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Published on: February 26, 2013
Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion
Trevor Simard1, Richard G Jung2, Kyle Lehenbauer3
1Department of Cardiovascular Diseases, Mayo Clinic School of Medicine, Rochester, Minnesota, USA. Electronic address: https://twitter.com/tjsimard.
Insights
Device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) increases ischemic event risk. Key predictors include hypercoagulability, pericardial effusion, renal insufficiency, implantation depth, and non-paroxysmal atrial fibrillation.
Area of Science:
- Cardiology
- Medical Devices
- Thrombosis Research
Background:
- Device-related thrombus (DRT) is a known complication of left atrial appendage occlusion (LAAO).
- Limited data exist on predicting DRT, hindering effective patient management.
Purpose of the Study:
- To establish a multicenter registry for Device-related Thrombus (DRT) following Left Atrial Appendage Occlusion (LAAO).
- To assess the clinical outcomes and identify predictors of DRT.
Main Methods:
- A registry of 711 patients (237 with DRT, 474 without) from 37 international centers undergoing LAAO.
- Analysis of patient and procedural factors associated with DRT development and mid-term outcomes.
Main Results:
- DRT was detected in 25.3% of patients at last follow-up and was linked to a 2.37-fold increased risk of composite endpoints (death, stroke, embolization).
- Significant DRT predictors identified: hypercoagulability disorder, pericardial effusion, renal insufficiency, implantation depth >10 mm, and non-paroxysmal atrial fibrillation.
- Patients with ≥2 risk factors had a 2.1-fold increased risk of DRT.
Conclusions:
- DRT following LAAO is associated with a higher incidence of ischemic events, particularly stroke.
- Identified patient and procedural factors can aid in stratifying LAAO patients at risk for DRT.
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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