Toronto Congenital Cardiac Centre for Adults, Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada.
Toronto General Hospital Research Institute, University Health Network, 10th Floor Eaton North, Room 237, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
Clin Res Cardiol. 2024 Oct;113(10):1485-1500. doi: 10.1007/s00392-023-02359-1. Epub 2023 Dec 19.
Chronic kidney disease (CKD) is a risk factor for embolic stroke, and many nonvalvular atrial fibrillation (NVAF) patients have concomitant CKD. Anticoagulation therapy can be challenging in CKD due to increased bleeding risk, and left atrial appendage occlusion (LAAO) may be a promising alternative.
This systematic review aimed to consolidate current evidence on the safety and effectiveness of transcatheter LAAO in patients with CKD and end-stage renal disease (ESRD).
Medline, Cochrane, and Embase databases were searched from inception to September 2, 2022. We conducted a meta-analysis if an outcome was evaluated in at least two similar studies.
We included 15 studies with 77,780 total patients. Of the 15 studies, 11 had a cohort design (five prospective and six retrospective), and four were case series. Patients with CKD were older and had a higher prevalence of comorbidities than non-CKD patients. The two groups did not differ in procedural failure rate, vascular complications, or pericardial tamponade. CKD patients exhibited higher odds of in-hospital acute kidney injury (AKI) and bleeding, longer-term bleeding, and mortality than those without CKD. The risk of in-hospital and longer-term cardioembolic events was similar between CKD and non-CKD populations (odds ratio = 1.01 [95% CI 0.70-1.15] and 1.05 [95% CI 0.55-2.00], respectively). Patients with ESRD had higher odds of in-hospital mortality and cardioembolic events than non-ESRD patients, with no differences in risk of pericardial tamponade.
Based on observational studies, LAAO may be an effective option to prevent cardioembolic events in CKD. However, CKD patients may have higher odds of AKI and in-hospital and long-term bleeding and mortality. The adverse clinical outcomes observed in CKD patients may be attributed to this population's high burden of comorbidities, especially among those with ERSD, rather than the LAAO procedure itself. To ensure maximum clinical benefit, careful patient selection, management, and surveillance involving multidisciplinary teams are essential for CKD patients undergoing LAAO.
慢性肾脏病（CKD）是栓塞性卒中的一个危险因素，许多非瓣膜性心房颤动（NVAF）患者同时患有 CKD。由于出血风险增加，抗凝治疗在 CKD 中可能具有挑战性，而左心耳封堵（LAAO）可能是一种有前途的替代方法。
本系统评价旨在综合目前关于 CKD 和终末期肾病（ESRD）患者经导管 LAAO 的安全性和有效性的证据。
从建库到 2022 年 9 月 2 日，我们检索了 Medline、Cochrane 和 Embase 数据库。如果至少有两项类似研究评估了某一结局，我们将进行荟萃分析。
我们纳入了 15 项研究，共纳入 77780 例患者。在这 15 项研究中，11 项为队列设计（5 项前瞻性研究，6 项回顾性研究），4 项为病例系列研究。CKD 患者比非 CKD 患者年龄更大，合并症患病率更高。两组在手术失败率、血管并发症或心包填塞方面无差异。与非 CKD 患者相比，CKD 患者住院期间急性肾损伤（AKI）和出血、长期出血和死亡率的发生风险更高。CKD 患者和非 CKD 患者住院期间和长期心源性栓塞事件的风险相似（比值比分别为 1.01 [95%置信区间 0.70-1.15] 和 1.05 [95%置信区间 0.55-2.00]）。ESRD 患者住院期间死亡率和心源性栓塞事件的发生风险高于非 ESRD 患者，但心包填塞的风险无差异。
基于观察性研究，LAAO 可能是预防 CKD 患者心源性栓塞事件的有效方法。然而，CKD 患者可能有更高的 AKI 以及住院期间和长期出血和死亡率的发生风险。在 CKD 患者中观察到的不良临床结局可能归因于该人群的合并症负担较高，尤其是在 ESRD 患者中，而不是 LAAO 本身。为了确保最大的临床获益，对于接受 LAAO 的 CKD 患者，需要多学科团队进行仔细的患者选择、管理和监测。
