Left atrial appendage thrombosis (LAAT) was found to occur frequently in patients who undergo transfemoral transcatheter aortic valve implantation (TF-TAVI), but was not found to be associated with an increased risk for periprocedural complications, according to a study published in the Canadian Journal of Cardiology.
In this retrospective analysis, the data of 2527 patients who had TF-TAVI performed at a single center, were examined. The study’s primary outcome was early safety at 30 days, which consisted of a composite of all-cause mortality, stroke, life-threatening bleeding, acute kidney injury stage 2 and 3, coronary obstruction requiring intervention, major vascular complication, and valve-related dysfunction requiring repeat procedure. All-cause and cardiovascular mortality rates were also assessed 30 days and 3 years after intervention.
In this cohort, 193 patients (7.6%) experienced LAAT, as indicated by transesophageal echocardiography (TEE). Of the 1099 patients with a history of atrial fibrillation (AF), 182 (16.6%) had LAAT. Patients with LAAT had higher rates of pre-existing AF compared with control INDIVIDUALS (94.8% vs 40.1%, respectively; P <.001).
At baseline, patients with vs without LAAT had a higher Society of Thoracic Surgeons (STS) score (9.2% vs 6.4%, respectively; P <.001), greater burden of comorbidities, including diabetes (52.1% vs 43.2%, respectively; P =.017) and chronic kidney disease stage ≥3b (43.2% vs 28.6%, respectively; P <.001), and had lower left ventricular ejection fraction (52% vs 58%, respectively; P <.001) and lower aortic valve area (0.6 vs 0.7 cm2, respectively; P =.005).
The rate of stroke at 30 days, as defined by the Valve Academic Research Consortium-2 (VARC-2), was similar in the LAAT and non-LAAT group (5.9% vs 4.7%, respectively; P =.495). Early safety at 30 days, as defined by the VARC-2 was comparable in the LAAT and non-LAAT group (29.2% vs 24.2%, respectively; P =.123). Early safety at 30 days (29.1% vs 22.9%; P =.072) and stroke rate (5.6% vs 3.3%; P =.142) were comparable in patients with AF with LAAT vs without LAAT.
No association was established between LAAT and 2-year mortality in the entire cohort and in the subgroup with AF. However, 2-year all-cause mortality in the entire cohort was associated with STS-score (hazard ratio [HR], 1.05; 95% CI 1.04-1.07; P <.001), New York Heart Association (NYHA) III/IV at baseline (HR, 1.81; 95% CI, 1.37-2.40; P <.001), and AF (HR, 1.32; 95% CI, 1.09-1.61; P =.005). In the AF cohort, independent predictors of 2-year all-cause mortality were male sex (HR, 1.42; 95% CI, 1.10-1.82; P =.007), STS-Score (HR, 1.05; 95% CI, 7 1.03-1.07; P <.001), and NYHA III/IV at baseline (HR, 1.59; 95% CI, 1.09-2.33; P =.017).
Limitations of the study include its retrospective, single-center design as well as the lack of complete data on stroke and bleeding rates beyond 30 days.
“Not LAAT but its underlying diseases were associated with 2-year all-cause mortality indicating that LAAT should be considered as a marker for patients who are at risk for worse outcome due to a higher comorbidity burden,” noted the study authors.
Stachel G, Woitek FJ, Crusius L, et al. Left atrial appendage thrombosis in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation [published online May 22, 2020]. Can J Cardiol. doi:10.1016/j.cjca.2020.05.025