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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Follow-up imaging after left atrial appendage closure
Kenji Kuroki1, Shephal K Doshi2, William Whang1
1Cardiology Division, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.
Insights
Delaying surveillance imaging after Watchman implantation to 4 months avoids detecting device-related thrombus (DRT) during the vulnerable period, showing no ischemic strokes occurred.
Area of Science:
- Cardiology
- Medical Devices
- Interventional Cardiology
Background:
- Device-related thrombus (DRT) after Watchman left atrial appendage closure is linked to poor outcomes.
- Current guidelines recommend surveillance transesophageal echocardiography (TEE) at 45 days and 1 year.
- Early TEE at 45 days may miss DRT due to concurrent oral anticoagulant use and subsequent aspirin monotherapy.
Purpose of the Study:
- To assess an alternative surveillance strategy using initial TEE or CT imaging at 4 months post-Watchman implantation.
- To evaluate the safety and efficacy of this delayed imaging approach.
Main Methods:
- A cohort of 530 patients received Watchman implantation and followed a truncated drug regimen.
- The regimen included 6 weeks of oral anticoagulant/clopidogrel plus aspirin, followed by 6 weeks of dual antiplatelet therapy, and then aspirin monotherapy.
- Patients underwent TEE or CT imaging at 4 months and 1 year.
Main Results:
- 16 ischemic strokes (ISs), 8 transient ischemic attacks (TIAs), and 1 systemic embolization occurred over a median 12-month follow-up.
- Crucially, no ISs occurred between 45 days and 4 months, the period of interest for this strategy.
- Device-related thrombus (DRT) was detected in 2.4% at 4 months and 0.9% at 1 year, with no associated ISs after DRT detection.
Conclusions:
- A 4-month delay for the first imaging post-Watchman implantation is associated with no ischemic strokes during this "vulnerable" period.
- This strategy appears safe and may allow for earlier detection of DRT after antiplatelet therapy has transitioned to monotherapy.
Background:
Because device-related thrombus (DRT) portends a poor prognosis after left atrial appendage closure with the Watchman device, surveillance transesophageal echocardiography (TEE) is recommended at 45 days and 1 year. However, oral anticoagulants are just discontinued at 45 days, rendering this early TEE unlikely to detect DRT. Indeed, DRT is most likely to occur after instituting aspirin monotherapy.
Objective:
The purpose of this study was to evaluate the alternative strategy of first TEE imaging (or computed tomography) at 4 months post-Watchman implantation.
Methods:
After Food and Drug Administration approval, consecutive patients undergoing Watchman implantation at 2 centers received TEE or CT at 4 months and 1 year, along with a truncated drug regimen: 6 weeks of an oral anticoagulant (or clopidogrel in a subset) plus aspirin, then 6 weeks of dual antiplatelet therapy, and finally aspirin monotherapy.
Results:
Of the 530-patient cohort (mean age 78.7±7.9 years; 65.5% (n = 347) male; CHA2DS2-VASc score 4.5±1.4), 465 patients (87.7%) received 4-month imaging: 83.0% (440 of 530) TEE and 4.7% (25 of 530) computed tomography. Over a median follow-up of 12 months, 16 ischemic strokes (ISs), 8 transient ischemic attacks, and 1 systemic embolization occurred. Importantly, no IS occurred between 45 days and 4 months; the sole transient ischemic attack in this period (at ∼2 months) occurred 1 week after transcatheter aortic valve replacement. DRT was detected in 2.4% (11 of 465) at 4 months and 0.9% (2 of 214) at 1 year. No IS, but 1 leg embolization, was observed after DRT detection.
Conclusion:
Delaying the first imaging post-Watchman implantation to 4 months was associated with no IS between 45 days and 4 months, the "vulnerable" period of this follow-up strategy.
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