Effectiveness of Left Atrial Appendage Occlusion Devices
- Noelck N, Papak J, Freeman M, et al.
- 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):
- The LAA is a major source of thrombus, resulting in stroke or systemic embolism in patients with nonvalvular AF.
- 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).
- A number of LAA occlusion devices have been implanted percutaneously, of which the WATCHMAN device (Boston Scientific) has been studied most extensively.
- 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.
- In patients who have undergone implantation of a WATCHMAN device, OAC is typically discontinued after surveillance transesophageal echocardiography fails to reveal a significant leak.
- The WATCHMAN device is probably associated with a similar risk of stroke and mortality as long-term OAC.
- Data in patients who are ineligible for long-term OAC are limited.
- 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.
- 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.
- Given the high prevalence of blood flow into the LAA following surgical exclusion, transesophageal echocardiography should be performed prior to considering discontinuation of OAC.
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