Left Atrial Appendage Occlusion Device and Novel Oral Anticoagulants Versus Warfarin for Stroke Prevention in Nonvalvular Atrial Fibrillation

Briceño, David; Villablanca, Pedro A.; Cyrille, Nicole; Massera, Daniele; Bader, Eric; Manheimer, Eric D.; Aagaard, Per; Ferrick, Kevin J.; Gross, Jay N.; Kim, Soo Gyum; Krumerman, Andrew; Palma, Eugen C.; Guttenplan, Nils; Romero, Jorge; Fisher, John D.; García, Mario J.; Biase, Luigi Di

doi:10.1161/circep.115.002993

Cited by 30 publications

(20 citation statements)

References 24 publications

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“…We were specifically interested in examining the long‐term death and/or disability outcomes of AF‐related and lacunar strokes because they have been the focus of several recent stroke trials, particularly of secondary prevention strategies 27, 28…”

Section: Methodsmentioning

confidence: 99%

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

Ganesh

Luengo-Fernández

Wharton

et al. 2017

JAHA

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BackgroundOutcome in stroke trials is often based on a 3‐month modified Rankin scale (mRS). How 3‐month mRS relates to longer‐term outcomes will depend on late recovery, delayed stroke‐related deaths, recurrent strokes, and nonstroke deaths. We evaluated 3‐month mRS and death/disability at 1 and 5 years in a population‐based cohort study.Methods and ResultsIn 3‐month survivors of ischemic stroke (Oxford Vascular Study; 2002‐2014), we related 3‐month mRS to disability (defined as mRS >2) at 1 and 5 years and/or death rates (age/sex adjusted). Accrual of disability and index‐stroke‐related and nonstroke deaths in each poststroke year was categorized according to 3‐month mRS. Among 1606 patients with acute ischemic stroke, 181 died within 3 months, but 126 index‐stroke‐related deaths and 320 other deaths occurred during the subsequent 4866 patient‐years of follow‐up up to 5 years. Although 69/126 (54.8%) post‐3‐month index‐stroke‐related deaths occurred after 1 year, mRS>2 at 1 year strongly predicted these deaths (adjusted hazard ratio=21.94, 95%CI 7.88‐61.09, P<0.0001). Consequently, a 3‐month mRS >2 was a strong independent predictor of death at both 1 year (adjusted hazard ratio=6.67, 95%CI 4.16‐10.69, P<0.0001) and 5 years (adjusted hazard ratio=2.93, 95%CI 2.38‐3.60, P<0.0001). Although mRS improved by ≥1 point from 3 months to 1 year in 317/1266 (25.0%) patients with 3‐month mRS ≥1, improvement in mRS after 1 year was limited (improvement by ≥1 point: 91/858 [10.6%]; improvement to mRS ≤2: 13/353 [3.7%]).ConclusionsOur results reaffirm use of the 3‐month mRS outcome in stroke trials. Although later recovery does occur, extending follow‐up to 1 year would capture most long‐term stroke‐related disability. However, administrative mortality follow‐up beyond 1 year has the potential to demonstrate translation of early disability gains into additional reductions in long‐term mortality without much erosion by non‐stroke‐related deaths.

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Section: Methodsmentioning

confidence: 99%

Time Course of Evolution of Disability and Cause‐Specific Mortality After Ischemic Stroke: Implications for Trial Design

Ganesh

Luengo-Fernández

Wharton

et al. 2017

JAHA

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“…28 More studies are required to assess whether we should occlude the LAA in all patients after its electric isolation.…”

Section: Biase and Natale Left Atrial Appendage Electrical Isolationmentioning

confidence: 99%

Left Atrial Appendage After Electrical Isolation

Biase

2016

Circ: Arrhythmia and Electrophysiology

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T he left atrial appendage (LAA) has been considered for years as a less relevant part of the left atrium. During the years, its function and role have been extensively studied.The LAA is recognized as the major source (95%) of cardiac emboli in patients with nonvalvular atrial fibrillation (AF). In addition, the LAA has been shown to have important roles in atrial natriuretic peptide secretion and as an underreported trigger site of AF. [1][2][3][4][5][6][7] From an anatomic point of view, the LAA has a trabecular tubular shape with variable morphologies and derives from the embryonic left atrium as an outgrowth of the pulmonary veins. 6,7 See Article by Panikker et alCatheter ablation of AF is a valid therapeutic option for the treatment of AF and has been shown to be superior to antiarrhythmic drugs for maintaining sinus rhythm. 8,9 Pulmonary vein (PV) isolation is the primary target for ablation. 9 Procedural success rates vary depending on the experience of the operator and on the subtype of atrial fibrillation: higher in paroxysmal and lower in persistent and longstanding, persistent AF. Many patients continue to experience AF recurrences, despite permanent PV isolation. In such cases, several authors have identified additional targets for ablation outside the pulmonary veins, the so called non-PV triggers. 10-12The most common non-PV trigger sites are the superior vena cava, the coronary sinus, the atrial septum, the posterior wall, the ligament of Marshall, and, more recently emphasized, the LAA. [12][13][14][15][16][17][18][19] It is important to consider that the Cox-Maze III surgery data have demonstrated a 90% success rate at maintaining sinus rhythm and a low incidence of thromboembolic events, and this procedure excludes or excises the LAA. 20 The surgical data and the experience and lessons learned by burning guided our group to consider the LAA as a target for ablation.In our first series in 2010, we showed that LAA electric isolation rather than focal LAA ablation was the best strategy to maintain sinus rhythm at follow-up in a series of patients that failed previous procedures and showed sustained LAA firing. 12 We also showed that after electric isolation of the LAA, in ≈50% of cases, lifelong anticoagulation is recommended to reduce the risk of thromboembolic complications.12 To eliminate the need for lifelong anticoagulation, LAA closure devices could potentially be used. It is also important to note that based on the current recommendations, 9 discontinuation of oral anticoagulation (OAC) after successful ablation is allowed only in patients with a CHA 2 DS 2 -VASc score <2 and that the majority of patients with nonparoxysmal AF that may require LAA electric isolation have a CHA 2 DS 2 -VASc score ≥2.In this issue of the Journal, Panikker et al 21 sought to assess the feasibility, safety, and efficacy of concomitant LAA electric isolation and LAA occlusion with the Watchman closure device in 22 patients undergoing long-standing, persistent AF ablation. Outcomes were compared with a balanced...

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“…Ancak bu ajanlar prostatik kapak hastalığında, ciddi mitral stenozda ve son dönem böbrek yetmezliğinde kontrendikedir [2] . Appendage Closure device) warfarinin kontrendike olduğu hastalarda kullanılabileceği bildirilmiştir [2,27] .…”

Section: Tromboflaksiunclassified