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Percutaneous left atrial appendage occlusion devices. (A) Watchman, (B) Watchman FLX, (C) fluoroscopic image of the Watchman, (D) TEE image showing a deployed Watchman, (E) Amplatzer Cardiac Plug (ACP), (F) Amulet, (G) Fluoroscopic image of the ACP device, (H) transesophageal echocardiogram image showing a deployed Amulet device, (I) PLAATO, (J) WaveCrest, (K) Occlutech, (L) LAmbre, (M) Sideris Patch, (N) Ultraseal, (O) Pfm, (P) LARIAT, (Q) Sierra Ligation System. Reprinted from Asmarats and Rodés-Cabau 74 with permission. Copyright ©2017 American Heart Association, Inc. ACP indicates Amplatzer Cardiac Plug; and PLAATO, percutaneous left atrial appendage transcatheter occlusion.
Source publication
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 i...
Contexts in source publication
Context 1
... first percutaneous LAAO device implanted in humans was the Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO) device (ev3 endovascular, Plymouth, MN) ( Figure 3I). 32 The device consisted of a self-expanding nitinol cage enclosed by polytetrafluoroethylene membrane. ...
Context 2
... Cardiac Plug (ACP; Abbott Vascular, Santa Clara, CA) is a self-expanding, double-disc device consisting of a nitinol mesh with polyester fabric ( Figure 3E). The length of the device is shorter than the diameter, thereby allowing its use in cases of shorter LAA anatomy. ...
Context 3
... size ranges from 16 mm to 30 mm, allowing broader options for different LAA sizes. The Amulet device is the latest generation of the ACP ( Figure 3F). It is based on a design similar to the ACP while incorporating some modifications to allow for easier implantation and reduce periprocedural complications. ...
Similar publications
Background
Both catheter left atrial appendage occlusion combined with ablation (COA) and thoracoscopic surgical left atrial appendage clipping combined with ablation (TCA) have shown favorable outcomes in management of patients with atrial fibrillation (AFib). However, studies comparing the endpoints of both techniques are still lacking. Herein, a...
Atrial fibrillation is the most common cardiac arrhythmia and is associated with morbidity and mortality due to cerebral or systemic embolization, with cardiac thrombi mainly forming in the left atrial appendage (LAA). Anticoagulation is the treatment of choice; however, in patients who do not tolerate anticoagulation, LAA occlusion (LAAO) is a val...
Background
Various randomized multicenter studies have shown that percutaneous left atrial appendage closure (LAAC) is not inferior in stroke prevention compared to vitamin K antagonists (VKA) and can be performed safely and effectively.
Aims
The prospective multicenter ORIGINAL registry in the Free State of Saxony (saxOnian RegIstry analyzinG and...
Although oral anticoagulants (OACs) are first-line therapy for stroke prevention in patients with atrial fibrillation (AF), some patients cannot be treated with OACs due to absolute or relative contraindications. Left atrial appendage (LAA) exclusion techniques have been developed over the years as a therapeutic alternative for stroke prevention. I...
Objective: Surgical left atrial appendage (LAA) closure using epicardial clips has become popular in stroke prevention in patients with atrial fibrillation. Optimal placement of the clip is essential to achieve complete LAA occlusion and to prevent complications due to compression of the circumflex artery. We determine the added value of immersive...
Citations
... Previous data mainly demonstrated the efficacy of this strategy in stroke prevention. 53 PLUG dementia trial (Percutaneous Left Atrial Appendage Closure on the Cognitive Decline and Dementia in Patients with Atrial Fibrillation Trial; NCT03091855) aimed to assess the effect of left atrial appendage closure on cognitive function among patients with AF. However, enrollment was low, and unfortunately, the trial was terminated. ...
The prevalence of atrial fibrillation among older adults is increasing. Research has indicated that atrial fibrillation is linked to cognitive impairment disorders such as Alzheimer and vascular dementia, as well as Parkinson disease. Various mechanisms are believed to be shared between atrial fibrillation and cognitive impairment disorders. The specific pathologies and mechanisms of different cognitive disorders are still being studied. Potential mechanisms include cerebral hypoperfusion, ischemic or hemorrhagic infarction, and cerebrovascular reactivity to carbon dioxide. Additionally, circulatory biomarkers and certain infectious organisms appear to be involved. This review offers an examination of the overlapping epidemiology between atrial fibrillation and cognitive disorders, explores different cognitive disorders and their connections with this arrhythmia, and discusses trials and guidelines for preventing and treating atrial fibrillation in patients with cognitive disorders. It synthesizes existing knowledge on the management of atrial fibrillation and identifies areas that require further investigation to bridge the gap in understanding the complex relationship between dementia and atrial fibrillation.
... When warfarin method is applied to patients with atrial fibrillation, it can timely inhibit the generation of coagulation factors and thromboembolism, effectively prevent the expansion and spread of thrombus, and effectively control the shedding of thrombus [15]. However, the therapeutic window of warfarin is narrow, and its anticoagulant effect will be affected by many factors such as food and drugs. ...
... The left atrial appendage (LAA) is indisputably the most "guilty" area while up to 91% of thrombi are formed here in non-rheumatic AF [4]. All three pillars of the Virchow triad contribute to the thrombogenesis in LAA in AF: blood stasis; endothelial injury (due to the blood stasis, appendage dilation and fibroelastic degeneration); hypercoagulable state (consequence of platelet activation secondary to growth factor imbalance) [5]. ...
Prophylactic left atrial appendage occlusion has been suggested as a means of reducing cardioembolism risk in patients with atrial fibrillation. Its clinical benefits have been discussed together with potential endocrine or hemodynamic adverse effects, with conflicting conclusions. We aimed to provide a thorough overview of the current literature and a recommendation for daily clinical decision-making. A comprehensive Medline search through PubMed was conducted to search for relevant articles, which were further filtered using the title and abstract. Sixty-five articles were selected as relevant to the topic. Concomitant left atrial appendage occlusion during cardiac surgery for other reasons is effective in terms of thromboembolism risk reduction in patients with a history of atrial fibrillation and higher CHA2DS2-VASc scores. Surgical occlusion is safe, and epicardial closure techniques are preferred. Thoracoscopic and transcatheter techniques are also feasible, and the individual treatment choice must be tailored to the patient. The concerns about endocrine imbalance or risk of heart failure after occlusion are not supported by evidence. Current evidence is conflicting with regard to hemodynamic consequences of appendage occlusion.
... Given that the majority of thrombi associated with atrial fibrillation (AF) in the left atrium originate within the left atrial appendage (LAA), historically, the surgical excision or exclusion of the appendage has been attempted as a prophylactic measure, albeit with initially elevated morbidity and mortality rates. 1 While less invasive surgical interventions, such as minimally invasive thoracoscopic LAA occlusion, have been implemented for stroke prophylaxis in patients with nonvalvular AF, percutaneous transcatheter LAA closure (LAAC) demonstrates comparable efficacy in preventing strokes in nonvalvular AF patients. 2 Furthermore, the transcatheter LAAC is associated with significantly shorter hospital stays than the thoracoscopic procedure, although with a higher risk of bleeding events and thrombosis. 2 Although transfemoral percutaneous vascular access remains the most widely used and preferred approach for LAAC, different approaches have been attempted when the anatomy of the appendage or the inferior vena cava (IVC) alters the angle at which the ostium of the appendage can be accessed. ...
... In patients with AF, the source of cardioembolic stroke in >90% of the cases is thrombi in the left atrial appendage (LAA) as detected by transesophageal echocardiography (TEE) or autopsy studies [4,5]. Blood stagnation, the absence of atrial contractility in patients with AF, and the partly multi-lobed LAA morphologies with highly trabeculated endocardium are major factors contributing to thrombus formation [6,7]. ...
Over the past two decades, percutaneous left atrial appendage occlusion (LAAO) has proven to be a viable alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF), in particular in those patients who are at increased risk for stroke and bleeding complications. This systematic review provides a comprehensive evaluation of anatomical features, patient selection, procedural planning and execution, complications, medical treatment following the procedure, and contemporary outcome data.
... Although cardioembolic stroke prevention is of paramount importance, the use of oral anticoagulants (OAC), both warfarin and direct oral anticoagulants (DOAC), can cause severe, and sometime fatal, hemorrhagic events [2,3]. This is particularly true for patients with contraindications for long-term anticoagulation like those with non-modifiable predisposing risk factors for bleeding, in whom left-atrial appendage (LAA) occlusion may be an option [4,5]. Moreover, LAA occlusion is also an important option for patients suffering a stroke while on active treatment with anticoagulant therapy and for those requiring concomitant dual antiplatelet therapy (DAPT) with baseline high-bleeding-risk features. ...
Background and Objectives: Percutaneous left-atrial appendage (LAA) occlusion is an important therapeutic option for preventing cardioembolic stroke in patients with non-valvular atrial fibrillation (AF) at high risk of thromboembolic events and with contraindications for oral anticoagulation (OAC). It is usually performed with transesophageal echocardiography (TOE) guidance under general anesthesia (GA). In this retrospective study, we present a multicenter experience of LAA occlusion performed with conscious sedation (CS) without an anesthesiologist on site. Materials and Methods: All the patients on the waiting list for LAA occlusion procedure at Infermi Hospital, Rivoli, and San Luigi Gonzaga University Hospital, Orbassano, from October 2018 to October 2022 were analyzed. All the procedures were performed with a Watchman/FLX LAA closure device under TOE and fluoroscopic guidance without an anesthesiologist on site. CS was performed with a combination of midazolam and fentanyl as needed. Results: One-hundred fifteen patients were included (age 76.4 ± 7.6 years, median CHA2DS2Vasc 4.4 ± 1.4). CS was performed using midazolam (mean dose 5.9 ± 2.1 mg), adding fentanyl for thirty-nine (33.9%) patients in case of poor tolerance for the procedure despite midazolam. The acute procedural success rate was 99.1%. We observed seven acute severe complications. No patients needed anesthesiological assistance during the procedure, and no cases of respiratory failure necessitating ventilation were reported. In a follow-up after 10 ± 9 months, one case of stroke (0.9%) and one case (0.9%) of transient ischemic attack (TIA) occurred. Conclusions: LAA occlusion performed under CS and without the presence of an anesthesiologist on site appears to be safe and effective. It can be an attractive alternative to general anesthesia (GA), as fewer resources are required.
... Although anticoagulant therapy is the primary treatment for atrial fibrillation (AF), its benefits do not clearly outweigh the risks for patients with a high bleeding risk. Therefore, left atrial appendage occlusion (LAAO) has become the main alternative for stroke prevention in patients with high HAS-BLED scores for nonvalvular AF, in whom 90% of the thrombi originate from the left atrial appendage (LAA) (1)(2)(3)(4)(5). With an increasing number of patients undergoing LAAO, more attention is being paid to relieving their clinical symptoms and improving their quality of life. ...
Background
With an increasing number of patients undergoing left atrial appendage occlusion (LAAO), more attention is being paid to relieving clinical symptoms and improving the quality of life of these patients. For patients with atrial fibrillation (AF), direct current cardioversion (DCCV) is an alternate, nonpharmacological choice to restore sinus rhythm and relieve clinical symptoms.
Objectives
The purpose of this study was to assess the feasibility and safety of the DCCV at the time of LAAO for patients with AF.
Methods
Forty patients were enrolled in the DCCV group undergoing the DCCV at the time of LAAO. The control group undergoing LAAO alone was formed by 1:1 matching.
Results
In the DCCV group, cardioversion was immediately successful in 30 (75%) patients, of which 12 (40%) had AF recurrence at the three-month follow-up. The failed-DCCV group was older (73.70 ± 4.74 vs. 62.20 ± 9.01 years old, P = 0.000), had a faster postcardioversion heart rate (88.80 ± 16.58 vs. 70.97 ± 14.73 times, P = 0.03), and had a higher mean HAS-BLED score (4.00 vs. 3.00, P = 0.01) than the successful-DCCV group. No patients experienced periprocedural pericardial effusion, occluder displacement, device embolism, or >5 mm peridevice leakage. One patient experienced a transient ischemic attack (TIA) in the DCCV group during the follow-up.
Conclusions
The DCCV at the time of LAAO is feasible and safe for AF patients with contraindications for catheter ablation or AF recurrence after previous catheter ablation to restore the sinus rhythm and relieve clinical symptoms. The DCCV at the time of LAAO is more likely to succeed for younger patients and patients with lower HAS-BLED scores.
... Mahmoudi et al LAA Remodeling Following Percutaneous Closure with low complication risk and favorable clinical efficacy outcomes. [3][4][5][6] Although the procedure is becoming more and more accepted, 6 the data regarding conformability, compression, and device-related left atrial appendage (LAA) remodeling are scarce. Moreover, the interrelationships between prosthesis and LAA dimensions following implantation are unknown. ...
... Mahmoudi et al LAA Remodeling Following Percutaneous Closure with low complication risk and favorable clinical efficacy outcomes. [3][4][5][6] Although the procedure is becoming more and more accepted, 6 the data regarding conformability, compression, and device-related left atrial appendage (LAA) remodeling are scarce. Moreover, the interrelationships between prosthesis and LAA dimensions following implantation are unknown. ...
Background
The interrelationships between left atrial appendage (LAA) dimensions and device following implantation are unknown. We aimed to analyze the impact of Watchman device implantation on LAA dimensions following its percutaneous closure and potential predictors of remodeling.
Methods and Results
All consecutive LAA closure procedures performed at 2 centers between November 2017 and December 2020 were included in the WATCH‐DUAL (Watchman 2.5 Versus Watchman FLX in a Dual‐Center Left Atrial Appendage Closure Cohort) registry. This study included patients who had pre‐ and postintervention computed tomography scan analysis. The LAA and device dimensions were measured in a centralized core lab by 3‐dimensional computed tomography scan reconstruction methods, focusing on the device landing zone. This analysis included 104 patients (age, 76.0 [range, 72.0–83.0] years; 72% men; 53% Watchman FLX; 47% Watchman 2.5). The baseline characteristics were comparable between Watchman 2.5 and Watchman FLX groups, except for the higher use of oversizing in the latter group. The median delay for computed tomography control was 49 (range, 43–64) days. The landing zone area (median, 446 [range, 363–523] versus 290 [222–366] mm ² ; P <0.001) and minimal diameter (median, 23.0 [range, 20.7–24.8] versus 16.7 [14.7–19.4] mm; P <0.001) significantly increased after implantation. The absolute (median, 157 [range, 98–220] versus 85 [18–148] mm ² , P <0.001) and relative (median, 50% [range, 32%–79%] versus 26% [4%–50%]; P <0.001) increases in landing zone area were more pronounced in patients with oversized device. Baseline LAA dimensions were smaller, landing zone eccentricity larger, and oversized device more frequent in patients with significant overexpansion compared with the others.
Conclusions
LAA dimensions increased at the site of the Watchman prosthesis after implantation, suggesting a local positive remodeling after the procedure. This phenomenon was more pronounced in the case of oversized devices.
... Other global strategies to improve adherence include lowering costs [21], focus on improving health literacy and social support [22] and introduction of telemedicine [23]. Likewise, consideration of alternative therapies, such as left atrial appendage occlusion (LAAO) may result in improved outcome in patients who are non-compliant or are unable to take OAC [24][25][26][27]. ...
Background
Real-world data have suggested inconsistent adherence to oral anticoagulation for thromboembolic event (TE) prevention in patients with Non valvular atrial fibrillation (NVAF), yet it remains unclear if event risk is elevated during gaps of non-adherence.
Objective
To compare difference in outcomes between direct oral anticoagulant (DOAC) and warfarin based on adherence to the therapy in patients with NVAF.
Methods
Using the MarketScan claims data, patients receiving prescription of warfarin or a DOAC for NVAF from January 2015 to June 2016 were included. Outcomes included hospitalization for TE (ischemic stroke or systemic embolism), hemorrhagic stroke, stroke of any kind, and major bleeding. Event rates were reported for warfarin and DOACs at a higher-adherence proportion of days covered (PDC > 80%) and lower-adherence (PDC 40–80%).
Results
The cohort included 83,168 patients prescribed warfarin (51% [n = 42,639]) or DOAC (49% [n = 40,529]). Lower adherence occurred in 36% (n = 15,330) of patients prescribed warfarin and 26% (n = 10,956) prescribed DOAC. As compared to higher-adherence warfarin after multivariable adjustment, the risk of TE was highest in lower-adherence DOAC (HR 1.26; 95% CI, 1.14–1.33), and lowest in higher-adherence DOAC (HR, 0.93; 95% CI, 0.88–0.99). There was a significantly higher risk of hemorrhagic stroke and stroke of any kind in the lower-adherence groups. Major bleeding was more common with lower-adherence DOAC (HR, 1.43, 95% CI, 1.35–1.52) and lower-adherence warfarin (HR, 1.32, 95% CI, 1.26–1.39).
Conclusions
In this large real-world study, low adherence DOAC was associated with higher risk of TE events as compared to high and low adherence warfarin.
... The left atrial appendage (LAA) has been identified as the primary origin of emboli in more than 90% of embolic strokes in patients with non-valvular AF [8,9]. Hence, percutaneous left atrial appendage closure (LAAC) with an occluder device has emerged as a non-pharmacological alternative for stroke prevention [10]. ...
... Transseptal puncture or local trauma to the LAA may result in PE and cardiac tamponade, which have been reported to be the main drivers of safety outcomes after LAAC [11,12]. Approximately 90% of PE occur within the first 24 h after LAAC, with rates of 1-2% [8,14,22,40,41], which are similar to the finding of 0.8% in this study. Advancements in operator experience, pre-procedural imaging, transesophageal (TEE) or intracardiac (ICE) echocardiographic guidance, adequate selection of transseptal puncture sites and advanced delivery systems reduce trauma to the LAA [42]. ...
Percutaneous left atrial appendage closure (LAAC) has emerged as a non-pharmacological alternative for stroke prevention in patients with atrial fibrillation (AF) not suitable for anticoagulation therapy. Real-world data on peri-procedural outcomes are limited. The aim of this study was to analyze outcomes of peri-procedural safety and healthcare resource utilization in 11,240 adult patients undergoing LAAC in the United States between 2016 and 2019. Primary outcomes (safety) were in-hospital ischemic stroke or systemic embolism (SE), pericardial effusion (PE), major bleeding, device embolization and mortality. Secondary outcomes (resource utilization) were adverse discharge disposition, hospital length of stay (LOS) and costs. Logistic and Poisson regression models were used to analyze outcomes by adjusting for 10 confounders. SE decreased by 97% between 2016 and 2019 [95% Confidence Interval (CI) 0–0.24] (p = 0.003), while a trend to lower numbers of other periprocedural complications was determined. In-hospital mortality (0.14%) remained stable. Hospital LOS decreased by 17% (0.78–0.87, p < 0.001) and adverse discharge rate by 41% (95% CI 0.41–0.86, p = 0.005) between 2016 and 2019, while hospital costs did not significantly change (p = 0.2). Female patients had a higher risk of PE (OR 2.86 [95% CI 2.41–6.39]) and SE (OR 5.0 [95% CI 1.28–43.6]) while multi-morbid patients had higher risks of major bleeding (p < 0.001) and mortality (p = 0.031), longer hospital LOS (p < 0.001) and increased treatment costs (p = 0.073). Significant differences in all outcomes were observed between male and female patients across US regions. In conclusion, LAAC has become a safer and more efficient procedure. Significant sex differences existed across US regions. Careful considerations should be taken when performing LAAC in female and comorbid patients.
