Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience

Imaging assessment after percutaneous left atrial appendage closure: from immediate to long-term follow-up

Growing evidence has demonstrated the clinical benefit of percutaneous left atrial appendage closure (LAAC) in patients with atrial fibrillation. Although procedural complication rates have declined with increasing experience, post-procedural device-related complications persist, impacting prognosis and reducing the long-term benefits of the procedure. Given the potential impact of these complications, surveillance imaging after LAAC is mandatory. Currently, different imaging modalities offer unique advantages to manage these complications which warrant a combined approach to optimize both short- and long-term follow-up. The aims of this review are to explore the distinct characteristics of each imaging modality, highlighting the primary findings to be assessed during follow-up imaging. Additionally, we propose an optimized clinical imaging surveillance roadmap from discharge to long-term follow-up.

Impact of CHA2DS2-VASc Score in the Outcomes of Patients Undergoing a Simplified Pathway for Percutaneous Left Atrial Appendage Closure

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) is usually performed after a pre-procedural evaluation by transesophageal echocardiography (TOE) or cardiac computed tomography angiography (CCTA). Nevertheless, these ad-hoc examinations imply an additional use of hospital resources and time spending.

AIMS

To investigate long-term clinical outcomes, effectiveness and safety of performing LAAC procedures without pre-procedural imaging assessment in patients with high and very high thromboembolic risk based on CHA2DS2-VASc score.

METHODS

From January 2016 to January 2023, 227 consecutive patients undergoing LAAC following an optimized pathway that removed the use of pre-procedural TOE or CCTA imaging assessment, were enrolled in this single-center, retrospective study. Patients were divided into two groups based on thromboembolic risk: 94 had CHA2DS2-VASc scores ≥ 5 and 133 had CHA2DS2-VASc scores < 5). The primary endpoint was a composite of all-cause death, stroke, systemic embolization, or bleeding events at 2 years. Co-primary endpoints were device success, device-related thrombosis (DRT) and peri-device leaks (PDL) ≥ 3 mm at TOE follow-up.

RESULTS

At 2 years, no significant differences were observed between groups in the primary composite endpoint (KM est. 24.81% vs. 20.21%, plog-rank = 0.7; aHR 0.85, CI: 0.48-1.50, p = 0.58). Device success was 98.7% overall, with no significant differences between groups (aOR 0.32% CI: 0.03-3.80; p = 0.37). DRT and PDL ≥ 3 mm rates were low (4.3% vs. 1.5%, p = 0.26% and 3.2% vs. 2.3%, p = 0.75, respectively). In-hospital complications were low and comparable in both groups.

CONCLUSIONS

In a consecutive series of patients undergoing LAAC, a simplified approach without pre-operative imaging assessment showed comparable results at 2-year for the primary composite endpoint of all-cause death, stroke, systemic embolization, or bleeding events in patients with CHA2DS2-VASc score ≥ 5 and those with CHA2DS2-VASc score < 5.

Left atrial appendage occlusion in patients with atrial fibrillation and intracerebral haemorrhage associated with cerebral amyloid angiopathy: a multicentre observational study and pooled analysis of published studies

BACKGROUND

Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral haemorrhage (ICH) with a high recurrence risk. Left atrial appendage occlusion (LAAO) is a method for ischaemic stroke prevention in patients with atrial fibrillation (AF), potentially reducing the risk of intracranial bleeding in CAA-associated ICH. We aimed to determine the outcomes of patients with AF with CAA-associated ICH undergoing LAAO.

METHODS

We conducted a multicentre study of patients with CAA-associated ICH who underwent LAAO for stroke prevention. We pooled our findings with data from a systematic review of relevant published studies of LAAO for AF in ICH survivors reporting CAA diagnosis.

RESULTS

We included data from two published studies (n=65) with CAA-specific data and our cohort study (n=37), providing a total of 102 participants (mean age 76.2±8.0 years, 74.6% male) with CAA-related symptomatic ICH and AF treated with LAAO. The median follow-up period was 9.4 months (IQR 4.2-20.6). Postprocedural antithrombotic regimens varied between single (73.0%) or dual antiplatelet therapy (16.2%), or direct oral anticoagulant (DOAC) (10.8%), with a median duration of 42 days (IQR 35-74). Postprocedural complications were uncommon, but included transient arrhythmias (2.1%) and non-life-threatening tamponade (2.1%). Pooled incidence rates of ischaemic stroke and ICH during follow-up were 5.16 (95% CI 1.36 to 17.48) and 2.73 (95% CI 0.41 to 13.94) per 100 patient years, respectively.

CONCLUSIONS

LAAO followed by short-term antithrombotic therapy might be a safe and effective ischaemic stroke preventive strategy in people with CAA-associated ICH and AF. However, randomised controlled trials are needed to determine how LAAO compares with long-term DOAC in this population.

PROSPERO REGISTRATION NUMBER

CRD42023415354.

Left Atrial Appendage Closure: What Do We Know?

Atrial fibrillation (AF) is the most common arrhythmia in the United States and the most common cause of embolic cerebrovascular events, with the majority of these thrombi originating in the left atrial appendage. The left atrial appendage (LAA) has separate developmental, ultrastructural, and physiological characteristics from the left atrium. Although LAA anatomy is highly variable, it can be categorized into 4 types: cactus, cauliflower, chicken wing, and windsock. The cauliflower type is associated with higher stroke risk in patients with nonvalvular AF. Although the cornerstone of therapy to prevent embolic strokes from AF has been anticoagulation with thrombin inhibitors, a large group of patients are unable to tolerate anticoagulation due to bleeding. This has led to the development and advancement of multiple surgical and percutaneous LAA closure devices to prevent embolic cerebrovascular accidents without the need for anticoagulation. In this article, we discuss the outcomes of major studies that utilized surgical LAA occlusion and its effectiveness. Furthermore, we summarize nonsurgical methods of LAA closure and future directions regarding LAA closure.

State of the Art in Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) has become an important therapeutic target for stroke prevention in patients with nonvalvular atrial fibrillation. Over the past 2 decades, several advancements in LAAO devices (percutaneous and surgical) have been made for stroke prevention and arrhythmia therapy. However, there are several unanswered questions regarding optimal patient selection, the preferred LAAO approach and device, the management of periprocedural and postprocedural complications, including pericardial effusion, device-related thrombus, and device leaks. This review focuses on fundamental foundational concepts in various aspects of the left atrial appendage and management strategies as they relate to current clinical needs.

Left Atrial Appendage Closure in Atrial Fibrillation Patients with Cancer

Background: There are limited data about left atrial appendage closure (LAAC) in patients with cancer. We therefore sought to compare the outcome after LAAC in patients with vs. without cancer in a multicentre registry. Methods: In this sub-analysis of the prospective Austrian LAAC Registry, we analysed consecutive patients undergoing LAAC to assess the relationship between baseline characteristics and outcome in patients with vs. without cancer. Inverse probability weighting was performed to adjust for differences in baseline characteristics. Results: A total of 486 consecutive patients from 9 centres with a median age of 75 years (IQR 70-79 years; 35.8% female) were included. Fifty-seven patients (11.7%) had a history of cancer. The median CHA2DS2-VASc and HAS-BLED scores were similar in both groups (median [IQR], 4 [4-6] vs. 5 [3-5], p = 0.415; 4 [3-4] vs. 3 [3-4], p = 0.428 in cancer vs. other patients). Cancer patients were significantly older, and anaemia and gastrointestinal bleeding were significantly more common. Major procedural complications occurred in 5.3% vs. 7.0% (p = 0.276) of patients. The cumulative five-year survival rates were 80.7% and 84.8% in cancer vs. other patients (adjusted hazard ratio for death 1.29 [95% CI 0.67-2.48], p = 0.443). There were also no differences in one-year survival (96.1% vs. 94.0%, p = 0.582) and five-year event-free survival (64.9% vs. 74.4%, p = 0.124). Conclusions: In daily clinical practice, LAAC has already been accepted as a treatment option in patients with cancer. This retrospective analysis shows that short-term and adjusted long-term complications are similar in patients with vs. without cancer undergoing LAAC.

Impact of left atrial appendage occlusion device position on potential determinants of device-related thrombus: a patient-specific in silico study

BACKGROUND

Device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) is potentially linked to adverse events. Although clinical reports suggest an effect of the device type and position on the DRT risk, in-depth studies of its mechanistic basis are needed. This in silico study aimed to assess the impact of the position of non-pacifier (Watchman) and pacifier (Amulet) LAAO devices on surrogate markers of DRT risk.

METHODS

The LAAO devices were modeled with precise geometry and virtually implanted in different positions into a patient-specific left atrium. Using computational fluid dynamics, the following values were quantified: residual blood, wall shear stress (WSS) and endothelial cell activation potential (ECAP).

RESULTS

In comparison to an ostium-fitted device position, deep implantation led to more residual blood, lower average WSS and higher ECAP surrounding the device, especially on the device's atrial surface and the surrounding tissue, suggesting increased risk for potential thrombus. For the non-pacifier device, an off-axis device orientation resulted in even more residual blood, higher ECAP and similar average WSS as compared to an ostium-fitted device position. Overall, the pacifier device showed less residual blood, higher average WSS and lower ECAP, compared to the non-pacifier device.

CONCLUSIONS

In this in silico study, both LAAO device type and implant position showed an impact on potential markers of DRT in terms of blood stasis, platelet adhesion and endothelial dysfunction. Our results present a mechanistic basis for clinically observed risk factors of DRT and the proposed in silico model may aid in the optimization of device development and procedural aspects.

Left Atrial Appendage Occlusion as a Strategy for Reducing Stroke Risk in Nonvalvular Atrial Fibrillation

Nonvalvular atrial fibrillation (AF) is a common rhythm disorder of middle-aged to older adults that can cause ischemic strokes and systemic embolism. Stroke prevention is a crucial aspect of management, considering the increasing AF population and the associated morbidity and mortality. The left atrial appendage (LAA) has been identified as a predominant source of AF-associated thrombus and stroke, with at least 90% of the thrombi originating from this anatomical structure. Lifelong use of oral anticoagulants reduces the risk of these ischemic events but increases the risk of major and clinically relevant hemorrhages. In addition, these medications also require strict compliance for efficacy and have high failure rates in higher-risk patients. LAA occlusion (LAAO) has emerged as an alternative strategy for stroke prevention with encompassing various percutaneous and surgical techniques. Randomized controlled trials evaluating this intervention have shown promising results in stroke reduction replacing anticoagulation therapy. In this review, we aim to provide a comprehensive overview on the anatomy of the LAA and its role in thrombus formation, the emergence of various LAAO techniques and devices, and provide evidence on the role of LAAO in the reduction of stroke risk among patients with nonvalvular AF.

Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Comprehensive Review

Atrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with an increased risk of stroke due to disrupted heart function and potential clot formation. This review examines current management strategies for stroke prevention in AF, focusing on the efficacy, safety, and long-term outcomes of anticoagulation therapies. Anticoagulants, including novel oral anticoagulants (NOACs) and vitamin K antagonists, play a crucial role in reducing stroke risk by preventing clot formation in the heart. Recent studies highlight NOACs as superior alternatives to traditional therapies, offering improved safety profiles and enhanced patient adherence. Despite the risk of bleeding complications, judicious use of anticoagulants significantly improves clinical outcomes in AF patients. The review synthesizes evidence from clinical trials and meta-analyses to underscore the pivotal role of NOACs in transforming stroke prevention strategies in AF. Moreover, it discusses emerging interventions such as left atrial appendage occlusion and emphasizes the importance of personalized, patient-centered care in optimizing treatment decisions for AF patients at risk of stroke.

Initial results of transcatheter modification of left atrial appendage by obliteration with device in patients with nonvalvular atrial fibrillation: Real-world data from the TERMINATOR registry

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) has increased for those who need alternative to long-term anticoagulation with non-valvular atrial fibrillation (NVAF).

METHODS AND RESULTS

From September 2019, after initiating WATCHMAN (Boston Scientific, Maple Grove, MN, USA) device implantation, we established Transcatheter Modification of Left Atrial Appendage by Obliteration with Device in Patients from the NVAF (TERMINATOR) registry. Utilizing 729 patients' data until January 2022, we analyzed percutaneous LAAC data regarding this real-world multicenter prospective registry. A total of 729 patients were enrolled. Average age was 74.9 years and 28.5 % were female. Paroxysmal AF was 37.9 % with average CHADS2 3.2, CHA2DS2-VASc 4.7, and HAS-BLED score of 3.4. WATCHMAN implantation was successful in 99.0 %. All-cause deaths were 3.2 %, and 1.2 % cardiovascular or unexplained deaths occurred during follow-up [median 222, interquartile range (IQR: 93-464) days]. Stroke occurred in 2.2 %, and the composite endpoint which included cardiovascular or unexplained death, stroke, and systemic embolism were counted as 3.4 % [median 221, (IQR: 93-464) days]. Major bleeding defined as BARC type 3 or 5 was seen in 3.7 %, and there was 8.6 % of all bleeding events in total [median 219, (IQR: 93-464) days].

CONCLUSIONS

These preliminary data demonstrated percutaneous LAAC with WATCHMAN device might have a potential to reduce stroke and bleeding events for patients with NVAF. Further investigation is mandatory to confirm the long-term results of this strategy using this transcatheter local therapy instead of life-long systemic anticoagulation.

A comparison of conventional and advanced 3D imaging techniques for percutaneous left atrial appendage closure

Background

Understanding complex cardiac anatomy is essential for percutaneous left atrial appendage (LAA) closure. Conventional multi-slice computed tomography (MSCT) and transesophageal echocardiography (TEE) are now supported by advanced 3D printing and virtual reality (VR) techniques for three-dimensional visualization of volumetric data sets. This study aimed to investigate their added value for LAA closure procedures.

Methods

Ten patients scheduled for interventional LAA closure were evaluated with MSCT and TEE. Patient-specific 3D printings and VR models were fabricated based on MSCT data. Ten cardiologists then comparatively assessed LAA anatomy and its procedure relevant surrounding structures with all four imaging modalities and rated their procedural utility on a 5-point Likert scale questionnaire (from 1 = strongly agree to 5 = strongly disagree).

Results

Device sizing was rated highest in MSCT (MSCT: 1.9 ± 0.8; TEE: 2.6 ± 0.9; 3D printing: 2.5 ± 1.0; VR: 2.5 ± 1.1; p < 0.01); TEE, VR, and 3D printing were superior in the visualization of the Fossa ovalis compared to MSCT (MSCT: 3.3 ± 1.4; TEE: 2.2 ± 1.3; 3D printing: 2.2 ± 1.4; VR: 1.9 ± 1.3; all p < 0.01). The major strength of VR and 3D printing techniques was a superior depth perception (VR: 1.6 ± 0.5; 3D printing: 1.8 ± 0.4; TEE: 2.9 ± 0.7; MSCT: 2.6 ± 0.8; p < 0.01). The visualization of extracardiac structures was rated less accurate in TEE than MSCT (TEE: 2.6 ± 0.9; MSCT: 1.9 ± 0.8, p < 0.01). However, 3D printing and VR insufficiently visualized extracardiac structures in the present study.

Conclusion

A true 3D visualization in VR or 3D printing provides an additional value in the evaluation of the LAA for the planning of percutaneous closure. In particular, the superior perception of depth was seen as a strength of a 3D visualization. This may contribute to a better overall understanding of the anatomy. Clinical studies are needed to evaluate whether a more comprehensive understanding through advanced multimodal imaging of patient-specific anatomy using VR may translate into improved procedural outcomes.

Should the Left Atrial Appendage Closure (LAAC) Technique Be the Main Form of Stroke Prevention in Patients With Long-Standing Persistent or Permanent Atrial Fibrillation?

Currently, oral anticoagulants are considered the gold standard for stroke prevention in patients with atrial fibrillation. Despite the efficacy of oral anticoagulants in reducing stroke incidence, patients are at risk of developing adverse reactions such as excessive bleeding and bruising, and can also have drug-drug interactions. In the early 2000s, a minimally invasive technique called the left atrial appendage closure emerged as an alternative for stroke prevention in atrial fibrillation patients who could not tolerate oral anticoagulants. Despite the success of the left atrial appendage closure, practitioners still opt for medication therapy and are reluctant to advocate for this procedure. Given the adverse effects of oral anticoagulants, physicians should question if this is the appropriate method of stroke prevention in long-standing persistent or permanent atrial fibrillation patients. This case report investigates an 82-year-old Middle Eastern male in the United States with long-standing persistent atrial fibrillation who underwent a left atrial appendage closure due to recurrent bleeding on oral anticoagulants. In addition, there will be further discussion on the appropriate method of stroke prevention in similar patients.

Left atrial appendage closure: the journey today and tomorrow

PURPOSE OF REVIEW

This review aims to discuss the rationale behind the development of percutaneous LAAC devices as a treatment option for atrial fibrillation patients ineligible for long-term anticoagulation. The evolution of LAAC, from early experiences and challenges to risk mitigation and improved devices and techniques, will be examined. Furthermore, the review will explore our current understanding of the potential and limitations of LAAC in stroke prevention.

RECENT FINDINGS

Multiple trials confirm LAAC device safety and efficacy for stroke prevention, but peri-device leak and thrombus remain concerns postimplantation. Even small leaks pose increased stroke risk. While guidelines suggest short-term anticoagulation postimplant; real-world data show equivalent efficacy with dual antiplatelet regimen.

SUMMARY

LAAC device design has evolved and now serve as a viable option for stroke prevention in high-risk atrial fibrillation patients, offering protection in the absence of anticoagulation.

Left Atrial Appendage Closure: A Narrative Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia and the cause of thromboembolic events in elderly patients worldwide. AF is associated with a significantly increased risk of morbidity and mortality due to cardiac emboli, primarily from left atrial appendage (LAA) thrombus. Oral anticoagulation therapy is the standard treatment to effectively reduce the risk of thromboembolic events in patients with AF. However, anticoagulation treatment increases bleeding risk. LAA closure (LAAC) has recently been introduced as a feasible mechanical preventive intervention for thromboembolic events while minimizing the risk of bleeding. Transcatheter LAAC devices have evolved in the past decade, and several ongoing trials have demonstrated the improvements of safety and outcomes in newer generation devices. This review summarizes the current perspectives and outcomes regarding LAAC as an alternative to pharmacologic therapy.

Effectiveness and Safety of an Outpatient Program for Percutaneous Left Atrial Appendage Occlusion

BACKGROUND

Left atrial appendage occlusion (LAAO) is a safe and effective alternative to oral anticoagulation for thromboprophylaxis in patients with nonvalvular atrial fibrillation. Technological development in devices and imaging techniques, as well as accumulated experience, have increased procedural success rates and decreased complications. Same-day discharge protocols have been proposed in the field of structural heart disease, but this approach has not been studied in detail for the LAAO procedure.

AIM

The aim of this study is to assess the safety and efficacy of an outpatient program for LAAO when compared to the conventional treatment approach.

METHODS

We present a retrospective, non-randomized single-center study of 262 consecutive patients undergoing LAAO. Patients were divided into two groups, the first (n = 131) followed a conventional protocol (CP), and the second (n = 131) an outpatient protocol (OP). The primary composite endpoint comprised MACCE (death, stroke, and bleeding), cardiac tamponade, vascular complication, or attendance in the emergency department after hospital discharge at 30 days.

RESULTS

The overall success rate was 99.6%, with a periprocedural complication rate of 2.29%. With regards to the CP versus OP group, there were no differences between incidences of the primary composite endpoint (6.1% PC vs. 3.0% PA, p = 0.24), or after an analysis, with propensity score matching. No differences were observed in the individual endpoints. There was a decrease in hospital length of stay in the same-day discharge group (p < 0.01).

CONCLUSIONS

A same-day discharge LAAO program is safe, effective, and feasible when compared to the conventional strategy. Moreover, it reduces hospital length of stay, which might have clinical and economic benefits.

Considerations for Left Atrial Appendage Occlusion During Cardiac Surgery

Atrial fibrillation is associated with an increased risk of stroke secondary to thrombus formation in the left atrial appendage. Left atrial appendage occlusion (LAAO) is an effective method of reducing the risk of stroke in patients with atrial fibrillation. Although LAAO does not remove the requirement for anticoagulation, it reduces the risk of stroke when compared to anticoagulation alone. We critically analyze the data on LAAO in cardiac surgery. We also discuss the methods of LAAO, the risks of LAAO, and patient populations that could benefit from LAAO. We discuss high-level evidence that LAAO at the time of cardiac surgery reduces the risk of stroke in patients with a history of atrial fibrillation. In patients without a history of atrial fibrillation undergoing cardiac surgery, we suggest that LAAO should be considered in select patients at high risk of atrial fibrillation and stroke, when technically feasible.

Left atrial appendage sizing for percutaneous closure in virtual reality-a feasibility study

Background and aims

The complex and highly variable three-dimensional anatomy of the left atrial appendage (LAA) makes planning and device sizing for interventional occlusion procedures (LAAC) challenging. Several imaging modalities [e.g. echocardiography, multi-slice computed tomography (MSCT)] are used for this purpose. Virtual reality (VR) is an emerging imaging technique to immerse into a three-dimensional left atrium and appendage, offering unprecedented options of visualization and measurement. This study aimed to investigate the feasibility, accuracy and reproducibility of visualizing the LAA in VR for preprocedural planning of LAAC.

Methods and results

Twenty-one patients (79 ± 7 years, 62% male) who underwent LAAC at University Hospital Düsseldorf were included in our study. A dedicated software generated three-dimensional VR models from preprocedural MSCT imaging data. Conventional measurements of LAA dimensions (ostium, landing zone and depth) using a commercially available software were compared to measurements in VR: MSCT and VR ostium min. (r = 0.93), max. (r = 0.80) and mean (r = 0.88, all p < 0.001) diameters as well as landing zone (LZ) min. (r = 0.84), max. (r = 0.86) and mean diameters (r = 0.90, all p < 0.001) showed strong correlations. Three-dimensional orientation was judged superior by physicians in VR compared to MSCT (p < 0.05).

Conclusion

Virtual reality visualization of the left atrium and appendage based on MSCT data is feasible and allows precise and reproducible measurements in planning of LAA occlusion procedures with enhanced 3D orientation. Further studies need to explore additional benefits of three-dimensional visualization for operators in preprocedural planning.

Left Atrial Appendage Occlusion Strengths and Weaknesses of the Lobe-Only Occluder Concept in Theory and in Practice

Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design. This review highlights the potential features and benefits of the single-lobe devices.

The Future of LAAC-In 5, 10, and 20 Years

Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation. Finally, we consider how to make the procedure safer and more effective.

Frequency and Clinical Significance of Atrial Cavities in situ Thrombosis: A Large-Scale Study and Literature Review

Background

Atrial tachyarrhythmias are the main cause of atrial thrombosis, and are usually in the left appendage. The prevalence and causes of endocavitarian thrombosis have not been investigated in recent large-scale studies. Aim of our work was to describe the epidemiology, the clinical characteristics and predisposing factors of "extra-appendicular" atrial thrombosis and to report a systematic review of recent literature.

Methods and Results

5,862 consecutive adult patients referred to a transesophageal echocardiographic exam, were enrolled. A total of 175 subjects with Atrial Thrombosis were found with a prevalence of 2.98%; among those 22 was found in left (0.38%) and 2 in the right (0.03%) atrium. Among the 22 patients with left atrial thrombosis, 8 were associated with prosthetic valves, 4 with mitral stenosis and the remaining with hypercoagulative conditions (cancer, septic shock, eosinophilic pneumonia, cardiogenic shock and warfarin under-dosage in permanent atrial fibrillation and decompensated heart failure). Cancer was associated in one of the two patients with a right atrial clot. The review of the literature from 2000 to December 2019 revealed conflicting results of 48 case reports of atrial cavity thrombosis; pooling this data proved the rarity of extra-appendage thrombosis and confirmed its association with a valvular heart disease or a systemic hypercoagulable state.

Conclusions

Atrial "extra-appendage" thrombosis is a rare condition usually associated to "valvular" atrial fibrillation (such as prosthetic valves and mitral stenosis). A minority, but significant, cases are secondary to a thrombophilic conditions. In absence of valvular heart disease an underlying condition should be sought.

Percutaneous left atrial appendage occlusion: impact on left atrial deformation indices

BACKGROUND

Percutaneous left atrial appendage occlusion (LAAO) is an accepted alternative to thromboprophylaxis in patients with atrial fibrillation (AF) who are: (i) intolerant to oral anticoagulation (OAC) (e.g. life-threatening haemorrhage), (ii) non-adherent to OAC, or (iii) at a high bleeding risk with OAC. Improvement in LA mechanics was shown post-LAAO in the LAFIT-LARIAT study, using the Lariat device. No significant change was seen in LA mechanics after LAAO with the Watchman device in the LAFIT-Watchman study. The impact of LAAO with the Amplatzer or Amulet device on LA deformation mechanics has not been investigated.

PURPOSE

To evaluate the impact of LAAO with the Amplatzer or Amulet device on echocardiographic LA deformation indices.

METHODS

All patients undergoing percutaneous LAAO from 2013 to 2021 at a single centre were included from an ongoing clinical registry. LA reservoir (ε_reservoir), conduit (ε_conduit) and contractile strain (ε_contractile) and strain rate (SR_reservoir, SR_conduit, SR_contractile) were assessed with two-dimensional speckle tracking echocardiography from an apical four-chamber view. Conduit and contractile strain and strain rates were only recorded for patients without AF at the time of echocardiography. Changes in LA deformation indices over time were compared with a linear mixed model.

RESULTS

28 LAAO recipients (mean age 73 ± 12 years, 68% male) were analysed. 5 (18%) patients had AF pre- or post-procedure. After a mean follow-up of 1.6 ± 1.4 months, the mean LA ε_reservoir increased from 10.15 ± 6.44% to 10.18 ± 8.72% (p = 0.985), the mean LA ε_conduit increased from 5.12 ± 5.48% to 5.31 ± 6.11% (p = 0.891) and the mean LA ε_contractile decreased from 5.14 ± 4.32% to 4.95 ± 5.30% (p = 0.898). During the same time interval, the mean LA SR_reservoir decreased from + 0.54 ± 0.23.s^- 1 to + 0.48 ± 0.43.s^- 1 (p = 0.566), the mean LA SR_conduit remained stable: -0.47 ± 0.41.s^- 1 to -0.47 ± 0.32.s^- 1 (p = 0.997) and the mean LA SR_contractile decreased from - 0.66 ± 0.50.s^- 1 to -0.55 ± 0.46.s^- 1 (p = 0.660).

CONCLUSION

No significant improvement in LA mechanical function was seen after LAAO with the Amplatzer or Amulet device. Different LAAO devices therefore appear to have divergent effects on LA deformation, the clinical implications of which may warrant further study.

The Impact of COVID-19 Pandemic on the Clinical Practice Patterns in Atrial Fibrillation: A Multicenter Clinician Survey in China

The COVID-19 pandemic has severely impacted healthcare systems worldwide. This study investigated cardiologists’ opinions on how the COVID-19 pandemic impacted clinical practice patterns in atrial fibrillation (AF). A multicenter clinician survey, including demographic and clinical questions, was administered to 300 cardiologists from 22 provinces in China, in April 2022. The survey solicited information about their treatment recommendations for AF and their perceptions of how the COVID-19 pandemic has impacted their clinical practice patterns for AF. The survey was completed by 213 cardiologists (71.0%) and included employees in tertiary hospitals (82.6%) and specialists with over 10 years of clinical cardiology practice (53.5%). Most respondents stated that there were reductions in the number of inpatients and outpatients with AF in their hospital during the pandemic. A majority of participants stated that the pandemic had impacted the treatment strategies for all types of AF, although to different extents. Compared with that during the assumed non-pandemic period in the hypothetical clinical questions, the selection of invasive interventional therapies (catheter ablation, percutaneous left atrial appendage occlusion) was significantly decreased (all p < 0.05) during the pandemic. There was no significant difference in the selection of non-invasive therapeutic strategies (the management of cardiovascular risk factors and concomitant diseases, pharmacotherapy for stroke prevention, heart rate control, and rhythm control) between the pandemic and non-pandemic periods (all p > 0.05). The COVID-19 pandemic has had a profound impact on the clinical practice patterns of AF. The selection of catheter ablation and percutaneous left atrial appendage occlusion was significantly reduced, whereas pharmacotherapy was often stated as the preferred option by participating cardiologists.

Combined MitraClip and Left Atrial Appendage Occlusion: Is It Still a Utopia?

Atrial fibrillation (AF) is the most common cardiac arrhythmia, affecting 32 million individuals worldwide, particularly the elderly. It is the main cause of ischemic strokes. Oral anticoagulation (OAC) is the gold standard strategy for stroke prevention. Still, there is a not negligible share of patients who have contraindications to this therapy, more frequently due to an increased risk of bleeding. AF is often associated with moderate-severe mitral regurgitation (MR), the second most frequent valvular disease in elderly patients. Data from the literature reported that more than half of patients with severe mitral regurgitation are not suitable candidates for cardiac surgery. Given the progressive aging of the population and the simultaneous increase in the number of patients with comorbidities, the advent of new therapeutic strategies, such as the combined approach of Left Atrial Appendage Occlusion (LAAO) and MitraClip procedure, is acquiring great interest. At present, the category of patients who may benefit from combined percutaneous therapies and the long-term risks and benefits might not have been identified. Despite the efforts of researchers, the correct selection of patients is a very important clinical need that has not yet been met to avoid committing human and financial resources to interventions that may be unnecessary. It is conceivable that the most modern and recent innovations in cardiovascular imaging, particularly three-dimensional echocardiography and new methods of volume imaging, could improve our ability to select patients appropriately. Since data in the literature are scarce, future studies will be needed to evaluate the efficacy and safety of combined MitraClip and LAA occlusion.

The Future of LAAC-In 5, 10, and 20 Years

Early experience with percutaneous LAA closure documented complication rates of ∼10%, with failure to implant devices in ∼10% of patients. These numbers are unrecognizable in contemporary practice due to the iterative changes made largely in the last 10 years. Here we look forward to ask what might change, and when, to bring percutaneous LAA closure out of the niche early adopter centers into routine use. We consider the opportunity to incorporate different technologies into LAAc devices in the context of managing patient with atrial fibrillation. Finally, we consider how to make the procedure safer and more effective.

Left Atrial Appendage Occlusion Strengths and Weaknesses of the Lobe-Only Occluder Concept in Theory and in Practice

Left atrial appendage closure aims to eliminate the stasis component of Virchow triad by eliminating a cul-de-sac that favors thrombosis, particularly when atrial contractility becomes inefficient, such as in atrial fibrillation. Left atrial appendage closure devices have a common objective of sealing the appendage completely, with device stability and avoidance of device thrombosis. Two main device designs have been used to perform left atrial appendage closure: those that use a pacifier design (lobe + disk) and those that use a plug (single lobe) design. This review highlights the potential features and benefits of the single-lobe devices.

Left atrial appendage closure - Current status and future directions

Percutaneous left atrial appendage closure (LAAC) has become an important non-pharmacological intervention for stroke prevention in patients with non-valvular atrial fibrillation (AF). LAAC aims to reduce the risk of thromboembolism without increasing the risk of bleeding, a crucial strategy for patients at high risk for bleeding. Over the last few decades, the safety and long-term efficacy of the procedure in specific populations have grown, and more patients are being treated with these devices. Current and future studies focus on expanding the target population as well as the iteration of current technology. This article reviews recent, present, and future LAAC studies on the two most common devices, the Watchman device (Boston Scientific Corporation) and the Amplatzer cardiac plug (ACP) (St. Jude Medical, Minneapolis, MN), and their subsequent next generations, the Watchman FLX, and the Amulet, respectively.

Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation

The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Effectiveness and safety of transcatheter left atrial appendage closure

Atrial fibrillation (AF) is responsible for cardiogenic stroke. Since left atrial appendage (LAA) is a cause of most of cardiac thrombus, LAA closure is an emerging novel stroke prevention procedure for patients with AF alternative to anticoagulation. WATCHMAN LAA Closure device (Boston Scientific, Marlborough, MA, USA) is the only approved device in the USA and Japan. The device is indicated in high bleeding risk and high stroke risk non-valvular AF patients. Cardiac tamponade, stroke, and device embolization are typical procedural complications. Procedural complication rate is reduced with implanters' experience and matured procedure steps. Several randomized trials demonstrated procedure safety and efficacy of the device. The device resulted in similar thromboembolic event rates but significantly reduced bleeding events compared to anticoagulants. After the procedure, optimal post procedural antithrombotic drug regimen has not been fully investigated. Also, device-related thrombosis can be a new issue. Modification of the device can improve issues, but not fully solve it. Tailor made treatment based on the individual risk by heart team communication with neurologists is essential to treat patients.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

Left Atrial Remodeling and Brain Natriuretic Peptide Levels Variation after Left Atrial Appendage Occlusion

Background: Few data are available about brain natriuretic peptide (BNP) variation and left atrial remodeling after the left atrial appendage occlusion (LAAO) technique. Methods: Prospective study included all consecutive patients successfully implanted with an LAAO device. Contrast-enhanced cardiac computed tomography (CT) was performed before and 6 weeks after the procedure with reverse left atrial remodeling defined by an increase in LA volume >10%, together with blood sampling obtained before, 48 h after device implantation and at the first visit after discharge (30–45 days) for BNP measurement. Results: Among the 43 patients implanted with a complete dataset, mean end-diastolic LA volume was 139 ± 64 mL and 141 ± 62 mL at baseline and during follow-up (45 ± 15 days), respectively, showing no statistical difference (p = 0.45). No thrombus was seen on the atrial side of the device. Peridevice leaks (defined as presence of dye in the LAA beyond the device) were observed in 17 patients (40%) but were trivial or mild. Reverse atrial remodeling (RAR) at 6 weeks was observed in six patients (14%). Despite no difference in BNP levels on admission, median BNP levels at 48 h were slightly increased in RAR patients when compared with controls. During FU, BNP levels were strictly identical in both groups. These results were not modified even when each RAR case was matched with two controls on age, LVEF, creatinine levels and ACE inhibitors treatment to avoid potential confounders. Conclusion: Our study showed that despite the fact that the LAAO technique can induce left atrial remodeling measured by a CT scan, it does not seem to impact BNP levels on the follow-up. The results need to be transposed to clinical outcomes of this expanding population in future studies.

The use of cardiac computed tomography angiography in the assessment of percutaneous left atrial appendage closure - Review and experts recommendations endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle

Atrial fibrillation is the most common cause of arrhythmia which is responsible for over 15% of ischemic strokes, most of these being secondary to migration of a left atrial appendage (LAA) thrombus. In patient with contraindication to anticoagulant therapy, percutaneous closure system placement may be indicated. Cardiac computed tomography (CT) angiography plays a central role in the initial assessment as well as in the follow-up. The purpose of the pre-implantation cardiac CT angiography is to evaluate the anatomy of the LAA in order to select the most suitable prosthesis and check for any contraindication to device implantation. Image analysis is divided into four steps that include analysis of the approach; search for a thrombus in the LAA; investigation of the anatomy of the LAA (morphology of the LAA, dimensions of the LAA and choice of device) and cardiac and thoracic assessments. Follow-up involves CT examination to check for correct placement of the device and to detect any complications. On the basis of the results of currently available published research, a panel of experts has issued recommendations regarding cardiac CT angiography prior to percutaneous LAA closure device placement, which were further endorsed by the Société française d'imagerie cardiaque et vasculaire diagnostique et interventionnelle (SFICV).

Percutaneous Left Atrial Appendage Occlusion: An Emerging Option in Patients with Atrial Fibrillation at High Risk of Bleeding

Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.

Left atrial appendage perforation during appendage angiography treated by percutaneous left atrial appendage closure: a case report

Background

Pericardial effusion is a common complication of percutaneous left atrial appendage (LAA) closure. Acute management is the cornerstone of pericardial effusion treatment and interrupting the intervention is often required.

Case summary

A 65-year-old man presented an acute 10 mm pericardial effusion following pigtail contrast appendage injection. A rapid Watchman Flex 24 mm (Boston Scientific) deployment permitted bleeding interruption. A needle pericardiocentesis was achieved in order to prevent any haemodynamical instability.

Discussion

This case report describes an atypical cause of pericardial effusion and a technique for bleeding control with LAA closure device deployment.

Neurologic complications of atrial fibrillation: Pharmacologic and interventional approaches to stroke prevention

Atrial fibrillation is a common cardiac arrhythmia that carries a risk of stroke. This is commonly stratified with the CHA₂DS₂-VASc score. Stroke risk can be reduced with anticoagulants or with interventions to close the left atrial appendage, the most common source of left atrial thrombi. While warfarin has been traditionally used as the only oral anticoagulant available, there are several direct oral anticoagulants that compare favorably with respect to both stroke and bleeding risk in randomized controlled trials. Multiple interventional options exist to close the left atrial appendage, but the Watchman device is the only one that compares favorably with warfarin in randomized controlled trials.

Multimodality Approach for Endovascular Left Atrial Appendage Closure: Head-To-Head Comparison among 2D and 3D Echocardiography, Angiography, and Computer Tomography

Background: Percutaneous left atrial appendage closure (LAAC) requires accurate pre- and intraprocedural measurements, and multimodality imaging is an essential tool for guiding the procedure. Two-dimensional (2D TOE) and three-dimensional (3D TOE) transoesophageal echocardiography, cardiac computed tomography (CCT), and conventional cardiac angiography (CCA) are commonly used to evaluate left atrial appendage (LAA) size. However, standardized approaches in measurement methods by different imaging modalities are lacking. The aims of the study were to evaluate the LAA dimension and morphology in patients undergoing LAAC and to compare data obtained by different imaging modalities: 2D and 3D TOE, CCT, and CCA. Methods: A total of 200 patients (mean age 70 ± 8 years, 128 males) were examined by different imaging techniques (161 2D TOE, 103 3D TOE, 98 CCT, and 200 CCA). Patients underwent preoperative CCT and intraoperative 2D and 3D TOE and CCA. Results: A significant correlation was found among all measurements obtained by different modalities. In particular, 3D TOE and CCT measurements were highly correlated with an excellent agreement for the landing zone (LZ) dimensions (LZ diameter: r = 0.87; LAA depth: r = 0.91, p < 0.001). Conclusions: Head-to-head comparison among imaging techniques (2D and 3D TOE, CCT, and CCA) showed a good correlation among LZ diameter measurements obtained by different imaging modalities, which is a parameter of paramount importance for the choice of the LAAC device size. LZ diameters and area by 3D TOE had the best correlation with CCT.

Advances in the management of atrial fibrillation with a special focus on non-pharmacological approaches to prevent thromboembolism: a review of current recommendations

Atrial fibrillation (AFIB) is the most common heart rhythm abnormality and is associated with significant morbidity and mortality. While the treatment of AFIB involves strategies of rate with or without rhythm control, it is also essential to strategize appropriate therapies to prevent thromboembolic complications arising from AFIB. Previously, anticoagulation was the main treatment option which exposed patients to higher than usual risk of bleeding. However, with the advent of new technology, novel therapeutic options aimed at surgical or percutaneous exclusion or occlusion of the left atrial appendage in preventing thromboembolic complications from AFIB have evolved. This review evaluates recent advances and therapeutic options in treating AFIB with a special focus on both surgical and percutaneous interventions which can reduce and/or eliminate thromboembolic complications of AFIB.

Plugs for left atrial appendage occlusion: an overview of available devices

INTRODUCTION

Approximately one-third of all ischemic strokes and the ensuing health and economic burden can be attributed to the presence of atrial fibrillation (AF). The global prevalence of AF continues to rise, thus making it by far the most common diagnosed cardiac arrhythmia. Percutaneous left atrial appendage (LAA) occlusion or obliteration has been developed to protect from the occurrence of stroke in patients with nonvalvular AF.

AREAS COVERED

We address the characteristics and techniques for implantation as well as some clinical registries and randomized trials of the various catheter-based devices for the occlusion of the LAA that are either currently available or in the clinical evaluation stage.

EXPERT OPINION

Over less than 2 decades, LAA occlusion progressed from being a concept applied in a few specialized centers to a globally recognized procedure implemented in numerous hospitals as part of daily interventional practice. The respective devices are to date safer and easier to deploy than initially. Periprocedural and postprocedural complications will continue to decrease as already evident from prospective randomized trials and registries. Although current indications focus on patients with nonvalvular AF and contraindications for oral anticoagulation, it is all but certain that the future will bring a widening in the spectrum of indications, applicability, and usage of these devices.

Left Atrial Appendage Occlusion: Past, Present and Future

There are several situations whereby oral anticoagulation may be unsuitable for stroke prevention in patients with atrial fibrillation (AF). Percutaneous left atrial appendage (LAA) occlusion has received much attention in this area. Various devices have already been developed and tested for this purpose. Data from registries and cohort studies have indicated favourable short- and long-term outcomes with LAA occlusion, and several international guidelines recommend its use in AF patients with contraindications to oral anticoagulation. However, prospective controlled trials in this very population are lacking. Furthermore, while modelling studies on cost analyses have suggested that LAA occlusion may be a cost-effective strategy compared with standard medical therapy, these have not been performed in high-risk patients who may have limited survival in the medium to long term. Thus, while LAA occlusion offers promise, there is a strong need for additional research to investigate its exact role, its long-term outcomes and cost efficacy.

Meta-Analysis Comparing WatchmanTM and Amplatzer Devices for Stroke Prevention in Atrial Fibrillation

Background: For patients with atrial fibrillation who are at high risk for bleeding or who cannot tolerate oral anticoagulation, left atrial appendage (LAA) closure represents an alternative therapy for reducing risk for thromboembolic events. Objectives: To compare the efficacy and safety of the Amplatzer and Watchman^TM LAA closure devices. Methods: A meta-analysis was performed of studies comparing the safety and efficacy outcomes of the two devices. The Newcastle-Ottawa Scale was used to appraise study quality. Results: Six studies encompassing 614 patients were included in the meta-analysis. Overall event rates were low for both devices. No significant differences between the devices were found in safety outcomes (i.e., pericardial effusion, cardiac tamponade, device embolization, air embolism, and vascular complications) or in the rates of all-cause mortality, cardiac death, stroke/transient ischemic attack, or device-related thrombosis. The total bleeding rate was significantly lower in the Watchman^TM group (Log OR = -0.90; 95% CI = -1.76 to -0.04; p = 0.04), yet no significant differences was found when the bleeding rate was categorized into major and minor bleeding. Total peridevice leakage rate and insignificant peridevice leakage rate were significantly higher in the Watchman^TM group (Log OR = 1.32; 95% CI = 0.76 to 1.87; p < 0.01 and Log OR = 1.11; 95% CI = 0.50 to 1.72; p < 0.01, respectively). However, significant peridevice leakages were similar in both the devices. Conclusions: The LAA closure devices had low complication rates and low event rates. Efficacy and safety were similar between the systems, except for a higher percentage of insignificant peridevice leakages in the Watchman^TM group. A randomized controlled trial comparing both devices is underway, which may provide more insight on the safety and efficacy outcomes comparison of the devices.

Current State of Surgical Left Atrial Appendage Exclusion: How and When

Left atrial appendage exclusion is efficacious for stroke prophylaxis in patients with atrial fibrillation. Surgical excision provides reliable left atrial appendage exclusion, whereas surgical occlusion does not. Specifically, 2-layer internal suture ligation has a high failure rate. Left atrial appendage exclusion concomitant to another cardiac surgical procedure is indicated in patients with atrial fibrillation but not in patients without baseline atrial fibrillation. Studies currently underway will further define the role of concomitant surgical left atrial appendage exclusion, especially for the population without baseline atrial fibrillation but at high risk of developing postoperative atrial fibrillation.

Systematic review on left atrial appendage closure with the LAmbre device in patients with non-valvular atrial fibrillation

BACKGROUND

Percutaneous closure (LAAC) of the left atrial appendage (LAA) is an efficacious preventive procedure for patients with non-valvular atrial fibrillation (NVAF) and considerable bleeding risk. We sought to systematically review the available LAAC data on the novel occluder device LAmbre™.

METHODS

For this systematic review, a search of the literature was conducted by 3 independent reviewers, reporting the safety and therapeutic success of LAAC in patients being treated with a LAmbre™. Publications reporting the safety and therapeutic success of LAAC using LAmbre™ in n > 5 patients were included.

RESULTS

The literature search retrieved n = 10 publications, encompassing n = 403 NVAF patients treated with a LAmbre™ LAAC, with relevant data regarding safety and therapeutic success of the procedure. The mean CHA₂DS₂-VASc Score was 4.0 + 0.9, and the mean HAS-BLED score was 3.4 + 0.5. The implantation success was 99.7%, with a mean procedure time of 45.4 ± 18.7 min, and a fluoroscopy time of 9.6 ± 5.9 min, and a contrast agent volume of 96.7 ± 0.7 ml. The anticoagulation regimen was switched to DAPT post procedure in the majority of the patients (96.8%). Partial and full recapture were done in 45.5% and in 25.6%, respectively. Major complications were reported in 2.9%, with 0.3% mortality, 1.7% pericardial tamponade, 0.3% stroke, and 0.6% major bleeding complications; no device embolization was observed. During follow up at 6 or 12 months, major adverse cardiovascular events were reported in 3.3%: Stroke or TIA in 1.7%, thrombus formation on the device in 0.7%, and residual flow > 5 mm in 1.0%. In some publications, the favorable implantion properties of the LAmbre™ for difficult anatomies such as shallow or multilobular LAA anatomies were described.

CONCLUSIONS

This systematic review on the LAmbre™ LAA-occluder including n = 403 NVAF patients demonstrates an excellent implantion success rate, promising follow-up clinical data, and favorable properties for also challenging LAA anatomies,. While its design seems to be helpful in preventing device embolization, pericardial tamponade may not be substantially reduced by the LAmbre™ as compared with other established LAAC devices. Further larger prospective multicenter registries and randomized trials are needed to scrutinize the value of the LAmbre™ compared with established LAAC devices.

Risk stratification in patients undergoing interventional left atrial appendage occlusion-Prognostic impact of EuroSCORE II

Background

Interventional closure of the left atrial appendage (LAA) is an alternative option to stroke prophylaxis, particularly in multimorbid patients with a high risk of bleeding under oral anticoagulation. Due to the multiple comorbidities, the prognosis of patients is reduced, and the clinical benefit of the procedure is therefore questionable in the individual patient.

Hypothesis

The present study aims to identify independent preprocedural risk factors to improve risk stratification in these highly selected patients.

Methods

This study consecutively included 128 patients who received an interventional LAA occlusion with Amplatzer device (St Jude Medical, St Paul, Minnesota). The preinterventional risk assessment was performed with the logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. The primary endpoint was all‐cause mortality. Secondary endpoints were thromboembolic events and severe bleeding.

Results

During a follow‐up of 781 ± 498 days the primary endpoint (all‐cause mortality) was reached in 35 patients (27%). The only independent predictor of mid‐term mortality was a logistic EuroSCORE II > 2% (Hazard risk [HR] 4.55, confidence interval [CI] 1.599‐12.966, P = .005). In our study, 33 patients (26%) suffered from end‐stage renal disease which was not associated with increased mortality (P = .371), increased thromboembolic events (P = .475), or severe bleeding (P = .613).

Conclusions

In patients undergoing interventional LAA occlusion, preprocedural assessment of logistic EuroSCORE II provide independent prognostic information. This parameter might help to improve risk stratification in these highly selected patients. In contrast, terminal renal failure was not associated with a significantly worse outcome.

4D Volume Intracardiac Echocardiography for Intraprocedural Guidance of Transcatheter Left Atrial Appendage Closure

Background

Fluoroscopy and transesophageal echocardiography (TEE) are used to guide transcatheter left atrial appendage (LAA) closure in patients with atrial fibrillation to prevent thromboembolic events. This study examines whether real-time three-dimensional volume ICE guidance (4D volume ICE) can be used as an alternative to TEE during LAA closure (LAAC).

Methods and Results

Fifteen patients with atrial fibrillation (AF), who had high risk for stroke and contraindication for long-term warfarin therapy, were enrolled in the study. The WATCHMAN device was used for transcatheter LAAC under fluoroscopy. LAA and device sizing was performed using TEE and volume ICE guidance from the right heart. Intraprocedural ICE measurements were consistent with TEE; LAA maximal width and depth, and maximal diameter of the implanted device were moderately correlated (Pearson's coefficient: 0.63, 0.65, and 0.71 respectively; p<0.05) with good agreement (bias: -0.03 cm, -0.07 cm, and 0.003 cm respectively). The average imaging success rate, defined by the number of patients with all the required intraprocedural measurements, was 67% for ICE and 100% for TEE. The WATCHMAN device was successfully implanted in all patients with a device to patient ratio of 1.33.

Conclusions

4D volume ICE can be used as an intraprocedural sizing and guidance tool for transcatheter LAAC with measurements comparable to TEE. Challenging patient characteristics significantly degrade the diagnostic image quality when imaging from the right heart. Standardized workflow with proper patient selection and optimal preprocedural planning may improve the diagnostic quality of volume ICE guidance for transcatheter LAAC procedure.

Clinical Outcomes of Mortality, Readmissions, and Ischemic Stroke Among Medicare Patients Undergoing Left Atrial Appendage Closure via Implanted Device

IMPORTANCE

Left atrial appendage closure (LAAC) has emerged as a nonpharmacological alternative for stroke prevention in patients with nonvalvular atrial fibrillation. Contemporary data regarding the characteristics and outcomes of patients undergoing this procedure are limited.

OBJECTIVE

To determine the characteristics, postprocedural mortality rate, and rates of readmission and ischemic stroke among Medicare beneficiaries who underwent LAAC via implanted device.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used Medicare inpatient claims from January 2015 to December 2017 for 13 627 patients aged older than 65 years with a diagnosis of atrial fibrillation who underwent LAAC with an implanted device from January 2015 to November 2017. Data analyses were conducted from January through August 2019.

EXPOSURE

Left atrial appendage closure.

MAIN OUTCOMES AND MEASURES

Mortality rates during the index admission and for 1 year after LAAC were assessed. The 30-day readmission rate and the primary reasons for readmission were also examined. In addition, the likelihood of hospitalization for ischemic stroke within 180 days among 9231 patients for whom 6 months of follow-up data were available was evaluated.

RESULTS

Among the 13 627 patients undergoing LAAC, the mean (SD) age was 78.0 (6.3) years, 9406 (69.0%) were older than 75 years, 11 980 (87.9%) were white, and 5630 (41.3%) were women. The mean (SD) CHA2DS2-VASc score was 4.3 (1.4). Twenty-eight patients (0.2%) died during the index admission. Mortality rates were 0.6% (80 patients) at 30 days, 1.9% (262 patients) at 90 days, 4.0% (547 patients) at 180 days, and 7.5% (1027 patients) at 365 days. The 30-day readmission rate among 13 599 patients discharged alive was 9.4% (1284 patients). Among 9231 patients with 6 months of follow-up data, 111 (1.2%) experienced readmission for ischemic stroke or transient ischemic attack within 180 days of discharge.

CONCLUSIONS AND RELEVANCE

In this cohort study of patients older than 65 years with atrial fibrillation who underwent LAAC with an implanted device, readmission rates for ischemic strokes over the course of 6 months were lower than expected given the patients' CHA2DS2-VASc scores in the absence of anticoagulation therapy. Mortality at 1 year was higher than that reported in previous randomized clinical trials, likely because the patients in the present study were older, had a higher number of comorbidities, and were ineligible to receive warfarin.

Percutaneous devices for left atrial appendage occlusion: A contemporary review

Patient with atrial fibrillation (AF) are at risk of developing stroke with the left atrial appendage (LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF, some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion (LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device. Watchman is the most common and only Food and Drug Administration (FDA) approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.