Key result
Device thrombus after LAAO is linked to ~137% higher MACE risk, driven by ischemic stroke.
Why the study?
Device-related thrombus is considered an Achilles' heel of left atrial appendage occlusion, but data on its prediction remain limited.
Case-Control (n=711)
Yes
Hazard Ratio: 2.37 (95% CI 1.58–3.56)
Absolute Event Rate: 29.5% vs 14.4%
p-value: p=<0.001
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Almost three-fourths of all the DRTs happened beyond the 45 days, which is when we currently tell patients they can stop the blood thinner, based on the [indications for use].... So the fact that DRT happens late remains concerning.”
“A recent large study of DRT showed hypercoagulability disorder, pericardial effusion, renal insufficiency, deep device implantation and nonparoxysmal AF to be independent risk factors for DRT.”
Multicenter case-control registry reveals predictors of device-related thrombus after left atrial appendage occlusion, highlighting elevated risks of stroke and adverse clinical outcomes.
BACKGROUND Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.
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Simard et al. (2021) conducted a case-control in Atrial fibrillation (n=711). Device-related thrombus vs. No device-related thrombus was evaluated on Composite of death, ischemic stroke, or systemic embolization (MACE) (HR 2.37, 95% CI 1.58-3.56, p=<0.001). Device-related thrombus following left atrial appendage occlusion was associated with a significantly higher risk of major adverse cardiovascular events (HR 2.37), driven primarily by ischemic stroke.
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