Perkutaner Vorhofohrverschluss nach Schlaganfall

ZUSAMMENFASSUNG

Der katheterbasierte Verschluss des linken Vorhofohrs stellt bei Patienten mit Vorhofflimmern, welche nicht für eine Langzeittherapie mit oralen Antikoagulanzien geeignet sind, eine potenzielle Therapieoption zur Reduktion des Schlaganfallrisikos dar. Die Weiterentwicklung der Device- und Implantationstechnik führte in den letzten Jahren zu einer Verbesserung des Sicherheitsprofils der Behandlungsmethode. Das Therapieprinzip wird durch neue Daten unterstützt, die die Wirksamkeit des operativen Verschlusses des linken Vorhofohrs zusätzlich zur Antikoagulation im Rahmen von kardiochirurgischen Eingriffen zeigen. Aktuell wird der katheterbasierte Verschluss des linken Vorhofohres in verschiedenen Patientenpopulationen in randomisierten Studien evaluiert. Die Datenlage, die Einsatzgebiete und randomisierte Studien unter besonderer Berücksichtigung der CLOSURE-AF-Studie sollen in der vorliegenden Übersichtsarbeit diskutiert werden.

ABSTRACT

Left atrial appendage closure (LAAC) is a potential treatment option for stroke prevention in patients not suitable for long-term oral anticoagulation. Due to advances in LAA closure devices and implantation techniques, the safety profile of LAAC has significantly improved over the last years. Recent data about the efficacy and safety of surgical closure of the left atrial appendage in conjunction with oral anticoagulation during open-heart surgery support the therapeutic concept of left atrial appendage closure. Presently, several randomized trials are underway to provide further data for LAAC in different patient populations. Recent data, potential indications for the procedure and ongoing randomized clinical trials with a special focus on the Closure-AF study will be summarized and discussed in this review.

Schlüsselwörter

Vorhofflimmern - linksatrialer Vorhofohrverschluss - orale Antikoagulation - Schlaganfallprävention

Key words

Atrial fibrillation left atrial appendage closure - oral anticoagulation - stroke prevention

Publikationsverlauf

Artikel online veröffentlicht:
07. Juni 2022

• Literatur

• 1 Haeusler K, Tutuncu S, Schnabel R. Detection of Atrial Fibrillation in Cryptogenic Stroke. Curr Neurol Neurosci Rep 2018; 18 (10) 66
• 2 Blackshear J, Odell J. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996; 61 (02) 755-9
• 3 January C. et al 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2019; 74 (01) 104-132
• 4 Lamassa M. et al Characteristics, outcome, and care of stroke associated with atrial fibrillation in Europe: data from a multicenter multinational hospital-based registry (The European Community Stroke Project). Stroke 2001; 32 (02) 392-8
• 5 Hindricks G. et al 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021; 42 (05) 373-498
• 6 Boston Area Anticoagulation Trial for Atrial Fibrillation, et al The effect of low-dose warfarin on the risk of stroke in patients with nonrheumatic atrial fibrillation. N Engl J Med 1990; 323 (22) 1505-11
• 7 Secondary prevention in non-rheumatic atrial fibrillation after transient ischaemic attack or minor stroke EAFT (European Atrial Fibrillation Trial) Study Group, Lancet. 1993; 342(8882): 1255–62
• 8 Steffel J. et al 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23 (10) 1612-1676
• 9 Hellwig S. et al Non-vitamin K-dependent oral anticoagulants have a positive impact on ischaemic stroke severity in patients with atrial fibrillation. Europace 2018; 20 (04) 569-574
• 10 Ruff C. et al Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation. Lancet 2014; 383 9921 955-62
• 11 Xian Y. et al Clinical Effectiveness of Direct Oral Anticoagulants vs Warfarin in Older Patients With Atrial Fibrillation and Ischemic Stroke: Findings From the Patient-Centered Research Into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) Study. JAMA Neurol 2019; 76 (10) 1192-1202
• 12 Steinberg B. et al International trends in clinical characteristics and oral anticoagulation treatment for patients with atrial fibrillation: Results from the GARFIELD-AF, ORBIT-AF I, and ORBIT-AF II registries. Am Heart J 2017; 194: 132-140
• 13 Haeusler K. et al Oral anticoagulation in patients with atrial fibrillation and acute ischaemic stroke: design and baseline data of the prospective multicentre Berlin Atrial Fibrillation Registry. Europace 2019; 21 (11) 1621-1632
• 14 Tutuncu S. et al Off-label-dosing of non-vitamin K-dependent oral antagonists in AF patients before and after stroke: results of the prospective multicenter Berlin Atrial Fibrillation Registry. J Neurol 2022; 269 (01) 470-480
• 15 Steinberg B. et al Off-Label Dosing of Non-Vitamin K Antagonist Oral Anticoagulants and Adverse Outcomes: The ORBIT-AF II Registry. J Am Coll Cardiol 2016; 68 (24) 2597-2604
• 16 Wang K. et al Efficacy and safety of reduced-dose non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation: a meta-analysis of randomized controlled trials. Eur Heart J 2019; 40 (19) 1492-1500
• 17 Verheugt F, Granger C. Oral anticoagulants for stroke prevention in atrial fibrillation: current status, special situations, and unmet needs. Lancet 2015; 386 9990 303-10
• 18 Martinez C.. et al Therapy persistence in newly diagnosed non-valvular atrial fibrillation treated with warfarin or NOAC. A cohort study. Thromb Haemost 2016; 115 (01) 31-9
• 19 Skurk C. et al [Left atrial appendage closure: Current data and future developments]. Herz 2021; 46 (05) 452-466
• 20 Lakkireddy Det al. Amplatzer Amulet Left Atrial Appendage Occluder Versus Watchman Device for Stroke Prophylaxis (Amulet IDE): A Randomized, Controlled Trial. Circulation 2021; 144 (19) 1543-1552
• 21 Simard T. et al Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion. J Am Coll Cardiol 2021; 78 (04) 297-313
• 22 Sedaghat A. et al Device-Related Thrombus After Left Atrial Appendage Closure: Data on Thrombus Characteristics, Treatment Strategies, and Clinical Outcomes From the EUROC-DRT-Registry. Circ Cardiovasc Interv 2021; 14 (05) e010195
• 23 O’Brien, et al Physician practices regarding contraindications to oral anticoagulation in atrial fibrillation: findings from the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation (ORBIT-AF) registry. Am Heart J 2014; 167 (04) 601-609 e1
• 24 Gundlund A. et al Prestroke and Poststroke Antithrombotic Therapy in Patients With Atrial Fibrillation: Results From a Nationwide Cohort. JAMA Netw Open 2018; 01 (01) e180171
• 25 Ong E. et al Prevalence and Outcome of Potential Candidates for Left Atrial Appendage Closure After Stroke With Atrial Fibrillation: WATCH-AF Registry. Stroke 2020; 51 (08) 2355-2363
• 26 Holmes D. et al Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009; 374 9689 534-42
• 27 Holmes D. et al Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol 2014; 64 (01) 1-12
• 28 Osmancik P. et al Left Atrial Appendage Closure Versus Direct Oral Anticoagulants in High-Risk Patients With Atrial Fibrillation. J Am Coll Cardiol 2020; 75 (25) 3122-3135
• 29 Osmancik P. et al 4-Year Outcomes After Left Atrial Appendage Closure Versus Nonwarfarin Oral Anticoagulation for Atrial Fibrillation. J Am Coll Cardiol 2022; 79 (01) 1-14
• 30 Turagam M. et al Left Atrial Appendage Closure Versus Oral Anticoagulants in Atrial Fibrillation: A Meta-Analysis of Randomized Trials. J Am Coll Cardiol 2020; 76 (23) 2795-2797
• 31 Boersma L. et al Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-Year follow-up outcome data of the EWOLUTION trial. Heart Rhythm 2017; 14 (09) 1302-1308
• 32 Landmesser U. et al Left atrial appendage occlusion with the AMPLATZER Amulet device: periprocedural and early clinical/echocardiographic data from a global prospective observational study. EuroIntervention 2017; 13 (07) 867-876
• 33 Brachmann J. et al Interventional occlusion of left atrial appendage in patients with atrial fibrillation. Acute and long-term outcome of occluder implantation in the LAARGE Registry. J Interv Card Electrophysiol 2020; 58 (03) 273-280
• 34 Nielsen-Kudsk J. et al Clinical Outcomes Associated With Left Atrial Appendage Occlusion Versus Direct Oral Anticoagulation in Atrial Fibrillation. JACC Cardiovasc Interv 2021; 14 (01) 69-78
• 35 Tzikas A. et al Patients with intracranial bleeding and atrial fibrillation treated with left atrial appendage occlusion: Results from the Amplatzer Cardiac Plug registry. Int J Cardiol 2017; 236: 232-236
• 36 Nielsen-Kudsk J. et al Left atrial appendage occlusion versus standard medical care in patients with atrial fibrillation and intracerebral haemorrhage: a propensity score-matched follow-up study. EuroIntervention 2017; 13 (03) 371-378
• 37 Whitlock R. et al Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med 2021; 384 (22) 2081-2091
• 38 Glikson M. et al EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update. EuroIntervention 2020; 15 (13) 1133-1180