Institutional and Operator Requirements for Left Atrial Appendage Occlusion

Authors:
Kavinsky CJ, Kusumoto FM, Bavry AA, et al.
Citation:
SCAI/ACC/HRS Institutional and Operator Requirements for Left Atrial Appendage Occlusion. J Am Coll Cardiol 2015;Dec 10:[Epub ahead of print].

The following are 10 key points to remember from a document outlining who should perform percutaneous closure of the left atrial appendage (LAA) and institutional support needed for this procedure:

  1. The Food and Drug Administration has approved the WATCHMAN device for percutaneous closure of the LAA for patients with nonvalvular atrial fibrillation (AF) who are at risk for stroke, suitable for anticoagulation, and for whom there is a rationale for seeking a nonpharmacologic alternative.
  2. It is anticipated that procedural specialists performing LAA occlusion will come from a variety of backgrounds, including interventional cardiology (adult or pediatric), electrophysiology, and cardiac surgery.
  3. It also is anticipated that physicians will operate within the context of a multidisciplinary team to optimize patient selection for percutaneous closure of the LAA.
  4. LAA occlusion should bring together physician and nonphysician experts, including electrophysiologists, interventional cardiologists, neurologists, imaging experts, primary care providers, and cardiac surgeons.
  5. In the PREVAIL trial, 40% of the patients were enrolled by new implanters, and success and complication rates were not significantly different from those achieved by experienced operators.
  6. Operators performing percutaneous closure of the LAA should be skilled in transseptal puncture through an intact septum. It is the writing committee’s consensus that new operators should have performed 50 lifetime de novo left-sided structural or ablation procedures, 25 of which involve transseptal puncture through an intact septum and should, on an ongoing basis to maintain proficiency, perform at least 25 transseptal punctures over a 2-year period, 12 of which are LAA occlusion procedures.
  7. Most devices require transseptal wire exchange for a large bore outer diameter sheath. Operators need to be skilled in relationships between the sheath and the LAA, atrial roof, pulmonary veins, and posterior atrial wall.
  8. It is the writing committee’s consensus that an aggregate of 50 structural heart disease or left-sided catheter ablations, at least 25 of which involve transseptal puncture through an intact septum, should be performed at the institution in the year leading to starting an LAA program and per year thereafter.
  9. It is the writing committee’s consensus that participation in a national registry should be mandatory for all LAA occlusion programs.
  10. Individual institutions should have aggregate and operator-specific quality analysis processes, in addition to participation in a registry.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Cardiac Surgical Procedures, Catheter Ablation, Electrophysiology, Patient Care Team, Quality Indicators, Health Care, Stroke


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