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Thrombus location in patients referred for left atrial appendage closure. *P<0.05, †P=0.063. IAT, intensification of antithrombotic therapy; LAAC, left atrial appendage closure.
Source publication
Objective:
Left atrial appendage (LAA) thrombus has heretofore been considered a contraindication to percutaneous LAA closure (LAAC). Data regarding its management are very limited. The aim of this study was to analyse the medical and invasive treatment of patients referred for LAAC in the presence of LAA thrombus.
Methods:
This multicentre obse...
Contexts in source publication
Context 1
... 3222 patients undergoing LAAC in 21 institutions, 126 (3.9%) patients with LAA thrombus on preprocedural imaging were included. The indication for LAAC and baseline antithrombotic treatment are presented in online supplemental figure 1. Thrombus location and dimensions by TEE (85.7%) or CT (14.3%) are presented in figure 1 and table 1. ...
Context 2
... 3222 patients undergoing LAAC in 21 institutions, 126 (3.9%) patients with LAA thrombus on preprocedural imaging were included. The indication for LAAC and baseline antithrombotic treatment are presented in online supplemental figure 1. Thrombus location and dimensions by TEE (85.7%) or CT (14.3%) are presented in figure 1 and table 1. ...
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Citations
... Natural concerns of periprocedural thrombus release support the use of various technical precautions, such as cerebral protection device or "touchless techniques" [38]. Pre-procedural intensification of antithrombotic therapy may be also reasonable, at the cost of higher bleeding risk [39]. Large retrospective data did not suggest increased periprocedural thromboembolism risk when thrombus/echo contrast was present [39][40][41]. ...
... Pre-procedural intensification of antithrombotic therapy may be also reasonable, at the cost of higher bleeding risk [39]. Large retrospective data did not suggest increased periprocedural thromboembolism risk when thrombus/echo contrast was present [39][40][41]. Further studies are warranted to better evaluate LAAO safety and to recommend eventual precautions in this tricky scenario. ...
Prophylactic left atrial appendage occlusion has been suggested as a means of reducing cardioembolism risk in patients with atrial fibrillation. Its clinical benefits have been discussed together with potential endocrine or hemodynamic adverse effects, with conflicting conclusions. We aimed to provide a thorough overview of the current literature and a recommendation for daily clinical decision-making. A comprehensive Medline search through PubMed was conducted to search for relevant articles, which were further filtered using the title and abstract. Sixty-five articles were selected as relevant to the topic. Concomitant left atrial appendage occlusion during cardiac surgery for other reasons is effective in terms of thromboembolism risk reduction in patients with a history of atrial fibrillation and higher CHA2DS2-VASc scores. Surgical occlusion is safe, and epicardial closure techniques are preferred. Thoracoscopic and transcatheter techniques are also feasible, and the individual treatment choice must be tailored to the patient. The concerns about endocrine imbalance or risk of heart failure after occlusion are not supported by evidence. Current evidence is conflicting with regard to hemodynamic consequences of appendage occlusion.
... Additionally, we found that the predicted thrombus-prone areas were mostly located at the tip and body of the LAA, especially the distal lobes of LAA. Our findings align with those of Luis Marroquin et al., who reported on 126 patients with LAA thrombi, which included 63.9% and 18.5% thrombi localized at the tip and body of the LAA, respectively [29]. ...
Background
Contrast retention (CR) is an important predictor of left atrial appendage thrombus (LAAT) and stroke in patients with non-valvular atrial fibrillation (AF). We sought to explore the underlying mechanisms of CR using computational fluid dynamic (CFD) simulations.
Methods
A total of 12 patients with AF who underwent both cardiac computed tomography angiography (CTA) and transesophageal echocardiography (TEE) before left atrial appendage occlusion (LAAO) were included in the study. The patients were allocated into the CR group or non-CR group based on left atrial appendage (LAA) angiography. Patient-specific models were reconstructed to evaluate time-averaged wall shear stress (TAWSS), oscillatory shear index (OSI), relative residence time (RRT), and endothelial cell activation potential (ECAP). Additionally, the incidence of thrombosis was predicted using residence time (RT) at different time-points.
Results
TAWSS was lower [median (Interquartile Range) 0.27 (0.19–0.47) vs 1.35 (0.92–1.79), p < 0.001] in LAA compared to left atrium. In contrast, RRT [1438 (409.70–13869) vs 2.23 (1.81–3.14), p < 0.001] and ECAP [122.70 (30.01–625.70) vs 0.19 (0.16–0.27), p < 0.001)] was higher in the LAA. The patients in the CR group had significantly higher RRT [(mean ± SD) 16274 ± 11797 vs 639.70 ± 595.20, p = 0.009] and ECAP [610.80 ± 365.30 vs 54.26 ± 54.38, p = 0.004] in the LAA compared to the non-CR group. Additionally, patients with CR had a wider range of thrombus-prone regions [0.44(0.27–0.66)% vs 0.05(0.03–0.27)%, p = 0.009] at the end of the 15th cardiac cycle.
Conclusions
These findings suggest that CR might be an indicator of high-risk thrombus formation in the LAA. And CT-based CFD simulation may be a feasible substitute for the evaluation of LAA thrombotic risk in patients with AF, especially in patients with CR.
... Clinical guidelines do not provide clear recommendations and therapeutical options in patients with direct oral anticoagulants (DOACs) contraindication are very limited [7]. According to several studies, intensification of OAC was associated with a suboptimal result and a concomitant increased bleeding risk, particularly if INR >3.5 [8,9]. Of paramount interest, the last European guidelines on valvular heart disease recommended left atrial appendage closure (LAAC) in all AF patients high thromboembolic risk undergoing valve surgery [10]. ...
Background: In patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy and therapeutical INR range the incidence of cardiac thromboembolism is not negligible and the subgroup carrying a mechanical prosthetic mitral valve (PMV) has the highest risk. We aimed to assess the long-term effects of left atrial appendage closure (LAAC) in AF patients carriers of mechanical PMV who experienced a failure of VKA therapy.
Methods: In this retrospective, multicenter study, patients who underwent LAAC because of thrombotic events including TIA/stroke, systemic embolism and evidence of left atrial appendage thrombosis/sludge during VKA therapy were enrolled. Patients with mechanical PMV were included and compared with controls. The primary endpoint was the composite of all-cause death, major cardiovascular events and major bleedings at follow-up. Feasibility and safety of LAAC was also assessed.
Results: A total of 55 patients (42% females; mean age 70 ± 9 years) including 12 carriers of mechanical PMV were enrolled. The most frequent indication to LAAC (71%) was LAA thrombosis or sludge. Procedural success was achieved in 96% of overall cases and in 100% of patients with PMV. In 35 patients a cerebral protection device was used. During a median follow-up of 6.1 ± 4.3 years, 4 patients with PMV and 20 patients without PMV reported adverse events (HR 0.73 [95% CI 0.25 - 2.16, p=0.564]).
Conclusion: LAAC seems to be a valuable alternative in AF patients with failure of VKA therapy who are carriers of mechanical PMV. This off-label, real-world clinical practice indication deserve validation in further studies.
... Intensification of antithrombotic therapy led to initial thrombus resolution in 60% of the cases but was associated with a relatively high bleeding rate. Direct LAAO, on the contrary, was feasible and safe [25]. However, expert consensus advocates against performing LAAO in patients with known LAA thrombus [26]. ...
Over the past two decades, percutaneous left atrial appendage occlusion (LAAO) has proven to be a viable alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF), in particular in those patients who are at increased risk for stroke and bleeding complications. This systematic review provides a comprehensive evaluation of anatomical features, patient selection, procedural planning and execution, complications, medical treatment following the procedure, and contemporary outcome data.
... Left atrial dysfunction (atrial myopathy) has recently been linked to these phenomena, even in sinus rhythm, and LAA exclusion is an accepted therapy for decades and is associated with a decrease in stroke events(4, 5) The classic thromboembolic prevention in high-risk patients is oral anticoagulation (OAC) (5), but unfortunately we are observing a growing number of patients who present LAA thrombus formation despite being under this treatment, which is linked to event risk and a false sense of protection to the patient and the treating physician (6- 14). The thrombus of the LAA is classically considered a contraindication to performing procedures in the left atrium and especially in the LAA (15)(16)(17)(18)(19)(20)(21), but is there something to offer to these patients in whom the OAC has failed? The aim of the study was to share experience with closure of LAA in patients with AF and with left atrial thrombus. ...
... The occupying lesion of the LAA is classically considered a contraindication to performing procedures in the left atrium and especially in the LAA (18)(19)(20)(21). Patients under OAC who present with thromboembolic events or if LAA occupying lesion is detected in images (TEE and/or CT) constitute a very high-risk population, and pose a great therapeutic challenge and there is no a universally accepted way to deal with this problem (18,20,21). ...
... The occupying lesion of the LAA is classically considered a contraindication to performing procedures in the left atrium and especially in the LAA (18)(19)(20)(21). Patients under OAC who present with thromboembolic events or if LAA occupying lesion is detected in images (TEE and/or CT) constitute a very high-risk population, and pose a great therapeutic challenge and there is no a universally accepted way to deal with this problem (18,20,21). The incidence of LAA thrombus or LAA sludge in patients under adequate OAC is little known. ...
... Therefore, both cardioversion and invasive procedures within LA are strongly contraindicated in the case of LAT presence [4]. However, a recent study demonstrated, that LAAO in the presence of LAT is feasible and quite safe, and the use of a cerebral protection device might reduce the risk of procedure-related thromboembolic events [5]. ...
... However, there is no specific data comparing any strategy of the OAC to the LAAC in this scenario. Marroquin et al. 25 reported the results of a multicentre observational registry of 126 consecutive patients referred to LAAC with LAAT detected at pre-procedural imaging. Comparing OAT and LAAC, their results also support the feasibility and safety of direct LAAC with high procedural success and the absence of periprocedural embolic complications. ...
Background:
AF patients who despite taking oral anticoagulant therapy (OAT) suffer a stroke or systemic embolism (SSE) without vascular cause or who develop LAA thrombus (LAAT) should be considered as having malignant left atrial appendage (LAA). The optimal treatment strategy to reduce SSE risk in such patients is unknown.
Objectives:
To investigate the diagnostic and therapeutic pathways for malignant LAA practiced in European cardiac centers.
Methods:
An 18-item online questionnaire on malignant LAA was disseminated by the European Heart Rhythm Association (EHRA) Scientific Initiatives Committee.
Results:
A total of 196 physicians participated in the survey. There seems to be high confidence in transoesophageal echocardiography (TEE) imaging considering LAAT diagnosis. Switching to another direct oral anticoagulant (DOAC) is the preferred initial step for the treatment of malignant LAA followed by a switch to vitamin K antagonist (VKA), low molecular weight heparin (LMWH), or continued/optimized DOAC dosage whereas LAA closure (LAAC) is the last option.LAAC is a viable option in patients with embolic stroke despite OAT and no evidence of thrombus at TEE (empty LAA) after comprehensive diagnostic measures to exclude other sources of embolism.
Conclusions:
This EHRA survey provides snapshot of the contemporary management of patients diagnosed with malignant LAA. Currently, the majority of patients are treated on an outpatient basis with either shifting VKA to DOAC or from one DOAC to another. LAAC in this population seems to be reserved for patients with higher bleeding risk or complications of malignant LAA such as stroke.
... The incidence of LAAT varies greatly owing to the patient's condition, and ranges from 1.2% to 22.6%; however, if adding LAA pre-thrombus conditions such as spontaneous echo contrast, the incidence will further increase. [16] Table 1 [16][17][18][19][20][21][22][23][24][25][26][27][28] summarizes the studies on the incidence of LAAT in AF patients. From August 2016 to December 2021, the incidence of LAAT diagnosed by TEE in AF patients at the Zhoupu hospital was 2.12% (23/1,086 cases). ...
... [20] Among 3,222 AF patients planning to undergo LAAC, the incidence of LAAT was 3.9%, and the distribution range of LAAT was 63.9% in apex, 18.5% in body, 4.2% in neck, 6.7% in orifices, and 6.7% where the thrombus overflowed the orifice of the LAA. [21] In patients undergoing transcatheter aortic valve implantation, the prevalence was 4.4% for LAAT and 5.4% for moderate/severe spontaneous echo contrast. [27] Another unique situation in patients with AF is that pulmonary vein electrical isolation (PVI) combined with LAA electrical isolation (LAAEI) could cause acute cerebral embolism owing to the shedding of LAAT within 24-30 h [31,32] ; the incidence of LAAT was 22.6% (54/239 cases) in patients with AF who received LAAEI during left atrial linear lesions or cryoballoon ablation. ...
... A meta-analysis demonstrated that NOACs were as efficacious and safe as VKA for the treatment of LAAT in patients with nonvalvular AF. [48] For the treatment of AF complicated with LAAT, antithrombotic therapy achieved an initial thrombus resolution of 60% but with a relatively high bleeding rate (~10%); direct LAAC had a high procedural success rate without periprocedural embolic complications; however, a high rate of device-related thrombus (DRT) was detected during follow-up. [21] Another retrospective cohort study showed that LAAT resolution in patients already undergoing OAC therapy may require a change of previous oral anticoagulant but the overall effectiveness of dissolution was approximately 50%. [46] In patients with AF who received LAAEI during left atrial linear lesions or cryoballoon ablation, the thrombus resolved in 72.2% of patients after adjusting the anticoagulant treatment regimen, but there were still 23.5% of AF patients for whom LAAT persisted. ...
Cardiac thrombus in patients with atrial fibrillation (AF) is most commonly found in the left atrial appendage (LAA). The incidence of LAA thrombus ranges from 1.2% to 22.6%, with the vast variation in incidence attributed to the patient’s condition. The effective rate of anticoagulation for thrombus dissolution therapy is only 50%–60%, and long-term anticoagulation treatment increases the risk of bleeding. Direct percutaneous LAA closure in AF patients with LAA thrombus in a suitable location is another alternative treatment option. LAA resection with cardiac surgery is also an effective treatment. This review presents the development of the incidence, diagnosis, and treatment of thrombus in LAA.
... Indeed, the current European guidelines do not recommend switching from one DOAC to another, nor to intensify anticoagulation strategies [8]. Several studies reported that intensification of OAC in order to achieve thrombus resolution/effective secondary prevention is associated with a suboptimal result and a concomitant increased bleeding risk [9,10]. Percutaneous catheter-based devices have been developed to exclude the LAA from systemic circulation. ...
... The Amplatzer Amulet (Abbott) was the most commonly used device (50%). In the largest multicenter observational study published so far [10], including 126 patients with LAA thrombus on procedural imaging referred for LAAO, Marroquin et al. demonstrated that patients who underwent LAAO showed lower stroke rate compared to a control group with intensified anticoagulant therapy (no CE vs. 2.9%) at a mean follow-up of 18 months. Procedural success was 90.5%. ...
... The Amplatzer Amulet (Abbott) was the most commonly use (50%). In the largest multicenter observational study published so far [10], inclu patients with LAA thrombus on procedural imaging referred for LAAO, Marroq demonstrated that patients who underwent LAAO showed lower stroke rate co to a control group with intensified anticoagulant therapy (no CE vs. 2.9%) at a m low-up of 18 months. Procedural success was 90.5%. ...
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and predisposes patients to an increased risk of cardioembolic events (CE), such as ischemic stroke, TIA, or systemic embolism [...]
... 7,8 In fact, intensification of OAC is usually the most used strategy to achieve thrombus resolution/effective secondary prevention, but this strategy is associated with a suboptimal result and a concomitant higher risk of bleeding. 10,11 Whether the addition of LAAO to prolonged OAC increases the efficacy of preventing embolism in patients who develop embolism or have LAA sludge despite appropriate anticoagulation therapy is a matter of debate not yet clarified. 12,13 Therefore, in this study, we want to present our real-world experience of a hybrid approach consisting of LAAO + OAC maintenance in a cohort of AF patients suffering from ischemic events, or documented to have LAA sludge, despite ongoing OAC therapy. ...
... [24][25][26][27][28] This is a clinical problem often leading to a switch or to an intensification in the anticoagulant regimen or perhaps to the addition of an antiplatelet agent. These approaches are not based on published data, present limited efficacy 11 and eventually increase the bleeding risk. 6,7 Moreover, the problem with OAC therapy discontinuation is still an actual one, even in the post-DOAC-era. ...
Background
The role of left atrial appendage occlusion (LAAO) for atrial fibrillation patients that during oral anticoagulant therapy (OAC) suffer from ischemic events or present LAA sludge, and the best postinterventional anticoagulant regimen, need to be defined. We present our experience with a hybrid approach of LAAO+ lifelong OAC therapy in this cohort of patients.
Methods
Out of 425 patients treated with LAAO, 102 underwent LAAO because, despite OAC, suffered from ischemic events or presented with LAA sludge. Patients without high bleeding risk were discharged with the aim of maintaining lifelong OAC. This cohort was then matched to a population who underwent LAAO in primary ischemic events prevention. The primary endpoint was the composite of all‐cause death and major adverse cardiovascular events consisting of ischemic stroke, systemic embolism (SE), and major bleeding.
Results
Procedural success was 98%, and 70% of patients were discharged with anticoagulant therapy. After a median follow‐up of 47.2 months, the primary endpoint occurred in 27 patients (26%). At multivariate analyses, coronary artery disease (OR 5.1, CI 1.89–14.27, p = .003) and OAC at discharge (OR 0.29, CI 0.11–0.80, p = .017) were associated with the primary endpoint. After propensity score matching, no significant difference was found in the survival free from the primary endpoint according to the indication for LAAO (p = .19).
Conclusions
In this high‐ischemic risk cohort, LAAO + OAC seem a long‐term safe and effective therapeutical approach, with no difference in the survival free from the primary endpoint according to the indication for LAAO in a matched cohort.
