Importance of the underlying substrate in determining thrombus location in atrial fibrillation: implications for left atrial appendage closure

Mahajan, Rajiv; Brooks, A.; Sullivan, Thomas; Lim, H.; Alasady, M.; Abed, H.; Ganesan, Anand N.; Nayyar, Sachin; Lau, Dennis H.; Roberts‐Thomson, Kurt C.; Kalman, Jonathan M.; Sanders, Prashanthan

doi:10.1136/heartjnl-2012-301799

Cited by 108 publications

(71 citation statements)

References 56 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Given the physiologic differences between an incompletely-closed versus a non-ligated LAA, it is possible that conventional stroke risk stratification schemes do not accurately predict the patient risk in the setting of such an entity. The same is for instance also true of patients with valvular (rheumatic) AF in whom the risk of stroke is nearly 17-fold greater, and virtually independent of the CHADS 2 /CHA 2 DS 2 -VASc risk score (2). As such, these findings support the notion that the presence of incomplete LAA closure may in fact be "worse" than no closure at all (7,13).…”

Section: Limitation Of Conventional Risk Stratification Scoressupporting

confidence: 76%

“…In patients with non-valvular AF, the risk of ischemic stroke/systemic embolization is nearly 5-fold greater after adjusting for all other risk factors (1). The left atrial appendage (LAA) has been identified as a common site of thrombus formation in patients with AF (2). As such, the LAA has been targeted for surgical closure using a variety of techniques for over 6 decades, a practice that is frequently performed in conjunction with mitral valve and AF surgery (3,4).…”

mentioning

confidence: 99%

See 1 more Smart Citation

Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Aryana¹,

Bhaskar²

2017

Ann. Transl. Med.

View full text Add to dashboard Cite

Section: Limitation Of Conventional Risk Stratification Scoressupporting

confidence: 76%

mentioning

confidence: 99%

Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Aryana¹,

Bhaskar²

2017

Ann. Transl. Med.

View full text Add to dashboard Cite

“…(20) Also to be considered, the LA cavity rather than the appendage can be the site of thrombus formation in more than half of patients with valvular AF and 1 in 9 with nonvalvular AF. (21) Endothelial dysfunction, systemic inflammatory response and atrial hypocontractility as cause and consequence of a fibrotic atrial cardiomyopathy have been implicated as the drivers of a hypercoagulable state in AF. (8) These factors do not abate in the absence of arrhythmia and advocate that AF, whether persistent or paroxysmal, could itself be viewed as a vascular disease ( Figure 1).…”

Section: Atrial Fibrillation As a Vascular Diseasementioning

confidence: 99%

Approach to device-detected subclinical atrial fibrillation

Zyl

McLeod²,

Gersh³

2017

SAHJ

View full text Add to dashboard Cite

INTRODUCTIONCardiac implantable electronic devices (CIEDs) are becoming more and more common due to an aging global population and expanded criteria for implantation. During 2009, over 1.3 million new or replaced implantable cardiac devices were implanted worldwide, with around a quarter of these occurring in the United States (US) alone.(1,2) South Africa has experienced substantial growth with an almost 25% rise in CIEDs implanted between 2005 and 2009, as opposed to only 8% in the US.(1) In addition, there is a greater availability of external surface monitoring and implantable loop recorders (ILR). Out of this vast increase in continuous arrhythmia monitoring arises the challenge of how to approach the abundance of data that identifies subclinical arrhythmia, and germane to this discussion, atrial fibrillation (AF).As the most pervasive sustained arrhythmia encountered in clinical practice, AF has risen in age-adjusted incidence over the last half century -a trend which may be plateauing over the last decade.(3,4) After age 40 the lifetime risk of developing AF is almost 1 in 4.(2) As many as 40% of patients are entirely asymptomatic -also termed subclinical AF -and the arrhythmia may only come to the attention of the patient and provider as an incidental finding.(5) Population screening of those over 65 years of age would detect subclinical AF in an estimated 1.4% of patients -of whom, more than two thirds would be at high risk for stroke based on clinical risk prediction models.(6) AF shares many risk factors -including age, male gender, heart failure and coronary disease -with indications for a permanent pacemaker or implantable cardioverter defibrillator (ICD) and, as such, the detection of clinically silent paroxysms of AF by device interrogation is not uncommon. In patients with CIEDs placed for unrelated indications, without a prior history of permanent AF, 43% had 5 minutes or more of AF detected over 2 years of follow-up in a pooled analysis of 5 large prospective trials (n=10 016).(7) Therefore, adoption of a strategy for dealing with device-detected subclinical AF is vital for clinicians.In the midst of several studies which demonstrate the con-

show abstract

“…However, transesophageal echocardiography guided cardioversion can be facilitated in the absence of left atrial and left atrial appendage thrombus. (14) In this instance, it is essential that effective peri--cardioversion anticoagulation is commenced and maintained for at least four weeks after to reduce new thrombus formation due to atrial stunning following restoration of sinus rhythm. (15,16) Importantly, the effect of atrial stunning is not limited to those who underwent electrical cardioversion with documented negative atrial inotropic effect seen in those treated with anti--arrhythmic drugs.…”

Section: Hemodynamically Stable Af With Onset >48 Hours or Unknowmentioning

confidence: 99%

Management of Recent-onset Sustained Atrial Fibrillation: Pharmacologic and Nonpharmacologic Strategies

Lau

Kalman

Sanders

2014

Clinical Therapeutics

Self Cite

View full text Add to dashboard Cite

After the embargo period via non-commercial hosting platforms such as their institutional repository  via commercial sites with which Elsevier has an agreement In all cases accepted manuscripts should: link to the formal publication via its DOI  bear a CC-BY-NC-ND license -this is easy to do, click here to find out how  if aggregated with other manuscripts, for example in a repository or other site, be shared in alignment with our hosting policy  not be added to or enhanced in any way to appear more like, or to substitute for, the published journal article Methods:We performed a comprehensive search of the literature on the management of recent onset sustained AF with focus on studies reporting cardioversion of AF, anti--arrhythmic agents and anticoagulation. We also reviewed recent practice guidelines on AF management. Findings:This review provides a guide on a tailored management approach of patients with recent onset sustained AF. Following initial detailed clinical assessment, optimal rate and rhythm control options can be provided depending on hemodynamic stability, duration of AF episode and AF stroke risk. Issues surrounding electrical and pharmacological cardioversion were discussed in detail. We emphasized the importance of thromboembolic risk assessment and appropriate anticoagulation surrounding the point of cardioversion. Last, we highlighted the need for appropriate specialized follow--up care following acute AF management. Implications: Despite the highly heterogeneous clinical presentations, managementof recent onset sustained AF must include stroke risk assessment, appropriate anticoagulation and follow--up care in all patients beyond optimum rate and rhythm control strategies.3

show abstract

Importance of the underlying substrate in determining thrombus location in atrial fibrillation: implications for left atrial appendage closure

Cited by 108 publications

References 56 publications

Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Incomplete surgical ligation of the left atrial appendage—time for a new look at an old problem

Approach to device-detected subclinical atrial fibrillation

Management of Recent-onset Sustained Atrial Fibrillation: Pharmacologic and Nonpharmacologic Strategies

Contact Info

Product

Resources

About