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      The feasibility and safety of combining atrial septal defect/patent foramen ovale and left atrial appendage closure: A systematic review and meta-analysis

      systematic-review

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          Abstract

          Introduction

          Atrial Septal Defect/Patent Foramen Ovale (ASD/PFO) occlusion is performed to prevent paradoxical embolism and reduce the risk of recurrent ischemic stroke. Left atrial appendage (LAA) closure is used as an alternative to medical therapy of non-valvular atrial fibrillation for prevention of stroke. Multiple studies have examined performing LAA and ASD/PFO occlusion. However, the feasibility and safety of combined occlusion of the left atrial appendage and ASD/PFO are not clear, furthermore, these studies are limited by their small sample sizes and retrospective analysis. In this study, we aimed to systematically review and meta-analyze the feasibility and safety of combining left atrial appendage and ASD/PFO closure.

          Methods

          PubMed, Web of Science, CNKI, Cochrane Library, Embase, and WanFang database were searched up to April 2022 to identify peer-reviewed human studies on assessing the feasibility, safety, and efficacy of combining left atrial appendage and ASD/PFO closure. The primary outcome was calculated: procedural feasibility outcome and procedural safety outcome.

          Results

          A total of 10 articles, including 340 patients from multiple countries, were included in the analysis. The principal findings of our study are: compared with single LAA closure, (i) combining PFO/ASD occlusion and LAA closure had similar procedural success proportion (98.43%, 95% CI: 96.67–100.00%), (ii) similar safety event incidences developed (1.67%, 95% CI: 0.24–3.92%), subgroup analyzed safety event incidences in death was 0.00 (95% CI: 0.00–0.33%), cardiac tamponade was 0.87% (95% CI: 0.00–2.77%), device embolization was 0.00 (95% CI: 0.00–0.60%), major bleeding was 0.00 (95% CI: 0.00–0.33%), stroke was 0.00 (95% CI: 0.00–0.02%).

          Conclusion

          Although this systematic review and meta-analysis demonstrate the technical feasibility and safety of combining closure of PFO/ASD and LAA, further studies of sufficient sample size, long-term follow-up, and rigor endpoint criteria are yet needed to fully evaluate this combination procedure for its role in clinical outcomes.

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          Most cited references42

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          Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment

          B Love, D L Gordon, J. Biller … (1993)
          Article 0 comments Cited 846 times – based on 0 reviews     Review now
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            Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.

            J Blackshear, J. A. Odell (1996)
            Left atrial appendage obliteration was historically ineffective for the prevention of postoperative stroke in patients with rheumatic atrial fibrillation who underwent operative mitral valvotomy. It is, however, a routine part of modern "curative" operations for nonrheumatic atrial fibrillation, such as the maze and corridor procedures. To assess the potential of left atrial appendage obliteration to prevent stroke in nonrheumatic atrial fibrillation patients, we reviewed previous reports that identified the etiology of atrial fibrillation and evaluated the presence and location of left atrial thrombus by transesophageal echocardiography, autopsy, or operation. Twenty-three separate studies were reviewed, and 446 of 3,504 (13%) rheumatic atrial fibrillation patients, and 222 of 1,288 (17%) nonrheumatic atrial fibrillation patients had a documented left atrial thrombus. Anticoagulation status was variable and not controlled for. Thrombi were localized to, or were present in the left atrial appendage and extended into the left atrial cavity in 254 of 446 (57%) of patients with rheumatic atrial fibrillation. In contrast, 201 of 222 (91%) of nonrheumatic atrial fibrillation-related left atrial thrombi were isolated to, or originated in the left atrial appendage (p < 0.0001). These data suggest that left atrial appendage obliteration is a strategy of potential value for stroke prophylaxis in nonrheumatic atrial fibrillation.
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              Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.

              David Holmes, Saibal Kar, Matthew Price … (2014)
              In the PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) trial that evaluated patients with nonvalvular atrial fibrillation (NVAF), left atrial appendage (LAA) occlusion was noninferior to warfarin for stroke prevention, but a periprocedural safety hazard was identified.
              Article 0 comments Cited 268 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Journal
                Journal ID (nlm-ta): Front Cardiovasc Med
                Journal ID (iso-abbrev): Front Cardiovasc Med
                Journal ID (publisher-id): Front. Cardiovasc. Med.
                Title: Frontiers in Cardiovascular Medicine
                Publisher: Frontiers Media S.A.
                ISSN (Electronic): 2297-055X
                Publication date (Electronic): 06 January 2023
                Publication date Collection: 2022
                Volume: 9
                Electronic Location Identifier: 1080257
                Affiliations
                [1] 1Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University , Zhengzhou, Henan, China
                [2] 2Department of Surgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University , Providence, RI, United States
                [3] 3Center for Systems Biology, Massachusetts General Hospital , Boston, MA, United States
                [4] 4Division of Cardiology, Department of Medicine, Cardiovascular Research Center, Rhode Island Hospital, Warren Alpert Medical School of Brown University , Providence, RI, United States
                Author notes

                Edited by: Masahiko Asami, Mitsui Memorial Hospital, Japan

                Reviewed by: Lam Cheung Chi Simon, Queen Mary Hospital, Hong Kong SAR, China; Flavio Tarasoutchi, University of São Paulo, Brazil

                *Correspondence: Yi Song, yisong8219@ 123456gmail.com

                This article was submitted to Structural Interventional Cardiology, a section of the journal Frontiers in Cardiovascular Medicine

                Article
                DOI: 10.3389/fcvm.2022.1080257
                PMC ID: 9854394
                PubMed ID: 36684606
                SO-VID: 6f4b7f89-b2f6-4d56-bdd5-f5453a98a0ac
                Copyright © Copyright © 2023 Song, Xing, Koch, Li and Zhang.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                Date received : 26 October 2022
                Date accepted : 15 December 2022
                Page count
                Figures: 3, Tables: 3, Equations: 0, References: 42, Pages: 10, Words: 5444
                Funding
                This research was supported by the National Natural Science Foundation of China (grant number: 82202177), Natural Science Foundation of Henan Province of China (grant number: 202300410446), Abroad Study Program for the Leadership of Medical Academic Technology of Henan Province (grant number: 2017025), and Key Scientific Research Project of Colleges and Universities in Henan Province (grant number: 19A320042).
                Categories
                Subject: Cardiovascular Medicine
                Subject: Systematic Review

                Keywords: atrial appendage closure/occlusion,atrial septal closure/occlusion,patent foramen ovale closure/occlusion,atrial fibrillation,staged
                Data availability:
                Keywords: atrial appendage closure/occlusion, atrial septal closure/occlusion, patent foramen ovale closure/occlusion, atrial fibrillation, staged

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