Citations 2
Left Atrial Appendage Occlusion vs Standard of Care After Ischemic Stroke Despite Anticoagulation
Seiffge, David , Group, STR-OAC LAAO, Macha, Kosmas , Takagi, Masahito, Arihiro, Shoji , Polymeris, Alexandros A. , Yoshimura, Sohei , Venti, Michele , Thilemann, Sebastian , Altavilla, Riccardo , Peters, Nils , Inoue, Manabu, Bobinger, Tobias , Agnelli, Giancarlo , Acciarresi, Monica, Jager, Hans, Bovi, Paolo, Schwab, Stefan , Registry, RAF, RAF-DOAC, CROMIS-2, SAMURAI, NOACISP, Erlangen Registry, and Verona, Aarnink, Errol W. , Fierro, Nicolai, Tondo, Claudio , Zieliński, Kamil , Korsholm, Kasper , Nielsen-Kudsk, Jens Erik, Caneiro‐Queija, Berenice, Benito‐González, Tomás , Holmes, David R. , Almakadma, Abdul H., Álvarez, Xavier Millán, Alla, Venkata , Agarwal, Himanshu , Paitazoglou, Christina , Freixa, Xavier , Cepas‐Guillén, Pedro , Chothia, Rashaad , Badejoko, Solomon O. , Bergmann, Martin , Spoon, Daniel B., Maddux, James T., Ram, Pradhum , Branca, Luca , Dijk, Vincent F. van , Rensing, Benno J. , Paciaroni, Maurizio , Kallmünzer, Bernd , Wilson, Duncan , Jäger, Hans Rolf , Korsholm, Kasper , Seiffge, David , Jäger, Hans Rolf , Cepas-Guillen, Pedro , Maarse, Moniek , Werring, David J. , Boersma, Lucas V.A. , Group, STR-OAC LAAO, Tsivgoulis, Georgios , Bonetti, Bruno , Alberti, Andrea , Ambler, Gareth , Bonati, Leo H. , Muir, Keith W. , Yamagami, Hiroshi, Inoue, Manabu , Brown, Martin M. , Sato, Shoichiro , Lyrer, Philippe A. , Marchis, Gian Marco De , Peper, Joyce , Simard, Trevor , Alkhouli, Mohamad , Registry, RAF, RAF-DOAC, CROMIS-2, SAMURAI, NOACISP, Erlangen Registry, and Verona, Mazzone, Patrizio , Beneduce, Alessandro , Gasperetti, Alessio , Pracoń, Radosław , Demkow, Marcin , Backer, Ole De , Nielsen‐Kudsk, Jens Erik , Estévez‐Loureiro, Rodrigo , Prado, Armando Pérez de , Nombela‐Franco, Luis , Salinas, Pablo , Berti, Sérgio , Romeo, Maria Rita , Arzamendi, Dabit , Eitel, Ingo , Bergmann, Martin W., El‐Chami, Mikhael F. , Adamo, Marianna , Suradi, Hussam , Zietz, Annaelle , Caso, Valeria , Koga, Masatoshi , Toyoda, Ḱazunori , Cappellari, Manuel , Engelter, Stefan T. , Swaans, Martin John
JAMA Neurology | September 23, 2024 | Volume: 81 | Issue: 11 | Pages: 1150
ImportancePatients with atrial fibrillation (AF) who have ischemic stroke despite taking oral anticoagulation therapy (OAT) have a very high risk of recurrence. Left atrial appendage occlusion (LAAO) is a mechanical stroke prevention strategy that may provide additional protection in patients with thromboembolic events under OAT.ObjectiveTo compare percutaneous LAAO with continuing OAT alone regarding stroke prevention in patients with AF who had a thromboembolic event despite taking OAT.Design, Setting, and ParticipantsThis cohort study was a propensity score–matched comparison of the STR-OAC LAAO cohort, an international collaboration of 21 sites combining patients from multiple prospective registries of patients who underwent LAAO between 2010 and 2022. STR-OAC LAAO cohort patients who had follow-up longer than 3 months were propensity score–matched to a previously published control cohort comprising patients from an established international collaboration of investigator-initiated prospective studies. This control cohort included patients with nonvalvular AF, recent ischemic stroke or transient ischemic attack, and follow-up longer than 3 months who were taking OAT before the index event. Analyses were adjusted for imbalances in gender, age, hypertension, diabetes, and CHA2 DS2-VASc score.ExposureLeft atrial appendage occlusion vs continuation of oral anticoagulation therapy alone (control group).Main Outcomes and MeasuresThe primary outcome was time to first ischemic stroke.ResultsFour hundred thirty-three patients from the STR-OAC LAAO cohort (mean [SD] age, 72 [9] years; 171 [39%] females and 262 [61%] males; mean [SD] CHA2 DS2-VASc score, 5.0 [1.6]) were matched to 433 of 1140 patients (38%) from the control group. During 2-year follow-up, 50 patients experienced ischemic stroke: an annualized event rate of 2.8% per patient-year in the STR-OAC LAAO group vs 8.9% per patient-year in the control group. Left atrial appendage occlusion was associated with a lower risk of ischemic stroke (hazard ratio, 0.33; 95% CI, 0.19-0.58; P < .001) compared with the control group. After LAAO, OAT was discontinued in 290 patients (67%), and the remaining 143 patients (33%) continued OAT after LAAO as an adjunctive therapy.Conclusions and RelevanceIn patients with nonvalvular AF and a prior thromboembolic event despite taking OAT, LAAO was associated with a lower risk of ischemic stroke compared with continued OAT alone. Randomized clinical trial data are needed to confirm that LAAO may be a promising treatment option for this population with a very high risk of stroke.
Diagnostic performance of coronary CTA and CT-FFR for the detection of coronary artery disease in routine TAVI work-up
Becker, Leonie M , Berg, Hans van den , Brouwer, Jorn , Ginkel, Dirk Jan van, Rensing, B M J W, Timmer, Lisa M.H., Berg, J. M. ten, Peper, Joyce , Berg, H Van Den, Bor, Willem L. , Nijenhuis, Vincent Johan , Rensing, Benno J. , Leiner, Tim , Swaans, Martin John
European Heart Journal | October 15, 2022 | Volume: 43 | Issue: Supplement_2 | Pages: No page available
10.1093/eurheartj/ehac544.1536
Abstract Objectives To assess the diagnostic performance of CT-FFR for the diagnosis of CAD in the work-up for TAVI. Background Work-up for transcatheter aortic valve implantation (TAVI) currently utilizes computed tomography (CT) to evaluate annulus diameter and peripheral vascular access, plus invasive coronary angiography (ICA) to assess significant coronary artery disease (CAD). ICA might partially be redundant with the use of Coronary CT Angiography (CCTA). Prior studies found improvement of the diagnostic accuracy of CCTA by use of CT derived fractional flow reserve (CT-FFR). Methods Consecutive patients with severe symptomatic aortic valve stenosis who underwent TAVI work-up between 2015–2019 were included in this cross-sectional study. All patients underwent CCTA and ICA within 3 months and diagnostic performance of both CCTA and CT-FFR were assessed using ICA as reference. Results Seventy-six of the 338 patients included in the analysis had ≥1 significant coronary stenosis at ICA. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy per-patient were 76.9%, 64.5%, 34.0%, 92.1% and 66.9% for CCTA and 84.6%, 88.3%, 63.2%, 96.0% and 87.6% for CT-FFR. The area under the receiver-operating characteristic-curve significantly differ between CCTA and CT-FFR (0.84 versus 0.90 p=0.02). A CT-FFR guided approach could avoid ICA in 57.1% versus 43.6% using CCTA. Conclusions CT-FFR significantly improves the diagnostic accuracy of CCTA without additional testing and increases the proportion of patients in whom ICA could have been safely avoided It has the potential to be integrated in the current clinical work-up for TAVI for diagnosing stable CAD requiring treatment. Funding Acknowledgement Type of funding sources: None.