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Concept: Left atrial appendage

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INTRODUCTION AND OBJECTIVES: Left atrial appendage closure can be an attractive option for patients with nonvalvular atrial fibrillation and a contraindication to oral anticoagulants, provided that satisfactory results can be achieved during implantation and follow-up. METHODS: Thirty-five consecutive patients, not eligible for randomized trials with oral anticoagulants, had an Amplatzer occlusion device implanted under general anesthesia. After the first 5 patients, 3-dimensional imaging was incorporated. The results of the implantation and the follow-up were analyzed over a 1-year period. RESULTS: The mean age was 74.65 (7.61) years, with a CHADS(2) score of 2.41 (1.53) and a CHA(2)DS(2)-VASc score of 3.17 (1.60). Implantation failed in 1 patient and 5 needed a change in the selected plug size. There were no cardiac complications during the implantation or hospital stay. There was 1 vascular complication (arteriovenous fistula). Transesophageal echocardiography monitoring was performed at 24h, 1, 3, 6 and 12 months and we found 5 thrombi which were resolved with heparin. In the follow-up period of 21.14 (10.09) months, 3 patients aged>80 years died, none of them due to heart problems, and one transient ischemic stroke without further consequences. CONCLUSIONS: Left atrial appendage closure by an experienced operator can be a treatment option with few complications and with efficient results at>1 year in reducing thromboembolic and hemorrhagic complications, even in very high-risk groups. Full English text available from:www.revespcardiol.org/en.

Concepts: Cardiology, Heart, Stroke, Atrial fibrillation, Warfarin, Anticoagulant, Heparin, Left atrial appendage

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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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This study investigated the left atrial appendage (LAA) by computed tomography (CT) and magnetic resonance imaging (MRI) to categorize different LAA morphologies and to correlate the morphology with the history of stroke/transient ischemic attack (TIA).

Concepts: Atrial fibrillation, Transient ischemic attack, Medical imaging, Nuclear magnetic resonance, Radiography, Magnetic resonance imaging, Radiology, 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