EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update
Notice bibliographique
Résumé
The rationale for the quest to close the left atrial appendage (LAA) for stroke prevention is composed of three elements: the concept that atrial fibrillation (AF) causes strokes, the concept that strokes are associated with thrombus formation in the LAA, and that these thrombi cause strokes by embolisation to the cerebral circulation. There are strong data supporting an association between AF and stroke. The Framingham study following 5,070 patients over 34 years demonstrated an approximately fivefold higher stroke risk in individuals with AF than in those without.1 Though this does not prove a causal relationship, it is important to mention that this risk remained even after adjustment for other risk factors such as hypertension, coronary artery disease, congestive heart failure, and age. Another element to support LAA closure is that there must be proof that thrombus formation occurs predominantly in the LAA. One would imagine that there are abundant data to support the concept that, in AF, thrombus formation occurs predominantly in the LAA; however, in almost all texts discussing the pathophysiology of stroke in AF there are few publications cited to support this concept. Blackshear et al included 1,288 patients with non-valvular AF who underwent either transoesophageal echocardiography (TOE) or autopsy. 2 Thrombus formation was reported in 222 patients, 91% of which was located in the LAA. It was further supported by a more comprehensive meta-analysis by Mahajan et al who demonstrated that 89% of thrombi in the left atrium (LA) were located in the LAA.3 This was corroborated by a study in the realm of degenerative aortic stenosis by Parashar et al.4 In this study, all left atrial thrombi resided in the LAA. It is worth mentioning that the LAA is the most common site of intracardiac thrombi not only in patients with AF but also in patients in sinus rhythm.5 More direct evidence is now available proving that a large proportion of strokes in AF are the result of thrombus in the LAA. The PROTECT AF and PREVAIL studies (described later in this document) provide evidence for the protective effect of LAA closure on thromboembolic events (Chapter 5), although some have debated the evidence (Chapter 6).6 In order to justify LAA closure it is important to show that, when thrombus occurs in the LAA, it can embolise in the cerebral circulation. o demonstrate this, a thrombus embolising to the brain would have to be caught in the act. Parekh et al describe real-time imaging capture of LAA thrombus embolisation during TOE with subsequent stroke after a delay of 4 hours of the witnessed embolisation, possibly due to initial retention at a non-occlusive location with subsequent fragmentation and delayed more distal embolisation.7 The fact that LAA closure prevents thromboembolic events as detailed above is also indirect proof for embolisation from LAA as a cause of embolic events.
Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.
Comment cette classification a été obtenuedéplier
Prédiction machine sur la base complète
Imitation des enseignantsNi prévalence calibrée, ni vérité terrain. Validation humaine à venir. Le volet Gemma est une étiquette directe du modèle pour chaque travail de la base, lue sur la notice réduite au titre. Le volet Codex est un classifieur appris des 10 348 étiquettes directes de Codex et calibré sur les taux pondérés de l'échantillon; les champs sans appui suffisant ne portent aucun appel Codex. Le mode candidate est l'union des deux volets; le consensus est leur intersection. Ces sorties portent le statut machine_predicted_unvalidated et ne sont pas des étiquettes humaines.
Scores du classifieur distillé par catégorie (deux têtes)
| Catégorie | Codex | Gemma |
|---|---|---|
| Métarecherche | 0,021 | 0,037 |
| Méta-épidémiologie (sens strict) | 0,001 | 0,001 |
| Méta-épidémiologie (sens large) | 0,003 | 0,003 |
| Bibliométrie | 0,005 | 0,003 |
| Études des sciences et des technologies | 0,001 | 0,001 |
| Communication savante | 0,004 | 0,003 |
| Science ouverte | 0,003 | 0,002 |
| Intégrité de la recherche | 0,005 | 0,007 |
| Charge utile insuffisante (le modèle a refusé de juger) | 0,005 | 0,004 |
Scores machine (provisoires)
Les deux têtes enseignantes du modèle étudiant, lues sur ce travail. Un score ordonne la base pour la relecture; il n'affirme jamais une catégorie, et le statut de validation accompagne chaque rangée tel quel.
Scores de référence d'un modèle non mature (critères de maturité non atteints, 7 itérations). Un score ordonne; il n'affirme jamais une catégorie.
score_only:v0-immature-baseline · tel quel depuis la passe de notation : score_only signifie que le nombre peut ordonner les travaux, et qu'aucune étiquette de catégorie n'en découleClassification
machine, non validéePrédiction automatique; un appel candidat d’une seule source (Gemma direct ou Codex distillé), pas un consensus.
Le détail, modèle par modèle et score par score, se trouve en fin de page sous « Comment cette classification a été obtenue ».