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The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Transcatheter left atrial appendage occlusion in patients with chronic kidney disease: a systematic review and
Eduardo Flores-Umanzor1, Areeba Asghar2,3, Pedro L Cepas-Guillén4
1Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
Insights
Left atrial appendage occlusion (LAAO) may prevent stroke in chronic kidney disease (CKD) patients. However, CKD patients face higher risks of bleeding and mortality, possibly due to comorbidities, not the LAAO procedure itself.
Area of Science:
- Cardiology
- Nephrology
- Interventional Cardiology
Background:
- Chronic kidney disease (CKD) increases stroke risk, particularly in nonvalvular atrial fibrillation (NVAF) patients.
- Anticoagulation is challenging in CKD due to bleeding risks, making left atrial appendage occlusion (LAAO) a potential alternative.
Approach:
- Systematic review and meta-analysis of 15 studies (77,780 patients) evaluating transcatheter LAAO in CKD and end-stage renal disease (ESRD).
- Searched Medline, Cochrane, and Embase databases up to September 2, 2022.
Key Points:
- CKD patients undergoing LAAO were older with more comorbidities.
- No differences in procedural failure, vascular complications, or tamponade between CKD and non-CKD groups.
- CKD patients had higher risks of in-hospital AKI, bleeding, and mortality, but similar cardioembolic event rates.
Conclusions:
- LAAO appears effective for stroke prevention in CKD patients.
- Higher adverse outcomes in CKD patients likely stem from comorbidities, especially in ESRD, rather than LAAO itself.
- Careful patient selection, management, and multidisciplinary surveillance are crucial for CKD patients undergoing LAAO.
Background:
Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative.
Objective:
This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD).
Methods:
Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies.
Results:
We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade.
Conclusions:
Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO.
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