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Remaining Challenges With Transcatheter Left Atrial Appendage Closure.

ABSTRACT: Left atrial appendage closure has emerged as a feasible stroke prevention strategy in selected patients with nonvalvular atrial fibrillation. Since its commercial approval in the United States in 2015, the use of percutaneous left atrial appendage closure has witnessed a substantial growth. However, certain issues remain unresolved with the technology. Knowledge of these issues, their significance, and the current and future efforts to resolve them is key for proper informed decision making by physicians and patients.

SUBMITTER: Alkhouli M

PROVIDER: S-EPMC7528944 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Remaining Challenges With Transcatheter Left Atrial Appendage Closure.

Alkhouli Mohamad M Holmes David R DR

Mayo Clinic proceedings 20201001 10

Left atrial appendage closure has emerged as a feasible stroke prevention strategy in selected patients with nonvalvular atrial fibrillation. Since its commercial approval in the United States in 2015, the use of percutaneous left atrial appendage closure has witnessed a substantial growth. However, certain issues remain unresolved with the technology. Knowledge of these issues, their significance, and the current and future efforts to resolve them is key for proper informed decision making by p ...[more]

PMID: 33012352

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Left atrial appendage closure: outcomes and challenges.

Project description:Whereas the left atrial appendage plays a rather minor role under physiological circumstances, it gains an importance in patients with atrial fibrillation. Compelling evidence has revealed that the left atrial appendage is implicated as the source of thrombus in the vast majority of strokes in atrial fibrillation. Oral anticoagulation remains the standard of care for stroke prevention in atrial fibrillation; nevertheless, this treatment has several limitations and is often contraindicated, particularly in the elderly population in whom the risk of stroke is high. Therefore, occluding the left atrial appendage is a logical approach to prevent thrombus formation and subsequent cardioembolic events in these patients. We present a review of clinical outcomes of patients with atrial fibrillation undergoing left atrial appendage closure and the challenges faced in this field.

| S-EPMC5260621 | biostudies-literature

Air emboli during the procedure of transcatheter left atrial appendage closure.

Project description: Not available

| S-EPMC5419975 | biostudies-literature

Left atrial appendage perforation during appendage angiography treated by percutaneous left atrial appendage closure: a case report.

Project description:BackgroundPericardial effusion is a common complication of percutaneous left atrial appendage (LAA) closure. Acute management is the cornerstone of pericardial effusion treatment and interrupting the intervention is often required.Case summaryA 65-year-old man presented an acute 10 mm pericardial effusion following pigtail contrast appendage injection. A rapid Watchman Flex 24 mm (Boston Scientific) deployment permitted bleeding interruption. A needle pericardiocentesis was achieved in order to prevent any haemodynamical instability.DiscussionThis case report describes an atypical cause of pericardial effusion and a technique for bleeding control with LAA closure device deployment.

| S-EPMC8183657 | biostudies-literature

Epicardial Contrast Injection to Guide Left Atrial Appendage Closure.

Project description: Not available

| S-EPMC8283536 | biostudies-literature

Clinical benefit of left atrial appendage closure in octogenarians.

Project description:OBJECTIVES:Whether left atrial appendage closure (LAAC) in octogenarians yield similar net clinical benefit compared to younger patients, was the purpose of the present study. METHODS:Two real-world LAAC registries, enrolling 744 consecutive Amplatzer and Watchman patients from 2009 to 2018, were retrospectively analyzed. RESULTS:All events are reported per 100 patient-years. Two hundred and sixty one octogenarians and 483 non-octogenarians with a mean follow-up of 1.7 ± 1.3 and 2.3 ± 1.6 years, and a total of 1,502 patient-years were included. Octogenarians had a higher risk for stroke (CHA2DS2-VASc score: 5.2 ± 1.2 vs. 4.3 ± 1.7, P < 0.0001) and bleeding (HAS-BLED score: 3.3 ± 0.8 vs. 3.1 ± 1.1, P = 0.001). The combined safety endpoint of major periprocedural complications and major bleeding events at follow-up was comparable (30/446, 6.7% vs. 47/1056, 4.4%; hazard ratio [HR] = 1.2; 95% confidence interval [CI]: 0.73-1.98;P = 0.48) between the groups. The efficacy endpoint of all-cause stroke, systemic embolism, and cardiovascular/unexplained death occurred more often in octogenarians (61/446, 13.7% vs. 80/1056, 7.6%; HR = 7.0; 95% CI: 4.53-10.93;P < 0.0001). Overall, octogenarians had a lower net clinical benefit, i.e., the composite of all above mentioned hazards, from LAAC compared to younger patients (82/446, 18.4% vs. 116/1056, 11.0%; HR = 4.6; 95% CI: 3.11-7.0;P < 0.0001). Compared to the anticipated stroke rate, the observed rate decreased by 41% in octogenarians and 53% in non-octogenarians. The observed bleeding rate was reduced by 10% octogenarians and 41% non-octogenarians. CONCLUSIONS:LAAC can be performed with similar safety in octogenarians as compared to younger patients. On the long-term, it both reduces stroke and bleeding events, although to a lesser extent than in non-octogenarians.

| S-EPMC8648545 | biostudies-literature

Left atrial appendage enlarged by coronary artery fistula after surgical closure of appendage.

Project description:Two years previously, a 73-year-old man with mitral regurgitation underwent mitral annuloplasty and left atrial appendage (LAA) exclusion by suturing the orifice from the endocardium. However, the mitral regurgitation became exacerbated, and the left atrium enlarged rapidly over a 6-month period. Computed tomography showed a heterogenic mass in the LAA, and coronary angiography revealed a coronary artery-LAA fistula. Reoperation revealed a thrombus filling the appendage and two small orifices of the coronary artery-LAA fistula located in the endocardium of the appendage. We excised the LAA and closed these fistula orifices concomitant with mitral valve replacement.

| S-EPMC4360659 | biostudies-other

Interventional Left Atrial Appendage Closure Affects the Metabolism of Acylcarnitines.

Project description:Left atrial appendage closure (LAAC) represents the interventional alternative to oral anticoagulation for stroke prevention in atrial fibrillation (AF). The metabolism of acylcarnitines was shown to affect cardiovascular diseases. This study evaluates the influence of successful LAAC on the metabolism of acylcarnitines.Patients undergoing successful LAAC were enrolled prospectively. Peripheral blood samples for metabolomics measurements were collected immediately before (i.e., index) and six months after LAAC (i.e., mid-term). A targeted metabolomics analysis based on electrospray ionization-liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed.44 patients with non-valvular AF (median CHA?DS?-VASc score 4, median HAS-BLED score 4) and successful LAAC were included. Significant changes in acylcarnitine levels were found in the total cohort, which were mainly attributed to patients with impaired left ventricular and renal function, elevated amino-terminal pro-brain natriuretic peptide (NT-proBNP) and diabetes mellitus. Adjusted multivariable regression models revealed significant changes of five metabolites over mid-term follow-up: C2, C14:1, C16, and C18:1 decreased significantly (each p < 0.05); short-chain C5 acylcarnitine plasma levels increased significantly (p < 0.05).This study demonstrates that successful LAAC affects the metabolism of acylcarnitines at mid-term follow-up.ClinicalTrials.gov Identifier: NCT02985463.

| S-EPMC5855722 | biostudies-literature

Percutaneous Closure of Left Atrial Appendage significantly affects Lipidome Metabolism.

Project description:Patients with non-valvular atrial fibrillation (AF) and a high risk for oral anticoagulation can be treated by percutaneous implantation of left atrial appendage occlusion devices (LAAC) to reduce the risk of cardio-embolic stroke. This study evaluates whether LAAC may influence lipid metabolism, which has never been investigated before. Patients with successful LAAC were included consecutively. Venous peripheral blood samples of patients were collected immediately before (T0, baseline) and 6 months after (T1, mid-term) LAAC. A targeted metabolomics approach based on electrospray ionization liquid chromatography-mass spectrometry (ESI-LC-MS/MS) and MS/MS measurements was performed. A total of 34 lipids revealed a significant change from baseline to mid-term follow-up after successful LAAC. Subgroup analysis revealed confounding influence by gender, age, diabetes mellitus type II, body mass index, left ventricular ejection fraction, creatinine and NT-proBNP. After multivariable adjustment within logistic regression models, these 34 lipids were still significantly altered after LAAC. Successful percutaneous LAAC may affect lipid metabolism and thereby may potentially affect pro-atherogenic and cardio-toxic effects.

| S-EPMC5897373 | biostudies-literature

Left Atrial Spontaneous Echo Contrast and Ischemic Stroke in Patients Undergoing Percutaneous Left Atrial Appendage Closure.

Project description:Objectives: Spontaneous echo contrast (SEC) in the left atrium (LA) is frequently observed in atrial fibrillation (AF) patients and may lead to thromboembolic events. We aimed to investigate both periprocedural and long-term stroke risks associated with LA SEC in AF patients undergoing percutaneous left atrial appendage closure (LAAC). Methods: A total of 408 consecutive AF patients treated with LAAC between March 2015 and February 2019 were divided into two groups based on preprocedural transesophageal echocardiography: the study group (moderate/severe LA SEC; n = 41) and the control group (none, mild, or mild to moderate LA SEC; n = 367). To attenuate the observed imbalance in baseline covariates, a propensity score matching technique was used. Results: No periprocedural stroke/transient ischemic attack (TIA) was documented. The incidence of device-related thrombus was higher in the study group than in the control group (8.8 vs. 1.3%; P = 0.025). The mean follow-up period was 3.2 ± 1.1 years, during which 8 patients (2.2%) in the control group and 4 (9.8%) in the study group experienced stroke/TIA (P = 0.024). Moderate/severe LA SEC was identified as an independent predictor of stroke/TIA in both the original population (HR = 5.71, 95% CI 1.47-22.19, P = 0.012) and the matched population (HR = 9.79, 95% CI 1.44-66.86, P = 0.020). Conclusions: LA SEC did not show a relationship with periprocedural stroke events in patients undergoing percutaneous LAAC. However, moderate/severe LA SEC increased the incidence of device-related thrombus and the risk of late stroke/TIA.

| S-EPMC8495018 | biostudies-literature

Percutaneous Retrieval of a Left Atrial Appendage Closure Device: The Device Waltz.

Project description:Embolization of a device in patients undergoing percutaneous left atrial appendage closure is an uncommon complication. We present an illustrative case of successful percutaneous retrieval of an embolized LAmbre device (Lifetech Scientiﬁc, Shenzhen, China) that was achieved with a combination of a snaring technique and forceps grasping and by using a steerable guiding catheter. (Level of Difficulty: Advanced.).

| S-EPMC8311156 | biostudies-literature

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