Percutaneous Left Atrial Appendage Occlusion—Current Evidence and Future Directions
Abstract
:1. Introduction
2. Patient Selection
2.1. Patients Who Should Be Considered
2.2. Patients Who Should Not Be Considered
3. Imaging
3.1. Anatomy and Function of the LAA
3.2. Baseline Imaging
3.3. Periprocedural Imaging
3.4. Postprocedural Imaging and Device Surveillance
4. Procedural Aspects
- The widely implemented TEE guidance for LAAO is the main reason for the utilization of general anesthesia in the US. As a feasible and safe alternative, many European centers routinely perform LAAO with a moderate conscious sedation protocol resulting in a reduction in procedural time, hospital stay, and costs [37,38].
- Vascular access is preferably achieved by ultrasound-guided puncture of the right femoral vein.
- Therapeutic anticoagulation is attained by administration of unfractionated heparin. Activated clotting time (ACT) should range between 250 and 300 s. Periodical ACT monitoring is obligatory. After completion of the intervention, administration of protamine may be considered if hemostasis is not achieved by other means (e.g., manual compression, suture, etc.).
- Coaxial orientation of the access sheath with the LAA is the purpose of a correct TSP. Typically, an inferior and posterior septal position on the interatrial septum is chosen. Specific anatomy may require a different TSP site; preprocedural imaging can help determine the location of the TSP. Passage through a patent foramen ovale should be avoided as it may not result in coaxiality of the device with the LAA. TEE guidance for TSP and sheath positioning is best achieved in a bicaval view.
- LAA dimensions vary depending on the hydration status. For correct device sizing, LAA measurements should be performed when mean LA pressure is ≥12 mmHg.
- Entry into the LAA should be as atraumatic as possible to reduce the risk of perforation/pericardial effusion. The use of a pigtail catheter is advocated.
- LAAO device deployment is performed according to the manufacturer’s instruction. Established release criteria for the two available devices should be considered (Table 2).
- Assessment of pericardial effusion should be performed at the beginning and end of the LAAO procedure.
- Given the risk of periprocedural stroke, a neurological assessment should be performed after anesthesia/sedation.
- Administration of appropriate endocarditis prophylaxis for 6 months after device implantation.
5. Intraprocedural Complications
5.1. Pericardial Effusion
5.2. Management of Pericardial Effusion/Tamponade
5.3. LAAO Device Embolization
5.4. Management of Device Embolization
5.5. Periprocedural Strokes
5.6. Management of Periprocedural Stroke
6. Postprocedural Complications
6.1. Device-Related Thrombosis
6.2. Peri-Device Leaks
7. Antithrombotic Regimen after LAAO
8. Further Directions
8.1. Patient Selection
8.2. Imaging
8.3. LAAO Devices
8.4. Antithrombotic Regimen
9. Conclusions
Funding
Conflicts of Interest
Abbreviations
ACT | Activated clotting time |
AF | Atrial fibrillation |
CT | Computed tomography |
DAPT | Dual antiplatelet therapy |
DOAC | Direct oral anticoagulant |
DRT | Device-related thrombosis |
ECG | Electrocardiogram |
FDA | Food and Drug Administration |
ICE | Intracardiac echocardiography |
LA | Left atrium |
LAA | Left atrial appendage |
LAAO | Left atrial appendage occlusion |
NCDR | National Cardiovascular Data Registry |
OAC | Oral anticoagulation |
PDL | Peri-device leak |
PVI | Pulmonary vein isolation |
RCT | Randomized controlled trial |
TAVR | Transcatheter aortic valve replacement |
TEE | Transesophageal echocardiography |
TTE | Transthoracic echocardiography |
TSP | Transseptal puncture |
VKA | Vitamin K antagonist |
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2020 ESC and 2019 AHA/ACC/HRS guideline recommendations 1,2 | “LAA occlusion may be considered for stroke prevention in patients with AF and contraindications for long-term anticoagulant treatment” (Class of recommendation IIb, Level of evidence B). |
Meet definition of clinical AF 1 | Minimum duration of an ECG tracing of AF required to establish the diagnosis of clinical AF is at least 30 s or entire 12-lead ECG. |
High thromboembolic risk |
|
Contraindication to long-term OAC 3 |
|
Life expectancy > 1 year | Assessing comorbidities prohibitive to LAAO. |
Quality of life benefit | Patient–provider shared decision. |
PASS for WATCHMAN™ FLX | CLOSE for AMPLATZER™ Amulet™ |
---|---|
Position: device is distal to or at the ostium of the LAA Anchor: fixation anchors engaged/device is stable Size compression: device is compressed 8–20% of original size Seal: device spans ostium, all lobes of LAA are covered | Closure: At least 2/3 of the device lobe should be distal to the left Circumflex artery on echocardiography Lobe compression: The device Lobe should be slightly compressed and have good apposition to the left atrial appendage wall Orientation: The Orientation of the device lobe must be in line with the axis of the intended landing zone in the left atrial appendage Separation: The disc must be Separated from the lobe Elliptical: The disc will have a concave (Elliptical) shape |
Immediately after LAAO | Prehospital Discharge | 45–90 Day Follow Up | |
---|---|---|---|
Imaging modality | TTE | TTE | TEE/CT |
Question | Pericardial effusion | Pericardial effusion Device embolization | DRT PDL |
Trial Acronym | NCT | N | Strategy |
---|---|---|---|
ADALA | NCT05632445 | 160 | Apixaban vs. DAPT after LAAO. |
ANDES | NCT03568890 | 350 | DAPT vs. DOAC for 8 weeks. |
ASPIRIN-LAAO | NCT03821883 | 1120 | Continuation vs. discontinuation of aspirin 6 months after LAAO. |
APPROACH | NCT04550637 | 200 | Apixaban for 12 weeks after LAAO. |
CLOSURE-AF | NCT03463317 | 1512 | DAPT after LAAO. |
CLEARANCE | NCT04298723 | 530 | DAPT for 3 months after LAAO, followed by aspirin for 12 months. Alternatively, 3 months of NOAC followed by aspirin for 12 months. |
CATALYST | NCT04226547 | 2650 | DAPT for 3 months after LAAO. |
CHAMPION-AF | NCT04394546 | 3000 | DOAC or DAPT for 3 months after LAAO. |
STROKECLOSE | NCT02830152 | 750 | Aspirin ± Clopidogrel for 45 d after LAAO. |
LAA-KIDNEY | NCT05204212 | 430 | DAPT for 3 months after LAAO. |
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Rotta detto Loria, J.; Desch, S.; Pöss, J.; Kirsch, K.; Thiele, H.; Sandri, M. Percutaneous Left Atrial Appendage Occlusion—Current Evidence and Future Directions. J. Clin. Med. 2023, 12, 7292. https://doi.org/10.3390/jcm12237292
Rotta detto Loria J, Desch S, Pöss J, Kirsch K, Thiele H, Sandri M. Percutaneous Left Atrial Appendage Occlusion—Current Evidence and Future Directions. Journal of Clinical Medicine. 2023; 12(23):7292. https://doi.org/10.3390/jcm12237292
Chicago/Turabian StyleRotta detto Loria, Johannes, Steffen Desch, Janine Pöss, Katharina Kirsch, Holger Thiele, and Marcus Sandri. 2023. "Percutaneous Left Atrial Appendage Occlusion—Current Evidence and Future Directions" Journal of Clinical Medicine 12, no. 23: 7292. https://doi.org/10.3390/jcm12237292