Left Atrial Appendage Exclusion for Stroke Prevention in Atrial Fibrillation

The public health burden of atrial fibrillation (AF) and associated thromboembolic stroke continues to grow at alarming rates. AF leads to a fivefold increase in the risk of stroke. Therefore, stroke prevention remains the most critical aspect of AF management. Current standard of care focuses on oral systemic anticoagulation, most commonly with warfarin and now with newer agents such as dabigatran, rivaroxaban, and apixaban. However, the challenges and limitations of oral anticoagulation have been well documented. Given the critical role of the left atrial appendage (LAA) in the genesis of AF-related thromboembolism, recent efforts have targeted removal or occlusion of the LAA as an alternative strategy for stroke prevention, particularly in patients deemed unsuitable for oral anticoagulation. This paper highlights recent advances in mechanical exclusion of the LAA. The problem of AF and stroke is briefly summarized, followed by an explanation for the rationale behind LAA exclusion for stroke prevention. After briefly reviewing the history of LAA exclusion, we highlight the most promising LAA exclusion devices currently available. Finally, we discuss future challenges and opportunities in this growing field

Outcomes of chronic total occlusion percutaneous coronary intervention in patients with reduced left ventricular ejection fraction

BACKGROUND: The relationship between left ventricular ejection fraction (LVEF) and the success and safety of coronary chronic total occlusion (CTO) percutaneous coronary intervention (PCI) has received limited study. METHODS: We examined the clinical characteristics and outcomes of CTO PCI in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO) after stratifying patients by LVEF (≤35%, 36%-49%, and ≥50%). RESULTS: A total of 7827 CTO PCI procedures with LVEF data were included. Mean age was 64 ± 10 years, 81% were men, 43% had diabetes mellitus, 61% had prior PCI, 45% had prior myocardial infarction, and 29% had prior coronary artery bypass graft surgery. Technical success was similar in the three LVEF strata: 85%, 86%, and 87%, p = 0.391 for LVEF ≤35%, 36%-49%, and ≥50%, respectively. In-hospital mortality was higher in lower LVEF patients (1.1%, 0.4%, and 0.3%, respectively, p = 0.001). In-hospital major adverse cardiovascular events (MACE) were numerically higher in lower EF patients (2.7%, 2.1%, and 1.9%, p = 0.271). At a median follow-up of 2 months (interquartile range: 19-350 days), patients with lower LVEF continued to have higher mortality (4.9%, 3.2%, and 1.4%, p \u3c 0.001) while the MACE rates were similar (9.3%, 9.6%, and 7.4%, p = 0.172). CONCLUSION: CTO PCI can be performed with high technical success in patients with reduced LVEF but is associated with higher in-hospital and post-discharge mortality

Prevalence and outcomes of balloon undilatable chronic total occlusions: Insights from the PROGRESS-CTO

BACKGROUND: The prevalence, treatment, and outcomes of balloon undilatable lesions encountered in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have received limited study. METHODS: We examined the clinical characteristics and procedural outcomes of balloon undilatable lesions in the Prospective Global Registry for the Study of CTO Intervention (PROGRESS-CTO). RESULTS: Of 6535 CTO PCIs performed between 2012 and 2022, 558 (8.5%) lesions were balloon undilatable. In this subset, patients were older (mean age 67 ± 10 vs. 64 ± 10, p \u3c 0.001) and had higher prevalence of comorbidities: diabetes mellitus (54% vs. 40%, p \u3c 0.001), prior PCI (71% vs. 59%, p \u3c 0.001), prior myocardial infarction (52% vs. 45%, p = 0.003), and prior coronary artery bypass graft surgery (44% vs. 25%, p \u3c 0.001). The CTO lesion length was estimated to be 34 ± 23 mm, mean J-CTO score was 2.9 ± 1.1 and mean PROGRESS-CTO score was 1.4 ± 1.0. A cutting balloon was used in 27%, a scoring balloon in 15%, laser in 14%, rotational atherectomy in 28%, orbital atherectomy in 10%, intravascular lithotripsy in 1% and other modalities/approaches in 5%. Balloon undilatable lesions had lower technical success (90.9% vs. 93.8%, p = 0.007) and higher incidence of major adverse cardiovascular events (MACE, composite of in-hospital death, acute myocardial infarction, stroke, re-PCI, emergency CABG, pericardiocentesis) (5.0% versus 1.3%, p \u3c 0.001). CONCLUSION: Approximately 1 in 12 CTO (8.5%) lesions are balloon undilatable. Treatment of balloon undilatable lesions is associated with lower technical success and higher in-hospital MACE

Post-Procedural Dabigatran Versus Interrupted Warfarin Therapy Following Catheter Ablation for Atrial Fibrillation

Patients undergoing catheter ablation for atrial fibrillation (AF) are at a higher risk of thromboembolic events post-procedure and therefore require therapeutic anticoagulation after ablation. Anticoagulation strategies include performing the procedure on or off therapeutic warfarin, though the latter approach requires post-procedure bridging therapy with low molecular-weight heparin (LMWH) until a therapeutic INR is achieved. The purpose of this study is to compare the safety and efficacy of post-ablation dabigatran as compared to warfarin with LMWH bridging. We performed a single-center retrospective analysis of consecutive patients who underwent catheter ablation for AF between January 2010 and December 2012 and received either post-procedure warfarin with a LMWH bridge or dabigatran. Warfarin was started the night of ablation; LMWH was started the next morning and continued until the INR was ≥ 2.0. Dabigatran was started the morning post-ablation. The analysis included 324 patients. Of these, mean age was 60 ± 9 years, 78% were male, 81% had CHADS scores of 0 or 1, and 181 (56%) received dabigatran post-ablation. Patients who received dabigatran had lower CHADS scores and were more likely to be in NYHA Class I. At 30-days post-procedure, there were 0 thromboembolic or bleeding complications in the dabigatran group versus 4 (2.8%) in the warfarin group (p=0.037). There were no deaths in either group at 30 days post-ablation. Post-ablation dabigatran appears safe and efficacious compared to an interrupted warfarin strategy with LMWH bridging

Preprocedural coronary computed tomography angiography in chronic total occlusion percutaneous coronary intervention: Insights from the PROGRESS-CTO registry

BACKGROUND: Preprocedural coronary computed tomography angiography (CCTA) can be useful in procedural planning for chronic total occlusion (CTO) percutaneous coronary intervention (PCI). METHODS: We examined the clinical, angiographic and procedural characteristics and outcomes of cases with vs. without preprocedural CCTA in PROGRESS-CTO (NCT02061436). Multivariable logistic regression was used to adjust for confounding factors. RESULTS: Of 7034 CTO PCI cases, preprocedural CCTA was used in 375 (5.3%) with increasing frequency over time. Patients with preprocedural CCTA had a higher prevalence of prior coronary artery bypass graft surgery (39% vs. 27%, p \u3c 0.001) and angiographically unfavorable characteristics including higher prevalence of proximal cap ambiguity (52% vs. 33%, p \u3c 0.001) and moderate/severe calcification (59% vs. 41%, p \u3c 0.001) compared with those without CCTA. CCTA helped resolve proximal cap ambiguity in 27%, identified significant calcium not seen on diagnostic angiography in 18%, changed estimated CTO length by \u3e5 mm in 10%, and was performed as part of initial coronary artery disease work up in 19%. CCTA cases had higher J-CTO (2.6 ± 1.2 vs. 2.3 ± 1.3, p \u3c 0.001) and PROGRESS-CTO (1.3 ± 1.0 vs. 1.2 ± 1.0 p = 0.027) scores. After adjusting for potential confounders, cases with preprocedural CCTA had similar technical success (odds ratio [OR]: 1.18, 95% confidence interval [CI], 0.83-1.67) and incidence of major adverse cardiovascular events (OR: 1.47, 95% CI, 0.72-3.00). CONCLUSION: Preprocedural CCTA was used in ~5% of CTO PCI cases. While CCTA may help with procedural planning, especially in complex cases, technical success and MACE were similar with or without CCTA

Periprocedural Mortality in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry

BACKGROUND: Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention. METHODS: We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO). RESULTS: Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%; P=0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3; P=0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1; P\u3c0.001), and PROGRESS-CTO pericardiocentesis (2.9±1.1 versus 1.9±1.3; P\u3c0.001) scores were higher in patients who died. In these patients, the use of left ventricular assist devices was also higher (41% versus 3.5%; P\u3c0.001), and retrograde crossing was more often the first crossing strategy (33% versus 13%; P\u3c0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%). CONCLUSIONS: Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention

Outcomes of subintimal plaque modification in chronic total occlusion percutaneous coronary intervention

BACKGROUND: When crossing into the distal true lumen fails during chronic total occlusion (CTO) percutaneous coronary intervention (PCI), subintimal plaque modification (SPM) is often performed to restore antegrade flow and facilitate subsequent lesion recanalization. METHODS: Between January 2012 and May 4, 2019, 4,659 CTO PCIs were included in the PROGRESS-CTO registry, of which 935 (20%) had a prior unsuccessful attempt. Of those 935 patients, 119 (13%) had prior SPM. We analyzed the outcomes of the 58 SPM procedures for which data were available, as well as the outcomes of the 60 subsequent CTO PCI attempts. RESULTS: Mean patient age was 67 ± 9 years and 86% were men. Patients had high prevalence of cardiovascular risk factors such as dyslipidemia (91%), hypertension (93%) diabetes (48%), prior PCI (61%), and prior coronary artery bypass graft surgery (47%). The target CTO lesions often had proximal cap ambiguity (54%), moderate/severe calcification (73%), moderate/severe tortuosity (63%), and high J-CTO score (mean 3.2 ± 1.1). The technical and procedural success of subsequent CTO PCI were high (83% for both) with an acceptable rate of in-hospital major adverse cardiovascular events (3.3%). Technical and procedural success were higher for repeat attempts that were performed ≥60 days after the index CTO PCI (94% vs. 69%, p = .015). Median (interquartile range) subsequent procedure time was 147 (100, 215) min, contrast volume was 185 (150, 260) ml, and air kerma radiation dose was 2.5 (1.4, 4.2) Gray. CONCLUSION: Repeat CTO PCI attempts after SPM are associated with high likelihood for successful revascularization with acceptable risks