Percutaneous alternative to the Maze procedure for the treatment of persistent or long-standing persistent atrial fibrillation (aMAZE trial): Rationale and design

Left Atrial Appendage Electrical Isolation for Treatment of Recurrent Atrial Fibrillation: A Meta-Analysis

OBJECTIVES

In this study, the authors sought to perform a meta-analysis of controlled studies assessing the relationship between left atrial appendage (LAA) electrical isolation (EI) and recurrent atrial fibrillation (AF).

BACKGROUND

LAA triggers could play an important role in AF and can be treated with complete EI of the LAA via surgical or percutaneous approaches.

METHODS

We conducted a meta-analysis of all controlled studies published as of November 21, 2016, assessing the relationship between left atrial appendage electrical isolation (LAAEI) and recurrent AF. The primary endpoint was atrial tachycardia (AT) or AF recurrence after the post-procedure blanking period. The association between LAAEI and AT/AF was estimated using random-effects modeling. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the DerSimonian and Laird method.

RESULTS

We identified 7 studies including 1,037 patients; LAAEI was performed in 566 patients (55%). LAAEI was associated with a significantly lower rate of AT/AF recurrence in the primary analysis (OR: 0.38; 95% CI: 0.16 to 0.90; p = 0.02). The association between LAAEI and recurrent AT/AF was strongest in a sensitivity analysis restricted to studies of percutaneous LAAEI (OR: 0.22; 95% CI: 0.11 to 0.46; p < 0.001; 5 studies, n = 623). LAAEI was not associated with thromboembolism (OR: 0.50; 95% CI: 0.18 to 1.39; p = 0.18; 5 studies, n = 767), although these studies either incorporated LAA occlusion (3 studies, n = 552 patients) or follow-up echocardiography to assess LAA function (2 studies, n = 215 patients) to inform antithrombotic strategies.

CONCLUSIONS

LAAEI is associated with a significant reduction in recurrent AT/AF. Randomized trials are required to confirm the efficacy and long-term safety of LAAEI and to determine the optimal concomitant antithrombotic strategy.

Anesthetic Management of Patients Undergoing Percutaneous Endocardial and Epicardial Left Atrial Appendage Occlusion

Atrial fibrillation is the most common cardiac arrhythmia in adults affecting almost 6 million adults in the United States. The 2 most common comorbidities associated with atrial fibrillation are heart failure and thromboembolic events. Heart failure symptoms may be treated with rate control, antiarrhythmic medications or by catheter ablation. Unfortunately, despite optimal medical management, thromboembolic events still occur. Recently, there has been a great deal of interest and innovation in finding an alternative to chronic anticoagulation. Several percutaneous left atrial appendage occlusion devices have been developed over recent years, some of which have proven to be noninferior to anticoagulation in preventing strokes in atrial fibrillation patients. The 2 most widely used left atrial appendage occlusion devices are the WATCHMAN (Atritech Inc, Plymouth, MN, USA) and the LARIAT (SentreHEART, Palo Alto, CA, USA) devices. After a detailed description of the procedures, the anesthetic considerations of each procedure and management of specific adverse events are discussed within this review.

Left Atrial Appendage Occlusion for Stroke Prevention

More than 2.3 million adults in the United States have atrial fibrillation (AF), which exposes them to a 5-fold increased risk of stroke. The left atrial appendage (LAA) appears to be the source of thrombus formation in the vast majority of these patients. Anticoagulation significantly reduces the risk of stroke, but often we encounter patients who have absolute or relative contraindication to anticoagulation. Percutaneous LAA exclusion offers an alternative to anticoagulation to decrease the risk of stroke. Three device systems are currently available in the United States. The WATCHMAN® device is the most studied and approved by Food and Drug Administration (FDA) to be used in patients with AF unsuitable for anticoagulation who are at a high risk of stroke. The Amulet® device is currently being used as part of the AMPLATZER® Amulet® LAA Occluder trial, which is a non-inferiority randomized trial comparing the Amulet® to the WATCHMAN® device. The third device in use is the LARIAT®, which is an FDA approved snare and pre-tied stich system. It is used to approximate soft tissue which in this case is the LAA. It is a hybrid system and requires both epicardial and endocardial access. The main obstacle to percutaneous LAA closure is procedural related complications, which can be minimized with optimum operator experience.

Novel stroke risk reduction in atrial fibrillation: left atrial appendage occlusion with a focus on the Watchman closure device

Atrial fibrillation (AF) remains an important clinical problem with severe complications such as stroke, which especially harms those with risk factors as calculated by the CHADS2 or CHA2DS2-VASc. Until now, no therapy has proven 100% effective against AF. Since the left atrial appendage (LAA) is the most prominent nonvalvular AF-related thromboembolic source and (novel) oral anticoagulant [(N)OAC] carries the hazard of bleeding, LAA occlusion may be an alternative, especially in patients who are ineligible for (N)OAC therapy. In this review, we discuss several LAA occlusion techniques with a focus on the Watchman device since this device is the most thoroughly studied device of all.

Five years of keeping a watch on the left atrial appendage-how has the WATCHMAN fared?

Left atrial appendage closure (LAAC) is a promising site-directed therapy for stroke prevention in patients with non-valvular atrial fibrillation (AF) who are ineligible or contraindicated for long-term oral anticoagulation. A variety of LAAC modalities are available, including percutaneous endocardial occluder devices such as WATCHMAN^TM (Boston Scientific Corp., Marlborough, MA, USA), and an ever-increasing body of evidence is helping to define the optimal use of each technique. Similarly increased experience with LAAC has revealed challenges such as device-related thrombi and peri-device leaks for which the long-term significance and appropriate management are areas of active investigation. We review the evolution and long-term outcomes with the WATCHMAN^TM device with particular emphasis on the nuances of its use and its role in the broader landscape of appendageology.

Left atrial appendage ligation with the next generation LARIAT(+) suture delivery device: Early clinical experience

BACKGROUND

The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure with a micropuncture pericardial access approach and the new LARIAT(+) suture delivery device.

METHODS

Seventy-two patients with atrial fibrillation were enrolled to undergo telescopic micropuncture pericardial access and percutaneous ligation of the LAA with the LARIAT(+) device. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 30days and 90days post-LAA ligation. Patients were monitored for 12months by an independent clinical research organization for adverse events, stroke, embolic events and death of any cause.

RESULTS

72 patients were screened for the LARIAT(+) procedure. Fourteen patients were screened failures (7 patients due to unfavorable anatomy and 7 patients with LAA thrombus). Fifty-eight patients underwent successful LAA ligation. All 58 patients had complete acute closure of the LAA. At 1month 52 of 54 patients (96.3%) had LAA closure, while at 3months 48 of 52 patients (92.3%) had LAA closure. There were no leaks greater than 3mm at both 1 and 3months. There were no device or procedural related complications, and only 1 30day adverse event involving late pericardial effusion. There were no strokes, embolic events or deaths after 12months.

CONCLUSIONS

LAA closure with the micropuncture pericardial access approach and the LARIAT(+) device can be performed effectively with acceptably low periprocedural adverse events.