Antithrombotic Therapy and Device-Related Thrombosis Following Endovascular Left Atrial Appendage Closure

ObjectivesThe aim of this study is to review the evidence on the use of antithrombotic therapy and risk of device-related thrombosis after left atrial appendage closure.BackgroundLeft atrial appendage closure (LAAC) is increasingly performed for stroke prevention in patients with nonvalvular atrial fibrillation, especially those who cannot tolerate or are ineligible for oral anticoagulation.MethodsAfter device implantation for LAAC, different antithrombotic regimens with varying duration of therapy are currently used. Such selection depends on patients’ risk for bleeding and physicians’ choice.ResultsDevice-related thrombosis remains an Achilles’ heel of LAAC, and the etiology remains incompletely understood. Dual-antiplatelet therapy, and direct oral anticoagulation may have similar safety and device-related thrombosis occurrence in real-world LAAC registries compared with warfarin and aspirin. Device imaging surveillance should be routinely performed to assess for device-related thrombosis, which if diagnosed should be treated aggressively, as it is associated with higher thromboembolic risks.ConclusionsGiven the uncertainties and therapeutic dilemma, the authors provide an in-depth discussion of the options and rationale for antithrombotic therapy post-LAAC.     

Propensity-Matched Comparison of Oral Anticoagulation Versus Antiplatelet Therapy After Left Atrial Appendage Closure With WATCHMAN

ObjectivesIn this propensity-matched analysis of post–left atrial appendage closure antithrombotic therapy, the safety and effectiveness of oral anticoagulation (OAC) and antiplatelet therapy (APT) were compared.BackgroundLeft atrial appendage closure with the WATCHMAN device is an alternative to OAC in patients with nonvalvular atrial fibrillation, who are at high bleeding risk. Initial trials included 45 days of post-implantation OAC, but registry data suggest that APT may suffice.MethodsPatients from the PROTECT-AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation), PREVAIL (Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy), CAP (Continued Access to PROTECT-AF), CAP2 (Continued Access to PREVAIL), ASAP (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology), and EWOLUTION (Registry on WATCHMAN Outcomes in Real-Life Utilization) trials receiving either OAC or APT post-implantation were matched and compared for nonprocedural bleeding and stroke or systemic thromboembolism over 6 months following implantation. Each patient on APT was matched with 2 patients on OAC, with propensity scores derived from age, sex, congestive heart failure, hypertension, diabetes, prior transient ischemic attack or stroke, peripheral vascular disease, left ventricular ejection fraction, renal impairment, and different atrial fibrillation subtypes.ResultsThe cohort on OAC (n = 1,018; 95% receiving warfarin and 5% receiving nonwarfarin OAC) was prescribed 45-day OAC post-implantation (92% also received single APT), followed by 6-month single or dual APT. The cohort on APT (n = 509; 91% receiving dual APT and 9% receiving single APT) received APT for variable durations. Six-month freedom from nonprocedural major bleeding was similar (OAC, 95.7%; APT, 95.5%; p = 0.775) despite more early bleeds with OAC. Freedom from thromboembolism beyond 7 days was similar between groups (OAC, 98.8%; APT, 99.4%; p = 0.089). However, device-related thrombosis was more frequent with APT (OAC, 1.4%; APT, 3.1%; p = 0.018).ConclusionsAfter left atrial appendage closure with the WATCHMAN, although device-related thrombosis was more common with APT, both APT and OAC strategies resulted in similar safety and efficacy endpoints.     

Predictors of Occurrence of Left Atrial Appendage Stunning After Electrical Cardioversion of Atrial Fibrillation to Sinus Rhythm

Objective To determine the predictors and risk factors of occurrence of atrial appendage stunning after electrical cardioversion of non-valvular atrial fibrillation.     

What Is the Role of Left Atrial Appendage Closure in the Rhythm Control of Atrial Fibrillation?

Interventional catheter ablation approaches to the rhythm control of atrial fibrillation (AF) have advanced significantly in the past decade. The foundation of the catheter ablation in AF is electrical isolation of the pulmonary veins (PVI). However, PVI only in more advanced stages of AF (persistent AF) has only modest to poor success rates prompting a search for alternative and adjunctive procedures to improve the outcomes of ablation in persistent AF. The left atrial appendage (LAA) is well understood to be a primary source of emboli in AF but less well known be a trigger or driver for AF. Therefore, LAA exclusion is an attractive target to potentially improve AF ablation outcomes in more advanced stages of AF and possibly as an alternative to chronic oral anticoagulation in the prevention of stroke and systemic embolism in AF. However, the precise role of LAA closure in the interventional approach to AF is still to be elucidated with ongoing clinical investigations.     

Predictors and Risk Factors of Occurrence of Left Atrial Thrombus Among Aged patients With Chronic Atrial Fibrillation

Objective To determine the predictors and risk factor of thrombus in left atrium among aged patients with chronic atrial fibrillation.     

Procedural Strategies to Reduce the Incidence of Contrast-Induced Acute Kidney Injury During Percutaneous Coronary Intervention

Contrast-induced acute kidney injury (CI-AKI) is a potentially serious complication following coronary angiography and percutaneous coronary intervention (PCI). The incidence of CI-AKI is particularly high in patients with advanced chronic kidney disease (defined as an estimated glomerular filtration rate <30 ml/min/1.73 m²). Although much effort has been dedicated to the identification and implementation of preventive measures for this complication at the pre-intervention stage, much less has been investigated on the procedural strategies and techniques to decrease the risk of CI-AKI during PCI. The mainstay of such approaches relies on the minimization of contrast volume by means of specific strategies or dedicated devices. Invasive imaging, such as intravascular ultrasound or non–contrast-based optical coherence tomography, is another pillar of any ultra-low-contrast-volume PCI protocol. Finally, an array of miscellaneous ancillary measures can be implemented to decrease the risk of CI-AKI, which includes the use of radial access, remote ischemic conditioning, and hemodynamic support in high-risk patients. The present review analyzes the technical aspects as well as the scientific evidence supporting these novel techniques, with the goal to improve the outcomes of patients at high risk for CI-AKI undergoing PCI.