Cardiovascular Therapies Targeting Left Atrial Appendage

Mohit K Turagam, Poonam Velagapudi, Saibal Kar, David Holmes, Vivek Y Reddy, Marwan M Refaat, Luigi Di Biase, Amin Al-Ahmed, Mina K Chung, Thorsten Lewalter, James Edgerton, James Cox, John Fisher, Andrea Natale, Dhanunjaya R Lakkireddy, Mohit K Turagam, Poonam Velagapudi, Saibal Kar, David Holmes, Vivek Y Reddy, Marwan M Refaat, Luigi Di Biase, Amin Al-Ahmed, Mina K Chung, Thorsten Lewalter, James Edgerton, James Cox, John Fisher, Andrea Natale, Dhanunjaya R Lakkireddy

Abstract

Left atrial appendage (LAA) closure has evolved as an effective strategy for stroke prevention in patients with atrial fibrillation who are considered suitable for oral anticoagulation. There is strong evidence based on randomized clinical trials with 1 percutaneous device, as well as a large registry experience with several devices, regarding the safety and efficacy of this strategy. In addition, there is encouraging data regarding the effect of epicardial LAA closure on decreasing arrhythmia burden and improvements in systemic homeostasis by neurohormonal modulation. However, there are several unresolved issues regarding optimal patient selection, device selection, management of periprocedural complications including device-related thrombus, residual leaks, and pericarditis. In this review, we summarize the rationale, evidence, optimal patient selection, and common challenges encountered with mechanical LAA exclusion.

Keywords: anticoagulants; atrial fibrillation; cardiac surgical procedures; stroke; thromboembolism.

Copyright © 2018 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

FIGURE 1
FIGURE 1
Various Types of LAA Exclusion Devices *WaveCrest (Biosense Webster, Irvine, California), LAmbre (Lifetech Scientific Corp., Shenzhen, China), Transcatheter patch (Custom Medical Devices, Greece), Ultracept (Cardia, Eagan, Minnesota), pfm LAA Occluder (pfm Medical, Cologne, Germany), and Occlutech (Occlutech International, Helsingborg, Sweden). ACP = Amplatzar cardiac plug; LAA = left atrial appendage; PLAATO = percutaneous left atrial appendage transcatheter occlusion.
FIGURE 2
FIGURE 2
Surgical LAA Exclusion Devices (A) AtriClip LAA exclusion system. Image courtesy of AtriCure. (B) ENDOLOOP Ligature. Image courtesy of Ethicon. (C) LigaSure Vessel Sealing System. Image courtesy of Medtronic. (D) ECHELON FLEX ENDOPATH Staplers. Image courtesy of Ethicon. (E) Endo Gia. Image courtesy of Medtronic. LAA = left atrial appendage.
FIGURE 3
FIGURE 3
Percutaneous LAA Exclusion Devices (A) Watchman device and Watchman FLX. Image courtesy of Boston Scientific. (B) Fluoroscopy image showing positioning of Watchman in the LAA. (C) TEE image demonstrating Watchman positioned in the LAA. (D) Amplatzer cardiac plug (ACP) device. (E) Amulet. (F) Fluoroscopy image showing positioning of the ACP in the LAA (G). TEE image demonstrating device positioned in the LAA. (H) Lariat suture delivery device. (I) Fluoroscopy image showing positioning of Lariat system at the LAA. (J) TEE image demonstrating device after LAA exclusion. Reprinted from Saw J, Lempereur M. Percutaneous left atrial appendage closure: procedural techniques and outcomes. J Am Coll Cardiol Intv 2014;7:1205–20. LAA = left atrial appendage; TEE = transesophageal echocardiography.
FIGURE 4
FIGURE 4
Expected and Annual Rate of Stroke in Watchman, ACP, and Lariat (A) Results from the ASAP registry. The observed rate of ischemic stroke was 1.7%, compared with an expected rate of ischemic stroke of 7.3% with similar CHADS2 score with aspirin and 5% with clopidogrel. Adapted with permission from Reddy et al. (63). (B) Results from Tzikas et al. (66). The observed rate of ischemic stroke was 2.3%, compared with an expected rate of ischemic stroke of 5.6% with similar CHADS2 score with aspirin. Adapted with permission from Tzikas et al. (66). (C) Results from Sievert et al. (69). The observed rate of ischemic stroke was 1%, compared with an expected rate of ischemic stroke of 6.2% with similar CHADS2 score with aspirin. Adapted with permission from Sievert et al. (69). ACP = Amplatzer cardiac plug; ASAP = ASA Plavix Feasibility Study With WATCHMAN Left Atrial Appendage Closure Technology; CHADS2 = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack.
FIGURE 5
FIGURE 5
Investigational LAA Exclusion Devices (A) Coherex Wavecrest device. Wavecrest implant image reprinted from De Backer O, Arnous S, Ihlemann N, et al. Percutaneous left atrial appendage occlusion for stroke prevention in atrial fibrillation: an update. Open Heart 2014;1:e000020. (B) Transcatheter patch (Custom Medical Devices). Reprinted with permission from Toumanides et al. (75). (C) LAmbre device (Lifetech Scientific). Reprinted with permission from Huang et al. (72). (D) Occlutech device. Image courtesy of Occlutech International AB. (E) pfm LAA Occluder. Image courtesy of pfm Medical. (F) Ultraseal device (Cardia). Image courtesy of Cardia. (G) Sierra ligation system. Image courtesy of Aegis Innovations. LAA = left atrial appendage.
FIGURE 6
FIGURE 6
Neurohormonal Modulation With LAA Exclusion BP = blood pressure; GP = ganglionated plexus; HR = heart rate; LAA = left atrial appendage; Na+ = sodium ion; RAAS = renin-angiotensin-aldosterone system.
FIGURE 7
FIGURE 7
Guide to Consider LAA Closure in Nonvalvular AF AF = atrial fibrillation; CHA2DS2-VASc = congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism, vascular disease, age 65–74 years, sex category (female); DOAC = direct oral anticoagulant; OAC = oral anticoagulant; other abbreviations as in Figure 6.
CENTRAL ILLUSTRATION
CENTRAL ILLUSTRATION
Impact of Left Atrial Appendage Exclusion

Source: PubMed

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