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Like Two Peas in a Pod: Heart Failure and Atrial Fibrillation

Cerit, Levent

doi: 10.1097/MAT.0000000000000576
Letter to the Editor

Department of Cardiology, Dr. Suat Günsel Girne University, Kyrenia, Cyprus

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To the Editor:

I have read the article entitled “Utility of CHA2DS2-VASc and HAS-BLED Scores as Predictor of Thromboembolism and Bleeding After Left Ventricular Assist Device Implantation” by Kemal et al.1 with great interest, recently published in journal. The investigators reported that baseline high HAS-BLED score was predictive of bleeding events after continuous-flow left ventricular assist device (CF-LVAD) implantation, whereas baseline CHA2DS2-VASc score was not predictive of thromboembolic (TE) events.1

Atrial fibrillation (AF) is the most common arrhythmia in patients with advanced heart failure (HF), and approximately 50% of patients with HF are affected by AF. AF has been shown to be associated with an increased incidence of TE complications, such as stroke.2 There are inconsistent knowledge regarding higher TE events in patients with LVAD and concomitant AF. On one hand, Stulak et al.3 reported that preoperative AF is a significant risk factor that increases TE events after LVAD implant, especially in patients younger than 70 years. Both AF and LVAD support represent prothrombotic states, and alterations in traditional LVAD anticoagulation strategies may be required to provide prophylaxis against late TE events.

On the other hand, several studies showed that preoperative AF is not associated with higher incidence of postoperative stroke, device thrombosis.4,5 Xuereb et al.4 demonstrated no significant difference in mortality or incidence of TE complications, such as stroke or device thrombosis, comparing patients with and without preoperative AF. Oezpeker et al.5 reported similar complication rates of stroke, pump thrombosis, and gastrointestinal hemorrhage, but significantly higher 2 year mortality in patients with permanent AF than in patients with sinus rhythm.

In this context, utility of basal CHA2DS2-VASc and HAS-BLED scores of patients as a predictor of TE and bleeding events risk after CF-LVAD implantation were evaluated, and correlation of this study’s results with presence of AF may shed light on future studies.

Levent Cerit

Department of Cardiology

Dr. Suat Günsel Girne University

Kyrenia, Cyprus

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1. Kemal HS, Ertugay S, Nalbantgil S, et al. Utility of CHA2DS2-VASc and HAS-BLED scores as predictor of thromboembolism and bleeding after left ventricular assist device implantation. ASAIO J. 2017.63: 720–724.
2. Lim HS, Willoughby SR, Schultz C, et al. Effect of atrial fibrillation on atrial thrombogenesis in humans: impact of rate and rhythm. J Am Coll Cardiol 2013.61: 852–860.
3. Stulak JM, Deo S, Schirger J, et al. Preoperative atrial fibrillation increases risk of thromboembolic events after left ventricular assist device implantation. Ann Thorac Surg 2013.96: 2161–2167.
4. Xuereb L, Go PH, Kaur B, et al. Impact of preoperative atrial fibrillation on postoperative thromboembolic events after left ventricular assist device implantation. Ann Thorac Surg 2016.102: 1543–1549.
5. Oezpeker C, Zittermann A, Pühler T, et al. Permanent atrial fibrillation and 2-year clinical outcomes in patients with a left ventricular assist device implant. ASAIO J. 2017.63: 419–424.
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