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Berti S, Pastormerlo LE, Korsholm K, Saw J, Alkhouli M, Costa MP, Odenstedt J, Packer EJ, Tondo C, Santoro G, Nielsen-Kudsk JE. Intracardiac echocardiography for guidance of transcatheter left atrial appendage occlusion: An expert consensus document. Catheter Cardiovasc Interv 2021; 98:815-825. [PMID: 34086394 DOI: 10.1002/ccd.29791] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/12/2021] [Accepted: 05/17/2021] [Indexed: 11/12/2022]
Abstract
Transcatheter left atrial appendage occlusion (LAAO) is an increasingly used alternative to oral anticoagulation in selected patients with atrial fibrillation. Intraprocedural imaging is a crucial for a successful intervention, with transesophageal echocardiography (TEE) as the current gold standard. Since some important limitations may affect TEE use, intracardiac echocardiography (ICE) is increasingly used as an alternative to TEE for guiding LAAO. The lack of a standardized imaging protocol has slowed the adoption of ICE into clinical practice. On the basis of current research and expert consensus, this paper provides a protocol for ICE support of left atrial appendage occlusion.
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Affiliation(s)
- Sergio Berti
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa
| | - Luigi E Pastormerlo
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy.,Life Science Institute, Scuola Superiore Sant'Anna, Pisa
| | - Kasper Korsholm
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Jacqueline Saw
- Interventional Cardiology, Division of Cardiology, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Mohamad Alkhouli
- Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| | - Marco P Costa
- Serviço de Cardiologia, Centro Hospilatar e Universitário de Coimbra, Coimbra, Portugal
| | - Jacob Odenstedt
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Erik Js Packer
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Claudio Tondo
- Heart Rhythm Center, Centro Cardiologico Monzino IRCCS, Milan, Italy, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Gennaro Santoro
- Fondazione CNR-RegioneToscana G Monasterio, Ospedale del Cuore G Massa, Italy
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2
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Turagam MK, Velagapudi P, Kar S, Holmes D, Reddy VY, Refaat MM, Di Biase L, Al-Ahmed A, Chung MK, Lewalter T, Edgerton J, Cox J, Fisher J, Natale A, Lakkireddy DR. Cardiovascular Therapies Targeting Left Atrial Appendage. J Am Coll Cardiol 2018; 72:448-463. [PMID: 29954658 PMCID: PMC8420938 DOI: 10.1016/j.jacc.2018.05.048] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/11/2018] [Accepted: 05/16/2018] [Indexed: 12/28/2022]
Abstract
Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.
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Affiliation(s)
- Mohit K Turagam
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Poonam Velagapudi
- Structural Heart and Valve Center, Center for Interventional Vascular Therapy, Division of Cardiology, Columbia University Medical Center, New York, New York
| | - Saibal Kar
- Division of Cardiology, Cedars Sinai Medical Center, Los Angeles, California
| | - David Holmes
- Cardiovascular Medicine Department, Mayo Clinic, Rochester, Minnesota
| | - Vivek Y Reddy
- Helmsley Electrophysiology Center in the Department of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Marwan M Refaat
- Department of Internal Medicine, Cardiology/Cardiac Electrophysiology and Department of Biochemistry and Molecular Genetics, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
| | - Luigi Di Biase
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Amin Al-Ahmed
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Mina K Chung
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - James Edgerton
- Department of Cardiac Surgery, The Heart Hospital Baylor Plano, Plano, Texas
| | - James Cox
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - John Fisher
- Electrophysiology Section, Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, New York
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute at St. David's Medical Center, Austin, Texas
| | - Dhanunjaya R Lakkireddy
- Kansas City Heart Rhythm Institute & Research Foundation, Overland Park Regional Medical Center, Kansas City, Kansas.
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3
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Wei Z, Zhang X, Wu H, Xie J, Dai Q, Wang L, Xu B. A meta-analysis for efficacy and safety evaluation of transcatheter left atrial appendage occlusion in patients with nonvalvular atrial fibrillation. Medicine (Baltimore) 2016; 95:e4382. [PMID: 27495048 PMCID: PMC4979802 DOI: 10.1097/md.0000000000004382] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES This meta-analysis was conducted to evaluate the efficacy and safety of transcatheter left atrial appendage (LAA) occlusion in patients with nonvalvular atrial fibrillation. METHODS The randomized controlled trials (RCT) or observational studies with any transcatheter LAA occlusion devices were searched in PubMed, Embase, and Cochrane library from inception to November 2015. The incidence rates from individual studies were combined to evaluate the procedural efficacy and safety, including all-cause death, cardiac/neurological death, stroke, transient ischemic attack (TIA), thrombosis, hemorrhagic complications, and pericardial effusion/tamponade. RESULTS Thirty-eight studies involving 3585 patients and 6 different occlusion devices were eligible for our inclusion criteria. The procedural failure rate for LAA closure was 0.02 (95% CI: 0.02-0.03). The all-cause mortality was 0.03 (95% CI: 0.02-0.03) and cardiac/neurological mortality was 0 (95% CI: 0.00-0.01). The stroke/TIA rate was estimated only 0.01 (95% CI: 0.01-0.01). The incidence of thrombus on devices was 0.01 (95% CI: 0.01-0.02). The major hemorrhagic complication rate was estimated 0.01 (95% CI: 0.00-0.01). Pericardial effusion/tamponade was estimated 0.02 (95% CI: 0.02-0.03). No heterogeneity was observed for above pooled estimates (I = 0). In devices subgroups analysis, the all-cause mortality and cardiac/neurological mortality of PLAATO group were the highest (P = 0.01 and P < 0.01 respectively), whereas the incidence of thrombus on devices in the ACP group was the highest (P < 0.01). In follow-up period subgroups analysis, there were significant differences in all-cause death, stroke/TIA, major hemorrhage, and pericardial effusion/tamponade events between the shorter and longer follow-up period subgroups (P < 0.05). However, the differences among the subgroups were numerically small. CONCLUSIONS the pooled data demonstrated that transcatheter LAA occlusion was effective and safe in the patients with nonvalvular atrial fibrillation who were not suitable for lifelong antithrombotic therapy.
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Affiliation(s)
| | | | | | | | | | - Lian Wang
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
- Correspondence: Lian Wang and Biao Xu, Department of Cardiology, DrumTower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (e-mails: [LW]; [BX])
| | - Biao Xu
- Department of Cardiology, Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
- Correspondence: Lian Wang and Biao Xu, Department of Cardiology, DrumTower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China (e-mails: [LW]; [BX])
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Möbius-Winkler S, Majunke N, Sandri M, Mangner N, Linke A, Stone GW, Dähnert I, Schuler G, Sick PB. Percutaneous left atrial appendage closure: Technical aspects and prevention of periprocedural complications with the watchman device. World J Cardiol 2015; 7:65-75. [PMID: 25717354 PMCID: PMC4325303 DOI: 10.4330/wjc.v7.i2.65] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 10/26/2014] [Accepted: 11/10/2014] [Indexed: 02/06/2023] Open
Abstract
Transcatheter closure of the left atrial appendage has been developed as an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation, and as a primary therapy for patients with contraindications to chronic oral anticoagulation. The promise of this new intervention compared with warfarin has been supported by several, small studies and two pivotal randomized trial with the Watchman Device. The results regarding risk reduction for stroke have been favourable although acute complications were not infrequent. Procedural complications, which are mainly related to transseptal puncture and device implantation, include air embolism, pericardial effusions/tamponade and device embolization. Knowledge of nature, management and prevention of complications should minimize the risk of complications and allow transcatheter left atrial appendage closure to emerge as a therapeutic option for patients with atrial fibrillation at risk for cardioembolic stroke.
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Left atrial appendage occlusion for prevention of stroke in nonvalvular atrial fibrillation: a meta-analysis. J Interv Card Electrophysiol 2015; 43:79-89. [PMID: 25711953 DOI: 10.1007/s10840-015-9988-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 02/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE When anticoagulation for stroke prevention is contraindicated, left atrial appendage occlusion (LAAO) may be performed. Studies of LAAO have been limited by their small size, disparate patient populations, and lack of control group. Our purpose was to perform a meta-analysis of the safety and efficacy of LAAO in comparison with standard therapy for stroke prevention in nonvalvular AF. METHODS Due to the lack of a control group in studies of LAAO, data on stroke prevention from multiple large outcomes studies were used to produce a hypothetical control group based on clinical variables in the individual studies. Results were stratified according to LAAO device type. RESULTS We identified 16 studies with a total of 1759 patients receiving LAAO. Summary estimates demonstrate LAAO reduced risk of stroke in comparison with no therapy or aspirin therapy [relative risk (RR), 0.34; 95 % CI, 0.25-0.46] and in comparison with warfarin therapy (RR, 0.65; 95 % CI, 0.46-0.91). Summary estimates differed based on the study used to derive the hypothetical control group. Device deployment was unsuccessful in 6.1 % of patients, and overall complication rate was 7.1 %. Efficacy and safety were similar across LAAO device type although a majority of patients in the meta-analysis received a Watchman device. CONCLUSION Our data suggest that LAAO is a reasonable option for stroke prophylaxis in AF when anticoagulation is not an option, and the risk for stroke outweighs the risk of procedural complications. Data were limited with the use of most available devices. To better establish the risk and benefit of LAAO in comparison with standard therapy, more randomized controlled trials are necessary.
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Proietti R, Joza J, Arensi A, Levi M, Russo V, Tzikas A, Danna P, Sagone A, Viecca M, Essebag V. Novel nonpharmacologic approaches for stroke prevention in atrial fibrillation: results from clinical trials. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2015; 8:103-14. [PMID: 25678828 PMCID: PMC4319717 DOI: 10.2147/mder.s70672] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Atrial fibrillation (AF), the most common cardiac arrhythmia, confers a 5-fold risk of stroke that increases to 17-fold when associated with mitral stenosis. At this time, the most effective long-term solution to protect patients from stroke and thromboembolism is oral anticoagulation, either with vitamin K antagonists (VKAs) or a novel oral anticoagulant (NOAC). Despite the significant benefits they confer, both VKAs and NOACs are underused because of their increased potential for bleeding, and VKAs are underused because of their narrow therapeutic range, need for regular international normalized ratio checks, and interactions with food or medications. In patients with nonvalvular AF, approximately 90% of strokes originate from the left atrial appendage (LAA); in patients with rheumatic mitral valve disease, many patients (60%) have strokes that originate from the left atrium itself. Surgical LAA amputation or closure, although widely used to reduce stroke risk in association with cardiac surgery, is not currently performed as a stand-alone operation for stroke risk reduction because of its invasiveness. Percutaneous LAA closure, as an alternative to anticoagulation, has been increasingly used during the last decade in an effort to reduce stroke risk in nonvalvular AF. Several devices have been introduced during this time, of which one has demonstrated noninferiority compared with warfarin in a randomized controlled trial. This review describes the available technologies for percutaneous LAA closure, as well as a summary of the published trials concerning their safety and efficacy in reducing stroke risk in AF.
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Affiliation(s)
- Riccardo Proietti
- McGill University Health Center, Montreal, QC, Canada ; Cardiology Department, Luigi Sacco Hospital, Milano, Italy
| | | | - Andrea Arensi
- Cardiology Department, Luigi Sacco Hospital, Milano, Italy
| | - Michael Levi
- McGill University Health Center, Montreal, QC, Canada
| | - Vincenzo Russo
- Cardiology Department, Second University of Naples, Monaldi Hospital, Naples, Italy
| | | | - Paolo Danna
- Cardiology Department, Luigi Sacco Hospital, Milano, Italy
| | - Antonio Sagone
- Cardiology Department, Luigi Sacco Hospital, Milano, Italy
| | | | - Vidal Essebag
- McGill University Health Center, Montreal, QC, Canada ; Hôpital Sacré-Coeur de Montréal, Montreal, QC, Canada
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7
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Moss JD. Left atrial appendage exclusion for prevention of stroke in atrial fibrillation: review of minimally invasive approaches. Curr Cardiol Rep 2014; 16:448. [PMID: 24408675 DOI: 10.1007/s11886-013-0448-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Stroke prevention is of vital importance in the management of atrial fibrillation (AF), though the proven strategy of systemic anticoagulation for thromboembolic prophylaxis is underutilized for a variety of reasons. The left atrial appendage (LAA) has long been suspected as the principal source of arterial emboli, particularly in nonvalvular AF, and a variety of techniques for its exclusion from the circulation have been developed. This review highlights the history of the LAA as a target of intervention, and the parallel advances in three minimally invasive strategies for its exclusion: percutaneous occlusion of the LAA orifice from within the left atrium, closed-chest ligation via a percutaneous pericardial approach, and minimally invasive thoracoscopic surgery. While further study is necessary, available evidence suggests that effective LAA exclusion is becoming a viable alternative to anticoagulation for stroke prevention in nonvalvular AF.
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Affiliation(s)
- Joshua D Moss
- Section of Cardiology, Department of Internal Medicine, University of Chicago, 5758 S. Maryland Ave, MC 9024, Chicago, IL, 60637, USA,
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8
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De Backer O, Arnous S, Ihlemann N, Vejlstrup N, Jørgensen E, Pehrson S, Krieger TDW, Meier P, Søndergaard L, Franzen OW. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart 2014; 1:e000020. [PMID: 25332785 PMCID: PMC4195925 DOI: 10.1136/openhrt-2013-000020] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/13/2014] [Accepted: 04/29/2014] [Indexed: 12/22/2022] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice. One of its most devastating complications is the development of thromboembolism leading to fatal or disabling stroke. Oral anticoagulation (OAC, warfarin) is the standard treatment for stroke prevention in patients with AF with an increased stroke risk. However, there are several obstacles to long-term OAC therapy, including the risk of serious bleeding, several drug–drug interactions and the need for frequent blood testing. Although newer oral anticoagulants have been developed, these drugs also face issues of major bleeding and non-compliance. Therefore, alternative treatment options for stroke prevention in patients with AF with a high stroke risk are needed. Percutaneous left atrial appendage (LAA) occlusion is an evolving therapy, which should be taken into consideration in those patients with non-valvular AF with a high stroke risk and contraindications for OAC. This article aims to discuss the rationale for LAA closure, the available LAA occlusion devices and their clinical evidence until now. Moreover, we discuss the importance of proper patient selection, the role of various imaging techniques and the need for a more tailored postprocedural antithrombotic therapy.
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Affiliation(s)
- O De Backer
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Arnous
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Ihlemann
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - N Vejlstrup
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - E Jørgensen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - S Pehrson
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - T D W Krieger
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - P Meier
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - L Søndergaard
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
| | - O W Franzen
- Department of Cardiology , Rigshospitalet , Copenhagen Ø , Denmark
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9
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Kapur S, Mansour M. Left Atrial Appendage Closure Devices For Stroke Prevention. Arrhythm Electrophysiol Rev 2014; 3:25-9. [PMID: 26835061 DOI: 10.15420/aer.2011.3.1.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 04/02/2014] [Indexed: 01/05/2023] Open
Abstract
Cardioembolic stroke is a major cause of morbidity and mortality in patients with atrial fibrillation (AF). The left atrial appendage (LAA) is the prominent source of clot formation. While systemic anticoagulation is the current standard of care, anticoagulants carry many contraindications and possible complications. Techniques for elimination of the LAA are in various stages of development and early clinical use. In the coming years, accumulating data will help guide the management of AF patients at risk of bleeding as well as potentially become first-line therapy to reduce the risk of thromboembolic stroke. The purpose of this article is to review current endovascular and epicardial catheter-based LAA occlusion devices and the clinical data supporting their use.
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Affiliation(s)
- Sunil Kapur
- Fellow in Cardiovascular Medicine, Brigham and Women's Hospital
| | - Moussa Mansour
- Associate Professor in Medicine, Harvard Medical School; Director, Cardiac Electrophysiology Laboratory; Director, Atrial Fibrillation Program, Massachussets General Hospital, US
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10
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Aryana A, Saad EB, d'Avila A. Left atrial appendage occlusion and ligation devices: what is available, how to implement them, and how to manage and avoid complications. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2012; 14:503-19. [PMID: 22886639 DOI: 10.1007/s11936-012-0203-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OPINION STATEMENT Atrial fibrillation (AF) is the most common cardiac arrhythmia worldwide, and it is associated with an elevated risk of thromboembolic events, including ischemic stroke. Evidence suggests that at least 90 % of left atrial thrombi discovered in patients with AF are localized to the left atrial appendage (LAA). Surgical ligation or excision of the LAA is considered the standard of care in patients who undergo mitral valve surgery or as an adjunct to a surgical Maze procedure for treatment of AF. In addition, in selected patients with AF and an elevated risk of thromboembolic events, particularly in those with contraindication to oral anticoagulation (OAC) therapy, it is reasonable to consider LAA exclusion to offer protection against ischemic stroke and other embolic complications. This can be achieved through a number of different strategies, including surgical amputation or ligation of the LAA, percutaneous endocardial occlusion of the LAA by deployment of occlusive devices, and also ligation of the LAA via a closed-chest, percutaneous, epicardial catheter-based approach in select patients. Although results from several recent percutaneous LAA closure and ligation studies are highly promising, the evidence for long-term efficacy and safety is insufficient to presently recommend this approach to all patients other than those in whom long-term OAC is contraindicated. Future randomized studies are required to further address the long-term safety and efficacy of these therapeutic options. Finally, the role for LAA occlusion and ligation seems less clear in patients who undergo successful catheter ablation of AF, since at least in a subgroup of these patients antiplatelet therapy alone has been shown to be sufficient.
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Affiliation(s)
- Arash Aryana
- Regional Cardiology Associates and Mercy Heart & Vascular Institute, Sacramento, CA, USA
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11
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Leithäuser B, Park JW. Cardioembolic stroke in atrial fibrillation-rationale for preventive closure of the left atrial appendage. Korean Circ J 2009; 39:443-58. [PMID: 19997539 PMCID: PMC2790130 DOI: 10.4070/kcj.2009.39.11.443] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Atrial fibrillation is the most common cardiac arrhythmias, and a major cause of morbidity and mortality due to cardioembolic stroke. The left atrial appendage is the major site of thrombus formation in non-valvular atrial fibrillation. Loss of atrial systole in atrial fibrillation and increased relative risk of associated stroke point strongly toward a role for stasis of blood in left atrial thrombosis, although thrombus formation is multifactorial, and much more than blood flow irregularities are implicated. Oral anticoagulation with vitamin-K-antagonists is currently the most effective prophylaxis for stroke in atrial fibrillation. Unfortunately, this treatment is often contraindicated, particularly in the elderly, in whom risk of stroke is high. Moreover, given the risk of major bleeding, there is reason to be skeptical of the net benefit when warfarin is used in those patients. This work reviews the pathophysiology of cardioembolic stroke and critically spotlights the current status of preventive anticoagulation therapy. Various techniques to exclude the left atrial appendage from circulation were discussed as a considerable alternative for stroke prophylaxis.
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Affiliation(s)
- Boris Leithäuser
- Asklepios General Hospital Harburg, 1st Medical Department, Cardiology, Intensive Care Medicine, Hamburg, Germany
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