What is the clinical evidence from this study?

Study design: Systematic Review. Population: Left atrial appendage thrombus (LAAT) in atrial fibrillation (n=136). Intervention: Left atrial appendage closure (LAAC). Primary outcome: Adverse clinical outcomes (composite of death, stroke, systemic thromboembolism, device-related thrombus, major bleeding, peri-device leakage, TIA, and device complications).

What does this research mean for the field?

Left atrial appendage closure shows preliminary effectiveness and safety in patients with persistent left atrial appendage thrombus, with low rates of thromboembolic and procedural complications. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.CHALLENGES_CONSENSUS.

March 21, 2024BMC Cardiovascular DisordersOpen Access

Overcoming barriers for left atrial appendage thrombus: a systematic review of left atrial appendage closure

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Key result

LAAC shows early feasibility and safety in persistent LAA thrombus with low adverse event rates.

n=136

Why the study?

Left atrial appendage thrombus (LAAT) occurs in 8% of non-valvular AF patients despite anticoagulation, and the feasibility and safety of left atrial appendage closure (LAAC) in LAAT patients remain undetermined.

Is left atrial appendage closure (LAAC) feasible and safe in patients with persistent left atrial appendage thrombus (LAAT)?

Study Design

Type

Systematic Review (n=136)

Structured PICO

Is left atrial appendage closure (LAAC) feasible and safe in patients with persistent left atrial appendage thrombus (LAAT)?

Population

136 patients with atrial fibrillation and persistent left atrial appendage thrombus who underwent left atrial appendage closure, followed for a mean of 13.2 months.

Intervention

Left atrial appendage closure (LAAC) using various devices (Amulet Amplatzer, Watchman, Watchman FLX, ACP, LAmbre), often utilizing modified procedural techniques such as the 'no-touch technique' and cerebral protection devices.

Outcome

Adverse clinical outcomes (composite of death, stroke or other systemic thromboembolism, device-related thrombus, major bleeding, peri-device leakage, transient ischemic attack, and device-related complications) during follow-up.safety

Left atrial appendage closure appears to be a feasible and preliminarily safe alternative for patients with persistent left atrial appendage thrombus, challenging the traditional view that LAAT is an absolute contraindication.

Limitations

Retrospective design of included studies introduces inherent selection biases
Potential for publication bias and outcome reporting bias
Applicability of findings may be limited to experienced operators
Lack of detailed descriptions of LAAT characteristics (size, location, morphology, mobility) in the included reports
Absence of long-term follow-up data limits the assessment of extended-term effectiveness and safety
Limited available data with small sample sizes
Majority of current research involved organized and securely attached LAATs within the fundus of the LAA
LAAT protruding out of the LAA remains a strict contraindication

Implication

Challenges contraindication consensus for left atrial appendage closure in persistent thrombus; supports prospective trials to confirm safety.

Abstract

BACKGROUND: Approximately 90% of intracardial thrombi originate from the left atrial appendage in non-valvular atrial fibrillation patients. Even with anticoagulant therapy, left atrial appendage thrombus (LAAT) still occurs in 8% of patients. While left atrial appendage closure (LAAC) could be a promising alternative, the current consensus considers LAAT a contraindication to LAAC. However, the feasibility and safety of LAAC in patients with LAAT have yet to be determined. METHODS: This systematic review synthesizes published data to explore the feasibility and safety of LAAC for patients with LAAT. RESULTS: This study included a total of 136 patients with LAATs who underwent successful LAAC. The Amulet Amplatzer device was the most frequently utilized device (48.5%). Among these patients, 77 (56.6%) had absolute contraindications to anticoagulation therapy. Cerebral protection devices were utilized by 47 patients (34.6%). Transesophageal echocardiography (TEE) is the primary imaging technique used during the procedure. Warfarin and novel oral anticoagulants were the main anticoagulant medications used prior to the procedure, while dual antiplatelet therapy was primarily used post-procedure. During a mean follow-up period of 13.2 ± 11.5 months, there was 1 case of fatality, 1 case of stroke, 3 major bleeding events, 3 instances of device-related thrombus, and 8 cases of peri-device leakage. CONCLUSIONS: This review highlights the preliminary effectiveness and safety of the LAAC procedure in patients with persistent LAAT. Future large-scale RCTs with varied LAAT characteristics and LAAC device types are essential for evidence-based decision-making in clinical practice.

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Published by BMC Cardiovascular Disorders · CC BY

Cite This Study

Zhang et al. (2024) conducted a systematic review in Left atrial appendage thrombus (LAAT) in atrial fibrillation (n=136). Left atrial appendage closure (LAAC) was evaluated on Adverse clinical outcomes (composite of death, stroke, systemic thromboembolism, device-related thrombus, major bleeding, peri-device leakage, TIA, and device complications). Left atrial appendage closure demonstrated preliminary effectiveness and safety in patients with persistent left atrial appendage thrombus, with low rates of adverse events including 1 stroke and 1 fatality over a mean follow-up of 13.2 months.

synapsesocial.com/papers/6ac45dd9b45745ab67b07618 https://doi.org/10.1186/s12872-024-03843-w