Effectiveness of Left Atrial Appendage Occlusion Devices

Authors:
Noelck N, Papak J, Freeman M, et al.
Citation:
Effectiveness of Left Atrial Appendage Exclusion Procedures to Reduce the Risk of Stroke: A Systematic Review of the Evidence. Circ Cardiovasc Qual Outcomes 2016;Jul 12:[Epub ahead of print].

The following are key points to remember from this systematic analysis, which explored the effectiveness of left atrial appendage (LAA) occlusion strategies in patients with nonvalvular atrial fibrillation (AF):

  1. The LAA is a major source of thrombus, resulting in stroke or systemic embolism in patients with nonvalvular AF.
  2. Oral anticoagulation (OAC) is indicated in patients at high risk of thromboembolism related to nonvalvular AF. However, OAC is limited by difficulty in maintaining the international normalized ratio within a narrow window (with warfarin), bleeding risks, cost (with the novel agents [NOACs]), and concerns over lack of a specific antidote (with NOACs).
  3. A number of LAA occlusion devices have been implanted percutaneously, of which the WATCHMAN device (Boston Scientific) has been studied most extensively.
  4. The WATCHMAN device is indicated as an alternative to long-term OAC with warfarin in patients with nonvalvular AF who are at increased risk of stroke.
  5. In patients who have undergone implantation of a WATCHMAN device, OAC is typically discontinued after surveillance transesophageal echocardiography fails to reveal a significant leak.
  6. The WATCHMAN device is probably associated with a similar risk of stroke and mortality as long-term OAC.
  7. Data in patients who are ineligible for long-term OAC are limited.
  8. Considering all devices, the risk of acute complications within 7 days of implantation is about 6-7%. These include perforation/pericardial effusion, access site bleeding, and device thrombus/embolization.
  9. It is possible that the reduction in bleeding events in the long-term in patients with an LAA occlusion device may offset the upfront risk of procedure-related complications.
  10. Given the high prevalence of blood flow into the LAA following surgical exclusion, transesophageal echocardiography should be performed prior to considering discontinuation of OAC.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Noninvasive Imaging, Pericardial Disease, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Echocardiography, Transesophageal, Embolism, Hemorrhage, Pericardial Effusion, Risk, Secondary Prevention, Stroke, Thromboembolism, Thrombosis, Warfarin


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