that JoVE offered in 2012. Browse the JoVE archives to see thousands of other videos, and stay tuned for what's coming up this year in JoVE: The Journal of Visualized Experiments.