Novedades

Novedades en el Cierre de Orejuela IzquierdaJos Ramn Lpez Mnguez

Hospital Infanta CristinaBadajoz

NOVEDADES en el Cierre de la Orejuela IzquierdaResultados a largo plazo y metanlisis en estudios randomizados de warfarina vs Watchman => Aprobacin FDARealidad de las poblaciones diana vs trialsResultados en estudios de pacientes que no pueden tomar ACOsAvances tcnicos dispositivosPapel del TAC

Trials Patient Risk Factors Across CharacteristicPROTECT AFN=707PREVAILN=407CAPN=566CAP2N=579p-valueCHADS2 Score 2.2 1.2 2.6 1.02.4 1.22.7 1.1 graves 4,5%) y es acumulable por ao

El porcentaje de casos con historia de sangrados previos no figura en estos trials o es mnimo (16%) vs > 70% en pacientes a los que se realiza cierre de Orejuela

Los sangrados relevantes son de 2 a 7 veces ms (6-21 %)Por ello los abandonos a dos aos > 25%

Las conclusiones de los trials se aplican slo al 60% de la poblacin que podra entrar en esos estudios.As, an hoy > 30-40% de pacientes que deberan recibir ACO no los reciben

En los ancianos el riesgo de Sangrados es mayor

Bleeding Rates After Percutaneous Coronary InterventionCumulative rates of first post-discharge bleeding event increased over time in all patients; a similar pattern was seen when patients were stratified according to requirement for blood transfusion.

Incidence, Predictors, and Impact ofPost-Discharge Bleeding After Percutaneous Coronary Intervention

J Am Coll Cardiol. 2015;66(9):1036-1045. Genereux P et al.

8582 all-comersT medio al primer PDB 300 d

All-Cause and Cardiac Mortality According to PDBKaplan-Meier estimates demonstrate higher rates of all-cause mortality (solid line) and cardiac mortality (dotted line) according to the occurrence of post-discharge bleeding (PDB) (salmon) compared to no PDB (blue) over 2 years of follow-up (A) as well as the landmark analysis at 30-day and 1-year follow-up (B).

Incidence, Predictors, and Impact ofPost-Discharge Bleeding After Percutaneous Coronary InterventionJ Am Coll Cardiol. 2015;66(9):1036-1045. Genereux P et al.

Clinical outcomes of atrial fibrillation patients receiving NSAIDs in the RELY trial. European Society of Cardiology Congress; 2015. Ezekowtiz M.

NSAID use (12,6%) was accompanied by increases in the rates of hospitalization, major bleeding, GI major bleeding, life-threatening bleeding, and any bleeding

Poblaciones actuales a los que se realiza cierre de OrejuelaHabitualmente ancianos > 75 aos, con alto riesgo de sangrado a los que su mdico no se atreve a anticoagular

Pacientes que han sangrado previamente ya con, o sin ACO, la mayora de ellos no entraran en los estudios NACO. Pacientes con anomalas vasculares digestivas o cerebrales (cavernomas), que tb son excluidos de los estudios.

Pacientes que han abandonado por sangrado previo o por no compliance con ACO

Pacientes que han hecho ictus a pesar de ACO

Pacientes que precisan de forma crnica DAAP

NOVEDADES en el Cierre de la Orejuela IzquierdaSeguimiento a4 aos del PROTECT AF y Resultados metanlisis en estudios randomizados de warfarina vs Watchman => Aprobacin FDARealidad de las poblaciones diana vs trialsResultados en estudios de pacientes que no pueden tomar ACOsAvances tcnicos dispositivosPapel del TAC

Estudios de cierre de orejuela en estos pacientes con > 150 casos:

- ASAP - ACP European Registry - ACP Multicenter Experience - Iberian Registry

Clopidogrel for 6 months & ASA for life - 4 European Centers (Czech Re 1, Germany 3) 150 pts: CHADS2 = 2.8 1.2 (Prior CVA/TIA in 40.7%), Mean Follow-up: 16.5 months(ASA Plavix Feasibility Study WithWatchman Left Atrial Appendage Closure Technology)

ACP Post Market European Registry

Baseline and procedure-associated characteristics (n = 167)Age (in years) 75 years: 84 (53.2%); 78 years: 63 (39.9%)74.68 8.58Men102 (61.1%)CHADS23 (2-4)CHA2DS2-VASC4 (3-6)HAS.BLED3 (3-4)Procedure indicationGastrointestinal haemorrhage51 (30.5%)Cranial haemorrhage38 (22.8%)Other haemorrhages28 (16.8%)CVA/Embolism with OAC 12 (7.2%)High risk of bleeding7 (4.2%)Others32 (19.2%)Device size24 (22-25)Need to change device6 (3.5%)Successful implantation158 (94.6%)Procedural complications9 (5.38%)TIA2 (1.2%)Vascular complication4 (2.39%)Cardiac tamponade2 (1.2%)Device migration (percutaneously snared)1 (0.6%)Values expressed as: Number (percentage), Mean Standard deviation or median (25th -75th percentiles). OAC: Oral anticoagulants; TIA: transient ischaemic attack.

Results

70,1 BE

REGISTROIBRICO

Heart 2015

Events12-month (158 patients year)Global follow-up (annual eventrates, 290 patients year)ObservedExpected*p-valueObservedExpected*p-valueDeath9 (5.8%)17 (5.8%)MajorBleeding8 (5.2%)6.6%HASBLED0.4009 (3.1%)6.6%HASBLED0.047Total bleeding (Major + Relevant)15 (9.5%)> 17.55 % *16 (5.5%)Stroke/TIA

6 (3.9%)9.6%CHADS20,0077 (2.4%)9.6%CHADS2 Aprobacin FDARealidad de las poblaciones diana vs trialsResultados en estudios de pacientes que no pueden tomar ACOsAvances tcnicos dispositivosPapel del TAC

WATCHMAN

Safety of left atrial appendage exclusion with the Lariat device: a systematic review of published reports and analytic review of the FDA MAUDE database. Chatterjee S, Herrmann HC, Wilensky RL, et al. JAMA Intern Med. 2015;Epub ahead of print.In 5 studies involving 309 patients, procedural success was 90.3%. Cardiac surgery was urgently needed in 2.3% of patients and 0.3% died in the hospital.

Pericardial Effusion Cited as a ProblemImplicationsUntil Lariat receives FDA approval specifically for LAA occlusion, its current off-label use in clinical practice should be questioned, says Dr. Paul Varosy.

NOVEDADES en el Cierre de la Orejuela IzquierdaSeguimiento a4 aos del PROTECT AF y Resultados metanlisis en estudios randomizados de warfarina vs Watchman => Aprobacin FDARealidad de las poblaciones diana vs trialsResultados en estudios de pacientes que no pueden tomar ACOsAvances tcnicos dispositivosPapel del TAC

Journal of Invasive Cardiology. 2014.

Aspecto Endocrdico de los Tipos AAI

ANATOMICAL CLASSIFICATION OF LEFT ATRIAL APPENDAGES IN SPECIMENS APPLICABLE TO CT IMAGING TECHNIQUES FOR IMPLANTATION OF AMPLATZER CARDIAC PLUG. Lpez-Mnguez, JR et alJournal of Cardiovascular Electrophysiology. 2014. Vol 25: 976-984

Aspecto Epicrdico de los Tipos AAI

Ver situacin del discoexterno en relacin a la CLI en dos casos diferentes

30%19%3%48%

Does the Left Atrial Appendage Morphology Correlate With the Risk of Stroke in Patients With Atrial Fibrillation?Results From a Multicenter Study. DiBiasse. J Am Coll Cardiol 2012;60:5318Of the 932 patients, (8%) had a history of ischemic stroke or TIA. The prevalence of pre-procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies was 12%, 4%, 10%, and 18%, respectively (p 0.003).

After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be 79% less likely to have a stroke/TIA history

Compared with Chicken Wing, Cactus was 4.08 times (p 0.046), Windsock was 4.5 times (p 0.038), and Cauliflower was 8.0 times (p 0.056) more likely to have had a stroke/TIA.

(J Am Coll Cardiol 2012;60:5318)

Predictores de trombo

Qualitative identification of thrombus in LAA by CCTA compared with TEE detection of thrombus had a sensitivity of 100%, a specificity of 77.9%, a positive predictive value (PPV) of 51.6%, an NPV of 100%, and a total accuracy of 82.1%.

The optimal LAA HU density cutoff for thrombus detection was 119 with a sensitivity of 88%, a specificity of 86%, PPV 56%, and an area under the curve of 0.923 (p [ 0.0004).

Comparison of Transesophageal Echocardiography Versus Computed Tomography for Detection of Left Atrial Appendage Filling Defect (Thrombus). Budoff et al. Am J Cardiol 2014;113:173e177

Otros Articulos de TAC y prediccin de trombos en AAILAA orifice enlargement was related to stroke risk in patients with NVAF even after adjustment for other risk factors, and it could be the cause of decreased flow velocity in LAA. Impact of Increased Orifice Size and Decreased Flow Velocity of Left Atrial Appendage on Stroke in Nonvalvular Atrial FibrillationLee Jm et al. Am J Cardiol 2014;113:963e969

It is proposed a new scoring system to predict LAAT (LAV 50 ml: score 2; EF 75 pg/ml: score 1). Patients with a score 2 have a higher risk of LAAT, whereas all patients with score 1 have no LAATs. Our scoring system is useful for evaluation the risk of LAAT in AF patients even with low CHADS2 score Prevalence and Clinical Determinants of Left Atrial Appendage Thrombus in Patients with Atrial Fibrillation Prior to Pulmonary Vein Isolation. Nishikii-Tachibana M et al. The American Journal of Cardiology (2015),

A superior LAA takeoff (OR: 9.1) was the only independent predictor of TE while LAA morphologies, inferior takeoff, and other LAA characteristics were similar between groups CONCLUSION: A higher LAA takeoff is associated with a tachycardia-mediated thrombogenic flow and an increased thromboembolic risk. These findings may have implications for anticoagulation management of AF patients with low CHA2 DS2 -VASc scores and higher LAA takeoff. Cardiogenic Stroke Despite Low CHA2 DS2 -VASc Score: Assessing Stroke risk by Left Atrial Appendage Anatomy (ASK LAA). Nedios S et al. J Cardiovasc Electrophysiol. 2015

2015 EuroIntervention. All rights reserved.EuroIntervention 2015;10:1109-1125EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion

Gracias