The Evolving Role of Left Atrial ­appendage Occlusion: A High-Volume Single-Centre Experience

Objectives: To report our 5-year single centre experience with percutaneous left atrial appendage occlusion (LAAO).
Background: LAAO evolved rapidly at our institution, as it has worldwide. The procedure requires experience to be safely performed. We evaluated indications, and short- and long-term outcome of LAAO.
Methods: LAAO was performed either (a) under general anaesthesia with transesophageal echocardiographic and fluoroscopic guidance, (b) under local anaesthesia with intracardiac echocardiographic and fluoroscopic guidance, or (c) with fluoroscopic guidance alone, depending on operator preference. A previously detected patent foramen ovale (PFO) or atrial septal defect (ASD) was used for left atrial access by one operator (FN) with Amplatzer devices only; transseptal puncture was routine in the rest. Patients were discharged on acetylsalicylic acid and clopidogrel for 1–6 months; oral anticoagulation (OAC) was stopped the day of the procedure.
Results: From June 2010 to November 2015, LAAO was performed in 284 patients at the University Heart Centre Zurich, of whom 247 were included in the analysis (164 males, 77 ± 8.9 years, CHA2DS2-Vasc-score 4.5 ± 1.4, HASBLED- score 3.6 ± 1.1). Devices used were the Amplatzer Cardiac Plug in 107 patients (42.9%), the Amplatzer Amulet in 87 patients (35.2%) and the Watchman device in 53 patients (21.5%). A PFO or ASD was used for left atrial access and occluded after LAAO in 20 (8.1%) patients. Procedures were performed with coronary angiography in 72 patients (29.2%), after a percutaneous coronary intervention in 36 patients (14.6%), with transcatheter aortic valve implantation in 56 patients (22.7%) and with a MitraClip procedure in 14 patients (5.7%). Periprocedural major adverse events (procedural death, stroke, tamponade with need for percutaneous drainage or surgical bailout, major or life-threatening vascular complication, kidney injury grade 3 or device embolisation) occurred in 12 (4.9%) patients. Follow-up was complete in 222 (89.9%) patients (mean 10 ± 9.6 months). Late deaths occurred in 22 patients (9.9%; 7 cardiovascular, 10 non-cardiac, 5 unexplained). Neurological events occurred in 3 patients (1.4%) and major bleeding in another 3 patients (1.4%).
Conclusion: In a large and experienced centre, LAAO could be performed with high success and low complication rates and was a valuable alternative to OAC. LAAO should be considered a first-line therapy for stroke prevention and discussed as a treatment option with all patients suffering from atrial fibrillation.