Percutaneous left atrial appendage occlusion: Device thrombosis in clopidogrel non-responders

Ketterer, Ulrike; Ancona, Giuseppe; Siegel, Isabel; Ortak, Jasmin; Ince, Hueseyin; Kische, Stephan

doi:10.1016/j.ijcard.2015.11.160

Cited by 16 publications

(11 citation statements)

References 5 publications

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“…Furthermore, a temporarily oral VKA therapy as used in the randomized trials (if not contraindicated) might lower the risk of DRT formation in the pre-endothelialization phase, which in CKD patients is presumably prolonged. These considerations as well as a potential clopidogrel resistance, which might play an important role in DRT formation as previously reported by Ketterer and colleagues [35], should be subject to further investigation.…”

Section: Discussionmentioning

confidence: 70%

Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device

Luani

Genz

Herold

et al. 2019

BMC Cardiovasc Disord

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Background Impaired renal function increases the bleeding risk, leading to a conservative prescription and frequent discontinuation of oral anticoagulation in atrial fibrillation patients with chronic kidney disease (CKD). Interventional left atrial appendage closure (LAAC) might be an alternative therapeutic strategy for these patients. Methods We aimed to prospectively assess cerebrovascular (CE) and bleeding events, as well as peri-procedural and long-term complications in a cohort of consecutive patients undergoing interventional LAAC using the WATCHMAN™ device, with focus on CKD patients. Results One hundred and eighty-nine consecutive patients undergoing interventional LAAC were included in this analysis; 171 (90.5%) patients had a reduced estimated glomerular filtration rate (eGFR; patients for each CKD stage: II = 66; IIIa = 32; IIIb = 43; IV = 18; V = 12). During a follow-up of 310 patient years three (1.0%) patients suffered a CE (two strokes, one transitory ischemic attack) and five (1.6%) other ones a bleeding complication. The observed stroke rate was more than two-thirds and the bleeding risk more than half lower than expected. Device related thrombi (DRT) were detected in twelve (6.5%) patients; women had significantly more DRT than men (12.5% vs. 2.6%; p = 0.009). Patients with an eGFR< 30 ml/min/1.73m 2 showed a trend to a higher DRT rate as compared to the opposite group (13.3% vs. 5.1%; p = 0.10). Thrombus resolved with temporary oral anticoagulation therapy in ten patients without sequelae; thrombus consolidation was confirmed by serial TEE controls in the remaining two patients. Conclusions Atrial fibrillation patients with CKD have low CE and bleeding rates after LAAC with the WATCHMAN™ device. DRT risk is higher in female and patients with severe CKD. More frequent post-interventional TEE controls might be justified for early DRT detection and safe management of patients at high DRT risk. Trial registration (German Clinical Trials Register ID: DRKS00 010768 ; Registration Date 07.07.2016).

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Section: Discussionmentioning

confidence: 70%

Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device

Luani

Genz

Herold

et al. 2019

BMC Cardiovasc Disord

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“…24 AFIB burden has also been discussed as a potential risk for LAAO DRT. 21 Clopidogrel nonresponsiveness measured by platelet function testing has been associated with DRT in one study 27 and showed an association with bleeding events and not with DRT after LAAO implantation in another cohort study. 28 Antithrombotic Treatment after LAA Closure and Treatment of LAAO DRT…”

Section: Risk Factors For Left Atrial Appendage Closure Device Thrombmentioning

confidence: 98%

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

et al. 2019

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As the number of, and the indications for, structural heart interventions are increasing worldwide, the optimal secondary prevention to reduce device thrombosis is becoming more important. To date, most of the recommendations are empiric. The current review discusses mechanisms behind device-related thrombosis, the available evidence with regard to antithrombotic regimen after cardiac device implantation, as well as providing an algorithm for identification of risk factors for device thrombogenicity and for management of device thrombosis after implantation of patent foramen ovale and left atrial appendage occluders, MitraClips/transcatheter mitral valve replacement, pacemaker leads, and left ventricular assist devices. Of note, the topic of antithrombotic therapy and thrombogenicity of prostheses in aortic position (transcatheter aortic valve replacement, surgical, mechanical, and bioprostheses) is not part of the present article and is discussed in detail in other contemporary focused articles.

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“…Although no significant differences between the treatment regimens was observed in the presented analysis, the role of optimal post‐procedural treatment after LAAc warrants further investigation. In fact, it has been hypothesized that a relevant rate of DRT after LAAc may be secondary to clopidogrel resistance 23 . On the other hand, even single antiplatelet regimens have proven safe and effective without negative impact on ischemic endpoints in certain studies 24,25 .…”

Section: Discussionmentioning

confidence: 99%

Incidence, predictors and outcomes of device‐related thrombus after left atrial appendage closure with the WATCHMAN device—Insights from the EWOLUTION real world registry

Sedaghat

Nickenig

Schrickel

et al. 2021

Cathet Cardio Intervent

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Background In this analysis of the EWOLUTION registry, we evaluated the incidence, relevance and predictors of device‐related thrombus in a large multi‐center real‐world cohort undergoing LAAc with the WATCHMAN device. Methods and Results We analyzed the 835 patients who underwent percutaneous LAA closure with the WATCHMAN device in the EWOLUTION registry in whom at least one TEE follow up was performed. Patients were 74 ± 9 y/o and were at high risk for stroke and bleeding (CHA2DS2‐VASC‐Score 4.3 ± 1.7; HAS‐BLED‐Score 2.3 ± 1.2). Device‐related thrombus was detected in 4.1% (34/835) after a median of 54 days (IQR 42–111 days) with 91.2% (31/34) being detected within 3 months after the procedure or at the time of first TEE. Hereby DRT occurred irrespective of postprocedural anticoagulation. Patients with DRT more frequently had long‐standing, non‐paroxysmal atrial fibrillation (82.4 vs. 64.9%, p < .01), evidence of dense spontaneous echo contrast (26.5 vs. 11.9%, p = .03) and larger LAA diameters at the ostium (22.8 ± 3.5 vs. 21.1 ± 3.5 mm, p < .01) compared to patients without DRT. Left ventricular ejection fraction, device compression ratio and the incidence of renal dysfunction did not differ between the two groups. In a multivariate analysis, only non‐paroxysmal atrial fibrillation identified as an independent predictor of developing DRT. Specific treatment of DRT was initiated in 62% (21/34) of patients whereas resolution was confirmed in 86% (18/21) of cases. Overall, no significant differences in annual rates of stroke/TIA or systemic embolism were observed in patients with or without DRT (DRT 1.7 vs. No‐DRT 2.2%/year, p = .8). Conclusions In real‐world patients undergoing LAAc with the WATCHMAN device, DRT is rare. DRT was most frequently detected within the first 3 months after LAAc regardless of post‐procedural regimen and was not associated with an increased risk of stroke or SE. While long‐standing atrial fibrillation was the only independent factor associated with DRT, medical treatment of DRT resulted in a resolution of thrombi in most cases.

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Percutaneous left atrial appendage occlusion: Device thrombosis in clopidogrel non-responders

Cited by 16 publications

References 5 publications

Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device

Cerebrovascular events, bleeding complications and device related thrombi in atrial fibrillation patients with chronic kidney disease and left atrial appendage closure with the WATCHMAN™ device

Thrombogenicity and Antithrombotic Strategies in Structural Heart Interventions and Nonaortic Cardiac Device Therapy—Current Evidence and Practice

Incidence, predictors and outcomes of device‐related thrombus after left atrial appendage closure with the WATCHMAN device—Insights from the EWOLUTION real world registry

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