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Follow-up imaging after left atrial appendage closure.
Heart Rhythm. 2020 Jun 27 [Online ahead of print]HR

Abstract

BACKGROUND

Because device-related thrombus (DRT) portends a poor prognosis after left atrial appendage closure with the Watchman device, surveillance transesophageal echocardiography (TEE) is recommended at 45 days and 1 year. However, oral anticoagulants are just discontinued at 45 days, rendering this early TEE unlikely to detect DRT. Indeed, DRT is most likely to occur after instituting aspirin monotherapy.

OBJECTIVE

The purpose of this study was to evaluate the alternative strategy of first TEE imaging (or computed tomography) at 4 months post-Watchman implantation.

METHODS

After Food and Drug Administration approval, consecutive patients undergoing Watchman implantation at 2 centers received TEE or CT at 4 months and 1 year, along with a truncated drug regimen: 6 weeks of an oral anticoagulant (or clopidogrel in a subset) plus aspirin, then 6 weeks of dual antiplatelet therapy, and finally aspirin monotherapy.

RESULTS

Of the 530-patient cohort (mean age 78.7±7.9 years; 65.5% male; CHA2DS2-VASc score 4.5±1.4), 465 patients (87.7%) received 4-month imaging: 83.0% (440 of 530) TEE and 4.7% (25 of 530) computed tomography. Over a median follow-up of 12 months, 16 ischemic strokes (ISs), 8 transient ischemic attacks, and 1 systemic embolization occurred. Importantly, no IS occurred between 45 days and 4 months; the sole transient ischemic attack in this period (at ∼2 months) occurred 1 week after transcatheter aortic valve replacement. DRT was detected in 2.4% (11 of 465) at 4 months and 0.9% (2 of 214) at 1 year. No IS, but 1 leg embolization, was observed after DRT detection.

CONCLUSION

Delaying first post-Watchman imaging to 4 months was associated with no IS between 45 days and 4 months, the "vulnerable" period of this follow-up strategy.

Authors+Show Affiliations

Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Pacific Heart Institute, Santa Monica, California.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Pacific Heart Institute, Santa Monica, California.Pacific Heart Institute, Santa Monica, California.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York.Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York. Electronic address: vivek.reddy@mountsinai.org.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

32603780

Citation

Kuroki, Kenji, et al. "Follow-up Imaging After Left Atrial Appendage Closure." Heart Rhythm, 2020.
Kuroki K, Doshi SK, Whang W, et al. Follow-up imaging after left atrial appendage closure. Heart Rhythm. 2020.
Kuroki, K., Doshi, S. K., Whang, W., Vanderzee, S., Ducharme, C. B., Enomoto, Y., Hanon, S., Koruth, J. S., Miller, M. A., Choudry, S., Sofi, A., Langan, N., Ellsworth, B., Dukkipati, S. R., & Reddy, V. Y. (2020). Follow-up imaging after left atrial appendage closure. Heart Rhythm. https://doi.org/10.1016/j.hrthm.2020.06.024
Kuroki K, et al. Follow-up Imaging After Left Atrial Appendage Closure. Heart Rhythm. 2020 Jun 27; PubMed PMID: 32603780.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Follow-up imaging after left atrial appendage closure. AU - Kuroki,Kenji, AU - Doshi,Shephal K, AU - Whang,William, AU - Vanderzee,Sarina, AU - Ducharme,Crystal B, AU - Enomoto,Yoshinari, AU - Hanon,Sam, AU - Koruth,Jacob S, AU - Miller,Marc A, AU - Choudry,Subbarao, AU - Sofi,Aamir, AU - Langan,Noelle, AU - Ellsworth,Betsy, AU - Dukkipati,Srinivas R, AU - Reddy,Vivek Y, Y1 - 2020/06/27/ PY - 2020/03/11/received PY - 2020/06/17/revised PY - 2020/06/21/accepted PY - 2020/7/1/pubmed PY - 2020/7/1/medline PY - 2020/7/1/entrez KW - Anticoagulant KW - Atrial fibrillation KW - Left atrial appendage closure KW - Transesophageal echocardiography KW - Watchman JF - Heart rhythm JO - Heart Rhythm N2 - BACKGROUND: Because device-related thrombus (DRT) portends a poor prognosis after left atrial appendage closure with the Watchman device, surveillance transesophageal echocardiography (TEE) is recommended at 45 days and 1 year. However, oral anticoagulants are just discontinued at 45 days, rendering this early TEE unlikely to detect DRT. Indeed, DRT is most likely to occur after instituting aspirin monotherapy. OBJECTIVE: The purpose of this study was to evaluate the alternative strategy of first TEE imaging (or computed tomography) at 4 months post-Watchman implantation. METHODS: After Food and Drug Administration approval, consecutive patients undergoing Watchman implantation at 2 centers received TEE or CT at 4 months and 1 year, along with a truncated drug regimen: 6 weeks of an oral anticoagulant (or clopidogrel in a subset) plus aspirin, then 6 weeks of dual antiplatelet therapy, and finally aspirin monotherapy. RESULTS: Of the 530-patient cohort (mean age 78.7±7.9 years; 65.5% male; CHA2DS2-VASc score 4.5±1.4), 465 patients (87.7%) received 4-month imaging: 83.0% (440 of 530) TEE and 4.7% (25 of 530) computed tomography. Over a median follow-up of 12 months, 16 ischemic strokes (ISs), 8 transient ischemic attacks, and 1 systemic embolization occurred. Importantly, no IS occurred between 45 days and 4 months; the sole transient ischemic attack in this period (at ∼2 months) occurred 1 week after transcatheter aortic valve replacement. DRT was detected in 2.4% (11 of 465) at 4 months and 0.9% (2 of 214) at 1 year. No IS, but 1 leg embolization, was observed after DRT detection. CONCLUSION: Delaying first post-Watchman imaging to 4 months was associated with no IS between 45 days and 4 months, the "vulnerable" period of this follow-up strategy. SN - 1556-3871 UR - https://www.unboundmedicine.com/medline/citation/32603780/Follow-Up_Imaging_after_Left_Atrial_Appendage_Closure L2 - https://linkinghub.elsevier.com/retrieve/pii/S1547-5271(20)30623-8 DB - PRIME DP - Unbound Medicine ER -
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