Device-related thrombosis after percutaneous left atrial appendage occlusion for atrial fibrillation
Selected in Journal of the American College of Cardiology by S. Brugaletta
Laurent Fauchier, Alexandre Cinaud, François Brigadeau, Antoine Lepillier, Bertrand Pierre, Selim Abbey, Marjaneh Fatemi, Frederic Franceschi, Paul Guedeney, Peggy Jacon, Olivier Paziaud, Sandrine Venier, Jean Claude Deharo, Daniel Gras, Didier Klug, Jacques Mansourati, Gilles Montalescot, Olivier Piot and Pascal Defaye
J Am Coll Cardiol 2018;71:1528–36
LinkRead the abstract
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Why this study – the rationale/objective?
Percutaneous left atrial appendage (LAA) occlusion is an alternative to lifelong oral anticoagulation (OAC) for stroke prevention in patients with nonvalvular atrial fibrillation (AF) and with contraindications to OAC. Thrombus formation on the device is a possible finding during follow-up after LAA closure. Most studies report an incidence of device-associated thrombus close to 3% to 6%, although a higher rate was reported in a small study. The clinical significance of thrombus formation on the device is poorly known, and whether it is associated with more frequent occurrence of ischemic strokes is debated. The aim of this study was to evaluate, in daily practice, clinical outcomes in patients using the 2 main LAA closure systems, differences in antithrombotic management at discharge from hospital, and the incidence, predictors, and prognosis of thrombus formation on the device after LAA occlusion.
How was it executed – the methodology?
This was a retrospective study analyzing data from patients treated with 2 LAA closure devices seen in 8 centers in France from February 2012 to January 2017.
What is the main result?
A total of 469 consecutive patients with AF underwent LAA closure (272 Watchman devices [Atritech, Boston Scientific, Natick, Massachusetts] and 197 Amplatzer devices [St. Jude Medical, Minneapolis, Minnesota]). Mean follow-up was 13 months, during which 339 (72.3%) patients underwent LAA imaging at least once. There were 98 major adverse events (26 thrombi on devices, 19 ischemic strokes, 2 transient ischemic attacks, 18 major hemorrhages, 33 deaths) recorded in 89 patients. The incidence of device-related thrombus in patients with LAA imaging was 7.2% per year. Older age (hazard ratio [HR]: 1.07 per 1-year increase; 95% confidence interval [CI]: 1.01 to 1.14; p = 0.02) and history of stroke (HR: 3.68; 95% CI: 1.17 to 11.62; p = 0.03) were predictors of thrombus formation on the devices, whereas dual antiplatelet therapy (HR: 0.10; 95% CI: 0.01 to 0.76; p =0.03) and oral anticoagulation at discharge (HR: 0.26; 95% CI: 0.09 to 0.77; p = 0.02) were protective factors. Thrombus on the device (HR: 4.39; 95% CI: 1.05 to 18.43; p = 0.04) and vascular disease (HR: 5.03; 95% CI: 1.39 to 18.23; p = 0.01) were independent predictors of ischemic strokes and transient ischemic attacks during follow-up.
Critical reading and the relevance for clinical practice
Thrombus formation on LAA devices is not uncommon after LAA closure. It is a consequential finding because it is strongly associated with a higher risk of strokes and TIA during follow-up. Therefore, active screening for early detection and treatment of device-associated thrombus should be performed during post-implantation surveillance. Older age and history of ischemic stroke are predictors of device-related thrombus, whereas DAPT and OAC at discharge may be associated with a lower risk of thrombus formation on the device. It is important to note that there is no standardization on which drug to use and how long after LAA closure. A large, prospective and randomized trial is needed to evaluate the optimal anti-thrombotic regimen in these patients.
What do you use in your practice? and after how many months do you usually perform a TEE to look for device thrombi?