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Zhao C, Girdauskas E, Schoones JW, Klautz RJ, Palmen M, Tomšič A. The clinical impact of prophylactic concomitant left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2025; 53:100534. [PMID: 40224643 PMCID: PMC11987691 DOI: 10.1016/j.ahjo.2025.100534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2025] [Revised: 03/23/2025] [Accepted: 03/25/2025] [Indexed: 04/15/2025]
Abstract
Background Recently, concomitant left atrial appendage occlusion (LAAO) has emerged as prophylactic treatment option for preventing thromboembolic events in patients undergoing cardiac surgery with no known history of atrial fibrillation. The efficacy of prophylactic LAAO remains unknown. Methods PubMed, Embase, Web of Science, Emcare, and the Cochrane Library were searched for studies on prophylactic LAAO in patients undergoing cardiac surgery. The primary endpoints were postoperative thromboembolic complications and postoperative atrial fibrillation (POAF). Results Three randomized trials and seven retrospective observational studies were included: in total, 7369 patients received either prophylactic LAAO (n = 3823) or no prophylactic LAAO (n = 3546) during their index cardiac surgery. Prophylactic LAAO reduced the risk of early thromboembolic events by 58 % (risk ratio: 0.42; 95 % confidence interval: 0.25 to 0.73; p = 0.002; I2 = 0 %) with an estimated absolute risk reduction of 0.8 %. On the other hand, a higher risk, albeit statistically not significant, of POAF was seen with LAAO (risk ratio: 1.15; 95 % confidence interval: 1.00 to 1.32; p = 0.051; I2 = 64 %). Prophylactic LAAO also reduced the risk of all-time thromboembolic complications by 52 % (hazards ratio: 0.48; 95 % CI: 0.29 to 0.80; p = 0.005; I2 = 41 %). Conclusion Prophylactic LAAO was associated with a reduction in early and all-time thromboembolic events but demonstrated a potential relation to a higher risk of POAF.
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Affiliation(s)
- Chengji Zhao
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, Augsburg University Medical Centre, Augsburg, Germany
| | - Jan W. Schoones
- Directorate of Research Policy, Leiden University Medical Centre, Leiden, Netherlands
| | - Robert J.M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
- Department of Cardiothoracic Surgery, Augsburg University Medical Centre, Augsburg, Germany
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Conroy PD, Rastogi V, Yadavalli SD, Solomon Y, Romijn AS, Dansey K, Verhagen HJM, Giles KA, Lombardi JV, Schermerhorn ML. The rise of endovascular repair for abdominal, thoracoabdominal, and thoracic aortic aneurysms. J Vasc Surg 2025; 81:14-28. [PMID: 38942397 DOI: 10.1016/j.jvs.2024.06.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/18/2024] [Accepted: 06/23/2024] [Indexed: 06/30/2024]
Abstract
BACKGROUND Given changes in intervention guidelines and the growing popularity of endovascular treatment for aortic aneurysms, we examined the trends in admissions and repairs of abdominal aortic aneurysms (AAAs), thoracoabdominal aortic aneurysms (TAAAs), and thoracic aortic aneurysms (TAAs). METHODS We identified all patients admitted with ruptured aortic aneurysms and intact aortic aneurysms repaired in the Nationwide Inpatient Sample between 2004 and 2019. We then examined the use of open, endovascular, and complex endovascular repair (OAR, EVAR, and cEVAR) for each aortic aneurysm location (AAA, TAAA, and TAA), alongside their resulting in-hospital mortality, over time. cEVAR included branched, fenestrated, and physician-modified endografts. RESULTS 715,570 patients were identified with AAA (87% intact repairs and 13% rupture admissions). Both intact AAA repairs and ruptured AAA admissions decreased significantly between 2004 and 2019 (intact 41,060-34,215, P < .01; ruptured 7175-4625, P = .02). Of all AAA repairs performed in a given year, the use of EVAR increased (2004-2019: intact 45%-66%, P < .01; ruptured 10%-55%, P < .01) as well as cEVAR (2010-2019: intact 0%-23%, P < .01; ruptured 0%-14%, P < .01). Mortality after EVAR of intact AAAs decreased significantly by 29% (2004-2019, 0.73%-0.52%, P < .01), whereas mortality after OAR increased significantly by 16% (2004-2019, 4.4%-5.1%, P < .01). In the study, 27,443 patients were identified with TAAA (80% intact and 20% ruptured). In the same period, intact TAAA repairs trended upward (2004-2019, 1435-1640, P = .055), and cEVAR became the most common approach (2004-2019, 3.8%-72%, P = .055). A total of 141,651 patients were identified with ascending, arch, or descending TAAs (90% intact and 10% ruptured). Intact TAA repairs increased significantly (2004-2019, 4380-10,855, P < .01). From 2017 to 2019, the mortality after OAR of descending TAAs increased and mortality after thoracic endovascular aneurysm repair decreased (2017-2019, OAR 1.6%-3.1%; thoracic endovascular aneurysm repair 5.2%-3.8%). CONCLUSIONS Both intact AAA repairs and ruptured AAA admissions significantly decreased between 2004 and 2019. The use of endovascular techniques for the repair of all aortic aneurysm locations, both intact and ruptured, increased over the past two decades. Most recently in 2019, 89% of intact AAA repairs, infrarenal through suprarenal, were endovascular (EVAR or cEVAR, respectively). cEVAR alone increased to 23% of intact AAA repairs in 2019, from 0% a decade earlier. In this period of innovation, with many new options to repair aortic aneurysms while maintaining arterial branches, endovascular repair is now used for the majority of all intact aortic aneurysm repairs. Long-term data are needed to evaluate the durability of these procedures.
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Affiliation(s)
- Patrick D Conroy
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular and Endovascular Surgery, Cooper University Hospital, Camden, NJ
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Sai Divya Yadavalli
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Yoel Solomon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Anne-Sophie Romijn
- Department of Trauma Surgery, Massachusetts General Hospital, Boston, MA
| | - Kirsten Dansey
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University of Washington Medical Center, Seattle, WA
| | - Hence J M Verhagen
- Department of Vascular Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kristina A Giles
- Department of Vascular Surgery, Maine Medical Center, Portland, ME
| | - Joseph V Lombardi
- Department of Vascular and Endovascular Surgery, Cooper University Hospital, Camden, NJ
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Kowalewski M, Święczkowski M, Kuźma Ł, Maesen B, Dąbrowski EJ, Matteucci M, Batko J, Litwinowicz R, Kowalówka A, Wańha W, Jiritano F, Raffa GM, Malvindi PG, Pannone L, Meani P, Lorusso R, Whitlock R, La Meir M, de Asmundis C, Cox J, Suwalski P, Thoracic Research Centre. Systematic review and meta-analysis of left atrial appendage closure's influence on early and long-term mortality and stroke. JTCVS OPEN 2024; 19:131-163. [PMID: 39015454 PMCID: PMC11247209 DOI: 10.1016/j.xjon.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 12/17/2023] [Accepted: 02/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Left atrial appendage closure (LAAC) concomitant to heart surgery in patients with underlying atrial fibrillation (AF) has gained attention because of long-term reduction of thromboembolic complications. As of mortality benefits in the setting of non-AF, data from both observational studies and randomized controlled trials are conflicting. Methods On-line databases were screened for studies comparing LAAC versus no LAAC concomitant to other heart surgery. End points assessed were all-cause mortality and stroke at early and longest-available follow-up. Subgroup analyses stratified on preoperative AF were performed. Risk ratios (RR) with 95% CIs served as primary statistics. Results Electronic search yielded 25 studies (N = 660 [158 patients]). There was no difference between LAAC and no LAAC in terms of early mortality. In the overall population analysis, LAAC reduced long-term mortality (RR, 0.86; 95% CI, 0.74-1.00; P = .05; I 2 = 88%), reduced early stroke risk by 19% (RR, 0.81; 95% CI, 0.72-0.93; P = .002; I 2 = 57%), and reduced late stroke risk by 13% (RR, 0.87; 95% CI, 0.84-0.90; P < .001; I 2 = 58%). Subgroup analysis showed lower mortality (RR, 0.85; 95% CI, 0.72-1.01; P = .06; I 2 = 91%), short-, and long-term stroke risk reduction only in patients with preoperative AF (RR, 0.81; 95% CI, 0.71-0.93; P = .003; I 2 = 71% and RR, 0.87; 95% CI, 0.84-0.91; P < .001; I 2 = 70%, respectively). No benefit of LAAC in patients without AF was found. Conclusions Concomitant LAAC was associated with reduced stroke rates at early and long-term and possibly reduced all-cause mortality at the long-term follow-up but the benefits were limited to patients with preoperative AF. There is not enough evidence to support routine concomitant LAAC in non-AF settings.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Michał Święczkowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Łukasz Kuźma
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Bart Maesen
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | - Emil Julian Dąbrowski
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Matteo Matteucci
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Jakub Batko
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Radosław Litwinowicz
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
| | - Adam Kowalówka
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
| | - Wojciech Wańha
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
| | - Federica Jiritano
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Pietro Giorgio Malvindi
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Luigi Pannone
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - Paolo Meani
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
| | | | - Mark La Meir
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
| | - Carlo de Asmundis
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
| | - James Cox
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
| | - Piotr Suwalski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Thoracic Research Centre
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Centre Maastricht, Maastricht, The Netherlands
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
- Cardiothoracic Anatomy Research Operative Lab, Department of Cardiovascular Surgery and Transplantology, Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- Department of Cardiac Surgery, Regional Specialist Hospital, Grudziądz, Poland
- Department of Cardiac Surgery, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Cardiac Surgery, Upper-Silesian Heart Center, Katowice, Poland
- Department of Invasive Cardiology and Structural Heart Diseases, Medical University of Silesia, School of Medicine in Katowice, Katowice, Poland
- Department of Experimental and Clinical Medicine, Magna Graecia University, Catanzaro, Italy
- Cardiac Surgery Unit, Lancisi Cardiovascular Center, Ospedali Riuniti delle Marche, Polytechnic University of Marche, Ancona, Italy
- Division of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Bluhm Cardiovascular Institute, Chicago, Ill
- Heart Rhythm Management Centre, Postgraduate Program in Cardiac Electrophysiology and Pacing, Universitair Ziekenhuis Brussel—Vrije Universiteit Brussel, European Reference Networks Guard-Heart, Brussels, Belgium
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, IRCCS Policlinico, San Donato Milanese, Milan, Italy
- McMaster University, Hamilton, Canada
- Department of Cardiac Surgery, UZ Brussel, Brussels, Belgium
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 833] [Impact Index Per Article: 833.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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5
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 278] [Impact Index Per Article: 278.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Ng AP, Chervu N, Sanaiha Y, Vadlakonda A, Kronen E, Benharash P. Sociodemographic disparities in concomitant left atrial appendage occlusion during cardiac valve operations. PLoS One 2023; 18:e0286337. [PMID: 37228108 DOI: 10.1371/journal.pone.0286337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Sociodemographic disparities in atrial fibrillation (AF) management and thromboembolic prophylaxis have previously been reported, which may involve inequitable access to left atrial appendage occlusion (LAAO) during cardiac surgery. The present study aimed to evaluate the association of LAAO utilization with sex, race, and hospital region among patients with AF undergoing heart valve operations. METHODS Adults with AF undergoing valve replacement/repair in the 2012-2019 National Inpatient Sample were identified and stratified based on concurrent LAAO. Multivariable linear and logistic regressions were developed to identify factors associated with LAAO utilization. Mortality, complications including stroke and thromboembolism, hospitalization costs and length of stay (LOS) were secondarily assessed. RESULTS Of 382,580 patients undergoing valve operations, 18.7% underwent concomitant LAAO. Over the study period, the proportion of female patients receiving LAAO significantly decreased from 44.8% to 38.9% (p<0.001). Upon risk adjustment, female (AOR 0.93 [95% CI 0.89-0.97]) and Black patients (0.91 [0.83-0.99]) had significantly reduced odds of undergoing LAAO compared to males and Whites, respectively. Additionally, hospitals in the Midwest (1.38 [1.24-1.51]) and West (1.26 [1.15-1.36]) had increased likelihood of LAAO whereas Northeast hospitals (0.85 [0.77-0.94)] had decreased odds relative to the South. Furthermore, LAAO was associated with decreased stroke (0.71 [0.60-0.84]) and thromboembolism (0.68 [0.54-0.86]), $4,200 reduction in costs and 1-day decrement in LOS. CONCLUSIONS Female and Black patients had significantly lower odds while Midwest and Western hospitals had greater odds of LAAO utilization. Enhancing access to LAAO during valvular surgery is warranted to improve clinical and financial outcomes for patients with AF.
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Affiliation(s)
- Ayesha P Ng
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Nikhil Chervu
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Amulya Vadlakonda
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
- Division of Cardiac Surgery, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, United States of America
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7
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Kowalewski M, Wańha W, Litwinowicz R, Kołodziejczak M, Pasierski M, Januszek R, Kuźma Ł, Grygier M, Lesiak M, Kapłon-Cieślicka A, Reczuch K, Gil R, Pawłowski T, Bartuś K, Dobrzycki S, Lorusso R, Bartuś S, Deja MA, Smolka G, Wojakowski W, Suwalski P. Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER): protocol for a prospective observational nationwide study. BMJ Open 2022; 12:e063990. [PMID: 36130748 PMCID: PMC9494590 DOI: 10.1136/bmjopen-2022-063990] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Atrial fibrillation (AF) is a prevalent disease considerably contributing to the worldwide cardiovascular burden. For patients at high thromboembolic risk (CHA2DS2-VASc ≥3) and not suitable for chronic oral anticoagulation, owing to history of major bleeding or other contraindications, left atrial appendage occlusion (LAAO) is indicated for stroke prevention, as it lowers patient's ischaemic burden without augmentation in their anticoagulation profile. METHODS AND ANALYSIS Stand-Alone Left Atrial appendage occlusion for throMboembolism prevention in nonvalvular Atrial fibrillatioN DiseasE Registry (SALAMANDER) will be conducted in 10 heart surgery and cardiology centres across Poland to assess the outcomes of LAAO performed by fully thoracoscopic-epicardial, percutaneous-endocardial or hybrid endo-epicardial approach. The registry will include patients with nonvalvular AF at a high risk of thromboembolic and bleeding complications (CHA2DS2-VASc Score ≥2 for males, ≥3 for females, HASBLED score ≥2) referred for LAAO. The first primary outcome is composite procedure-related complications, all-cause death or major bleeding at 12 months. The second primary outcome is a composite of ischaemic stroke or systemic embolism at 12 months. The third primary outcome is the device-specific success assessed by an independent core laboratory at 3-6 weeks. The quality of life (QoL) will be assessed as well based on the QoL EQ-5D-5L questionnaire. Medication and drug adherence will be assessed as well. ETHICS AND DISSEMINATION Before enrolment, a detailed explanation is provided by the investigator and patients are given time to make an informed decision. The patient's data will be protected according to the requirements of Polish law, General Data Protection Regulation (GDPR) and hospital Standard Operating Procedures. The study will be conducted in accordance with the Declaration of Helsinki. Ethical approval was granted by the local Bioethics Committee of the Upper-Silesian Medical Centre of the Silesian Medical University in Katowice (decision number KNW/0022/KB/284/19). The results will be published in peer-reviewed journals and presented during national and international conferences. TRIAL REGISTRATION NUMBER NCT05144958.
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Affiliation(s)
- Mariusz Kowalewski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wojciech Wańha
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Radoslaw Litwinowicz
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Michalina Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Ludwik Rydygier Collegium Medicum, Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland
| | - Michal Pasierski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Rafal Januszek
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Łukasz Kuźma
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Marek Grygier
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | - Maciej Lesiak
- Department of Cardiology, Poznan University of Medical Sciences, Poznań, Poland
| | | | - Krzysztof Reczuch
- Centre for Heart Disease, University Hospital Wroclaw Department of Heart Disease, Wroclaw Medical University, Wrocław, Poland
| | - Robert Gil
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Tomasz Pawłowski
- Department of Invasive Cardiology, Center of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland
| | - Krzysztof Bartuś
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University, John Paul II Hospital, Krakow, Poland
| | - Sławomir Dobrzycki
- Department of Invasive Cardiology, Medical University of Bialystok, Bialystok, Poland
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Stanislaw Bartuś
- Department of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Marek Andrzej Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
| | - Grzegorz Smolka
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Wojciech Wojakowski
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland
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8
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Kalisnik JM, Santarpino G, Balbierer AI, Zibert J, Vogt FA, Fittkau M, Fischlein T. Left Atrial Appendage Amputation for Atrial Fibrillation during Aortic Valve Replacement. J Clin Med 2022; 11:jcm11123408. [PMID: 35743478 PMCID: PMC9224923 DOI: 10.3390/jcm11123408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2022] [Revised: 05/25/2022] [Accepted: 06/03/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Occluding the left atrial appendage (LAA) during cardiac surgery reduces the risk of ischemic stroke; nonetheless, it is currently only softly recommended with "may be considered" by the current guidelines. We aimed to assess thromboembolic risk after LAA amputation in patients with atrial fibrillation (AF) and aortic stenosis undergoing biological aortic valve replacement (AVR) as primary cardiac surgery. METHODS Two cohorts were generated retrospectively: patients with AF undergoing AVR alone or combined with revascularization either with LAA amputation or without. Data were collected from the hospital-specific data system. Follow-up was completed by telephone interview or in person. Thirty-day and follow-up results were compared in patients with vs. without LAA amputation. RESULTS One hundred and fifty-seven patients were investigated retrospectively, and seventy-four pairs were matched with regard to baseline characteristics. Patients with LAA amputation exhibited a lower incidence of cumulative and late ischemic stroke (6.4% vs. 25%, p = 0.028 and 3.2% vs. 20%, p = 0.008, respectively; hazard ratio 0.30; 95% confidence interval 0.11; 0.84; p = 0.021) during follow-up of 48 months vs. patients without intervention during follow-up of 45 months, p = 0.494. No significant differences were observed in postoperative stroke, 2 (2.7%) vs. 3 (4.1%), p = 1.000, re-exploration for bleeding 3 (4.1%) vs. 6 (8.1), p = 0.494 or late pericardial effusion 2 (2.7%) vs. 3 (4.1%), p = 1.000, in-hospital 2 (2.7%) vs. 4 (5.4%), p = 0.681 and all-cause mortality 15 (23.8%) vs. 9 (15%), p = 0.315 in patients with vs. without LAA amputation, respectively. CONCLUSIONS A combination of leading aortic stenosis and AF in patients undergoing isolated or combined biological AVR represents a subpopulation with excessive thromboembolic risk. Concomitant LAA amputation during cardiac surgery reduces the risk of ischemic stroke without posing an additional periprocedural risk for the patient. Therefore, the minimal invasive approach at the expense of omitting LAA amputation should be discouraged to maximize the clinical benefits of AVR in this setting.
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Affiliation(s)
- Jurij M. Kalisnik
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
- Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence: ; Tel.: +49-(0)-911-398-5441; Fax: +49-(0)-911-398-5443
| | - Giuseppe Santarpino
- Klinikum Nürnberg, Paracelsus Medical University, Campus Nuremberg, 90419 Nuremberg, Germany; (G.S.); (A.I.B.)
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care & Research, 73100 Lecce, Italy
- Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy
| | - Andrea I. Balbierer
- Klinikum Nürnberg, Paracelsus Medical University, Campus Nuremberg, 90419 Nuremberg, Germany; (G.S.); (A.I.B.)
| | - Janez Zibert
- Department of Biostatistics, Faculty of Health Sciences, University of Ljubljana, 1000 Ljubljana, Slovenia;
| | - Ferdinand A. Vogt
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
- Department of Cardiac Surgery, Artemed Clinic Munich-South, 81379 Munich, Germany
| | - Matthias Fittkau
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
| | - Theodor Fischlein
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, 90471 Nuremberg, Germany; (F.A.V.); (M.F.); (T.F.)
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9
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Nso N, Nassar M, Zirkiyeva M, Lakhdar S, Shaukat T, Guzman L, Alshamam M, Foster A, Bhangal R, Badejoko S, Lyonga Ngonge A, Tabot-Tabot M, Mbome Y, Rizzo V, Munira MS, Thambidorai S. Outcomes of cardiac surgery with left atrial appendage occlusion versus no Occlusion, direct oral Anticoagulants, and vitamin K Antagonists: A systematic review with Meta-analysis. IJC HEART & VASCULATURE 2022; 40:100998. [PMID: 35655531 PMCID: PMC9152299 DOI: 10.1016/j.ijcha.2022.100998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 01/13/2023]
Abstract
Surgical left atrial appendage occlusion (LAAO) is being used increasingly in the setting of atrial fibrillation but has been associated with procedural complications. This systematic review and meta-analysis compared the outcomes of surgical LAAO with those of no LAAO and the use of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) using the PRISMA guidelines. A literature search was undertaken for relevant studies published between January 1, 2003, and August 15, 2021. Primary clinical outcomes were all-cause mortality, embolic events, and stroke. Secondary clinical outcomes included major adverse cardiac events (MACE), postoperative atrial fibrillation, postoperative complications, reoperation for bleeding, and major bleeding. There was a statistically significant 34% reduction in incidence of embolic events (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.57-0.77, p < 0.001) and a significant 42% reduction in risk of MACE (OR 0.58, 95% CI 0.38-0.88, p = 0.01) in patients who underwent LAAO.Surgical LAAO has the potential to reduce embolic events and MACE in patients undergoing cardiac surgery for atrial fibrillation. However, complete replacement of DOACs and warfarin therapy with surgical LAAO is unlikely despite its non-inferiority in terms of minimizing all-cause mortality, embolic events, MACE, major bleeding, and stroke in patients on oral anticoagulation therapies.
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Key Words
- AF, atrial fibrillation
- All-cause mortality
- Atrial fibrillation
- CI, confidence interval
- DOACs, direct oral anticoagulants
- Direct oral anticoagulants
- LA, left atrium
- LAA, left atrial appendage
- LAAO, left atrial appendage occlusion
- Left atrial appendage occlusion
- MACE, major adverse cardiac events
- NOACs, novel oral anticoagulants
- OR, odds ratio
- Stroke
- VKAs, vitamin K antagonists
- Vitamin K antagonists
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Affiliation(s)
- Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Milana Zirkiyeva
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Sofia Lakhdar
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Tanveer Shaukat
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Laura Guzman
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Mohsen Alshamam
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Allison Foster
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Rubal Bhangal
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Solomon Badejoko
- Department of Medicine, St. Joseph’s Medical Center, Stockton, CA, USA
| | | | - Mpey Tabot-Tabot
- Department of Medicine, Howard University Hospital, Washington, DC, USA
| | - Yolanda Mbome
- Department of Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Most S. Munira
- Division of Cardiovascular Disease, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, NY, USA
| | - Senthil Thambidorai
- Chief of Cardiovascular Medicine Division, HCA Medical City of Fort Worth, TX/ Assistant Professor of Medicine -TCU and UNTHSc School of Medicine, Fort Worth, TX, USA
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10
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Role of EPA in Inflammation: Mechanisms, Effects, and Clinical Relevance. Biomolecules 2022; 12:biom12020242. [PMID: 35204743 PMCID: PMC8961629 DOI: 10.3390/biom12020242] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 01/31/2022] [Indexed: 02/01/2023] Open
Abstract
Many chronic inflammatory processes are linked with the continuous release of inflammatory mediators and the activation of harmful signal-transduction pathways that are able to facilitate disease progression. In this context atherosclerosis represents the most common pathological substrate of coronary heart disease, and the characterization of the disease as a chronic low-grade inflammatory condition is now validated. The biomarkers of inflammation associated with clinical cardiovascular risk support the theory that targeted anti-inflammatory treatment appears to be a promising strategy in reducing residual cardiovascular risk. Several literature data highlight cardioprotective effects of the long-chain omega-3 polyunsaturated fatty acids (PUFAs), such as eicosapentaenoic acid (EPA). This PUFA lowers plasma triglyceride levels and has potential beneficial effects on atherosclerotic plaques. Preclinical studies reported that EPA reduces both pro-inflammatory cytokines and chemokines levels. Clinical studies in patients with coronary artery disease that receive pharmacological statin therapy suggest that EPA may decrease plaque vulnerability preventing plaque progression. This review aims to provide an overview of the links between inflammation and cardiovascular risk factors, importantly focusing on the role of diet, in particular examining the proposed role of EPA as well as the success or failure of standard pharmacological therapy for cardiovascular diseases.
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11
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Elbadawi A, Mahmoud AA, Mahmoud K, Elgendy IY, Omer MA, Elsherbeny A, Ogunbayo GO, Cameron SJ, Ghanta R, Paniagua D, Jimenez E, Jneid H. Temporal Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Aortic Syndromes in Bicuspid Aortic Valves: Insights from a National Database. Cardiol Ther 2021; 10:531-545. [PMID: 34431068 PMCID: PMC8555072 DOI: 10.1007/s40119-021-00237-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 07/27/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION There is paucity of data on the outcomes of hospitalization for bicuspid aortic valve (BAV)-related aortopathies. METHODS We queried the NIS database (2012-2016) for hospitalizations for elective thoracic aortic repair or acute aortic syndrome (AAS) among those with BAV versus trileaflet aortic valve (TAV). RESULTS Our analysis yielded 38,010 hospitalizations for elective aortic repair, of whom 34.4% had BAV, as well as 81,875 hospitalizations for thoracic AAS, of whom 1.1% had BAV. Hospitalizations for BAV were younger and had fewer comorbidities compared with their TAV counterparts. The number of hospitalizations for BAV during the observational period was unchanged. After propensity matching, elective aortic repair for BAV was associated with lower mortality (0.5% versus 1.7%, odds ratio = 0.28; 95% CI 1.5-0.50, p < 0.001), use of mechanical circulatory support, acute stroke, and shorter length of hospital stay compared with TAV. After propensity matching, AAS among those with BAV had a greater incidence of bleeding events, blood transfusion, cardiac tamponade, ventricular arrhythmias, and a longer length of hospital stay compared with TAV. Among those with BAV, predictors of lower mortality if undergoing elective aortic repair included larger hospitals and teaching hospitals. Predictors of higher mortality in patients with AAS included heart failure, chronic kidney disease, and coronary artery disease. CONCLUSION Data from a national database showed no change in the number of hospitalizations for BAV-related aortopathy, with relatively lower incidence of AAS. Compared with TAV, elective aortic repair for BAV is associated with lower mortality, while BAV-related AAS is associated with higher in-hospital complications.
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Affiliation(s)
- Ayman Elbadawi
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Ahmad A Mahmoud
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Karim Mahmoud
- Department of Internal Medicine, Floyd Medical Center, Rome, GA, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Mohmed A Omer
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elsherbeny
- Division of Cardiothoracic Anaesthesia, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Scott J Cameron
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ravi Ghanta
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - David Paniagua
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Ernesto Jimenez
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.
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12
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Prasad RM, Saleh Y, Al-Abcha A, Abdelkarim O, Abdelfattah OM, Abdelnabi M, Almaghraby A, Elwany M, DeBruyn E, Abela GS. Left atrial appendage closure during cardiac surgery for atrial fibrillation: A meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:26-36. [PMID: 34801420 DOI: 10.1016/j.carrev.2021.11.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/30/2021] [Accepted: 11/01/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) during cardiac surgery in atrial fibrillation (AF) patients has been investigated in multiple studies with variable safety and efficacy results. METHODS A comprehensive review was performed of all studies comparing LAAC and placebo arm during cardiac surgery in AF patients. A random-effect model was used to calculate risk ratios, mean differences, and 95% confidence intervals. RESULTS Five randomized controlled trials and 22 observational studies were included with a total of 540,111 patients. The LAAC group had significantly decreased postoperative stroke/embolic events as compared to the no LAAC group with all cardiac surgeries (3.74% vs 4.88%, p = 0.0002), isolated valvular surgery (1.95% vs 4.48%, p = 0.002). However, CABG insignificantly favored the LAAC group for stroke/embolic events (6.72% vs 8.30%, p = 0.07). There was no difference between both groups in all-cause mortality in the perioperative period (p = 0.42), but was significantly lower in the LAAC arm after two years (14.1% vs 18.3%, p = 0.02). There was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time between both groups (p = 0.53 and p = 0.45). The bypass and the cross-clamp time were longer in the LAAC group (4 and 9 min, respectively). CONCLUSION In AF patients, LAAC during cardiac surgery had a decreased risk of stroke and long-term all-cause mortality. Additionally, there was no difference in major bleeding, all-cause rehospitalizations, or cross-clamp time.
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Affiliation(s)
- Rohan Madhu Prasad
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA.
| | - Yehia Saleh
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Abdullah Al-Abcha
- Department of Internal Medicine, Michigan State University, East Lansing, MI, USA
| | - Ola Abdelkarim
- Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA; Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Omar M Abdelfattah
- Department of Internal Medicine, Morristown Medical Center, Atlantic Health System, Morristown, NJ, USA
| | - Mahmoud Abdelnabi
- Internal Medicine Department, Texas Tech University Health Science Center, Lubbock, Texas, USA
| | | | - Mostafa Elwany
- Department of Cardiology, Alexandria University, Alexandria, Egypt
| | - Elise DeBruyn
- College of Medicine, University of Illinois, Chicago, IL, USA
| | - George S Abela
- Department of Cardiology, Michigan State University, East Lansing, MI, USA
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13
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Ariss RW, Khan Minhas AM, Patel NJ, Zafrullah F, Bhavsar K, Nazir S, Jneid H, Moukarbel GV. Contemporary trends and in-hospital outcomes of catheter and stand-alone surgical ablation of atrial fibrillation. Europace 2021; 24:218-225. [PMID: 34347080 DOI: 10.1093/europace/euab198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 07/14/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS The contemporary trends in catheter ablation (CA) and surgical ablation (SA) utilization and surgical techniques [open vs. thoracoscopic, with or without left atrial appendage closure (LAAC)] are unclear. In addition, the in-hospital outcomes of stand-alone SA compared with CA are not well-described. METHODS AND RESULTS The National Inpatient Sample 2010-18 was queried for atrial fibrillation (AF) hospitalizations with CA or stand-alone SA. Complex samples multivariable logistic and linear regression models were used to compare the association between stand-alone SA vs. CA and the primary outcomes of in-hospital mortality and stroke. Of 180 243 hospitalizations included within the study, 167 242 were for CA and 13 000 were for stand-alone SA. Catheter ablation and stand-alone SA hospitalizations decreased throughout the study period (Ptrend < 0.001). Surgical ablation had higher rates of in-hospital mortality [adjusted odds ratio (aOR) 2.26; 95% confidence interval (CI) 1.41-3.61; P = 0.001] and stroke (aOR 4.64; 95% CI 3.25-6.64; P < 0.001) compared with CA. When examining different surgical approaches, thoracoscopic SA was associated with similar in-hospital mortality (aOR 1.53; 95% CI 0.60-3.89; P = 0.369) and similar risk of stroke (aOR 1.75; 95% CI 1.00-3.07; P = 0.051) compared with CA. CONCLUSION Stand-alone SA comprises a minority of AF ablation procedures and is associated with increased risk of mortality, stroke, and other in-hospital complications compared to CA. However, when a thoracoscopic approach was utilized, the risks of mortality and stroke appear to be reduced.
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Affiliation(s)
- Robert W Ariss
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
| | | | - Neha J Patel
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
| | - Fnu Zafrullah
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
| | - Krupa Bhavsar
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
| | - Salik Nazir
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
| | - Hani Jneid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - George V Moukarbel
- Division of Cardiovascular Medicine, University of Toledo Medical Center, 3000 Arlington Avenue, Toledo, OH 43614, USA
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14
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Elbadawi A, Elgendy IY, Jimenez E, Omer MA, Shahin HI, Ogunbayo GO, Paniagua D, Jneid H. Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States. Am J Med 2021; 134:902-909.e5. [PMID: 33631161 DOI: 10.1016/j.amjmed.2021.01.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND There is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. METHODS We queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality. RESULTS The analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (Ptrend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (Ptrend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome. CONCLUSION Contemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Ernesto Jimenez
- Division of Cardiothoracic Surgery, Baylor School of Medicine, Houston, Tex
| | - Mohmed A Omer
- Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minn
| | - Hend I Shahin
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston
| | | | - David Paniagua
- Division of Cardiology, Baylor School of Medicine, Houston, Tex
| | - Hani Jneid
- Division of Cardiology, Baylor School of Medicine, Houston, Tex.
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Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
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Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
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16
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Elbadawi A, Elgendy IY, Mohamed AH, Almahmoud MF, Omer M, Abuzaid A, Mahmoud K, Ogunbayo GO, Denktas A, Paniagua D, Banerjee S, Jneid H. Temporal Trends and Outcomes of Transcatheter Mitral Valve Repair and Surgical Mitral Valve Intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2020; 21:1560-1566. [PMID: 32620401 DOI: 10.1016/j.carrev.2020.05.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND There is a paucity of data regarding the contemporary changes in the uptake and outcomes of transcatheter mitral valve repair (TMVR) and surgical mitral valve repair/replacement (SMVR). METHODS We queried the NIS database (2012-2016) to identify hospitalizations for TMVR and SMVR. We reported the temporal trends for uptake of TMVR and SMVR and their in-hospital outcomes. RESULTS The analysis included 77,645 hospitalizations: 8760 (11.3%) for TMVR and 68,885 (88.7%) for SMVR. Those undergoing TMVR were older and had a higher prevalence of comorbidities, but shorter length of stay (5.5 ± 8.8 vs. 14.3 ± 13.8, p < 0.001) compared with SMVR. There was a marked increase in the number of TMVRs over time (from 420 in 2012 to 3850 in 2016; +917%; Ptrend = 0.008) but a modest increase in the number of SMVRs (+117%; Ptrend = 0.02). Overall, TMVR was associated with low in-hospital mortality (2%) and favorable safety profile. After adjusting for clinical and hospital variables, there were non-significant trends towards lower adjusted mortality among TMVR and SMVR (Ptrend = 0.16 and Ptrend = 0.13, respectively). Notably, among TMVR patients, female sex was associated with lower in-hospital mortality while CKD was associated with increased in-hospital mortality. There was a significant downtrend in the incidences of cardiac arrest, hemodialysis and length of stay in TMVR patients. CONCLUSION Real world data showed a steady increase in the number of TMVR and SMVR procedures. Overall, TMVR was associated with low in-hospital mortality and complications rates. Despite older age and increased comorbidities, TMVR patients had lower in-hospital mortality and shorter length than their SMVR counterparts.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, United States of America
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States of America
| | - Ahmed H Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, United States of America
| | - Mohamed F Almahmoud
- Division of Cardiovascular Medicine, University of South Carolina, Charleston, SC, United States of America
| | - Mohmed Omer
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, MN, United States of America
| | - A Abuzaid
- Division of Cardiovascular Medicine, University of California San Francisco, San Francisco, CA, United States of America
| | - Karim Mahmoud
- Department of Internal Medicine, Houston Medical Center, Warner Robins, GA, United States of America
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, United States of America
| | - Ali Denktas
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, TX, United States of America
| | - David Paniagua
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, TX, United States of America
| | - Subhash Banerjee
- Division of Cardiovascular Medicine, University of Texas South Western, Dallas, TX, United States of America
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, TX, United States of America.
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Jiang S, Zhang H, Wei S, Zhang L, Gong Z, Li B, Wang Y. Left atrial appendage exclusion is effective in reducing postoperative stroke after mitral valve replacement. J Card Surg 2020; 35:3395-3402. [PMID: 32939788 DOI: 10.1111/jocs.15020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/11/2020] [Accepted: 08/17/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE This study aimed to evaluate the role of surgical left atrial appendage (LAA) exclusion in the prevention of stroke after mitral valve replacement (MVR). METHODS We retrospectively reviewed clinical data of 860 patients who received MVR in our center from January 2008 to January 2013. The patients were randomly assigned to two surgical groups, namely LAA exclusion group (n = 521) and LAA nonexclusion group (n = 339) according to whether concurrent surgical exclusion of the LAA was to be undertaken or not before surgery in a blind fashion. MVR was performed by two experienced surgeons. The LAA was explored during the operation and mural thrombus removed in all cases. The LAA was left intact in nonocclusion group whereas the neck of the LAA was closed with a two-layer continued suture in exclusion group. The incidence of early postoperative ischemic stroke between the two groups was compared. RESULTS The patients' age was 53 ± 12 years, with 48.1% male and 67.9% with rheumatic disease. Mural thrombosis was seen in 18.8% of the patients and atrial fibrillation (AF) coexisted in 62.4%. All operations were successfully performed and no difference was noted in in-hospital mortality, re-exploration for bleeding, and other major complications between the two groups. The incidence of ischemic stroke in LAA exclusion group was significantly lower than in nonexclusion group (0.6% vs. 2.7%, p = .011). The subgroup multivariate analysis showed that LAA exclusion significantly reduced the risk of postoperative stroke in patients with AF (odds ratio [OR] = 0.070, 95% confidence interval [CI]: 0.006-0.705, p = .025) but not in non-AF patients (OR = 1.902, 95% CI: 0.171-21.191, p = .601). CONCLUSIONS Concurrent LAA exclusion during MVR is a safe and effective way to reduce postoperative ischemic stroke, particularly in patients with AF.
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Affiliation(s)
- Shengli Jiang
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Huajun Zhang
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
- Department of Cardiovascular Surgery, PLA Medical School, Beijing, China
| | - Shixiong Wei
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
- Department of Cardiovascular Surgery, PLA Medical School, Beijing, China
| | - Lin Zhang
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Zhiyun Gong
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Bojun Li
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
| | - Yao Wang
- Department of Cardiovascular Surgery, Chinese PLA General Hospital, Beijing, China
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Zheng Y, Rao CF, Chen SP, He L, Hou JF, Zheng Z. Surgical left atrial appendage occlusion in patients with atrial fibrillation undergoing mechanical heart valve replacement. Chin Med J (Engl) 2020; 133:1891-1899. [PMID: 32826451 PMCID: PMC7462216 DOI: 10.1097/cm9.0000000000000967] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Surgical left atrial appendage occlusion (SLAAO) may be associated with a lower risk of thromboembolism in patients with atrial fibrillation undergoing cardiac surgery. However, evidence regarding the effectiveness of SLAAO in patients undergoing mechanical heart valve replacement (MHVR) is lacking. Therefore, we aimed to evaluate the association between SLAAO and the cardiovascular outcomes in patients with atrial fibrillation undergoing MHVR. METHODS We retrospectively analyzed data for 497 patients with atrial fibrillation; 27.6% of the patients underwent SLAAO, and the remainder of the patients did not (No-SLAAO group). The primary outcome was a composite of ischemic stroke, systemic embolism, and all-cause mortality. Cumulative event-free survival rates were estimated using Kaplan-Meier curves, and we performed multivariate Cox analyses to evaluate the association between SLAAO and outcomes. We used one-to-one propensity score matching to balance patients' baseline characteristics, and analyzed 120 matching pairs. RESULTS Five patients died within 30 days postoperatively, and there were no significant differences between the two groups regarding in-hospital complications (all P > 0.05). After a median follow-up of 14 months, 14 primary events occurred. Kaplan-Meier curves showed no difference in the cumulative incidence of freedom from the primary outcome (log-rank P = 0.830), hemorrhagic events (log-rank P = 0.870), and the secondary outcome (log-rank P = 0.730), between the two groups. Multivariable Cox proportional hazards regression analysis showed no association between SLAAO and any outcome (all P > 0.05). After propensity score matching, cardiopulmonary bypass time and aortic cross-clamp time, and the postoperative length of stay were significantly longer in the SLAAO group (all P < 0.05); results were similar to the unadjusted analyses. CONCLUSIONS Concomitant SLAAO and MHVR was associated with longer length of stay, and cardiopulmonary bypass time and aortic cross-clamp time, but was not associated with additional protective effects against thromboembolic events and mortality during the 14-month follow-up.
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Affiliation(s)
- Ye Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chen-Fei Rao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Si-Peng Chen
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Li He
- Information Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jian-Feng Hou
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhe Zheng
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Elbadawi A, Elgendy IY, Mentias A, Saad M, Mohamed AH, Choudhry MW, Ogunbayo GO, Gilani S, Jneid H. Outcomes of urgent versus nonurgent transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2020; 96:189-195. [PMID: 31647180 DOI: 10.1002/ccd.28563] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 10/13/2019] [Indexed: 11/11/2022]
Abstract
BACKGROUND There is a paucity of data regarding the outcomes of transcatheter valve replacement (TAVR) performed in an urgent clinical setting. METHODS The Nationwide Inpatient Sample (NIS) database years 2011-2014 was used to identify hospitalizations for TAVR in the urgent setting. Using propensity score matching, we compared patients who underwent TAVR in nonurgent versus urgent settings. RESULTS Among 42,154 hospitalizations in which TAVR was performed, 10,114 (24%) underwent urgent TAVR. There was an uptrend in the rate of urgent TAVR procedures (p = .001). The rates of in-hospital mortality among this group did not change during the study period (p = .713). Nonurgent TAVR was associated with lower mortality (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.69-0.89, p < .001) compared with urgent TAVR. Nonurgent TAVR was associated with lower incidence of cardiogenic shock (OR = 0.46; 95%CI: 0.40-0.53 p < .001), use of mechanical circulatory support devices (OR = 0.69; 95%CI: 0.59-0.82, p < .001), AKI (OR = 0.60; 95%CI: 0.56-0.64 p < .001), hemodialysis (OR = 0.67; 95%CI: 0.56-0.80 p < .001), major bleeding (OR = 0.94; 95%CI: 0.89-0.99 p = .045) and shorter length of stay (7.08 ± 6.317 vs. 12.39 ± 9.737 days, p < .001). There was no difference in acute stroke (OR = 0.96; 95%CI: 0.81-1.14, p = .636), vascular complications (OR = 1.07; 95%CI: 0.89-1.29, p = .492), and pacemaker insertions (OR = 0.92; 95%CI: 0.84-1.01, p = .067) between both groups. Among those undergoing urgent TAVR, subgroup analysis showed higher mortality in patients ≤80 years (p = .033), women (p < .001), chronic kidney disease (p = .001), heart failure (p < .001), and liver disease (p = .003). CONCLUSION In this large nationwide analysis, almost a quarter of TAVR procedures were performed in the urgent settings. Although urgent TAVR was associated with higher mortality and increased complications compared with nonurgent TAVR, the absolute difference in in-hospital mortality was not remarkably higher. Thus, urgent TAVR can be considered as a reasonable approach when indicated.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Marwan Saad
- Cardiovascular Institute, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Ahmed H Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | | | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Syed Gilani
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor School of Medicine, Houston, Texas
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Mahmood E, Matyal R, Mahmood F, Xu X, Sharkey A, Chaudhary O, Karani S, Khabbaz K. Impact of Left Atrial Appendage Exclusion on Short-Term Outcomes in Isolated Coronary Artery Bypass Graft Surgery. Circulation 2020; 142:20-28. [PMID: 32489114 DOI: 10.1161/circulationaha.119.044642] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the impact of left atrial appendage (LAA) exclusion on short-term outcomes in patients with atrial fibrillation undergoing isolated coronary artery bypass graft surgery. METHODS We queried the 2010 to 2014 National Readmissions Database for patients who underwent coronary artery bypass graft repair with and without LAA ligation by using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification: 36.1xx). Only patients with a history of atrial fibrillation were included in our analysis. The primary outcome of our study was 30-day readmissions following discharge. Secondary outcomes were in-hospital mortality and stroke. To assess the postoperative outcomes, we used multivariate logistic regression models to adjust for clinical and demographic covariates. RESULTS In total, we analyzed 253 287 patients undergoing coronary artery bypass graft surgery, 7.0% of whom received LAA closure. LAA exclusion was associated with a greater risk of postoperative respiratory failure (8.2% versus 6.2%, P<0.0001) and acute kidney injury (21.8% versus 18.5%, P<0.0001), but it did not significantly change the rate of blood transfusions or occurrence of cardiac tamponade. LAA exclusion was associated with a nonsignificant reduction in stroke (7.9% versus 8.6%, P=0.12), no difference in in-hospital mortality (2.2% versus 2.2% P=0.99), and a greater risk of 30-day readmission (16.0% versus 9.6%, P<0.0001). After covariate adjustment, LAA ligation remained a significant predictor of 30-day readmission (odds ratio, 1.640 [95% CI, 1.603-1.677], P<0.0001). CONCLUSIONS LAA exclusion during isolated coronary artery bypass graft surgery in patients with atrial fibrillation is associated with a higher rate of 30-day readmission. Postoperative measures to mitigate the loss of the hormonal and hemodynamic effects of the LAA may increase the therapeutic benefit of this procedure.
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Affiliation(s)
- Eitezaz Mahmood
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Department of Internal Medicine, North Shore University Hospital, Manhasset, NY (E.M.)
| | - Robina Matyal
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Feroze Mahmood
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Xinling Xu
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Aidan Sharkey
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Omar Chaudhary
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Sadia Karani
- Anesthesia Critical Care and Pain Medicine (R.M., F.M., X.X., A.S., O.C., S.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Kamal Khabbaz
- Departments of Cardiothoracic Surgery (E.M., K.K.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
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Martín Gutiérrez E, Castaño M, Gualis J, Martínez-Comendador JM, Maiorano P, Castillo L, Laguna G. Beneficial effect of left atrial appendage closure during cardiac surgery: a meta-analysis of 280 585 patients. Eur J Cardiothorac Surg 2019; 57:252-262. [DOI: 10.1093/ejcts/ezz289] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/22/2019] [Accepted: 08/26/2019] [Indexed: 12/30/2022] Open
Abstract
Abstract
In non-rheumatic atrial fibrillation (AF), left atrial appendage (LAA) is thought to be the source of embolism in 90% of the strokes. Thus, as recent clinical trials have shown the non-inferiority of percutaneous LAA closure (LAAc) in comparison to medical treatment, and despite a IIb recommendation in the latest guidelines for concomitant surgical LAAc, we sought to investigate the beneficial effect of LAAc in the surgical population. A meta-analysis model was performed comparing studies including any cardiac surgery with or without concomitant surgical LAAc reporting stoke/embolic events and/or mortality, from inception to January 2019. Twenty-two studies (280 585 patients) were included in the model. Stroke/embolic events both in the perioperative period [relative risk (RR) 0.66, 95% confidence interval (CI) 0.53–0.82; P = 0.0001] and during follow-up of >2 years (RR 0.67, 95% CI 0.51–0.89; P < 0.005) were significantly reduced in patients who underwent surgical LAAc (RR 0.71, 95% CI 0.58–0.87; P = 0.001). Regarding the rate of preoperative AF, LAAc showed protective effect against stroke/embolic events in studies with >70% preoperative AF (RR 0.64, 95% CI 0.53–0.77; P < 0.00001) but no benefit in the studies with <30% of preoperative AF (RR 0.77, 95% CI 0.46–1.28; P = 0.31). Postoperative mortality was also significantly lower in surgical patients with LAAc at the mid- and long-term follow-up. (RR 0.72, 95% CI 0.67–0.78; P < 0.00001; I2 = 0%). Based on these findings, concomitant surgical LAAc is associated with lower rates of embolic events and stroke in the postoperative period in patients with preoperative AF and also improves postoperative mortality in the mid- and long-term follow-up.
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Affiliation(s)
| | - Mario Castaño
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Javier Gualis
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | | | - Pasquale Maiorano
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Laura Castillo
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
| | - Gregorio Laguna
- Servicio de Cirugía Cardiaca, Hospital Universitario de León – CAULE, León, Spain
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Elbadawi A, Ahmed HMA, Mahmoud K, Mohamed AH, Barssoum K, Perez C, Mahmoud A, Ogunbayo GO, Omer MA, Jneid H, Chatterjee A. Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Rheumatoid Arthritis (from the Nationwide Inpatient Database). Am J Cardiol 2019; 124:1099-1105. [PMID: 31378321 DOI: 10.1016/j.amjcard.2019.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 06/25/2019] [Accepted: 07/02/2019] [Indexed: 11/29/2022]
Abstract
Little is known on the outcomes of surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI) in patients with rheumatoid arthritis (RA). We queried the Nationwide Inpatient Sample Database (2012 to 2016). We performed a propensity-score-matched analysis based on 25 clinical and hospital variables to compare patients with RA who underwent SAVR versus TAVI. Our primary outcome was in-hospital mortality. Our final analysis included 5,640 hospitalizations with RA who underwent isolated AVR; of whom, 2,465 (43.7%) underwent TAVI. There was an increasing trend in TAVI procedures during the study years (ptrend= 0.001). There was a trend toward reduced in-hospital mortality among TAVI compared with SAVR but did not reach statistical significance (0.8% vs 1.6%, odds ratio = 0.50; 95% confidence interval 0.23 to 1.06, p = 0.097). TAVI was associated with lower rates of postoperative bleeding (28.7% vs 43.9%, p <0.001), blood transfusion (12.3% vs 40.2%, p <0.001), acute kidney injury (9.8% vs 16.0%, p <0.001), cardiac tamponade (0.0% vs 1.6%, p <0.001), and discharges to skilled nursing facility (SNF) (20.1% vs 42.2%, p <0.001). However, TAVI was associated with a higher rate of complete heart block (14.3% vs 6.1%, p <0.001) and pacemaker implantations (14.8% vs 5.7%, p <0.001). There were no differences between both groups in cardiogenic shock, acute stroke, acute myocardial infarction, and vascular complications. In conclusion, real-word data showed no significant difference in in-hospital mortality between TAVI and SAVR in patients with RA. TAVI was associated with lower rates of acute kidney injury and bleeding complications at the expense of higher incidence of pacemaker implantations.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas.
| | - Hamdy M A Ahmed
- Division of Rheumatology, University of Alabama, Birmingham, Alabama
| | - Karim Mahmoud
- Department of Internal Medicine, Houston Medical Center, Warner Robbins, Georgia
| | - Ahmed H Mohamed
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Kirolos Barssoum
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Christopher Perez
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Ahmad Mahmoud
- Department of Internal Medicine, University of Florida, Gainesville, Florida
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Mohamed A Omer
- Department of Cardiovascular Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas
| | - Arka Chatterjee
- Division of Cardiology, Division of Cardiovascular Disease, University of Alabama, Birmingham, Alabama
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Elbadawi A, Saad M, Elgendy IY, Barssoum K, Omer MA, Soliman A, Almahmoud MF, Ogunbayo GO, Mentias A, Gilani S, Jneid H, Aronow HD, Kleiman N, Abbott JD. Temporal Trends and Outcomes of Transcatheter Versus Surgical Aortic Valve Replacement for Bicuspid Aortic Valve Stenosis. JACC Cardiovasc Interv 2019; 12:1811-1822. [PMID: 31537280 DOI: 10.1016/j.jcin.2019.06.037] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to assess the temporal trends of transcatheter aortic valve replacement (TAVR) in patients with bicuspid aortic stenosis (AS), and to compare the outcomes between TAVR and surgical aortic valve replacement (SAVR) in this population. BACKGROUND Randomized trials comparing TAVR to SAVR in AS with bicuspid valve are lacking. METHODS The study queried the National Inpatient Sample database (years 2012 to 2016) to identify hospitalizations for bicuspid AS who underwent isolated aortic valve replacement. A propensity-matched analysis was used to compare outcomes of hospitalizations for TAVR versus SAVR for bicuspid AS and TAVR for bicuspid AS versus tricuspid AS. RESULTS The analysis included 31,895 hospitalizations with bicuspid AS, of whom 1,055 (3.3%) underwent TAVR. TAVR was increasingly utilized during the study period for bicuspid AS (ptrend = 0.002). After matching, TAVR and SAVR had similar in-hospital mortality (3.1% vs. 3.1%; odds ratio: 1.00; 95% confidence interval: 0.60 to 1.67). There was no difference between TAVR and SAVR in the rates of cardiac arrest, cardiogenic shock, acute kidney injury, hemopericardium, cardiac tamponade, or acute stroke. TAVR was associated with lower rates of acute myocardial infarction, post-operative bleeding, vascular complications, and discharge to nursing facility as well as a shorter length of hospital stay. On the contrary, TAVR was associated with a higher incidence of complete heart block and permanent pacemaker insertion. TAVR for bicuspid AS was associated with similar in-hospital mortality compared with tricuspid AS. CONCLUSIONS This nationwide analysis showed similar in-hospital mortality for TAVR and SAVR in patients with bicuspid AS. TAVR for bicuspid AS was also associated with similar in-hospital mortality compared with tricuspid AS. Further studies are needed to evaluate long-term outcomes of TAVR for bicuspid AS.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas; Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt.
| | - Marwan Saad
- Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt; Division of Cardiology, Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Islam Y Elgendy
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Kirolos Barssoum
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Mohamed A Omer
- Department of Cardiovascular Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Ahmed Soliman
- Division of Cardiovascular Medicine, Houston Methodist Hospital, Houston, Texas
| | - Mohamed F Almahmoud
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Amgad Mentias
- Division of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Syed Gilani
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas
| | - Hani Jneid
- Division of Cardiovascular Medicine, Baylor College of Medicine, Houston, Texas
| | - Herbert D Aronow
- Division of Cardiology, Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Neil Kleiman
- Division of Cardiovascular Medicine, Houston Methodist Hospital, Houston, Texas
| | - J Dawn Abbott
- Division of Cardiology, Cardiovascular Institute, Warren Alpert Medical School at Brown University, Providence, Rhode Island
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Alsagheir A, Koziarz A, Belley-Côté EP, Whitlock RP. Left Atrial Appendage Occlusion: A Narrative Review. J Cardiothorac Vasc Anesth 2019; 33:1753-1765. [DOI: 10.1053/j.jvca.2019.01.054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Indexed: 12/21/2022]
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25
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Elbadawi A, Elgendy IY, Mahmoud AH, Ogunbayo GO, Saad M, Megaly M, Alotaki E, Mentias A, Barakat AF, London B. Outcomes of Surgical Ablation in Patients With Atrial Fibrillation Undergoing Cardiac Surgeries. Ann Thorac Surg 2019; 107:1395-1400. [PMID: 30481521 DOI: 10.1016/j.athoracsur.2018.10.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 08/18/2018] [Accepted: 10/10/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Surgical ablation procedure is commonly performed in patients with atrial fibrillation (AF) undergoing cardiac surgeries; however, the evidence regarding its impact on in-hospital cardiovascular outcomes is controversial. METHODS We queried the Nationwide Inpatient Sample Database for patients with AF who underwent cardiac surgeries from 1998 to 2013. We performed a propensity-score matching including 21 various baseline characteristics to compare those who underwent surgical ablation with those who had not. RESULTS A total of 47,964 hospitalizations were included in our final analysis. On propensity matching, 23,975 were in the surgical ablation group and 23,990 in the control group. The primary outcome of in-hospital mortality was lower in the surgical ablation group compared with the control group (3.6% versus 4.2%, p < 0.001). The surgical ablation group was associated with lower in-hospital cerebrovascular accident (2.0% versus 2.8%, p < 0.001), cardiogenic shock (2.6% versus 3.6%, p < 0.001), use of intraaortic balloon pump (5.1% versus 5.8%, p = 0.001), and shorter length of hospital stay (12.3 ± 10.1 versus 12.5 ± 10.3 days, p = 0.008). There was no difference between the surgical ablation and control groups in the incidence of cardiac tamponade (0.4% versus 0.3%, p = 0.296). The surgical ablation group was associated with a higher rate of complete heart block (5.2% versus 4.3%, p < 0.001) and permanent pacemaker insertion (8.6% versus 8.0%, p = 0.01). CONCLUSIONS In this large analysis of almost 50,000 patients with AF undergoing cardiac surgery, surgical ablation appears to be safe in the short term. Future studies should focus on evaluating the long-term effectiveness of this procedure.
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Affiliation(s)
- Ayman Elbadawi
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, Texas; Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Ahmed H Mahmoud
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Marwan Saad
- Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt; Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Michael Megaly
- Minneapolis Heart Institute at Abbot Northwestern Hospital, Minneapolis, Minnesota
| | - Erfan Alotaki
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Amgad Mentias
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
| | - Amr F Barakat
- UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barry London
- Department of Cardiovascular Medicine, University of Iowa, Iowa City, Iowa
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Elbadawi A, Elgendy IY, Ha LD, Mahmoud K, Lenka J, Olorunfemi O, Reyes A, Ogunbayo GO, Saad M, Abbott JD. National Trends and Outcomes of Percutaneous Coronary Intervention in Patients ≥70 Years of Age With Acute Coronary Syndrome (from the National Inpatient Sample Database). Am J Cardiol 2019; 123:25-32. [PMID: 30360891 DOI: 10.1016/j.amjcard.2018.09.030] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/16/2018] [Accepted: 09/21/2018] [Indexed: 10/28/2022]
Abstract
Several randomized trials have demonstrated the benefits of an invasive strategy for older patients with acute coronary syndromes (ACS); however, there are limited real-world data of the temporal trends in the use of percutaneous coronary intervention (PCI) in this population. This was a retrospective observational analysis. We queried the National Inpatient Sample database from 1998 to 2013 for patients aged ≥70 years who had non-ST-elevation acute coronary syndrome (NSTE-ACS) or ST-elevation myocardial infarction (STEMI). We reported the temporal trends of PCI and in-hospital mortality. A total of 6,720,281 hospitalizations with ACS were identified in advanced age patients, 18.3% of whom also underwent PCI. There was an upward trend in the rate of PCI in older adults ≥70 years with any ACS from 9.4% in 1998 to 28.3% in 2013 (p <0.001), as well as in cases of PCI for NSTE-ACS (7.3% in 1998 vs 24.9% in 2013, p <0.001) and PCI for STEMI (11% in 1998 vs 35.7% in 2013, p = 0.002). This upward trend was consistent in all age categories (70 to 79), (80 to 89) and ≥90 years. Despite an increase in the prevalence of comorbidities for ACS hospitalizations aged ≥70 years who received PCI, the in-hospital mortality rate showed a downward trend (p <0.001). Multivariate analysis adjusting for various comorbidities showed that PCI was associated with lower in-hospital mortality and length of hospital stay among elderly with NSTE-ACS and STEMI. In conclusion, in this 16-year analysis there was an increase in the rate of PCI procedures among older adults with ACS. PCI was independently associated with lower mortality in elderly patients with ACS.
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Affiliation(s)
- Ayman Elbadawi
- Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX; Department of Cardiovascular Medicine, Ain shams university, Cairo, Egypt.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, FL
| | - Le Dung Ha
- Department of Cardiovascular Medicine, New York Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
| | - Karim Mahmoud
- Department of Internal Medicine, Houston Medical Center, Warner Robbins, GA
| | - Jyotirmayee Lenka
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | | | - Amy Reyes
- Department of Geriatrics and Palliative Medicine, Mount Sinai Hospital, NY
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY
| | - Marwan Saad
- Division of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR; Department of Cardiovascular Medicine, Ain shams university, Cairo, Egypt
| | - J Dawn Abbott
- Division of Cardiovascular Medicine, Warren Alpert School of Medicine at Brown University, Providence, RI
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27
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Goldman S. Safe and secure. J Thorac Cardiovasc Surg 2018; 156:e209-e210. [DOI: 10.1016/j.jtcvs.2018.07.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/26/2018] [Indexed: 11/29/2022]
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28
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Atti V, Anantha-Narayanan M, Turagam MK, Koerber S, Rao S, Viles-Gonzalez JF, Suri RM, Velagapudi P, Lakkireddy D, Benditt DG. Surgical left atrial appendage occlusion during cardiac surgery: A systematic review and meta-analysis. World J Cardiol 2018; 10:242-249. [PMID: 30510641 PMCID: PMC6259031 DOI: 10.4330/wjc.v10.i11.242] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/08/2018] [Accepted: 10/12/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the safety and efficacy of surgical left atrial appendage occlusion (s-LAAO) during concomitant cardiac surgery. METHODS We performed a comprehensive literature search through May 31st 2018 for all eligible studies comparing s-LAAO vs no occlusion in patients undergoing cardiac surgery. Clinical outcomes during follow-up included: embolic events, stroke, all-cause mortality, atrial fibrillation (AF), reoperation for bleeding and postoperative complications. We further stratified the analysis based on propensity matched studies and AF predominance. RESULTS Twelve studies (n = 40107) met the inclusion criteria. s-LAAO was associated with lower risk of embolic events (OR: 0.63, 95%CI: 0.53-0.76; P < 0.001) and stroke (OR: 0.68, 95%CI: 0.57-0.82; P < 0.0001). Stratified analysis demonstrated this association was more prominent in the AF predominant strata. There was no significant difference in the incidence risk of all-cause mortality, AF, and reoperation for bleeding and postoperative complications. CONCLUSION Concomitant s-LAAO during cardiac surgery was associated with lower risk of follow-up thromboembolic events and stroke, especially in those with AF without significant increase in adverse events. Further randomized trials to evaluate long-term benefits of s-LAAO are warranted.
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Affiliation(s)
- Varunsiri Atti
- Department of Medicine, Michigan State University-Sparrow Hospital, East Lansing, MI 48912, United States
| | - Mahesh Anantha-Narayanan
- Division of Cardiovascular diseases, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States.
| | - Mohit K Turagam
- Helmsley Electrophysiology Center, Icahn School of medicine at Mount Sinai, New York City, NY 10029, United States
| | - Scott Koerber
- Department of Cardiac Electrophysiology, Medical University of South Carolina, Charleston, SC 29425, United States
| | - Sunil Rao
- Department of Cardiovascular diseases, Genesys Heart Institute, Ascension Genesys Hospital, Grand Blanc, MI
| | - Juan F Viles-Gonzalez
- Baptist Health South Florida, Professor of Medicine at Wertheim College of Medicine, Miami, FL 33176
| | - Rakesh M Suri
- Cleveland Clinic Foundation and Cleveland Clinic Abu Dhabi, Department of Thoracic and Cardiovascular Surgery. Cleveland Clinic, Cleveland, OH 44195, United States
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York City, NY 10027, United States
| | - Dhanunjaya Lakkireddy
- Kansas City Heart Rhythm Institute and Research Foundation, Kansas City, MO 64132, United States
| | - David G Benditt
- Division of Cardiovascular diseases, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, United States
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Ligating the left atrial appendage in atrial fibrillation: What additional evidence do surgeons need? J Thorac Cardiovasc Surg 2018; 157:1004-1006. [PMID: 30414767 DOI: 10.1016/j.jtcvs.2018.09.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 09/11/2018] [Indexed: 11/20/2022]
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Mangrolia N, Punjabi P. The cessation of oral anticoagulation following left atrial appendage surgery. Future Cardiol 2018; 14:407-415. [PMID: 30232906 DOI: 10.2217/fca-2018-0010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Atrial fibrillation is associated with a significantly increased risk of stroke, and oral anticoagulation is the mainstay of preventative treatment. Scenarios arise where the risks of treatment with oral anticoagulation may outweigh the benefits, most commonly when there is an elevated risk of bleeding. Studies of percutaneous closure of the left atrial appendage have strongly implicated this structure in the etiology of stroke in atrial fibrillation, and provide some rationale for the discontinuation of oral anticoagulation following percutaneous closure device implantation. A common clinical concern is the safety of cessation of oral anticoagulation after surgical closure of the left atrial appendage in patients with a history of atrial fibrillation. Here, we review the evidence guiding this management decision and draw comparison with data on percutaneous closure.
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Affiliation(s)
- Neil Mangrolia
- NHLI Cardiothoracic Surgery, B Block BN2/15, Hammersmith Hospital Campus, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, England
| | - Prakash Punjabi
- NHLI Cardiothoracic Surgery, B Block BN2/15, Hammersmith Hospital Campus, Imperial College Healthcare NHS Trust, Du Cane Road, London W12 0NN, England
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Ogunbayo GO, Messerli AW, Ha LD, Elbadawi A, Olorunfemi O, Darrat Y, Guglin M, Okwechime R, Akanya D, Abdel-Latif A, Smyth SS, Elayi CS. Trends in the Incidence and In-Hospital Outcomes of Patients With Atrial Fibrillation Complicated by Non-ST-Segment Elevation Myocardial Infarction. Angiology 2018; 70:317-324. [PMID: 30231624 DOI: 10.1177/0003319718801087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atrial fibrillation (AF) can present with non-ST-segment elevation myocardial infarction (NSTEMI). The incidence, characteristics, outcomes, and treatment of this subgroup of patients with AF remains poorly studied. Using data from the National Inpatient Sample database, we (1) compared baseline characteristics of patients with AF with/without NSTEMI, (2) evaluated their outcomes and associated trends over the study period (2004-2013), and (3) evaluated revascularization (by percutaneous coronary intervention or coronary artery bypass graft [CABG]) and the impact on patient outcomes. Of the 3 923 436 patients admitted with a primary diagnosis of AF, 47 785 (1.2%) had a secondary diagnosis of NSTEMI. In this subgroup with AF and NSTEMI, there was a significant trend toward a decrease in mortality ( P = .002), stroke ( P < .001), and gastrointestinal bleeding ( P < .001) during the study period. Compared to unrevascularized patients, revascularized patients were more likely to be younger (72.2 ± 10.2 vs 77.0 ± 11.8 years old, P < .001), male (57.8 vs 42.7%, P < .001), and had a much higher incidence of coronary risk factors. Revascularization was associated with increased survival in multivariable analysis (odds ratio: 0.562, 95% confidence interval: 0.334-0.946, P = .03). In conclusion, among patients admitted with AF, 1.2% were diagnosed with NSTEMI. A minority of patients with AF and NSTEMI underwent revascularization and had better in-hospital outcomes.
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Affiliation(s)
- Gbolahan O Ogunbayo
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Adrian W Messerli
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Le Dung Ha
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ayman Elbadawi
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Odunayo Olorunfemi
- 2 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Yousef Darrat
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Maya Guglin
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Remi Okwechime
- 3 Department of Internal Medicine, Wychoff Heights Medical Center, NY, USA
| | - Deborah Akanya
- 4 Department of Internal Medicine, St Vincents Medical Center, Bridgeport, CT, USA
| | - Ahmed Abdel-Latif
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Susan S Smyth
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Claude S Elayi
- 1 Division of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
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32
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Juo YY, Lee Bailey K, Seo YJ, Aguayo E, Benharash P. Does left atrial appendage ligation during coronary bypass surgery decrease the incidence of postoperative stroke? J Thorac Cardiovasc Surg 2018; 156:578-585. [DOI: 10.1016/j.jtcvs.2018.02.089] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Revised: 02/07/2018] [Accepted: 02/14/2018] [Indexed: 02/05/2023]
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Ogunbayo GO, Ha LD, Ahmad Q, Misumida N, Elbadawi A, Olorunfemi O, Kolodziej A, Messerli AW, Abdel-Latif A, Elayi CS, Guglin M. In-hospital outcomes of percutaneous ventricular assist devices versus intra-aortic balloon pumps in non-ischemia related cardiogenic shock. Heart Lung 2018; 47:392-397. [DOI: 10.1016/j.hrtlng.2018.02.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 02/04/2018] [Indexed: 10/17/2022]
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34
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Elbadawi A, Elgendy IY, Ha LD, Mentias A, Ogunbayo GO, Tahir MW, Biniwale N, Olorunfemi O, Barssoum K, Guglin M. National Trends and Outcomes of Endomyocardial Biopsy for Patients With Myocarditis: From the National Inpatient Sample Database. J Card Fail 2018; 24:337-341. [PMID: 29626516 DOI: 10.1016/j.cardfail.2018.03.013] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 03/28/2018] [Accepted: 03/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND The utility of endomyocardial biopsy (EMB) in the management of myocarditis in the era of advanced cardiac imaging has been challenged. METHODS AND RESULTS The Nationwide Inpatient Sample Database (years 1998-2013) was queried to identify hospitalization records with a primary diagnosis of myocarditis, and underwent EMB procedure. We identified 22,299 hospitalization records with a diagnosis of myocarditis during the study period. Of those, 798 (3.6%) underwent EMB procedures. There was an average decrease in the incidence of EMB for myocarditis by 0.15% (P < .01) over the study period. Younger patients, women, and those with chronic kidney disease were more likely to undergo EMB. On multivariate analysis, patients with myocarditis who underwent EMB had higher in-hospital mortality (hazard ratio [HR] 1.97, 95% confidence interval [CI] 1.41-2.74) and longer median hospital stay (9 days vs 3 days; P < .001). EMB was associated with a higher incidence of cardiac tamponade (odds ratio [OR] 5.21, 95% CI 2.76-9.82), cardiogenic shock (OR 4.66, 95% CI 3.75-5.78), need for intra-aortic balloon pump (OR 3.52, 95% CI 2.49-4.97), and need for extracorporeal membrane oxygenation (OR 4.26, 95% CI 2.78-6.53). CONCLUSIONS The use of EMB in hospitalizations with myocarditis has decreased over time. The use of EMB was associated with a higher likelihood of in-hospital mortality and morbidity. Whether these findings represent a causative association from the procedure or a consequence of more severe disease in this group could not be confirmed in this study.
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Affiliation(s)
- Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Le Dung Ha
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Amgad Mentias
- Department of Cardiovascular Medicine, University of Iowa, Iowa city, Iowa
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Muhammad Waqas Tahir
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Nishit Biniwale
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Odunayo Olorunfemi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Kirolos Barssoum
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Maya Guglin
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
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Hanke T. Surgical management of the left atrial appendage: a must or a myth? Eur J Cardiothorac Surg 2018; 53:i33-i38. [DOI: 10.1093/ejcts/ezy088] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 01/24/2018] [Indexed: 01/04/2023] Open
Affiliation(s)
- Thorsten Hanke
- Department for Cardiac Surgery, Asklepios Klinikum Harburg, Hamburg, Germany
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36
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Ando M, Funamoto M, Cameron DE, Sundt TM. Concomitant surgical closure of left atrial appendage: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2018; 156:1071-1080.e2. [PMID: 29628346 DOI: 10.1016/j.jtcvs.2018.03.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 12/08/2017] [Accepted: 03/02/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Although percutaneous closure of the left atrial appendage is supported as a potential alternative to lifelong anticoagulation in patients with atrial fibrillation, comprehensive evidence on surgical left atrial appendage closure in heart surgery is limited. METHODS We conducted a meta-analysis of studies comparing patients who underwent open cardiac surgery with or without left atrial appendage closure. A literature search was performed on PubMed, Embase, and Cochrane Trials databases. Outcomes of interest were 30-day/in-hospital mortality and cerebrovascular accident. I2 statistics were used to evaluate heterogeneity, and publication bias was evaluated by Begg's and Egger's tests. RESULTS We reviewed 1284 articles and selected for main analysis 7 articles including 3897 patients (1963 in the left atrial appendage closure group and 1934 in the non-left atrial appendage closure group). Among the 7 studies, 3 were randomized-controlled studies, 3 were propensity-matched studies, and 1 was a case-matching study. At 30-day/in-hospital follow-up, left atrial appendage closure was significantly associated with decreased risk of mortality and cerebrovascular accident (odds ratio, 0.384, 95% confidence interval, 0.233-0.631 for mortality, and odds ratio, 0.622, 95% confidence interval, 0.388-0.998 for cerebrovascular accident). Stratified analysis demonstrated that this association was more prominent in preoperative atrial fibrillation strata. CONCLUSIONS Concomitant surgical left atrial appendage closure should be considered at the time of open cardiac surgery, particularly among those in atrial fibrillation preoperatively. The benefit of left atrial appendage closure for patients not in atrial fibrillation and for those undergoing nonvalvular surgery is still unclear. Further prospective investigations are indicated.
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Affiliation(s)
- Masahiko Ando
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass.
| | - Masaki Funamoto
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Duke E Cameron
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
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Elbadawi A, Elgendy IY, Ha LD, Baig B, Saad M, Adly H, Ogunbayo GO, Olorunfemi O, Mckillop MS, Maffett SA. In-Hospital Cerebrovascular Outcomes of Patients With Atrial Fibrillation and Cancer (from the National Inpatient Sample Database). Am J Cardiol 2018; 121:590-595. [PMID: 29352566 DOI: 10.1016/j.amjcard.2017.11.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 12/12/2022]
Abstract
Limited data are available regarding the impact of cancer on cerebrovascular accidents in patients with atrial fibrillation (AF). We queried the Nationwide Inpatient Survey Database to identify patients who have diagnostic code for AF. We performed a 1:1 propensity matching based on the CHA2DS2VASc score and other risk factors between patients with AF who had lung, breast, colon, and esophageal cancer, and those who did not (control). The final cohort included a total of 31,604 patients. The primary outcome of in-hospital cerebrovascular accidents (CVA) was lower in the cancer group than in the control group (4% vs 7%, p < 0.001), but with only a weak association (ф = -0.067). In-hospital mortality was higher in the cancer group than in the control group (18% vs 11%, p < 0.001; ф = -0.099). A subgroup analysis according to cancer type showed similar results with a weak association with lower CVA in breast cancer (4% vs 7%; ф = -0.066, p < 0.001), lung cancer (4% vs 6%; ф = -0.062, p < 0.001), colon cancer (4% vs 6%; ф = -0.062, p < 0.001), and esophageal cancer (3% vs 7%; ф = -0.095, p < 0.001) compared with the control groups. A weak association with higher in-hospital mortality was demonstrated in lung cancer (20% vs 11%; ф = -0.127, p < 0.001), colon cancer (16% vs 11%; ф = -0.076, p < 0.001), and esophageal cancer (20% vs 12%; ф = -0.111, p < 0.001) compared with the control groups, but no significant difference between breast cancer and control groups in mortality (11% vs 11%; ф = -0.002, p = 0.888). In conclusion, in patients with AF, cancer diagnosis may not add a predictive role for in-hospital CVA beyond the CHADS2VASc score.
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Affiliation(s)
- Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York; Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt.
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Le Dung Ha
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Basarat Baig
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Marwan Saad
- Department of Cardiovascular Medicine, Ain Shams University, Cairo, Egypt; Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Hussain Adly
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Odunayo Olorunfemi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Matthew S Mckillop
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Scott A Maffett
- Department of Cardiovascular Medicine, Ohio State University, Columbus, Ohio
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Shinbane JS, Saxon LA. Virtual medicine: Utilization of the advanced cardiac imaging patient avatar for procedural planning and facilitation. J Cardiovasc Comput Tomogr 2017; 12:16-27. [PMID: 29198733 DOI: 10.1016/j.jcct.2017.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/08/2017] [Accepted: 11/12/2017] [Indexed: 01/17/2023]
Abstract
Advances in imaging technology have led to a paradigm shift from planning of cardiovascular procedures and surgeries requiring the actual patient in a "brick and mortar" hospital to utilization of the digitalized patient in the virtual hospital. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance (CMR) digitalized 3-D patient representation of individual patient anatomy and physiology serves as an avatar allowing for virtual delineation of the most optimal approaches to cardiovascular procedures and surgeries prior to actual hospitalization. Pre-hospitalization reconstruction and analysis of anatomy and pathophysiology previously only accessible during the actual procedure could potentially limit the intrinsic risks related to time in the operating room, cardiac procedural laboratory and overall hospital environment. Although applications are specific to areas of cardiovascular specialty focus, there are unifying themes related to the utilization of technologies. The virtual patient avatar computer can also be used for procedural planning, computational modeling of anatomy, simulation of predicted therapeutic result, printing of 3-D models, and augmentation of real time procedural performance. Examples of the above techniques are at various stages of development for application to the spectrum of cardiovascular disease processes, including percutaneous, surgical and hybrid minimally invasive interventions. A multidisciplinary approach within medicine and engineering is necessary for creation of robust algorithms for maximal utilization of the virtual patient avatar in the digital medical center. Utilization of the virtual advanced cardiac imaging patient avatar will play an important role in the virtual health care system. Although there has been a rapid proliferation of early data, advanced imaging applications require further assessment and validation of accuracy, reproducibility, standardization, safety, efficacy, quality, cost effectiveness, and overall value to medical care.
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Affiliation(s)
- Jerold S Shinbane
- Division of Cardiovascular Medicine/USC Center for Body Computing, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States.
| | - Leslie A Saxon
- Division of Cardiovascular Medicine/USC Center for Body Computing, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
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Elbadawi A, Ogunbayo GO, Elgendy IY, Olorunfemi O, Saad M, Ha LD, Alotaki E, Baig B, Abuzaid AS, Shahin HI, Shah A, Rao M. Impact of Left Atrial Appendage Exclusion on Cardiovascular Outcomes in Patients With Atrial Fibrillation Undergoing Coronary Artery Bypass Grafting (From the National Inpatient Sample Database). Am J Cardiol 2017; 120:953-958. [PMID: 28754565 DOI: 10.1016/j.amjcard.2017.06.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 05/23/2017] [Accepted: 06/13/2017] [Indexed: 02/08/2023]
Abstract
Left atrial appendage (LAA) exclusion is performed by some surgeons in patients with atrial fibrillation (AF) who undergo coronary artery bypass grafting (CABG). However, the available evidence regarding the efficacy and safety of this procedure remains mixed. We queried the Nationwide Inpatient Survey Database for the 10-year period from 2004 to 2013. Using International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes, we identified patients who had a diagnosis of AF and underwent a primary procedure of CABG with or without LAA exclusion. We then performed a 1:5 matching based on the CHA2DS2VASc score between patients who got LAA exclusion and those who did not (control group). The primary outcome was the incidence of in-hospital cerebrovascular events, whereas the secondary outcomes included in-hospital bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and mortality. Our analysis included a total of 15,114 patients. Patients who underwent LAA exclusion had significantly less incidence of cerebrovascular events (2.0% vs 3.1%, p = 0.002). However, LAA exclusion group had higher incidences of bleeding events (36.4% vs 21.3%, p <0.001), pericardial effusion (2.7% vs 1.2%, p <0.001), cardiac tamponade (0.6% vs 0.2%, p <0.001), and postoperative shock (1.2% vs 0.4%, p <0.001). LAA exclusion was associated with higher in-hospital mortality (1.6% vs 0.3%, p <0.001). Multivariate regression analysis showed that LAA exclusion was significantly associated with lower cerebrovascular accident events and higher in-hospital mortality. In conclusion, LAA exclusion in patients with AF undergoing CABG might be associated with a lower incidence of in-hospital cerebrovascular events. This benefit is offset by a higher incidence of higher bleeding events, pericardial effusion, cardiac tamponade, postoperative shock, and in-hospital mortality.
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Affiliation(s)
- Ayman Elbadawi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York.
| | - Gbolahan O Ogunbayo
- Department of Cardiovascular Medicine, University of Kentucky, Lexington, Kentucky
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Odunayo Olorunfemi
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Marwan Saad
- Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Le Dung Ha
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Erfan Alotaki
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - Basarat Baig
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York
| | - A S Abuzaid
- Division of Cardiovascular Medicine, Sidney Kimmel Medical College at Thomas Jefferson University/Christiana Care Health System, Newark, Delaware
| | - Hend I Shahin
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmaceutical Sciences and Pharmaceutical Industries, Future University, Cairo, Egypt
| | - Abrar Shah
- Sands Constellation Heart Institute, Rochester General Hospital, Rochester, New York
| | - Mohan Rao
- Sands Constellation Heart Institute, Rochester General Hospital, Rochester, New York
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