Recurrence of Device-Related Thrombus After Percutaneous Left Atrial Appendage Closure
2019; Lippincott Williams & Wilkins; Volume: 140; Issue: 17 Linguagem: Inglês
10.1161/circulationaha.119.040860
ISSN1524-4539
AutoresLluís Asmarats, Ignacio Cruz‐González, Luis Nombela‐Franco, Dabit Arzamendi, Vicente Peral, Fabian Nietlispach, Azeem Latib, Diego Maffeo, Rocío González-Ferreiro, Tania Rodríguez‐Gabella, Víctor Agudelo, Marta Alamar, Raffael Ghenzi, Antonio Mangieri, Mathieu Bernier, Josep Rodés‐Cabau,
Tópico(s)Cardiac tumors and thrombi
ResumoHomeCirculationVol. 140, No. 17Recurrence of Device-Related Thrombus After Percutaneous Left Atrial Appendage Closure Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBRecurrence of Device-Related Thrombus After Percutaneous Left Atrial Appendage Closure Lluis Asmarats, MD, Ignacio Cruz-González, MD, PhD, Luis Nombela-Franco, MD, PhD, Dabit Arzamendi, MD, PhD, Vicente Peral, MD, PhD, Fabian Nietlispach, MD, PhD, Azeem Latib, MD, Diego Maffeo, MD, Rocío González-Ferreiro, MD, Tania Rodríguez-Gabella, MD, Victor Agudelo, MD, Marta Alamar, MD, Raffael A. Ghenzi, MD, Antonio Mangieri, MD, Mathieu Bernier, MD and Josep Rodés-Cabau, MD Lluis AsmaratsLluis Asmarats Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.). , Ignacio Cruz-GonzálezIgnacio Cruz-González University Hospital Salamanca, Spain (I.C-G., R.G-F.). , Luis Nombela-FrancoLuis Nombela-Franco Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (L.N-F., T.R-G.). , Dabit ArzamendiDabit Arzamendi Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A.). , Vicente PeralVicente Peral Hospital Universitario Son Espases, Palma, Spain (V.P., M.A.). , Fabian NietlispachFabian Nietlispach University Heart Center Zürich, University Hospital of Zurich, Switzerland (F.N., R.G.). , Azeem LatibAzeem Latib San Raffaele Hospital, Milan, Italy (A.L., A.M.). Montefiore Medical Center, New York (A.L.). , Diego MaffeoDiego Maffeo Fondazione Poliambulanza, Brescia, Italy (D.M.). , Rocío González-FerreiroRocío González-Ferreiro University Hospital Salamanca, Spain (I.C-G., R.G-F.). , Tania Rodríguez-GabellaTania Rodríguez-Gabella Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain (L.N-F., T.R-G.). , Victor AgudeloVictor Agudelo Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (D.A., V.A.). , Marta AlamarMarta Alamar Hospital Universitario Son Espases, Palma, Spain (V.P., M.A.). , Raffael A. GhenziRaffael A. Ghenzi University Heart Center Zürich, University Hospital of Zurich, Switzerland (F.N., R.G.). , Antonio MangieriAntonio Mangieri San Raffaele Hospital, Milan, Italy (A.L., A.M.). , Mathieu BernierMathieu Bernier Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.). and Josep Rodés-CabauJosep Rodés-Cabau Josep Rodés-Cabau, MD, Quebec Heart & Lung Institute, Laval University, 2725 Chemin Ste-Foy, G1V 4GS. Quebec City, Quebec, Canada. Email E-mail Address: [email protected] Quebec Heart and Lung Institute, Laval University, Quebec City, Canada (L.A., M.B., J.R-C.). Originally published21 Oct 2019https://doi.org/10.1161/CIRCULATIONAHA.119.040860Circulation. 2019;140:1441–1443Percutaneous left atrial appendage closure (LAAC) has become a stroke-prevention alternative to oral anticoagulation (OAC).1 However, there has been increasing concern regarding device-related thrombosis (DRT) after LAAC, with a reported incidence of ≈4% (range, 0 to 17%).2 Although originally believed to be confined to early (45 days) endothelization, recent reports suggest increased recognition of delayed DRT with extended surveillance imaging.2,3 Although DRT usually resolves with anticoagulation therapy, no study to date has assessed DRT recurrence. We sought to determine the recurrence rate and clinical outcomes after a first DRT after LAAC.This study analyzed patients with resolution of a first DRT after LAAC with any approved device in 8 centers from Europe and Canada, from 2014 through 2018. Only patients with repeat imaging after initial DRT resolution, as assessed by transesophageal echocardiography (TEE) or computed tomography (CT), were included. Patients provided signed informed consent for the procedures. Clinical follow-up and timing of surveillance imaging were performed according to each institution's protocol (TEE in 6 centers, CT in 2). Antiplatelet therapy/anticoagulant treatment was decided by attending physicians on an individual bleeding risk basis. DRT was defined as a well-circumscribed echo-reflective mass or enhancement defect by TEE or CT, respectively, on the left atrial side of the device.A total of 1344 consecutive patients underwent LAAC. DRT was detected on 40 of 1197 (3.3%) patients undergoing follow-up imaging within the first year after LAAC. Complete thrombus resolution was documented in 28 of 35 patients (80.0%) with repeat imaging. Patients with surveillance imaging postresolution of an initial DRT form the basis of the present study (Figure).Download figureDownload PowerPointFigure. Flowchart of study population. Among 1344 LAAC recipients, 40 DRT occurred. DRT recurred in 8 of 23 (35%) patients with repeat imaging after initial thrombus resolution (1 of 4 ischemic strokes occurred in a patient with no follow-up imaging*). AF indicates atrial fibrillation; CT, computed tomography; DAPT, dual antiplatelet therapy; DRT, device-related thrombus; DRT-R, device-related thrombus recurrence; LAAC, left atrial appendage closure; SAPT, single antiplatelet therapy; and TEE, transesophageal echocardiography.Twenty-three patients (age: 80±7 years, CHA2DS2-VASc score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, sex category): 4.9±1.4, HAS-BLED score (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile INR, elderly, drugs/alcohol): 3.3±1.1) were included. Most patients (65%) were discharged on single- or dual-APT after LAAC. Mean time to first DRT was 3±2 months. Thrombus originated from the central screw/insert in 4 patients (17%) and over the disk or fabric insert in 19 (83%). At the time of thrombus diagnosis, 16 patients (70%) received single- or dual-APT, 4 received (17%) low-molecular-weight heparin, and 3 (13%) received no APT/anticoagulant agents. Anticoagulation with therapeutic low-molecular-weight heparin (48%) or direct OAC (39%) was initiated or continued in all patients but 3 (with absolute contraindications for OAC, receiving prophylactic doses of low-molecular-weight heparin, dual-APT, and none, respectively), with complete thrombus resolution in all patients.At a median follow-up of 15 (IQR: 8 to 27) months postthrombus resolution, DRT recurred in 8 patients (35%): 5 patients were on single-APT and 3 patients were on no APT/anticoagulation at the time of recurrence. Median time to first imaging study postresolution was 6 (IQR: 4 to 14) months, and median time to recurrence was 6 (IQR: 4 to 9) months. Surgical excision of a Watchman device was required in 1 patient. Two ischemic strokes—confirmed by a neurologist—occurred 14 and 9 months after initial DRT resolution, none with evidence of DRT recurrence. One stroke occurred with severe stasis by TEE, but no thrombus, in a patient receiving no APT/anticoagulation therapy. A second stroke occurred in a patient receiving aspirin at an outside institution with no imaging at the time of stroke; OAC was initiated, with no evidence of DRT at last follow-up. After initial DRT resolution, patients were stratified according to long-term management: no APT/anticoagulation therapy (n=4), single- or dual-APT (n=13), or vitamin K or non–vitamin K antagonist therapy (n=6). DRT recurrence occurred in 3 of 4 (75%) of the patients on no APT/anticoagulation, 5 of 13 (38%) on single- or dual-APT, and none on long-term anticoagulation (P=0.031).Data on thrombus recurrence have been limited to isolated cases.4,5 The current study is the first evaluating DRT recurrence after LAAC. Thrombus recurrence was common (>1 of 3), particularly among patients not receiving long-term anticoagulation after a first DRT (≈50%). The stroke rate in atrial fibrillation patients with DRT after LAAC in the current study was similar to that reported in a recent meta-analysis (11.4%).2 Recurrent DRT appeared to be predominantly clinically silent. Nevertheless, among patients experiencing a stroke after initial DRT resolution, TEE/CT at the time of the event showed dense echocontrast (n=1) or was not available (n=1), and a relationship between recurrent DRT and stroke cannot be excluded.Most studies assessing DRT after LAAC failed to specify the APT/anticoagulation regimen after thrombus resolution, with surveillance imaging commonly interrupted after DRT resolution. Although the goal of LAAC is to avoid long-term anticoagulation in a high–bleeding risk population, our findings suggest that DRT may carry an increased risk of subsequent thrombosis and that long-term anticoagulation effectively prevents DRT recurrence. Hence, continued anticoagulation should probably be encouraged after a first DRT in the absence of absolute contraindications.Limitations of our study include lack of core laboratory adjudication and the limited sample size. Imaging follow-up and APT/anticoagulation regimens were not uniform across centers, reflecting real-life LAAC practice. However, these findings raise the importance of close imaging monitoring after thrombus resolution and should stimulate further investigations to address this unmet clinical need.Sources of FundingDr Asmarats has been supported by a grant from the Fundación Alfonso Martin Escudero. Dr Rodés-Cabau holds the Research Chair "Fondation Famille Jacques Larivière" for the Development of Structural Heart Disease Interventions.DisclosuresDr Cruz-González is proctor for Boston Scientific, Abbott, Lifetech. Dr Arzamendi is proctor for Abbott. Dr Rodés-Cabau has received institutional research grants from Boston Scientific. The other authors report no conflicts.Footnoteshttps://www.ahajournals.org/journal/circData sharing: The data that support the findings of this study and research materials, as well as experimental procedures and protocols, are available from the corresponding author and the authors from different participating centers upon reasonable request.Josep Rodés-Cabau, MD, Quebec Heart & Lung Institute, Laval University, 2725 Chemin Ste-Foy, G1V 4GS. Quebec City, Quebec, Canada. Email josep.[email protected]ulaval.caReferences1. Asmarats L, Rodes-Cabau J. 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Asmarats L, O'Hara G, Champagne J, Paradis J, Bernier M, O'Connor K, Beaudoin J, Junquera L, Del Val D, Muntané-Carol G, Côté M and Rodés-Cabau J (2020) Short-Term Oral Anticoagulation Versus Antiplatelet Therapy Following Transcatheter Left Atrial Appendage Closure, Circulation: Cardiovascular Interventions, 13:8, Online publication date: 1-Aug-2020. Liu B, Shi X, Ding K, Lv M, Qian Y, Zhu S, Guo C and Zhang Y (2020) The Joint Analysis of Multi-Omics Data Revealed the Methylation-Expression Regulations in Atrial Fibrillation, Frontiers in Bioengineering and Biotechnology, 10.3389/fbioe.2020.00187, 8 October 22, 2019Vol 140, Issue 17 Advertisement Article InformationMetrics © 2019 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.119.040860PMID: 31634013 Originally publishedOctober 21, 2019 Keywordsatrial appendageatrial fibrillationstrokethrombosisPDF download Advertisement SubjectsAtrial Fibrillation
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