A synthesis of evidence for policy from behavioural science during COVID-19.

Scientific evidence regularly guides policy decisions1, with behavioural science increasingly part of this process2. In April 2020, an influential paper3 proposed 19 policy recommendations ('claims') detailing how evidence from behavioural science could contribute to efforts to reduce impacts and end the COVID-19 pandemic. Here we assess 747 pandemic-related research articles that empirically investigated those claims. We report the scale of evidence and whether evidence supports them to indicate applicability for policymaking. Two independent teams, involving 72 reviewers, found evidence for 18 of 19 claims, with both teams finding evidence supporting 16 (89%) of those 18 claims. The strongest evidence supported claims that anticipated culture, polarization and misinformation would be associated with policy effectiveness. Claims suggesting trusted leaders and positive social norms increased adherence to behavioural interventions also had strong empirical support, as did appealing to social consensus or bipartisan agreement. Targeted language in messaging yielded mixed effects and there were no effects for highlighting individual benefits or protecting others. No available evidence existed to assess any distinct differences in effects between using the terms 'physical distancing' and 'social distancing'. Analysis of 463 papers containing data showed generally large samples; 418 involved human participants with a mean of 16,848 (median of 1,699). That statistical power underscored improved suitability of behavioural science research for informing policy decisions. Furthermore, by implementing a standardized approach to evidence selection and synthesis, we amplify broader implications for advancing scientific evidence in policy formulation and prioritization.

Hydro-geomorphic perspectives on microplastic distribution in freshwater river systems: A critical review.

Freshwater river systems are commonly defined as the main transport paths of microplastics (MP) from land into the seas. A shift in research interest from oceans to rivers can be observed, as a large number of i) case studies, ii) review papers and iii) experimental studies in this field have been published recently. Still, studies often lack an in-depth consideration of quantification, as units are mostly based on item numbers. Spatiotemporal aspects are often neglected. Transport paths linking MP sources and sinks in the environment are insufficiently understood and only recently the awareness increased that sustainable management of the MP pollution cannot be addressed without a sound knowledge of water- and sediment-driven MP transport. Within this review paper, we therefore i) reviewed 92 MP case-studies, with a special focus on spatiotemporal aspects and ii) gathered and compared global load-estimation data from these studies. We then outlined the key processes determining MP movement in rivers on the basis of existing laboratory experiments and theoretical approaches. A procedure to effectively compare units of MP in the water column and in riverine sediments was developed on the basis of i) an extensive MP-dataset in German waterways and ii) suspended sediment concentrations (SSC) of nearest monitoring stations of the German water and shipping authority. Our analysis indicates that relating MP in water samples to SSC reduces the often stated large difference between MP concentrations in the water column and bed sediments and therefore relativizes the importance of river beds as a major "MP sink". As for a quantification of MP fluxes, the use of MP masses as unit is crucial, we applied an approach to convert MP items to masses with the help of i) a power-law distribution of MP-particle size, triangular distributions of ii) form-ratios and iii) polymer densities. An evaluation with an own, extensive dataset of MP-particles showed reasonable results. Therefore, we translated global load data from item numbers to mass values for further analysis. Values were within a reasonable range, especially when considering the respective catchment size of each river at the sampling site.

The persistence of cognitive biases in financial decisions across economic groups.

While economic inequality continues to rise within countries, efforts to address it have been largely ineffective, particularly those involving behavioral approaches. It is often implied but not tested that choice patterns among low-income individuals may be a factor impeding behavioral interventions aimed at improving upward economic mobility. To test this, we assessed rates of ten cognitive biases across nearly 5000 participants from 27 countries. Our analyses were primarily focused on 1458 individuals that were either low-income adults or individuals who grew up in disadvantaged households but had above-average financial well-being as adults, known as positive deviants. Using discrete and complex models, we find evidence of no differences within or between groups or countries. We therefore conclude that choices impeded by cognitive biases alone cannot explain why some individuals do not experience upward economic mobility. Policies must combine both behavioral and structural interventions to improve financial well-being across populations.

Sedimentary microplastic concentrations from the Romanian Danube River to the Black Sea.

A multitude of recent studies have detailed microplastic concentrations in aquatic and terrestrial environments, although questions remain over their ultimate fate. At present, few studies have detailed microplastic characteristics and abundance along a freshwater-marine interface, and considerable uncertainties remain over the modelled contribution of terrestrial and riverine microplastic to the world's oceans. In this article, for the first time, we detail sedimentary microplastic concentrations along a River-Sea transect from the lower reaches of a major continental river, the River Danube, through the Danube Delta, the Black Sea coast to the Romanian and Bulgarian inner shelf of the Black Sea. Our results indicate that isolated areas of the Danube Delta are still relatively pristine, with few microplastic particles in some of the sediments sampled.

Mental health effects of infection containment strategies: quarantine and isolation-a systematic review and meta-analysis.

Due to the ongoing COVID-19 pandemic, an unprecedented number of people worldwide is currently affected by quarantine or isolation. These measures have been suggested to negatively impact on mental health. We conducted the first systematic literature review and meta-analysis assessing the psychological effects in both quarantined and isolated persons compared to non-quarantined and non-isolated persons. PubMed, PsycINFO, and Embase databases were searched for studies until April 22, 2020 (Prospero Registration-No.: CRD42020180043). We followed PRISMA and MOOSE guidelines for data extraction and synthesis and the Newcastle-Ottawa Scale for assessing risk of bias of included studies. A random-effects model was implemented to pool effect sizes of included studies. The primary outcomes were depression, anxiety, and stress-related disorders. All other psychological parameters, such as anger, were reported as secondary outcomes. Out of 6807 screened articles, 25 studies were included in our analyses. Compared to controls, individuals experiencing isolation or quarantine were at increased risk for adverse mental health outcomes, particularly after containment duration of 1 week or longer. Effect sizes were summarized for depressive disorders (odds ratio 2.795; 95% CI 1.467-5.324), anxiety disorders (odds ratio 2.0; 95% CI 0.883-4.527), and stress-related disorders (odds ratio 2.742; 95% CI 1.496-5.027). Among secondary outcomes, elevated levels of anger were reported most consistently. There is compelling evidence for adverse mental health effects of isolation and quarantine, in particular depression, anxiety, stress-related disorders, and anger. Reported determinants can help identify populations at risk and our findings may serve as an evidence-base for prevention and management strategies.

Tyre and road wear particles - A calculation of generation, transport and release to water and soil with special regard to German roads.

Tyre and road wear is one of the main emission sources of particulate plastics (microplastics). In this study, the emissions of tyre wear particles (TWP) which are annually generated on the German road network were calculated. Emissions are calculated by applying two different data sets of emission factors and the annual mileage for distinct vehicles and road types (urban roads, rural roads, highways). Environmental entry paths of tyre and road wear particles (TRWP) were considered including releases to ambient air, soils and surface waters. Road runoff treatment was taken into account differentiated into sewage systems in urban areas and at non-urban roads. This study identifies the soundest data available concerning emission factors, data on traffic and road systems as well as comprehensive information on road runoff treatment in Germany. Applying this data and assuming that 5% of the total emissions are 'fine' air-borne particles, the emissions of coarse 'non-airborne' particles are 75,200-98,400 t/a; . the transport to road banks and soils near roads is 57,300-65,400 t/a (66-76%) including runoff and drift; 8700-19,800 t/a (12-20%) are released to surface waters. Due to lack of data, degradation in soils and surface waters was not considered. Besides soils, urban wastewater treatment plants are expected to be an important sink of TRWP assuming that most of the particles are incorporated in the sewage sludge. Due to the application of sewage sludge as a fertilizer, 1400-2800 t/a TWP are currently deposited on agricultural areas. No reliable data was available to estimate the masses of TWP which are transported from freshwaters into the marine environment. Existing mitigation measures should be improved according to the principle of precaution by installation of road runoff treatment systems and retrofitting of existing plants regarding optimum fine particle retention.

Quantitative and qualitative evaluation of plastic particles in surface waters of the Western Black Sea.

Microplastic abundances have been studied intensively in the last years in marine and freshwater environments worldwide. Though several articles have been published about the Mediterranean Sea, only few studies about the Black Sea exist. The Black Sea drains into the Mediterranean Sea and may therefore significantly contribute to the Mediterranean marine pollution. So far, only very few articles have been published about micro-, meso- and macroplastic abundances in the Western Black Sea. In order to fill this knowledge gap and to decipher the number of plastics on the water surface, 12 samples were collected from surface waters with a neustonic net (mesh size 200 µm) in the Black Sea close to the Danube Delta and the Romanian shore. Organic matter was digested and plastic particles were isolated by density separation. The results of visual inspection, pyrolysis GC-MS (for microplastics) and ATR-FTIR (for mesoplastics >5 mm) revealed an average concentration of 7 plastic particles/m³, dominated by fibers (∼76%), followed by foils (∼13%) and fragments (∼11%). Only very few spherules were detected. The polymers polypropylene (PP) and polyethylene (PE) dominated which is in line with other studies analyzing surface waters from rivers in Western Europe as well as in China. Statistical analyses show that the plastic concentration close to the mouth of the Danube River was significantly higher than at four nearshore regions along the Romanian and Bulgarian coastline. This could be explained by plastic inputs from the Danube River into the western part of the Black Sea.

Comparative assessment of microplastics in water and sediment of a large European river.

Aquatic ecosystems are globally contaminated with microplastics (MP). However, comparative data on MP levels in freshwater systems is still scarce. Therefore, the aim of this study is to quantify MP abundance in water and sediment of the German river Elbe using visual, spectroscopic (Fourier-transform infrared spectroscopy) and thermo analytical (pyrolysis gas chromatography mass spectrometry) methods. Samples from eleven German sites along the German part of the Elbe were collected, both in the water and sediment phase, in order to better understand MP sinks and transport mechanisms. MP concentrations differed between the water and sediment phase. Sediment concentrations (mean: 3,350,000 particles m-3, 125-5000 µm MP) were in average 600,000-fold higher than water concentrations (mean: 5.57 particles m-3, 150-5000 µm MP). The abundance varied between the sampling sites: In sediments, the abundance decreased in the course of the river while in water samples no such clear trend was observed. This may be explained by a barrage retaining sediments and limiting tidal influence in the upstream parts of the river. Particle shape differed site-specifically with one site having exceptionally high quantities of spheres, most probably due to industrial emissions of PS-DVB resin beads. Suspended MP consisted predominantly of polyethylene and polypropylene whereas sediments contained a higher diversity of polymer types. Determined MP concentrations correspond well to previous results from other European rivers. In a global context, MP levels in the Elbe relate to the lower (water) to middle section (sediment) of the global range of MP concentrations determined for rivers worldwide. This highlights that elevated MP levels are not only found in single countries or continents, but that MP pollution is an issue of global concern.

Tyre and road wear particles (TRWP) - A review of generation, properties, emissions, human health risk, ecotoxicity, and fate in the environment.

In this paper, the current knowledge on tyre and road wear particles (TRWP) is compiled regarding all environmental and health aspects. TRWP generated on roads during driving processes contribute to airborne non-exhaust emissions and are discussed in connection with the microplastic pollution. The major amount of TRWP consists of coarser heterogenous particles released to road surface, soils and aquatic compartments. The extensive compilation of annual emissions of tyre wear for numerous countries shows per-capita-masses ranging from 0.2 to 5.5 kg/(cap*a). Ecotoxicological studies revealed effects on aquatic organisms, but test concentrations and materials do not reflect environmental conditions. Contribution of tyre wear to PM10 accounts for up to approx. 11 mass %. A recent thorough risk assessment indicates the risk for human health via inhalation to be low, but no information is available on the risk caused by intake via the food chain. Data on degradation is scarce and most studies do not use realistic materials and conditions. The only published degradation study performed under environmental conditions implies a half-life of tyre rubber particles in soils of 16 months. For truck tyres, which mainly contain natural rubber, shorter periods were observed under optimum conditions in laboratory tests. Concentrations of tyre wear compiled from environmental monitoring studies show highly variable concentrations in road runoff, road dust, roadside soils, river sediments and river water, with a general decrease following the transport paths. However, the behaviour of TRWP in freshwater referring to transport, degradation, and sedimentation is still unclarified. Environmental monitoring of TRWP is still hampered by challenges for analytics. Thus, data on environmental concentrations is rare and has mainly exemplary character. Further research is needed with regard to emission factors, development of analytical methods for environmental matrices, long-period monitoring, fate in surface waters and soils, (eco)toxicological impacts and degradation under realistic conditions.

Microplastics and their possible sources: The example of Ofanto river in southeast Italy.

Monitoring studies have quantified microscopic plastic debris, so-called microplastics, in freshwater systems, including banks, surface waters and sediments. However, there is a lack of knowledge of freshwater and terrestrial environments. When microplastics are released in freshwater environments, they will be transported and will not remain stationary. Moreover, their transport from sink to source (land-based to river systems) may depend on several factors such as weather conditions and river hydrology. The present study aims to investigate the abundance and composition of microplastics in the most important river of Apulia Region (Southeast Italy) evaluating the main drivers and possible input sources of microplastic debris. The following work is the first study showing an Italian river context. For this research five sampling campaigns have been conducted west of the Ofanto river mouth. Microplastics were collected by three surface plankton nets fixed in the middle of the river in order to reduce the spatial and temporal variability. For each campaign, a total of six replicates were sampled during two time slots. Microplastic concentrations ranged from 0.9 ±â€¯0.4 p/m3 to 13 ±â€¯5 p/m3 showing comparable values to or greater than those ones reported in other studies. A statistically significant difference in the average microplastic concentrations in different campaigns of this study has been observed, suggesting thus a temporal variation in plastic abundances. These significant differences could be explained by the hydrology of the river that influences the particle concentration with its physical forces such as flow velocity, water level and seasonal variability. Microplastics were found at higher concentrations during wet periods indicating a land-based origin probably connected to waste produced by the surroundings agricultural areas. In fact, Spearman's correlation results show a strong positive statistically significant correlation between the concentration of microplastics and the water level (R = 0.8475, p < 0.0001).

Cierre de la orejuela izquierda por ictus pese a la anticoagulación oral (ictus resistente): resultados del registro Amplatzer Cardiac Plug / Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry

INTRODUCCIÓN Y OBJETIVOS: A pesar de la eficacia de los anticoagulantes orales (ACO), algunos pacientes mantienen una alto riesgo residual y presentan ictus aun estando en tratamiento con ACO, y falta evidencia sobre el tratamiento de estos pacientes. El objetivo del estudio es analizar la seguridad y la eficacia del cierre percutáneo de la orejuela izquierda (OI) como prevención secundaria para pacientes con fibrilación auricular no valvular que han experimentado un ictus/accidente isquémico transitorio a pesar de los ACO (ictus resistente [IR]). MÉTODOS: Se estudió a 1.047 pacientes consecutivos con fibrilación auricular no valvular sometidos a cierre percutáneo de la OI incluidos en el registro multicéntrico Amplatzer Cardiac Plug. Se seleccionó a los pacientes con IR como indicación para el cierre de la OI, y se los comparó con pacientes con otras indicaciones. RESULTADOS: En un total de 115 pacientes (11%) se produjo un IR. Las escalas CHA2DS2-VASc y HAS-BLED eran significativamente más altas en el grupo de IR (5,5+/-1,5 frente a 4,3+/-1,6; p <0,001 y 3,9+/-1,3 frente a 3,1+/-1,2; p <0,001). No hubo diferencias significativas en los eventos mayores de seguridad periprocedimiento (el 7,8 frente al 4,5%; p = 0,1). Tras 16,2+/-12,2 meses de seguimiento medio, la tasa anual de ictus/accidente isquémico transitorio observada fue del 2,6% (el 65% de reducción del riesgo) y la tasa anual de hemorragia mayor observada fue del 0% (el 100% de reducción del riesgo) en los pacientes con IR. CONCLUSIONES: Los pacientes con IR sometidos a cierre percutáneo de la OI presentaron resultados de seguridad similares que los pacientes sin IR, con una reducción significativa de los eventos de ictus/accidente isquémico transitorio y hemorragia mayor durante el seguimiento

INTRODUCTION AND OBJECTIVES: Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment. METHODS: We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications. RESULTS: A total of 115 patients (11%) with RS were identified. The CHA2DS2-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5+/-1.5 vs 4.3+/-1.6; P <.001; 3.9+/-1.3 vs 3.1+/-1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2+/-12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction). CONCLUSIONS: Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients

Left atrial appendage occlusion for stroke despite oral anticoagulation (resistant stroke). Results from the Amplatzer Cardiac Plug registry.

INTRODUCTION AND OBJECTIVES: Despite the efficacy of oral anticoagulant (OAC) therapy, some patients continue to have a high residual risk and develop a stroke on OAC therapy (resistant stroke [RS]), and there is a lack of evidence on the management of these patients. The aim of this study was to analyze the safety and efficacy of left atrial appendage occlusion (LAAO) as secondary prevention in patients with nonvalvular atrial fibrillation who have experienced a stroke/transient ischemic attack despite OAC treatment. METHODS: We analyzed data from the Amplatzer Cardiac Plug multicenter registry on 1047 consecutive patients with nonvalvular atrial fibrillation undergoing LAAO. Patientes with previous stroke on OAC therapy as indication for LAAO were identified and compared with patients with other indications. RESULTS: A total of 115 patients (11%) with RS were identified. The CHA2DS2-VASc and the HAS-BLED score were significantly higher in the RS group (respectively 5.5±1.5 vs 4.3±1.6; P <.001; 3.9±1.3 vs 3.1±1.2; P <.001). No significant differences were observed in periprocedural major safety events (7.8 vs 4.5%; P=.1). With a mean clinical follow-up of 16.2±12.2 months, the observed annual stroke/transient ischemic attack rate for the RS group was 2.6% (65% risk reduction) and the observed annual major bleeding rate was 0% (100% risk reduction). CONCLUSIONS: Patients with RS undergoing LAAO showed similar safety outcomes to patients without RS, with a significant reduction in stroke/transient ischemic attack and major bleeding events during follow-up. Adequately powered controlled trials are needed to further investigate the use of LAAO in RS patients.

Toxicity of microplastics and natural particles in the freshwater dipteran Chironomus riparius: Same same but different?

Microplastics (MP) are contaminants of emerging concern in aquatic ecosystems. While the number of studies is rapidly increasing, a comparison of the toxicity of MP and natural particulate matter is largely missing. In addition, research focusses on the impacts of hydrophobic chemicals sorbed to plastics. However, the interactive effects of MP and hydrophilic, dissolved chemicals remain largely unknown. Therefore, we conducted chronic toxicity studies with larvae of the freshwater dipteran Chironomus riparius exposed to unplasticised polyvinyl chloride MP (PVC-MP) as well as kaolin and diatomite as reference materials for 28 days. In addition, we investigated the effects of particles in combination with the neonicotinoid imidacloprid in a multiple-stressor experiment. High concentrations of kaolin positively affected the chironomids. In contrast, exposure to diatomite and PVC-MP reduced the emergence and mass of C. riparius. Likewise, the toxicity of imidacloprid was enhanced in the presence of PVC-MP and slightly decreased in the co-exposure with kaolin. Overall, parallel experiments and chemical analysis indicate that the toxicity of PVC-MP was not caused by leached or sorbed chemicals. Our study demonstrates that PVC-MP induce more severe effects than both natural particulate materials. However, the latter are not benign per se, as the case of diatomite highlights. Considering the high, environmentally irrelevant concentrations needed to induce adverse effects, C. riparius is insensitive to exposures to PVC-MP.

On the geoarchaeology of Limyra (SW Anatolia)-new insights into the famous Lycian city and its environs.

Geoarchives in ancient settlement sites and their environs bear valuable information about Holocene landscape evolution and human-environment interactions. During the last six millennia, sea-level and coastline changes have had a significant impact on coastal settlements, some of which even had to be relocated. This paper reveals new insights into the spatio-temporal development of the Lycian city of Limyra. Selected sediment cores were analyzed using a multiproxy approach, combining sedimentology, geochemistry, micropaleontology, and 14C dating. When the postglacial sea-level rise decelerated, a coastal barrier and a deep lake, presumably a lagoon, evolved after the mid-Holocene. The siltation history of the lake is complex: three coastal peat layers (mid-4th millennium BC, end of 3rd/beginning of 2nd millennium BC, beginning of 1st millennium BC), indicate periods of semiterrestrial conditions. That they are sandwiched by lake sediments is consistent with new expansion phases of the lake, most likely triggered by coseismic subsidence. There is evidence of a former lakeshore, dated to between 1400 and 1100 BC, with an intentionally deposited layer of anthropogenic remains, now at 5.5 m below the surface. In the mid-1st millennium BC, the lake silted up, river channels evolved, and people started to settle the area of the later city of Limyra.

A new approach in separating microplastics from environmental samples based on their electrostatic behavior.

Numerous studies on microplastics (MPs; Ø < 5 mm) in the aquatic environment have been published, but knowledge about the occurrence and ecological risks of MPs is limited. This is in part because current data on the distribution of MPs are comparable only to a limited extent, due to the many different methods of investigation. In addition, sample preparation is often difficult such that standard procedures are lacking. The aim of this work was to simplify the preparation of different kinds of MP samples. Our method makes use of the electrostatic behavior of plastic particles to facilitate their separation from sample matter, with up to 99% of the original sample mass removed without any loss of MPs. To determine the efficacy of this approach, four different materials (quartz sand, freshwater suspended particulate matter, freshwater sediment, and beach sand) were spiked with MPs (size: 0.063-5 mm from the seven most common types of plastics, one bioplastic type, polyethylene fibers, and tire wear. A modified electrostatic metal/plastic separator was used to reduce the sample mass and concentrate the plastics based on their physical separation. The recovery achieved with this method was as high as nearly 100% for each type of material. The method was then tested on plastic particles of different shapes and types isolated from the Rhine River. These were successfully electroseparated from the four materials, which demonstrated the utility of this method. Its advantages include the simplified handling and preparation of different field samples as well as a much shorter processing time, because after the last separation step there is hardly any biological material remaining in the sample fraction.

A comparison of two-dimensional and real-time 3D transoesophageal echocardiography and angiography for assessing the left atrial appendage anatomy for sizing a left atrial appendage occlusion system: impact of volume loading.

AIMS: Correct sizing of a left atrial appendage (LAA) closure system is important to avoid redeployment of the device and peri-device leaks. The aims of this study were to assess the significance of two-dimensional transoesophageal echocardiography (2D-TEE), real-time 3D transoesophageal echocardiography (RT 3D-TEE) and angiography for measuring the size of the LAA landing zone and to determine the impact on sizing an LAA closure device. Furthermore, we investigated the relevance of volume loading on LAA size. METHODS AND RESULTS: In a prospective study, 46 patients underwent 2D-TEE and RT 3D-TEE 24 hours prior to LAA closure, at the beginning of the procedure and just before the procedure after volume loading with an average of 1,035±246 ml. Angiography was performed immediately before the implantation. Maximal diameter (2.2±0.4 versus 2.3±0.4 cm; p<0.01), perimeter (6.5±1.0 versus 6.8±1.0 cm, p<0.01) and area (3.2±1.0 versus 3.5±1.1 cm², p<0.01) of the LAA increased significantly after volume loading. The highest correlation (R) between measurements and LAA device size was found for RT 3D-TEE-derived perimeter (R=0.97) and area (R=0.96), whereas the maximal diameter (R=0.78) measured by 2D-TEE and angiography (R=0.76) correlated less closely. Sizing based on an RT 3D-TEE-measured perimeter resulted only in 4% of undersizing the implanted device. Peri-device leaks occurred in seven cases (15%) and were associated with a lower compression of LAA devices (7±1.3% versus 14±3.2% for patients without leaks, p<0.001). CONCLUSIONS: Volume loading before LAA closure increases LAA dimensions significantly. RT 3D-TEE measurements show a closer correlation to LAA closure device size than 2D-TEE or angiographic measurements.

Characterization of Cerebrovascular Events After Left Atrial Appendage Occlusion.

Cardioembolic strokes are generally more lethal and disabling than other source of strokes. Data from PROTECT AF (Watchman Left Atrial Appendage Closure Technology for Embolic Protection in Patients With Atrial Fibrillation) suggest that strokes after left atrial appendage occlusion (LAAO) with the Watchman device are less disabling than those in the warfarin group. No data assessing the severity of strokes after LAAO with the AMPLATZER Cardiac Plug (ACP) are available. The objective of the study was to evaluate the severity of cerebrovascular events after LAAO with the ACP in a population mostly characterized by an absolute or relative contraindication to oral anticoagulation. Data from the ACP multicenter registry were analyzed. Disabling strokes were defined as those with a modified Rankin score of 3 to 6 at 90 days after the event. A total of 1,047 subjects were included. The mean age and CHADS2 score were 75 ± 8 years and 2.8 ± 1.3, respectively. Procedural success was achieved in 97.3% and 4.9% of the patients presented procedural major adverse events. Clinical follow-up was complete in 98.2% of patients with a median of 13 months. There were 9 strokes (0.9%), 9 transient ischemic attacks (0.9%), and no intracranial hemorrhages (0%) at follow-up. After excluding 2 patients with pre-LAAO disability, functional assessment showed disabling events in 3 (19%) of the remaining 16 patients. The median time of presentation was 420 days (interquartile range 234 to 671) after LAAO, and 17 patients (94%) were on single-antiplatelet therapy when the event occurred. According to our results, cerebrovascular events after LAAO with the ACP system were infrequent and mostly nondisabling.

Comparison of Efficacy and Safety of Left Atrial Appendage Occlusion in Patients Aged <75 to ≥ 75 Years.

Left atrial appendage occlusion (LAAO) is emerging as a promising alternative to oral anticoagulation. Because aged patients present a greater risk of not only cardioembolic events but also major bleeding, LAAO might represent a valid alternative as this would allow oral anticoagulation cessation while keeping cardioembolic protection. The objective of the study was to explore the safety and efficacy of LAAO in elderly patients. Data from the AMPLATZER Cardiac Plug multicenter registry were analyzed. The cohort was categorized in 2 groups (<75 vs ≥ 75 years). A total of 1,053 subjects were included in the registry. Of them, 219 were excluded because of combined procedures. As a result, 828 subjects were included (54.6% ≥ 75 years). Procedural success was high and similar in both groups (97.3%). Acute procedural major adverse events were not statistically different among groups (3.2% in <75 years vs 5.1%; p = 0.17) although stratified analysis showed a higher incidence of cardiac tamponade in elderly patients (0.5% vs 2.2%; p = 0.04). With a median follow-up of 16.8 months, no significant differences in stroke/TIA (1.9% vs 2.3%; p = 0.89) and major bleeding (1.7% vs 2.6%; p = 0.54) were observed. In conclusion, LAAO was associated with similar procedural success in patients aged <75 and ≥ 75 years although older patients had a higher incidence of cardiac tamponade. At follow-up, stroke and major bleeding rates were similar among groups.

Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug.

AIMS: To investigate the safety, feasibility, and efficacy of left atrial appendage occlusion (LAAO) with the AMPLATZER Cardiac Plug (ACP) for stroke prevention in patients with atrial fibrillation (AF). METHODS AND RESULTS: Data from consecutive patients treated in 22 centres were collected. A total of 1,047 patients were included in the study. Procedural success was 97.3%. There were 52 (4.97%) periprocedural major adverse events. Follow-up was complete in 1,001/1,019 (98.2%) of successfully implanted patients (average 13 months, total 1,349 patient-years). One-year all-cause mortality was 4.2%. No death at follow-up was reported as device-related. There were nine strokes (0.9%) and nine transient ischaemic attacks (0.9%) during follow-up. The annual rate of systemic thromboembolism was 2.3% (31/1,349 patient-years), which is a 59% risk reduction. There were 15 major bleedings (1.5%) during follow-up. The annual rate of major bleeding was 2.1% (28/1,349 patient-years), which is a 61% risk reduction. Patients with single LAAO on aspirin monotherapy or no therapy and longer follow-up had fewer cerebral and fewer bleeding events. CONCLUSIONS: In this multicentre study, LAAO with the ACP showed high procedural success and a favourable outcome for the prevention of AF-related thromboembolism. Modification in antithrombotic therapy after LAAO may result in reduction of bleeding events.