Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion
Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion
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DOI：
10.1016/j.jacc.2021.04.098
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发表时间：
2021-07-19
影响因子：
24
通讯作者：
Alkhouli, Mohamad
中科院分区：
文献类型：
--
作者：
Simard, Trevor;Jung, Richard G.;Alkhouli, Mohamad
背景：器械相关血栓（DRT）被认为是左心耳封堵术（LAAO）的致命弱点。然而，关于DRT预测的数据仍然有限。本研究通过多中心合作构建了一个DRT注册表，旨在评估DRT的结局和预测因素。方法：37家国际中心提供了LAAO病例（有和无DRT）（器械匹配且与DRT病例时间相关）。本研究描述了DRT的管理模式和中期结局，并评估了DRT的患者和手术预测因素。结果共纳入711例患者（237例DRT和474例未DRT）。DRT组和非DRT组的随访持续时间相似，中位数分别为1.8年（四分位距：0.9-3.0年）和1.6年（四分位距：1.0-2.9年）（P = 0.76）。DRT在0 - 45天、45 - 180天、180 - 365天和>365天的检出率分别为24.9%、38.8%、16.0%和20.3%。DRT的存在与缺血性卒中（HR：3.49; 95% CI：1.35-9.00; P = 0.01）驱动的死亡、缺血性卒中或全身性栓塞（HR：2.37; 95% CI：1.58-3.56; P <0.001）复合终点的风险较高相关。在最后一次已知随访时，25.3%的患者发生DRT。LAAO后出院用药对DRT没有影响。多因素分析确定了5个DRT危险因素：高凝障碍（比值比[OR]：17.50; 95% CI：3.39-90.45），心包积液（OR：13.45; 95%CI：1.46-123.52），肾功能不全（OR：4.02; 95% CI：1.22-13.25），植入深度距离肺静脉利姆布斯>10 mm（OR：2.41; 95%CI：1.573.69）和非阵发性房颤（OR：1.90; 95%CI：1.22-2.97）。转换为风险因素点后，与没有任何风险因素的患者相比，DRT风险点为2美元的患者的DRT风险增加了2.1倍。结论LAAO术后DRT与缺血事件相关。患者和手术特异性因素与DRT的风险相关，可能有助于对接受LAAO的患者进行风险分层。（J Am科尔心脏病学2021;78：297-313）（c）美国心脏病学会基金会2021。
BACKGROUND Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited. OBJECTIVES This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT. METHODS Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT. RESULTS A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180,180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.573.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with $2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors. CONCLUSIONS DRT after LAAO is associated with ischemic events. Patient-and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO. (J Am Coll Cardiol 2021;78:297-313) (c) 2021 by the American College of Cardiology Foundation.