Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease

Ronco, Federico; Mazzone, Patrizio; Hosseinian, Leila; Genovesi, Simonetta

doi:10.1159/000470856

Cited by 13 publications

(8 citation statements)

References 59 publications

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“…Anticoagulation therapy is a challenge in ESRD patients: warfarin accelerated extraosseal calcification, and ESRD patients were excluded from the larger controlled clinical trials of new oral anticoagulants, so data are sparse. As an alternative, left atrial appendage closure using a device or surgery are options (45).…”

Section: Atrial Fibrillationmentioning

confidence: 99%

Heart disease in chronic kidney disease – review of the mechanisms and the role of dialysis access

Malík

2018

J Vasc Access

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REVIEW misinterpreted as pure overhydration and vice versa. Various attempts to emphasize the role of heart disease in chronic kidney disease (CKD) patients have been published-from the well-known cardiorenal syndrome classification by Ronco et al (2) to the recent conclusions of the Acute Dialysis Quality Initiative XI Workgroup (3), which proposed a new classification of heart failure in ESRD patients. The latter workgroup specifically excludes patients with simple water overload and a normal heart, and focuses on those having specific echocardiographical changes. These include 3 elements: (i) ECHO evidence of structural or functional heart abnormalities; (ii) shortness of breath occurring in the absence of pulmonary disease; and (iii) the response of congestive symptoms to ultrafiltration (3). The same group (4) selected the following 8 echocardiographic criteria of structural heart disease; it is present if at least 1 criterion is detected (see Tab. I). Although this attempt to standardize the definition of structural heart disease in ESRD patients is respectable, some important issues were missed, such as pulmonary hypertension, lack of any cardiac calcification score, and the presence of significant coronary artery disease. Moreover, their cutoff values for various pathological findings differ from the European and American guidelines for echocardiography (Tab. I). The particular pathological changes are noted below. Arterial disease Characteristics Patients suffering from ESRD are also affected by accelerated atherosclerosis (disease of the intimal arterial wall layer) and from medial calcinosis. Etiopathogenesis Atherogenesis is accelerated due to the higher occurrence of traditional risk factors: diabetes mellitus, arterial hypertension, changes of serum lipids, plus the uremic millieu interieur Heart disease in chronic kidney diseasereview of the mechanisms and the role of dialysis access

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Section: Atrial Fibrillationmentioning

confidence: 99%

Heart disease in chronic kidney disease – review of the mechanisms and the role of dialysis access

Malík

2018

J Vasc Access

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“…Evidence for direct-acting oral anticoagulants (DOACs) in chronic kidney disease is derived, at best, from post-hoc analyses. LAA occlusion has shown comparable efficacy in stroke prevention in patients with or without chronic kidney disease [6][7][8]. Avoiding contrast in LAA occlusion procedures offers the additional benefit of reducing the risk of contrast-associated acute kidney injury [9].…”

Section: Discussionmentioning

confidence: 99%

Transesophageal Echocardiography-Guided WATCHMAN Implantation Without Contrast Use: A Three-Year, Single-Center Experience

Shaukat

Patel

Alimohammad

et al. 2020

Cureus

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Background It is unclear if the WATCHMAN device (Boston Scientific, St. Paul, Minnesota) can be implanted without contrast to prevent complications in patients with advanced chronic kidney disease (CKD) or contrast allergy. Objective The efficiency and safety of WATCHMAN implantation under transesophageal echocardiography (TEE)-guidance and fluoroscopy without contrast use. Methods This was a retrospective single-center study at Albany Medical Center between June 2016 and June 2019. Consecutive procedure notes for all WATCHMAN devices implanted between June 2016 and June 2019 were screened to identify patients who did not receive contrast. Patients with incomplete information on the calculation of the 'Congestive heart failure, Hypertension, Age [>75 years], Stroke, Diabetes mellitus, Vascular disease, Age [65 to 74 years], Sex category' (CHA2DS2VASc)/'Hypertension, Abnormal renal/liver function, Stroke, Bleeding history, Labile international normalized ratio, Elderly, Drugs/alcohol' (HAS-BLED) score and reason(s) precluding safe contrast use were excluded. Efficiency was measured as i) accuracy of device size estimation based on TEE-measured left atrial appendage (LAA) dimensions were determined by the need to change the size of the device initially selected, ii) number of implantation attempts, irrespective of change in device size, iii) whether more than one device was used secondary to inaccurate initial size estimation or other procedural complexities, and iv) successful LAA seal on TEE immediately and 45-days post-implantation (peri-device leak of < 5 mm by color Doppler). Procedure-related complications, immediate and delayed (0-45 days), were recorded. Results Twelve patients received WATCHMAN without contrast. The mean age was 79.2 years, with male predominance (n=8). The mean CHA2DS2VASc and HAS-BLED scores were 5.50 (+/-1.24) and 4.08 (+/-1.08), respectively. Contrast was avoided because of a history of CKD stage IV (n=5), rapidly progressive CKD stage III (n=1), and contrast allergy (n=6). In 11 out of 12 patients, initial TEE-based device size estimation was accurate with successful implantation at 1 2 3 3

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“…67 Furthermore, there is a growing debate over the role of device therapy in stroke patients with ESRD, with registry data showing similar efficacy and safety in patients with CKD. 68 There is a clear attractiveness in patients with ESRD, given the requirement for only short-term periprocedural warfarin, but there are also a lack of data from left atrial appendage occlusion trials in this group. The role of reversal agents in cases of overdose or major bleeding is also yet to be clarified in patients with ESRD.…”

Section: Key Knowledge Gapsmentioning

confidence: 99%

Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease

Zaman

Bhandari

2019

J Cardiovasc Pharmacol Ther

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The role of oral anticoagulants (OAC) in atrial fibrillation (AF) is well established. However, none of the randomized controlled trials included patients with end-stage renal disease (ESRD) leaving a lack of evidence in this large, challenging and unique patient group. Patients on hemodialysis (HD) with AF have additional risk factors for stroke due to vascular comorbidities, HD treatment, age, and diabetes. Conversely, they are also at increased risk of major bleeding due to uremic platelet impairment. Anticoagulants increase bleeding risk in patients with ESRD and HD up to 10-fold compared with non chronic kidney disease (CKD) patients on warfarin. There are conflicting data and recommendations regarding use of OACs in ESRD which will be reviewed in this article. We conclude by proposing a modified strategy for OAC use in ESRD based on the latest evidence.

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Recent Advances in Stroke Prevention in Patients with Atrial Fibrillation and End-Stage Renal Disease

Cited by 13 publications

References 59 publications

Heart disease in chronic kidney disease – review of the mechanisms and the role of dialysis access

Heart disease in chronic kidney disease – review of the mechanisms and the role of dialysis access

Transesophageal Echocardiography-Guided WATCHMAN Implantation Without Contrast Use: A Three-Year, Single-Center Experience

Oral Anticoagulants in Patients With Atrial Fibrillation and End-Stage Renal Disease

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