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Clinical and echocardiographic risk factors for device-related thrombus after left atrial appendage closure: an analysis from the multicenter EUROC-DRT registry

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Abstract

Background

Data on Device-related Thrombus (DRT) after left atrial appendage closure (LAAC) remain scarce. This study aimed to investigate risk factors for DRT from centers reporting to the EUROC-DRT registry.

Methods

We included 537 patients (112 with DRT and 425 without DRT) who had undergone LAAC between 12/2008 and 04/2019. Baseline and implantation characteristics, anti-thrombotic treatment and clinical outcomes were compared between both groups in uni- and multivariate analyses. Additional propensity-score matching (PSM) was conducted to focus on the role of implantation characteristics.

Results

Patients with DRT showed higher rates of previous stroke/transient ischemic attack (TIA) (49.1% vs. 34.7%, p < 0.01), spontaneous echocardiographic contrast (SEC) (44.9% vs. 27.7%, p < 0.01) and lower left atrial appendage (LAA) peak emptying velocity (35.4 ± 18.5 vs. 42.4 ± 18.0 cm/s, p = 0.02). Occluders implanted in DRT patients were larger (25.5 ± 3.8 vs. 24.6 ± 3.5 mm, p = 0.03) and implanted deeper in the LAA (mean depth: 7.6 ± 4.7 vs. 5.7 ± 4.7 mm, p < 0.01). Coverage of the appendage ostium was achieved less often in DRT patients (69.5% vs. 81.5%, p < 0.01), while DRT patients were less frequently on oral anticoagulation (7.1% vs. 16.7%, p < 0.01). Multivariate analysis identified age, prior stroke/TIA and SEC as independent risk factors for DRT. After PSM, implantation depth was found to be predictive. Rates of stroke/TIA were higher in DRT patients (13.5% vs. 3.8%, Hazard Ratio: 4.21 [95%-confidence interval: 1.88–9.49], p < 0.01).

Conclusions

DRT after LAAC is associated with adverse outcome and appears to be of multifactorial origin, depending on patient characteristics, anticoagulation regimen and device position.

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Abbreviations

AF:

Atrial fibrillation

CI:

Confidence interval

CT:

Computer tomography

DAPT:

Dual antiplatelet therapy

DRT:

Device-related thrombosis

FU:

Follow-up

LA:

Left atrium

LAA:

Left atrial appendage

LAAC:

Left atrial appendage closure

LUPV:

Left upper pulmonary vein

NOAC:

Novel oral anticoagulation

OAC:

Oral anticoagulation

OR:

Odds ratio

PSM:

Propensity score matching

SAPT:

Single antiplatelet therapy

SEC:

Spontaneous echocardiographic contrast

TEE:

Transoesophageal echocardiography

TIA:

Transient ischaemic attack

VKA:

Vitamin K antagonist

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Acknowledgements

We thank Dr. Marie-Therese Schmitz and the Institute for Biometry of the University Bonn (IMBIE) for statistical support.

Author information

Authors and Affiliations

  1. Department of Cardiology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany

    Vivian Vij, Dominik Nelles, Jan Wilko Schrickel, Georg Nickenig & Alexander Sedaghat

  2. CardioVasculäres Centrum, Frankfurt, Germany

    Kerstin Piayda & Horst Sievert

  3. University Hospital Bern, Bern, Switzerland

    Steffen Gloekler, Roberto Galea, Monika Fürholz, Bernhard Meier & Marco Valgimigli

  4. Cardiocentro Ticino, Lugano, Switzerland

    Marco Valgimigli

  5. Quebec Heart & Lung Institute, Laval University, Quebec City, Canada

    Gilles O’Hara, Lluis Asmarats & Josep Rodes-Cabau

  6. Hospital de La Santa Creu I Sant Pau, Barcelona, Spain

    Dabit Arzamendi, Victor Agudelo & Lluis Asmarats

  7. Hospital Clinic Barcelona, Barcelona, Spain

    Xavier Freixa & Eduardo Flores-Umanzor

  8. Rigshospitalet, Copenhagen University Hospital Copenhagen, København, Denmark

    Ole De Backer & Lars Sondergaard

  9. Hospital Clinico San Carlos Madrid, Madrid, Spain

    Luis Nombela-Franco & Angela McInerney

  10. Aarhus University Hospital, Aarhus, Denmark

    Kasper Korsholm & Jens Erik Nielsen-Kudsk

  11. University Hospital Düsseldorf, Düsseldorf, Germany

    Shazia Afzal & Tobias Zeus

  12. Agaplesion Bethanien Krankenhaus, CBB, Frankfurt, Germany

    Felix Operhalski & Boris Schmidt

  13. Surbonne University Pitié-Salpêtrière Hospital (AP-HP), Paris, France

    Gilles Montalescot & Paul Guedeney

  14. University Hospital Bordeaux, Bordeaux, France

    Xavier Iriart & Noelie Miton

  15. Vancouver General Hospital, Vancouver, Canada

    Jacqueline Saw

  16. Stadtspital Waid and Triemli, Zurich, Switzerland

    Thomas Gilhofer

  17. University Hospital Tours, Tours, France

    Laurent Fauchier

  18. St. Georg Hospital Hamburg, Hamburg, Germany

    Egzon Veliqi & Felix Meincke

  19. University Hospital Würzburg, Würzburg, Germany

    Nils Petri & Peter Nordbeck

  20. Russian Cardiology Research and Production Complex, Moscow, Russia

    Dmitrii Ognerubov & Evgeny Merkulov

  21. University Hospital of Salamanca, CIBER CV, IBSAL, Salamanca, Spain

    Ignacio Cruz-González & Rocio Gonzalez-Ferreiro

  22. Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School, Boston, USA

    Deepak L. Bhatt

  23. Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy

    Alessandra Laricchia & Antonio Mangieri

  24. Marienkrankenhaus, Bonn, Germany

    Heyder Omran

  25. Humanitas Research Hospital IRCCS, Rozzano, Italy

    Alessandra Laricchia & Antonio Mangieri

Authors
  1. Vivian Vij
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  2. Kerstin Piayda
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  3. Dominik Nelles
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  4. Steffen Gloekler
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  5. Roberto Galea
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  6. Monika Fürholz
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  7. Bernhard Meier
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  8. Marco Valgimigli
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  9. Gilles O’Hara
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  10. Dabit Arzamendi
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  11. Victor Agudelo
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  13. Xavier Freixa
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  14. Eduardo Flores-Umanzor
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  15. Ole De Backer
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  16. Lars Sondergaard
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  17. Luis Nombela-Franco
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  18. Angela McInerney
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  19. Kasper Korsholm
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  20. Jens Erik Nielsen-Kudsk
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  21. Shazia Afzal
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  22. Tobias Zeus
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  23. Felix Operhalski
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  24. Boris Schmidt
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  25. Gilles Montalescot
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  26. Paul Guedeney
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  27. Xavier Iriart
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  28. Noelie Miton
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  29. Jacqueline Saw
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  30. Thomas Gilhofer
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  31. Laurent Fauchier
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  32. Egzon Veliqi
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  33. Felix Meincke
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  34. Nils Petri
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  35. Peter Nordbeck
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  36. Dmitrii Ognerubov
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  37. Evgeny Merkulov
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  38. Ignacio Cruz-González
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  39. Rocio Gonzalez-Ferreiro
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  40. Deepak L. Bhatt
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  41. Alessandra Laricchia
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  42. Antonio Mangieri
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  43. Heyder Omran
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  44. Jan Wilko Schrickel
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  45. Josep Rodes-Cabau
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  46. Horst Sievert
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  47. Georg Nickenig
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  48. Alexander Sedaghat
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Corresponding author

Correspondence to Alexander Sedaghat.

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Conflict of interest

Alexander Sedaghat has received travel grants from Abbott and Boston Scientific and is a proctor for Lifetech. Lars Sondergaard has received consultant fees and institutional research grants from Abbott and Boston Scientific, and is shareholder in Eclipse Medical. Dr Cruz-Gonzalez is a proctor for Abbott, Boston Scientific and Lifetech and was funded by ISCIII (PI19/00658) and co-funded by ERDF, "A way to make Europe". Jens Erik Nielsen-Kudsk is a proctor and consultant for Abbott and Boston Scientific. Dabit Arzamendi is a proctor for Abbott and Boston Scientific. Xavier Freixa is a proctor for Abbott, Boston Scientific and Lifetech. Antonio Mangieri is part of the advisory board of Boston Scientific and received an institutional grant from Boston Scientific. Dr. Nombela-Franco has served as a proctor of Abbott Vascular and received speaker honoraria from Boston Scientific and Abbott Vascular. Dr. Meier has received consultant fees from Abbott. Xavier Iriart is a proctor for Abbott and Boston Scientific. Dr. Deepak L. Bhatt discloses the following relationships - Advisory Board: AngioWave, Bayer, Boehringer Ingelheim, Cardax, CellProthera, Cereno Scientific, Elsevier Practice Update Cardiology, High Enroll, Janssen, Level Ex, McKinsey, Medscape Cardiology, Merck, MyoKardia, NirvaMed, Novo Nordisk, PhaseBio, PLx Pharma, Regado Biosciences, Stasys; Board of Directors: AngioWave (stock options), Boston VA Research Institute, Bristol Myers Squibb (stock), DRS.LINQ (stock options), High Enroll (stock), Society of Cardiovascular Patient Care, TobeSoft; Chair: Inaugural Chair, American Heart Association Quality Oversight Committee; Consultant: Broadview Ventures; Data Monitoring Committees: Acesion Pharma, Assistance Publique-Hôpitaux de Paris, Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute, for the PORTICO trial, funded by St. Jude Medical, now Abbott), Boston Scientific (Chair, PEITHO trial), Cleveland Clinic (including for the ExCEED trial, funded by Edwards), Contego Medical (Chair, PERFORMANCE 2), Duke Clinical Research Institute, Mayo Clinic, Mount Sinai School of Medicine (for the ENVISAGE trial, funded by Daiichi Sankyo; for the ABILITY-DM trial, funded by Concept Medical), Novartis, Population Health Research Institute; Rutgers University (for the NIH-funded MINT Trial); Honoraria: American College of Cardiology (Senior Associate Editor, Clinical Trials and News, ACC.org; Chair, ACC Accreditation Oversight Committee), Arnold and Porter law firm (work related to Sanofi/Bristol-Myers Squibb clopidogrel litigation), Baim Institute for Clinical Research (formerly Harvard Clinical Research Institute; RE-DUAL PCI clinical trial steering committee funded by Boehringer Ingelheim; AEGIS-II executive committee funded by CSL Behring), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Canadian Medical and Surgical Knowledge Translation Research Group (clinical trial steering committees), Cowen and Company, Duke Clinical Research Institute (clinical trial steering committees, including for the PRONOUNCE trial, funded by Ferring Pharmaceuticals), HMP Global (Editor in Chief, Journal of Invasive Cardiology), Journal of the American College of Cardiology (Guest Editor; Associate Editor), K2P (Co-Chair, interdisciplinary curriculum), Level Ex, Medtelligence/ReachMD (CME steering committees), MJH Life Sciences, Oakstone CME (Course Director, Comprehensive Review of Interventional Cardiology), Piper Sandler, Population Health Research Institute (for the COMPASS operations committee, publications committee, steering committee, and USA national co-leader, funded by Bayer), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), Society of Cardiovascular Patient Care (Secretary/Treasurer), WebMD (CME steering committees), Wiley (steering committee); Other: Clinical Cardiology (Deputy Editor), NCDR-ACTION Registry Steering Committee (Chair), VA CART Research and Publications Committee (Chair); Patent: Sotagliflozin (named on a patent for sotagliflozin assigned to Brigham and Women's Hospital who assigned to Lexicon; neither I nor Brigham and Women's Hospital receive any income from this patent.) Research Funding: Abbott, Acesion Pharma, Afimmune, Aker Biomarine, Amarin, Amgen, AstraZeneca, Bayer, Beren, Boehringer Ingelheim, Boston Scientific, Bristol-Myers Squibb, Cardax, CellProthera, Cereno Scientific, Chiesi, CSL Behring, Eisai, Ethicon, Faraday Pharmaceuticals, Ferring Pharmaceuticals, Forest Laboratories, Fractyl, Garmin, HLS Therapeutics, Idorsia, Ironwood, Ischemix, Janssen, Javelin, Lexicon, Lilly, Medtronic, Merck, Moderna, MyoKardia, NirvaMed, Novartis, Novo Nordisk, Owkin, Pfizer, PhaseBio, PLx Pharma, Recardio, Regeneron, Reid Hoffman Foundation, Roche, Sanofi, Stasys, Synaptic, The Medicines Company, 89Bio; Royalties: Elsevier (Editor, Braunwald’s Heart Disease); Site Co-Investigator: Abbott, Biotronik, Boston Scientific, CSI, Endotronix, St. Jude Medical (now Abbott), Philips, SpectraWAVE, Svelte, Vascular Solutions; Trustee: American College of Cardiology; Unfunded Research: FlowCo, Takeda.

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Vij, V., Piayda, K., Nelles, D. et al. Clinical and echocardiographic risk factors for device-related thrombus after left atrial appendage closure: an analysis from the multicenter EUROC-DRT registry. Clin Res Cardiol 111, 1276–1285 (2022). https://doi.org/10.1007/s00392-022-02065-4

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