Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman

Background: Left atrial appendage occlusion (LAAO) is mostly performed by transesophageal echocardiography (TEE) guidance. Intracardiac echocardiography (ICE) may be an alternative imaging modality for LAAO that precludes the need for general anesthesia or sedation. Methods and Results: All consecutive single center, single operator LAAO candidates were analyzed. Baseline clinical and procedural characteristics and in‐hospital outcomes were compared between patients in whom a Watchman was implanted with ICE vs. TEE guidance. In 76 consecutive patients the Watchman device was deployed under ICE in 32 patients (42%) and under TEE guidance in 44 patients (58%). Baseline characteristics were comparable between groups, except that patients in the TEE group were older (81 [75–85] years vs. 75 [68–80] years, P = 0.007). Total injected contrast media as well as fluoroscopy time were comparable between groups (90 ml [54–140] vs. 85 ml [80–110], P = 0.86 and 7.9 min [6.4–15.5] vs. 9.8 min [7.0–13.2], P = 0.51, for TEE vs. ICE, respectively). However, time from femoral venous puncture to transseptal puncture and to closure was longer in the ICE group (14 min [7.3–20] vs. 6 min [3.3–11], P = 0.007 and 48 min [40–60] vs. 34.5 min [27–44], P = 0.003, respectively). In the TEE group one patient suffered esophageal erosion with bleeding, which was managed conservatively and one non‐LAAO related in‐hospital mortality occurred in an 88‐year‐old patient. Device implantation success rate was 100% in both groups. No device embolization, no significant peri‐device leak, no tamponade, no stroke, and no access site bleeding occurred in any patient. Total hospital stay for stand‐alone LAAO was comparable between groups (2 days [2–2] vs. 2 days [2–3.3], P = 0.17, in ICE vs. TEE, respectively). Conclusions: ICE guidance for LAAO with the Watchman device is feasible and comparable to TEE and may become the preferred imaging modality for LAAO. © 2016 Wiley Periodicals, Inc.     

Update on the efficacy of statins in primary and secondary prevention of atrial fibrillation

Atrial fibrillation is the most common arrhythmia in adults and its prevalence is growing rapidly. It has been shown that AF is associated with increased risk of heart failure, ischemic and hemorrhagic stroke, and mortality. Hence, there is growing interest among researchers in seeking preventive and therapeutic interventions regarding AF. In recent decades, it has been suggested that statins may decrease the incidence of AF and may also decrease its recurrence after cardioversion and catheter ablation. These effects are thought to be mediated by different mechanisms such as modulating inflammation, altering the properties of transmembrane ion channels, interfering with activation of matrix metalloproteinases, and acting on endothelial function. In this article, we review and update current knowledge about the role of statins in primary and secondary prevention of AF in general and specific populations.     

Registo de encerramento percutâneo do apêndice auricular esquerdo e experiência inicial com ecografia intracardíaca

Introduction

Percutaneous closure of the left atrial appendage (LAA) is a promising therapy in patients with atrial fibrillation with high risk for stroke and contraindication for oral anticoagulation (OAC). Intracardiac echocardiography (ICE) may make this percutaneous procedure feasible in patients in whom transesophageal echocardiography (TEE) is inadvisable. Our aim was to assess the efficacy and safety of LAA closure and the feasibility of ICE compared to TEE to guide the procedure.

Impact of catheter ablation for atrial fibrillation in patients with heart failure and left ventricular systolic dysfunction

Introduction and AimsCatheter ablation has been shown to improve left ventricular (LV) ejection fraction (LVEF) in patients with atrial fibrillation (AF) and heart failure (HF). Our aim was to assess the impact of AF ablation on the outcome of patients with HF and LV systolic dysfunction.MethodsWe performed a retrospective observational cohort study of all patients with HF and LVEF <50% and with no apparent cause for systolic dysfunction other than AF who underwent catheter ablation in a tertiary referral center between July 2016 and November 2018. The primary endpoint was a ≥5% improvement in LVEF. Secondary endpoints included improvement in New York Heart Association (NYHA) class and reduction in LV end-diastolic diameter (LVEDD) and left atrial diameter (LAD).ResultsOf 153 patients who underwent AF ablation in this period, 22 (77% male, median age 61 [IQR 54-64] years) fulfilled the inclusion criteria. Median follow-up was 11.1 months (IQR 6.1-19.0). After ablation, median LVEF increased from 40% (IQR 33-41) to 58% (IQR 55-62) (p<0.01), mean NYHA class improved from 2.35±0.49 to 1.3±0.47 (p<0.001), and median LAD and LVEDD decreased from 48.0 (IQR 43.5-51.5) mm to 44 (IQR 40-49) mm (p<0.01) and from 61.0 (IQR 54.0-64.8) mm to 55.0 (52.2-58.0) mm (p<0.01), respectively.ConclusionIn patients with HF and LV systolic dysfunction, AF ablation is associated not only with improved functional status but also with favorable structural remodeling, including improvement in LVEF and decreases in LAD and LVEDD.     

Effect of direct oral anticoagulants versus vitamin K antagonists or warfarin in patients with left ventricular thrombus outcomes: A systematic review and meta-analysis

IntroductionLeft ventricular thrombus commonly occurs as a complication of acute anterior myocardial infarction and nonischemic cardiomyopathies with severe left ventricular systolic dysfunction. Its frequency is still high despite medical advances. Current guidelines recommend the use of vitamin k antagonists as first-line therapy, however, the off-label use of direct oral anticoagulants is becoming more frequent and attractive, given the better pharmacological and clinical profile, with the improvement of the patient's quality of life.AimTo provide an update on the currently existing evidence regarding the outcomes of efficacy and safety of direct oral anticoagulants (DOACs) as first-line therapy in left ventricular thrombus, in comparison to vitamin K antagonists (VKAs).MethodsA systematic review and meta-analysis of studies on the effects of direct oral anticoagulants versus vitamin K antagonists on left ventricular thrombi and on the results was performed.ResultsFourteen studies were included in the meta-analysis, with a total of 2498 patients (n=631 direct oral anticoagulants and n=1867 for VKAs). No significant differences were found in efficacy and safety outcomes (odds ratio (OR) 0.86; 95% confidence interval (CI), 0.55–1.33; p=0.50; I²=32%) and (OR 1.0; 95% CI, 0.78–1.30; p=0.93; I²=2%) respectively. No difference was noted in all-cause mortality (OR 0.92; 95% CI, 0.58–1.45; p=0.74; I²=0%). Thrombus resolution was observed in 288/416 in direct oral anticoagulants vs. 732/1085 patients treated with VKAs (OR 1.14; 95% CI, 0.77–1.66; p=0.50; I²=33%).ConclusionsThe findings of this meta-analysis suggest the potential utility of DOACs as a first-line strategy in patients with left ventricular thrombus.     

Comparison of the effects of left atrial appendage closure and oral anticoagulants in preventing stroke in patients with non-valvular atrial fibrillation: A protocol for systematic review and meta-analysis

Background:This study aims to analyze and evaluate the difference in efficacy between left atrial appendage closure (LAAC) and oral anticoagulants (OA) in preventing stroke in patients with non-valvular atrial fibrillation (NVAF) through the method of meta-analysis. The purpose is to provide for the prevention of stroke in patients with NVAF valuable treatment guidance.Methods:This study is a comprehensive collection of randomized controlled studies of LAAC and OA in the prevention of stroke in patients with NVAF, and searches PubMed, Embase, the Cochrane Library, Web of Science, CNKI, SinoMed, VIP Database, WANFANG Database, and other Chinese and English databases by combining subject words with free words, and the retrieval time is from the establishment of each database to June 1, 2021. At the same time, searching the included literature and literature of related reviews by manual. Two researchers independently conduct literature screening and quality evaluation. Statistical software RevMan 5.3 and Stata 12.0 were used for meta-analysis.Results:This study evaluating the difference in efficacy between LAAC and OA in preventing stroke in patients with NVAF will be published in high-quality medical academic journals.Conclusion:This study will give the best treatment strategy to prevent stroke in patients with NVAF, and provide some reference for clinical medical staff.OSF registration number: DOI 10.17605/OSF.IO/2UXPA (https://osf.io/2uxpa).     

Non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation and atrial thrombosis: An appraisal of current evidence

Central illustration Mechanisms underlying atrial and left atrial appendage thrombosis in patients with atrial fibrillation. AF: atrial fibrillation; LAA: left atrial appendage; TF: tissue factor; VWF: von Willebrand factor.