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Device-Related Thrombosis After Percutaneous Left Atrial Appendage Occlusion for Atrial Fibrillation
Laurent Fauchier Alexandre Cinaud François Brigadeau Antoine Lepillier Bertrand Pierre Selim Abbey Marjaneh Fatemi Frederic Franceschi Paul Guedeney Peggy Jacon Olivier Paziaud Sandrine Venier Jean Claude Deharo Daniel Gras Didier Klug Jacques Mansourati Gilles Montalescot Olivier Piot Pascal Defaye 《Journal of the American College of Cardiology》2018,71(14):1528-1536
Background
Transcatheter left atrial appendage (LAA) occlusion is an alternative strategy for stroke prevention in patients with atrial fibrillation (AF).Objectives
This study sought to determine the incidence, predictors, and prognosis of thrombus formation on devices in patients with AF who were treated with LAA closure.Methods
The study retrospectively analyzed data from patients treated with 2 LAA closure devices seen in 8 centers in France from February 2012 to January 2017.Results
A total of 469 consecutive patients with AF underwent LAA closure (272 Watchman devices [Atritech, Boston Scientific, Natick, Massachusetts] and 197 Amplatzer devices [St. Jude Medical, Minneapolis, Minnesota]). Mean follow-up was 13 ± 13 months, during which 339 (72.3%) patients underwent LAA imaging at least once. There were 98 major adverse events (26 thrombi on devices, 19 ischemic strokes, 2 transient ischemic attacks, 18 major hemorrhages, 33 deaths) recorded in 89 patients. The incidence of device-related thrombus in patients with LAA imaging was 7.2% per year. Older age (hazard ratio [HR]: 1.07 per 1-year increase; 95% confidence interval [CI]: 1.01 to 1.14; p = 0.02) and history of stroke (HR: 3.68; 95% CI: 1.17 to 11.62; p = 0.03) were predictors of thrombus formation on the devices, whereas dual antiplatelet therapy (HR: 0.10; 95% CI: 0.01 to 0.76; p = 0.03) and oral anticoagulation at discharge (HR: 0.26; 95% CI: 0.09 to 0.77; p = 0.02) were protective factors. Thrombus on the device (HR: 4.39; 95% CI: 1.05 to 18.43; p = 0.04) and vascular disease (HR: 5.03; 95% CI: 1.39 to 18.23; p = 0.01) were independent predictors of ischemic strokes and transient ischemic attacks during follow-up.Conclusions
Thrombus formation on the device is not uncommon in patients with AF who are treated by LAA closure. Such events are strongly associated with a higher risk of ischemic stroke during follow-up. (REgistry on Real-Life EXperience With Left Atrial Appendage Occlusion [RELEXAO]; NCT03279406) 相似文献2.
PCI to improve survival is currently recommended as a reasonable alternative to CABG in patients with unprotected left main disease. However, RCTs to support this recommendation has generated mixed results and recently published EXCEL trial has sparked debate about differences in late mortality. To address this point, we performed landmark meta-analysis of 4 RCTs with 5 year follow up data — EXCEL, NOBLE, PRECOMBAT and SYNTAX LEFT MAIN. Overall, there was no significant difference in all-cause mortality between PCI and CABG at 5 years (RR = 1.03 [95% CI = 0.79–1.33]). However, there was apparent change in the direction of association before and after the 1 year landmark that underscores the need for long term follow up in these trials. In addition, we found that PCI was associated with significantly lower rate of intermediate stroke at 1 year (RR = 0.44 [0.24–0.82]) but higher rate of late MI after 1 year (3.31 [2.11–5.18]) compared to CABG. 相似文献
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Anthony H. Gershlick David E. Kandzari Amerjeet Banning David P. Taggart Marie-Claude Morice Nicholas J. Lembo W. Morris Brown Adrian P. Banning Béla Merkely Ferenc Horkay Ad J. van Boven Piet W. Boonstra Ovidiu Dressler Joseph F. Sabik Patrick W. Serruys Arie Pieter Kappetein Gregg W. Stone 《JACC: Cardiovascular Interventions》2018,11(13):1224-1233
Objectives
The authors sought to determine the extent to which the site of the left main coronary artery (LM) lesion (distal bifurcation versus ostial/shaft) influences the outcomes of revascularization with percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG).Background
Among 1,905 patients with LM disease and site-assessed SYNTAX scores of <32 randomized in the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, revascularization with PCI and CABG resulted in similar rates of the composite primary endpoint of death, myocardial infarction (MI), or stroke at 3 years.Methods
Outcomes from the randomized EXCEL trial were analyzed according to the presence of angiographic core laboratory–determined diameter stenosis ≥50% involving the distal LM bifurcation (n = 1,559; 84.2%) versus disease isolated to the LM ostium or shaft (n = 293; 15.8%).Results
At 3 years, there were no significant differences between PCI and CABG for the primary composite endpoint of death, MI, or stroke for treatment of both distal LM bifurcation disease (15.6% vs. 14.9%, odds ratio [OR]: 1.08, 95% confidence interval [CI]: 0.81 to 1.42; p = 0.61) and isolated LM ostial/shaft disease (12.4% vs. 13.5%, OR: 0.90, 95% CI: 0.45 to 1.81; p = 0.77) (pinteraction = 0.65). However, at 3 years, ischemia-driven revascularization occurred more frequently after PCI than CABG in patients with LM distal bifurcation disease (13.0% vs. 7.2%, OR: 2.00, 95% CI: 1.41 to 2.85; p = 0.0001), but were not significantly different in patients with disease only at the LM ostium or shaft (9.7% vs. 8.4%, OR: 1.18, 95% CI: 0.52 to 2.69; p = 0.68) (pinteraction = 0.25).Conclusions
In the EXCEL trial, PCI and CABG resulted in comparable rates of death, MI, or stroke at 3 years for treatment of LM disease, including those with distal LM bifurcation disease. Repeat revascularization rates during follow-up after PCI compared with CABG were greater for lesions in the distal LM bifurcation but were similar for disease isolated to the LM ostium or shaft. 相似文献9.
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Jamie Diamond Mahesh V. Madhavan Joseph F. Sabik Patrick W. Serruys Arie Pieter Kappetein Martin B. Leon David P. Taggart Jacques Berland Marie-Claude Morice Bernard J. Gersh David E. Kandzari Ovidiu Dressler Gregg W. Stone 《JACC: Cardiovascular Interventions》2018,11(24):2441-2450
Objectives
The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG).Background
Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization.Methods
In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed.Results
Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (pinteraction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (pinteraction = 0.14) were consistent in patients with and those without prior CEVD.Conclusions
Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD. 相似文献11.
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Katharina Schoene Arash Arya Cosima Jahnke Ingo Paetsch Sotirios Nedios Sebastian Hilbert Andreas Bollmann Gerhard Hindricks Philipp Sommer 《JACC: Cardiovascular Interventions》2018,11(16):1626-1632
Objectives
The aim of the present study was to analyze and report a single-center experience with catheter interventional treatment of radiofrequency-induced pulmonary vein stenosis (PVS) following atrial fibrillation (AF) ablation.Background
Catheter interventional treatment of radiofrequency-induced PVS following AF ablation remains a challenging field because of a lack of randomized data and treatment guidelines.Methods
All patients at a single center who underwent catheter interventional treatment for radiofrequency-induced PVS were retrospectively assessed.Results
From January 2004 to September 2017, the total rate of PVS following interventional AF ablation was 0.78% (87 of 11,103). Thirty-nine patients with PVS were treated with 84 catheter interventions: 68 (81%) with percutaneous transluminal balloon angioplasty (PTA) and 16 (19%) with stent implantation. The distribution of stent type was 3 drug-eluting stents (19%) and 13 bare-metal stents (81%). The overall restenosis rate was 53% after PTA versus 19% after stent implantation (p = 0.007) after a median follow-up period of 6 months (interquartile range: 3 to 55 months). The total complication rate for PTA was 10% versus 13% for stenting (p = NS).Conclusions
This study demonstrates significantly better outcomes in terms of restenosis after stent implantation versus PTA only, with comparable complication rates for these 2 options of interventional treatment of radiofrequency-induced PVS. In summary, despite the lack of randomized studies, the present data and currently available published studies seem to favor stent implantation as a first-line therapy in patients with radiofrequency-induced severe PVS. 相似文献14.
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Joseph M. Bumgarner Cameron T. Lambert Ayman A. Hussein Daniel J. Cantillon Bryan Baranowski Kathy Wolski Bruce D. Lindsay Oussama M. Wazni Khaldoun G. Tarakji 《Journal of the American College of Cardiology》2018,71(21):2381-2388
Background
The Kardia Band (KB) is a novel technology that enables patients to record a rhythm strip using an Apple Watch (Apple, Cupertino, California). The band is paired with an app providing automated detection of atrial fibrillation (AF).Objectives
The purpose of this study was to examine whether the KB could accurately differentiate sinus rhythm (SR) from AF compared with physician-interpreted 12-lead electrocardiograms (ECGs) and KB recordings.Methods
Consecutive patients with AF presenting for cardioversion (CV) were enrolled. Patients underwent pre-CV ECG along with a KB recording. If CV was performed, a post-CV ECG was obtained along with a KB recording. The KB interpretations were compared to physician-reviewed ECGs. The KB recordings were reviewed by blinded electrophysiologists and compared to ECG interpretations. Sensitivity, specificity, and K coefficient were measured.Results
A total of 100 patients were enrolled (age 68 ± 11 years). Eight patients did not undergo CV as they were found to be in SR. There were 169 simultaneous ECG and KB recordings. Fifty-seven were noninterpretable by the KB. Compared with ECG, the KB interpreted AF with 93% sensitivity, 84% specificity, and a K coefficient of 0.77. Physician interpretation of KB recordings demonstrated 99% sensitivity, 83% specificity, and a K coefficient of 0.83. Of the 57 noninterpretable KB recordings, interpreting electrophysiologists diagnosed AF with 100% sensitivity, 80% specificity, and a K coefficient of 0.74. Among 113 cases where KB and physician readings of the same recording were interpretable, agreement was excellent (K coefficient = 0.88).Conclusions
The KB algorithm for AF detection supported by physician review can accurately differentiate AF from SR. This technology can help screen patients prior to elective CV and avoid unnecessary procedures. 相似文献17.
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