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Concept: Left atrial appendage occlusion

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Left atrial appendage closure (LAAC) using the Watchman device was FDA-approved as a stroke prevention alternative to warfarin for patients with non-valvular atrial fibrillation. However, clinical decision-making is confounded by the fact that while LAAC avoids the anticoagulant-related lifetime risk of bleeding, implantation is associated with up-front complications. Thus, enthusiasm for LAAC as a treatment option has been appropriately tempered, particularly as the therapy is introduced beyond the clinical trial sites into general clinical practice.

Concepts: Clinical trial, Stroke, Atrial fibrillation, Warfarin, Atrial flutter, Clinical trial protocol, Left atrial appendage occlusion, Left atrial appendage

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Introduction Atrial fibrillation (AF) increases risk of thromboembolic events by promoting clot formation in the left atrial appendage (LAA). Transesophageal echocardiography (TEE) is routinely used to exclude presence of LAA thrombus prior toAF ablation. The optimal combination of non-invasive parameters for thromboembolic risk stratification in this setting and the need for TEE in very low risk patients have not been established. Objectives To assess predisposing factors for LAA thrombus in patients scheduled for AF ablation and to identify those in whom pre-procedural TEE could be omitted. Patients and methods In consecutive 151 patients (107 males, mean age 57±10 years) the type of AF and renal function were used in addition to CHA2DS2VASc score to improve thromboembolic risk stratification. Results LAA thrombus or dense echo contrast with probable thrombus were detected in 15 (10%) patients. Diabetes, age≥65 years, persistent AF and eGFR<60 ml/min/1.73 m2 were predictors of LAA thrombus. Multivariate logistic regression showed that only persistent AF and eGFR<60 ml/min/1.73 m2 were independent predictors of LAA thrombus. The ROC curves showed that the greatest AUC (0.845) was achieved for CHA2DS2VASc+AF type+renal status (NS). A 100% sensitivity in identifying patients with LAA thrombus was achieved for CHA2DS2VASc-AFR≥2 or CHA2DS2VASc≥1 with a corresponding specificity of 54% and 36%, respectively. Conclusions LAA thrombus or dense contrast are often encountered in patients scheduled for AF ablation. Addition of AF type and renal function to the CHA2DS2VASc score slightly improves thromboembolic risk stratification and may help to identify patients who do not need pre-procedural TEE.

Concepts: Cardiology, Echocardiography, Stroke, Atrial fibrillation, Warfarin, Thrombus, Left atrial appendage occlusion, Left atrial appendage

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OBJECTIVES: The purpose of the study was to determine the efficacy and safety of left atrial appendage (LAA) closure via a percutaneous LAA ligation approach. BACKGROUND: Embolic stroke is the most devastating consequence of atrial fibrillation. Exclusion of the LAA is believed to decrease the risk of embolic stroke. METHODS: Eighty-nine patients with atrial fibrillation were enrolled to undergo percutaneous ligation of the LAA with the LARIAT device. The catheter-based LARIAT device consists of a snare with a pre-tied suture that is guided epicardially over the LAA. LAA closure was confirmed with transesophageal echocardiography (TEE) and contrast fluoroscopy immediately, then with TEE at 1 day, 30 days, 90 days, and 1 year post-LAA ligation. RESULTS: Eighty-five (96%) of 89 patients underwent successful LAA ligation. Eighty-one of 85 patients had complete closure immediately. Three of 85 patients had a ≤2-mm residual LAA leak by TEE color Doppler evaluation. One of 85 patients had a ≤3-mm jet by TEE. There were no complications due to the device. There were 3 access-related complications (during pericardial access, n = 2; and transseptal catheterization, n = 1). Adverse events included severe pericarditis post-operatively (n = 2), late pericardial effusion (n = 1), unexplained sudden death (n = 2), and late strokes thought to be non-embolic (n = 2). At 1 month (81 of 85) and 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by TEE. Of the patients undergoing 1-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks. CONCLUSIONS: LAA closure with the LARIAT device can be performed effectively with acceptably low access complications and periprocedural adverse events in this observational study.

Concepts: Cardiology, Doppler echocardiography, Echocardiography, Stroke, Atrial fibrillation, Pericardial effusion, Left atrial appendage occlusion, Left atrial appendage

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The purpose of this study was to investigate the frequency and clinical impact of incomplete left atrial appendage (LAA) sealing and consequent peri-device residual blood flow in patients undergoing percutaneous LAA closure with the Watchman device (Atritech, Inc., Plymouth, Minnesota).

Concepts: Heart, Stroke, Atrial fibrillation, Warfarin, Atrial flutter, Anticoagulant, Left atrial appendage occlusion, Left atrial appendage

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The aim of the study was to determine whether routine left atrial appendage ligation in cardiac surgery would reduce the risk of postoperative atrial fibrillation-related cerebrovascular accident.

Concepts: Heart, Atrial fibrillation, Left atrial appendage occlusion, Left atrial appendage, Cerebrovascular disease

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BACKGROUND: The multicenter PROTECT AF study was conducted to determine whether percutaneous left atrial appendage (LAA) closure with a filter device (Watchman) was noninferior to warfarin for stroke prevention in atrial fibrillation (AF). METHODS AND RESULTS: Patients (n = 707) with nonvalvular AF and at least one risk factor (age > 75, hypertension, heart failure, diabetes or prior stroke/TIA) were randomized to either the Watchman device (n = 463) or continued warfarin (n = 244) in a 2:1 ratio. After device implantation, warfarin was continued for ~45 days, followed by clopidogrel for 4.5 months and lifelong aspirin. Study discontinuation rates were 15.3% (71/463) and 22.5% (55/244) for the Watchman and warfarin groups respectively. The time in therapeutic range for the warfarin group was 66%. The composite primary efficacy endpoint included stroke, systemic embolism and cardiovascular death, and the primary analysis was by intention-to-treat. After 1,588 patient-years of follow-up (mean 2.3±1.1 years), the primary efficacy event rates were 3.0% and 4.3% (percent per 100-patient years) in the Watchman and warfarin groups, respectively (RR = 0.71, 95% CI 0.44-1.30%/y), meeting the criteria for non-inferiority (probability of non-inferiority > 0.999). There were more primary safety events in the Watchman group (5.5%/y, 95% CI 4.2-7.1%/y) than in the control group (3.6%/y; 95% CI 2.2-5.3%/y; RR 1.53, 95% CI 0.95-2.70). CONCLUSIONS: The “local” strategy of LAA closure is noninferior to “systemic” anticoagulation with Warfarin. PROTECT AF has, for the first time, implicated the LAA in the pathogenesis of stroke in AF. CLINICAL TRIAL REGISTRATION INFORMATION: Clinicaltrials.gov; Unique Identifier: NCT00129545.

Concepts: Myocardial infarction, Heart, Stroke, Atrial fibrillation, Warfarin, Anticoagulant, Left atrial appendage occlusion, Left atrial appendage

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We sought to develop and validate an intracardiac echocardiography (ICE) imaging strategy for evaluation of left atrial (LA) appendage (LAA) anatomy and function to clarify equivocal findings of LAA thrombus with transesophageal echocardiography (TEE).

Concepts: Echocardiography, Atrial fibrillation, Medical imaging, Left atrial appendage occlusion, Left atrial appendage

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The classic cut and sew maze is thought to reduce stroke, in part because of left atrial appendage (LAA) elimination. Multiple LAA elimination techniques have evolved with the introduction of new surgical treatment options for atrial fibrillation (AF), but the impact on stroke remains unknown. We studied the rate of late neurologic event (LNE) in the era of contemporary AF surgery.

Concepts: Medicine, Hospital, Atrial fibrillation, Surgery, Neurosurgery, Atrial flutter, Left atrial appendage occlusion, Left atrial appendage

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BACKGROUND: The aims of this study were to evaluate the relationship of the CHA(2)DS(2)-VASc score and risk categories with transesophageal echocardiographic (TEE) risk factors for thromboembolism and to compare the CHA(2)DS(2)-VASc and CHADS(2) risk stratification schemes with respect to their ability to predict these risk factors in a multiethnic US population with nonvalvular atrial fibrillation. METHODS: Transesophageal echocardiograms of 167 patients (mean age, 66.3 ± 11.6 years; 146 men [87%]; 100 whites [60%]; 40 Hispanics [24%]; 27 blacks [16%]) with nonvalvular atrial fibrillation were retrospectively reviewed for smoke, sludge, thrombus, and left atrial appendage (LAA) emptying velocity ≤20 cm/sec. The patients' CHA(2)DS(2)-VASc and CHADS(2) risk scores and categories were also calculated. RESULTS: Any LAA abnormality, smoke, sludge, thrombus, and abnormal LAA emptying velocity were present in 45%, 38%, 13%, 3%, and 22% of patients, respectively. Heart failure (P < .001), age (P < .001 for age ≥75 vs ≤64 years, P = .013 for age 65-74 vs ≤64 years), and diabetes (P = .019) were independent predictors of LAA abnormalities, while ethnicity was not. The prevalence of TEE risk factors for thromboembolism increased with increasing CHA(2)DS(2)-VASc score and risk category. The CHADS(2) risk categories of 35 patients (21%) were upgraded by the CHA(2)DS(2)-VASc scheme. Using the latter scheme, fewer patients were classified as at intermediate risk compared with the CHADS(2) system (21 [13%] vs 46 [28%]). Patients classified as at low risk by either scheme had almost no TEE risk factors. Of 30 intermediate-risk patients by CHADS(2) score upgraded to high risk using CHA(2)DS(2)-VASc score, eight (27%) had at least one TEE risk factor for thromboembolism. C-statistics, sensitivity, and specificity for predicting any LAA abnormality were 0.607 (95% confidence interval, 0.549-0.665), 92.0%, and 28.9% for CHA(2)DS(2)-VASc score and 0.685 (95% confidence interval, 0.615-0.755), 81.3%, and 54.2% for CHADS(2) score. CONCLUSIONS: CHA(2)DS(2)-VASc score is associated with TEE risk factors for thromboembolism in a multiethnic US population. Compared with CHADS(2) score, it has increased sensitivity, decreased specificity, and lower ability for predicting TEE risk factors in this population.

Concepts: Cardiology, Echocardiography, Atrial fibrillation, Prediction, Thrombus, Hispanic and Latino Americans, Left atrial appendage occlusion, Left atrial appendage

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Although the initial results of patients who have had left atrial appendage (LAA) occlusion devices implanted have been promising, there have been associated complications requiring surgical intervention. We report a case of a LAA occlusion device migrating into the left ventricle requiring cardiac surgery to retrieve it.

Concepts: Blood, Hospital, Heart, Atrial fibrillation, Surgery, Ventricle, Left atrial appendage occlusion, Left atrial appendage