Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation

Reddy, Vivek Y.; Sievert, Horst; Halperin, Jonathan L.; Doshi, Shephal K.; Buchbinder, Maurice; Neužil, Petr; Huber, Kenneth C.; Whisenant, Brian; Kar, Saibal; Swarup, Vijay; Gordon, Nicole; Holmes, David

doi:10.1001/jama.2014.15192

Cited by 830 publications

(531 citation statements)

References 26 publications

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“…Despite the utility of TOE for thrombus detection in the LAA [13], a small number of thromboembolic events continue to occur even when no thrombus is detected in a pre-cardioversion [8] or LAA-occlusion setting (1-2%) [5,6]. Possible causes include absent or sub-therapeutic anticoagulation [14] and air embolism due to insufficient venting during LAA occlusion [5].…”

Section: Toe-guided Thrombus Detectionmentioning

confidence: 99%

“…Possible causes include absent or sub-therapeutic anticoagulation [14] and air embolism due to insufficient venting during LAA occlusion [5]. It is conceivable that thrombi may be missed during TOE examination, particularly in patients with retroverted LAAs and/or multiple lobes and large anof the main tubular body of the LAA or (2) lying in a different anatomic plane to the main tubular body.…”

Section: Toe-guided Thrombus Detectionmentioning

confidence: 99%

“…The ranges and frequencies of orientation were similar between sexes, with a slightly higher frequency of retroverted LAAs in women (16%) than in men (6%), device design and procedural technique. As the thin walls of the LAA (muscular wall ≤1 mm) are vulnerable, device maneuvering during the procedure [18] together with anatomical variation in the LAA may partly explain the most common (4-5%) [5,6] risk of perforation and pericardial hemorrhage. Malalignment of the delivery system with the central axis of the LAA may cause tension/stress on the LAA or may result in suboptimal device positioning, leading to more manipulations including device recapturing and redeployment.…”

Section: Orientation/angulationmentioning

confidence: 99%

“…, Stefan Bertog, MD 1,3 , Timothy Betts, MD 4 , Neil Wilson, MD 1,5 , Saul Myerson, MD closure is at least as safe and effective as anticoagulation with warfarin with regard to all-cause mortality and stroke risk [5]. LAA-occlusion devices have a fixed shape designed to provide an effective seal and stable positioning, but this may not take into account significant variability in LAA shape, orientation, and structure.…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, regardless of the LAA closure device used, co-axial alignment of the delivery sheath within the appendage is crucial for safe and successful implantation, and this depends on the orientation of the LAA. Suboptimal alignment of the delivery system within the appendage may cause perforation [5,6] and poor final device position, potentially promoting residual leaks [7] and thrombus formation. These complications remain the Achilles heel of the procedure, partially offsetting its potential benefits.…”

Section: Introductionmentioning

confidence: 99%

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Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

Joy¹,

Bertog²,

Betts³

et al. 2017

jshd

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Aims: Percutaneous left atrial appendage (LAA) occlusion has now become a suitable alternative to oral anticoagulation for stroke prevention in selected patients with atrial fibrillation (AF). However, LAA closure can be technically challenging and results suboptimal, in part due to variable left atrial anatomy.We aimed to characterize LAA morphology and identify potential anatomical pitfalls during LAA closure or LAA thrombus detection during transoesophageal echocardiography (TOE). Methods and Results: 103 patients with AF underwent cardiac magnetic resonance angiography to assess pulmonary venous anatomy. Adequate imaging quality was present in 76 in whom LAA morphology was assessed. The majority of LAAs (71%) were anterolaterally directed and 82% were 'claw'-shaped. However, there was significant variation in anatomy and course in the remainder: 11% were anteverted, 9% laterally directed and 9% retroverted. The shape was cone-like in 8%, fan-like in 5% and s-configured in 5% and there was significant variation in the curvature of the LAA body. While 66% had a single lobe, 30% were bilobed and 4% trilobed; 90% also had additional lobules. Conclusion: Our results demonstrate the significant variability of LAA geometry in AF patients. This may have implications for future device design for percutaneous LAA occlusion. The variable anatomy may affect LAA thrombus detection with TOE emphasizing the importance of multiple views to ensure complete assessment.

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Section: Toe-guided Thrombus Detectionmentioning

confidence: 99%

Section: Toe-guided Thrombus Detectionmentioning

confidence: 99%

Section: Orientation/angulationmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 3 more Smart Citations

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

Joy¹,

Bertog²,

Betts³

et al. 2017

jshd

Self Cite

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Progress Against Cardiovascular Disease

Greenland

Peterson

Gaziano

2014

JAMA

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The JAMA theme issue on cardiovascular disease (CVD) recognizes the progress made in CVD but also acknowledges the challenges that remain. On the positive side, from 2000 to 2010 age-adjusted death rates attributable to overall CVD in the United States declined by more than 30%. Yet CVD continued to account for a third (787 650) of the 2.5 million deaths in the United States per year, an average of 1 death every 40 seconds. 1 Worldwide, the picture is more concerning. The incidence of CVD is increasing rapidly in low-or-moderate income countries, and according to current World Health Organization statistics, ischemic heart disease and stroke were the number 1 and number 2 leading causes of death in the world in 2012. 2 With renewed interest in noncommunicable diseases, there has been greater focus on CVD.This theme issue includes reports addressing several important aspects of CVD including atherosclerotic disease, heart failure, valvular heart disease, and atrial fibrillation. For example, in one report from a large observational Swedish heart failure registry, patients with heart failure and preserved ejection fraction (HFPEF) showed possible benefit of β-blocker treatment in reducing all-cause mortality. 3 These observational results suggest a rationale for a clinical trial of β-blockers in HFPEF. Another article describes an unblinded trial of patients with nonvalvular atrial fibrillation at elevated risk for stroke who were followed up for 3.8 years. Compared with patients who received warfarin, those who received percutaneous left atrial appendage closure met criteria for both noninferiority and superiority for preventing the combined outcome of stroke, systemic embolism, and cardiovascular death, as well as superiority for cardiovascular and all-cause mortality. 4 A research letter in this issue shows both positive and negative trends in mortality rates for specific cardiovascular diseases between 2000 and 2010. The report confirms the wellknown statistic that overall CVD mortality remains the leading cause of death in the United States despite major declines in mortality rate, driven mostly by a decrease in coronary heart disease mortality. Less well-recognized, as indicated in the report by Ritchey et al, 5 is the increase in heart disease deaths attributable to hypertensive heart disease and arrhythmia in this same period. As signified by the research reports in this issue, there is good news because of some successes, but substantial ongoing challenges remain. Keeping both sides of the story in focus is necessary to understand the full picture.A prime example of both the promise and problems in addressing CVD has played out this past year in the area of CVD prevention. Since the time of the 2013 JAMA CVD theme is-Opinion

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Left Atrial Appendage Closure for Atrial Fibrillation

Stöllberger

2015

JAMA

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Percutaneous Left Atrial Appendage Closure vs Warfarin for Atrial Fibrillation

Abstract: clinicaltrials.gov Identifier: NCT00129545.

Cited by 830 publications

References 26 publications

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

Progress Against Cardiovascular Disease

Left Atrial Appendage Closure for Atrial Fibrillation

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