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Submission Deadline: 15 Jan 2021
Contacts: Alisa Wang, Assistant Editor, Alisa@vpjournal.net
Type: Original Article
Title: Functional outcomes after endovascular thrombectomy in patients with atrial fibrillation
Authors: Dennis J. Cordato, Cecilia Cappelen-Smith
Affiliations: Ingham Institute for Applied Medical Research, Sydney, 2000, Australia.
Correspondence: Dr. Dennis John,Cordato, MD, PHD, Ingham Institute for Applied Medical Research, Sydney, 2000, Australia. E-mail: Dennis.Cordato@health.nsw.gov.au
Abstract: Background: Endovascular thrombectomy (EVT) improves functional outcomes and mortality in ischemic stroke patients with large vessel occlusions (LVO). Patients with atrial fibrillation (AF) are over-represented in EVT populations, due to a high prevalence of LVO and contraindication to intravenous thrombolysis. However, the influence of AF on thrombectomy outcomes remains unclear.
Methods: A retrospective analysis of 394 prospectively collected patients who received EVT for anterior cerebral circulation (ACC) LVO at a single Australian comprehensive stroke center. This study aims to: (1) compare 90-day functional outcomes (modified Rankin Score mRS 0-2) and mortality in AF vs. non-AF patients receiving EVT; (2) compare 90-day functional outcomes and mortality in AF patients on therapeutic vs. non-therapeutic anticoagulation receiving EVT; (3) identify prognostic factors that influence outcomes in AF patients undergoing EVT.
Results: 171 of 394 (49%) EVT patients had AF. Patients with AF were significantly older, had higher CHADS2, higher NIHSS and lower rates of thrombolysis administration. There was no significant difference in 90-day mRS (P = 0.970) or mortality (P = 0.391) between AF and non-AF groups. Similarly, there was no significant difference in 90-day mRS (P = 0.935) or mortality (P = 0.428) between AF patients on therapeutic vs. non-therapeutic anticoagulation. Advancing age and higher NIHSS were independent predictors of worse 90-day functional outcome (OR 1.045, P = 0.020; OR 1.086, P = 0.001) and mortality (OR 1.138, P < 0.001; OR 1.107, P = 0.002). Thrombolysis administration improved mortality (OR 0.215, P = 0.016) but not functional outcomes (P = 0.092).
Conclusion: AF does not significantly modify 90-day functional outcomes or mortality after EVT in patients with ACC LVO. Furthermore, therapeutic anticoagulation does not influence EVT outcomes.
Title: Prevention of cardioembolic stroke in patients with atrial fibrillation: The emerging role of the left atrial appendage occlusion. Is the future now?
Authors: Giovanni Cimmino1,2*, Francesco Loffredo1,2,3, Emanuele Gallinoro4, Dario Prozzo1, Dario Fabiani1,2, Luigi Cante1,2, Maurizio Cappelli Bigazzi2, Paolo Golino1,2
Affiliations: 1Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy. 2Vanvitelli Cardiology Unit, Monaldi Hospital, Naples, Italy. 3Molecular Cardiology, International Centre for Genetic Engineering and Biotechnology, Trieste, Italy. 4Cardiovascular Center, OLV Clinic, Aalst, Belgium.
*Corresponding author: Prof. Giovanni Cimmino, Department of Translational Medical Sciences, Section of Cardiology, University of Campania “Luigi Vanvitelli”, c/o Monaldi Hospital, Via L. Bianchi, 1 , 80131 Naples, Italy. E-mail: firstname.lastname@example.org
Abstract: Atrial fibrillation (AF) is the most common cardiac arrhythmia in general population, with an estimated prevalence of 1%, but it is expected to increase in the next decades, in both Europe and US, because of the rising life expectancy. It is well known that AF increases the risk of ischemic stroke, silent cerebral ischemia and related cognitive impairment. Because of the blood stasis, mostly in the left atrial appendage (LAA), thrombus formation may occur. This is particularly true in the setting of nonvalvular AF (NVAF). Previous studies have shown that over 90% of emboli related to NVAF originate from the LAA, so prevention of systemic cardioembolism is indicated. According the current guidelines, anticoagulation with Direct Oral Anticoagulants (DOACs) or Vitamin K Antagonists (VKAs), represents the standard care in AF patients to prevent stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown non-inferiority for stroke prevention while having significantly fewer bleeding complications compared to VKAs, some issues remain a matter of debate, including contraindications, side effects and adherence. An increasing number of patients cannot take anticoagulants because of high bleeding risk or the experience of life-threatening bleeding. In the last few years, a new procedure is emerging to prevent the cardioembolic stroke in the setting of patients at high bleeding risk: the percutaneous Left Atrial Appendage Occlusion (LAAO). Various devices have been developed over the last years, not all approved in Europe and with some of them still under clinical investigation. Currently available devices have shown a decreasing in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure always requires transesophageal echocardiography, anesthesia, femoral vein access and transeptal puncture. After the approval of the first device, the indication for LAAO was changed. The available literature indicates that LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation.
Giovanni Cimmino MD, PhD
Associate Professor of Cardiology
Department of Translational Medical Sciences
University of Campania "Luigi Vanvitelli"
Cardiology Unit "Vanvitelli"