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Performing transcatheter left atrial appendage closure: Techniques and challenges

Published:August 06, 2022DOI:https://doi.org/10.1016/j.hrthm.2022.07.025
      The left atrial appendage (LAA) has been demonstrated to be the major source of thromboemboli in patients with atrial fibrillation.
      • Cresti A.
      • Garcia-Fernandez M.A.
      • Sievert H.
      • et al.
      Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study.
      The rationale of LAA closure is based on eliminating LAA continuity with the left atrium (LA), thereby reducing stroke risk. Indeed, left atrial appendage occlusion (LAAO) procedures play an important role in anticoagulation-intolerant patients who are at risk for atrial fibrillation–related stroke. Based on the PROTECT AF (Watchman Left Atrial Appendage System for Embolic PROTECTion in Patients With Atrial Fibrillation)
      • Holmes D.R.
      • Reddy V.Y.
      • Turi Z.G.
      • et al.
      Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.
      and PREVAIL (Prospective Randomized Evaluation of the WATCHMAN LAA Closure Device in Patients With Atrial Fibrillation [AF] Versus Long Term Warfarin Therapy)
      • Holmes Jr., D.R.
      • Kar S.
      • Price M.J.
      • et al.
      Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.
      studies, the Food and Drug Administration (FDA) approved use of the Watchman (Boston Scientific, Marlborough, MA) device in 2015, with an updated generation of device subsequently ratified in 2020 following the PINNACLE-FLX (Protection Against Embolism for Nonvalvular AF Patients: Investigational Device Evaluation of the Watchman FLX LAA Closure Technology) study.
      • Kar S.
      • Doshi S.K.
      • Sadhu A.
      • et al.
      Primary outcome evaluation of a next-generation left atrial appendage closure device: results from the PINNACLE FLX trial.
      The Amplatzer Amulet (Abbott, Chicago, IL) device received FDA approval in 2021 following results of the Amulet IDE (Amplatzer Amulet Left Atrial Appendage Occluder IDE) study.
      • Lakkireddy D.
      • Thaler D.
      • Ellis C.R.
      • et al.
      Amplatzer amulet left atrial appendage occluder versus watchman device for stroke prophylaxis (Amulet IDE): a randomized, controlled trial.
      Numerous studies have demonstrated the safety and efficacy of these LAAO devices, with no statistically significant difference in rates of any stroke or systemic embolism between device and medical therapy arms, yet with lower rates of hemorrhagic stroke and non–procedure-related major bleeding with LAAO devices.
      • Reddy V.Y.
      • Doshi S.K.
      • Kar S.
      • et al.
      5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials.
      ,
      • Turagam M.K.
      • Osmancik P.
      • Neuzil P.
      • Dukkipati S.R.
      • Reddy V.Y.
      Left atrial appendage closure versus oral anticoagulants in atrial fibrillation: a meta-analysis of randomized trials.
      Here we delineate our approach to LAAO while illustrating some unique challenges that may be encountered.

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      References

        • Cresti A.
        • Garcia-Fernandez M.A.
        • Sievert H.
        • et al.
        Prevalence of extra-appendage thrombosis in non-valvular atrial fibrillation and atrial flutter in patients undergoing cardioversion: a large transoesophageal echo study.
        EuroIntervention. 2019; 15: e225-e230
        • Holmes D.R.
        • Reddy V.Y.
        • Turi Z.G.
        • et al.
        Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.
        Lancet. 2009; 374: 534-542
        • Holmes Jr., D.R.
        • Kar S.
        • Price M.J.
        • et al.
        Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.
        J Am Coll Cardiol. 2014; 64: 1-12
        • Kar S.
        • Doshi S.K.
        • Sadhu A.
        • et al.
        Primary outcome evaluation of a next-generation left atrial appendage closure device: results from the PINNACLE FLX trial.
        Circulation. 2021; 143: 1754-1762
        • Lakkireddy D.
        • Thaler D.
        • Ellis C.R.
        • et al.
        Amplatzer amulet left atrial appendage occluder versus watchman device for stroke prophylaxis (Amulet IDE): a randomized, controlled trial.
        Circulation. 2021; 144: 1543-1552
        • Reddy V.Y.
        • Doshi S.K.
        • Kar S.
        • et al.
        5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials.
        J Am Coll Cardiol. 2017; 70: 2964-2975
        • Turagam M.K.
        • Osmancik P.
        • Neuzil P.
        • Dukkipati S.R.
        • Reddy V.Y.
        Left atrial appendage closure versus oral anticoagulants in atrial fibrillation: a meta-analysis of randomized trials.
        J Am Coll Cardiol. 2020; 76: 2795-2797
        • Alkhouli M.
        • Chaker Z.
        • Alqahtani F.
        • Raslan S.
        • Raybuck B.
        Outcomes of routine intracardiac echocardiography to guide left atrial appendage occlusion.
        JACC Clin Electrophysiol. 2020; 6: 393-400
        • Hemam M.E.
        • Kuroki K.
        • Schurmann P.A.
        • et al.
        Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: procedural and cost considerations.
        Heart Rhythm. 2019; 16: 334-342
        • Korsholm K
        • Berti S
        • Iriart X
        • et al.
        Expert recommendations on cardiac computed tomography for planning transcatheter left atrial appendage occlusion.
        JACC Cardiovasc Interv. 2020; 13: 277-292
        • Patel A.
        • Venkataraman R.
        • Schurmann P.
        • Dave A.
        • Valderrabano M.
        Left atrial appendage occlusion using intracardiac echocardiography.
        Heart Rhythm. 2021; 18: 313-317
        • Alkhouli M.
        • Simard T.
        • Killu A.M.
        • Friedman P.A.
        • Padang R.
        First-in-human use of a novel live 3D intracardiac echo probe to guide left atrial appendage closure.
        JACC Cardiovasc Interv. 2021; 14: 2407-2409
        • Alkhouli M.
        • Du C.
        • Killu A.
        • et al.
        Clinical impact of residual leaks following left atrial appendage occlusion: insights from the NCDR LAAO registry.
        JACC Clin Electrophysiol. 2022; 8: 766-778
        • Killu A.M.
        • Gbolabo Adeola O.
        • Della Rocca D.G.
        • et al.
        Leak closure following left atrial appendage exclusion procedures: a multicenter registry.
        Catheter Cardiovasc Interv. 2022; 99: 1867-1876
        • Mendelson T.B.
        • Santangeli P.
        • Frankel D.S.
        • et al.
        Feasibility of complex transfemoral electrophysiology procedures in patients with inferior vena cava filters.
        Heart Rhythm. 2019; 16: 873-878
        • Wang S.L.
        • Siddiqui A.
        • Rosenthal E.
        Long-term complications of inferior vena cava filters.
        J Vasc Surg Venous Lymphat Disord. 2017; 5: 33-41
        • van Niekerk C.J.
        • Pandey A.C.
        • Nelson T.
        • Wang H.
        • Gibson D.N.
        Successful left atrial appendage closure using a percutaneous hepatic venous approach.
        HeartRhythm Case Rep. 2019; 5: 545-548
        • Aizer A.
        • Young W.
        • Saric M.
        • Holmes D.
        • Fowler S.
        • Chinitz L.
        Three-dimensional transesophageal echocardiography to facilitate transseptal puncture and left atrial appendage occlusion via upper extremity venous access.
        Circ Arrhythm Electrophysiol. 2015; 8: 988-990
        • Hammerstingl C.
        • Lickfett L.
        • Jeong K.M.
        • et al.
        Persistence of iatrogenic atrial septal defect after pulmonary vein isolation—an underestimated risk?.
        Am Heart J. 2006; 152 (e361–365): 362
        • Liang J.J.
        • Mohanty S.
        • Fahed J.
        • et al.
        Bailout atrial balloon septoplasty to overcome challenging left atrial transseptal access for catheter ablation of atrial fibrillation.
        JACC Clin Electrophysiol. 2018; 4: 1011-1019