Early and late risk of ischemic stroke after TAVR as compared to a nationwide background population.

Ischemic stroke is a feared complication associated with transcatheter aortic valve replacement (TAVR). Data on the late risk of ischemic stroke following TAVR are scarce. This study aimed to investigate the early (0-90 days) and late (90 days-5 years) risk of ischemic cerebrovascular events (CVE) in a large, unselected cohort of patients undergoing TAVR and to compare this risk with a matched background population. Therefore, all patients undergoing first-time TAVR in Denmark were matched to a background population (controls) in a 1:4 ratio based on age, sex, atrial fibrillation (AF), and the major stroke risk factors. A total of 2455 TAVR patients were matched with 9820 controls. TAVR was associated with a significantly higher ischemic CVE risk as compared with their controls in the early phase [hazard ratio (HR) 5.35 [95% CI 3.50-8.17]; p < 0.001) but not in the late phase (HR 1.17 [95% CI 0.94-1.46]; p = 0.15). In a predefined stratified analysis, no patient-related factors were associated with this higher CVE risk in the early phase. The cumulative 90-day ischemic CVE risk was the lowest in TAVR-patients with known AF receiving oral anticoagulant (OAC) therapy (1.3% [95% CI 0.6-2.5%] and was two-fold higher in OAC-naïve TAVR-patients (2.4% [95% CI 1.8-3.3%] in patients without AF and 2.5% [95% CI 0.9-5.3%] in patients with AF). In conclusion, TAVR was associated with an increased risk of ischemic CVE in the early phase, but not in the late phase, as compared to their matched controls-OAC therapy reduced this early risk of ischemic CVE by half.

Percutaneous retrieval of an embolized left atrial appendage closure device from the left atrium in a patient with previous MitraClips.

BACKGROUND: Left atrial appendage closure is increasingly used. LAA closure procedures can rarely be complicated by device embolization, typically towards the aorta. In this case report, we describe the successful percutaneous retrieval of an embolized Amulet device from the left atrium in a patient with previous MitraClips. CASE PRESENTATION: By guidance of intracardiac echocardiography (ICE) and under local anaesthesia, two guiding systems were introduced into the LA; one to stabilize the device against the lateral LA wall and one large system to retrieve the device. However, the LAA closure device was finally snared by a three-loop snare and pulled across the interatrial septum (IAS) without taking the device into a protective guiding sheath - and this without tearing the IAS. CONCLUSIONS: In conclusion, percutaneous retrieval of an embolized LAA closure device from the LA is feasible by transseptal approach under local anaesthesia and with ICE guidance.

Propensity-Matched Comparison of Oral Anticoagulation Versus Antiplatelet Therapy After Left Atrial Appendage Closure With WATCHMAN.

OBJECTIVES: In this propensity-matched analysis of post-left atrial appendage closure antithrombotic therapy, the safety and effectiveness of oral anticoagulation (OAC) and antiplatelet therapy (APT) were compared. BACKGROUND: Left atrial appendage closure with the WATCHMAN device is an alternative to OAC in patients with nonvalvular atrial fibrillation, who are at high bleeding risk. Initial trials included 45 days of post-implantation OAC, but registry data suggest that APT may suffice. METHODS: Patients from the PROTECT-AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation), PREVAIL (Watchman LAA Closure Device in Patients With Atrial Fibrillation Versus Long Term Warfarin Therapy), CAP (Continued Access to PROTECT-AF), CAP2 (Continued Access to PREVAIL), ASAP (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology), and EWOLUTION (Registry on WATCHMAN Outcomes in Real-Life Utilization) trials receiving either OAC or APT post-implantation were matched and compared for nonprocedural bleeding and stroke or systemic thromboembolism over 6 months following implantation. Each patient on APT was matched with 2 patients on OAC, with propensity scores derived from age, sex, congestive heart failure, hypertension, diabetes, prior transient ischemic attack or stroke, peripheral vascular disease, left ventricular ejection fraction, renal impairment, and different atrial fibrillation subtypes. RESULTS: The cohort on OAC (n = 1,018; 95% receiving warfarin and 5% receiving nonwarfarin OAC) was prescribed 45-day OAC post-implantation (92% also received single APT), followed by 6-month single or dual APT. The cohort on APT (n = 509; 91% receiving dual APT and 9% receiving single APT) received APT for variable durations. Six-month freedom from nonprocedural major bleeding was similar (OAC, 95.7%; APT, 95.5%; p = 0.775) despite more early bleeds with OAC. Freedom from thromboembolism beyond 7 days was similar between groups (OAC, 98.8%; APT, 99.4%; p = 0.089). However, device-related thrombosis was more frequent with APT (OAC, 1.4%; APT, 3.1%; p = 0.018). CONCLUSIONS: After left atrial appendage closure with the WATCHMAN, although device-related thrombosis was more common with APT, both APT and OAC strategies resulted in similar safety and efficacy endpoints.

An overview of current and emerging devices for percutaneous left atrial appendage closure.

Atrial fibrillation (AF) is common and is a prominent risk factor for ischemic stroke. Oral anticoagulant (OAC) therapy has been the main strategy for stroke prevention in AF patients; however, OAC therapy carries a bleeding risk and is not tolerated by all patients. Left atrial appendage (LAA) closure offers a non-pharmacological alternative for stroke prevention in patients with non-valvular AF. In this update, an overview of current and emerging LAA occluders is given - with special attention to the key design features of every single device and, if available, preclinical or clinical data.