New SCAI/HRS Expert Consensus Statement Addresses Transcatheter LAAC
With transcatheter endovascular left atrial appendage closure (LAAC) continuing to mature and evolve in terms of technologies, published research, technical expertise and clinical practice, a new expert consensus statement from the Society for Cardiovascular Angiography and Interventions (SCAI) and the Heart Rhythm Society (HRS) provides recommendations on contemporary, evidence-based best practices.
The statement, endorsed by the ACC and published in JACC: Cardiovascular Interventions, identifies transcatheter LACC as appropriate for patients with nonvalvular atrial fibrillation with high thromboembolic risk who are not suited for long-term oral anticoagulation and who have life expectancy of greater than one year. The authors, including Chair Jacqueline Saw, MD, FACC, and Vice Chair David R. Holmes Jr., MD, MACC, stress the importance of shared decision-making discussions between patients and providers, as well as the need for interventional imaging physicians to have prior experience before supporting any LAAC procedures independently. The statement provides specific recommendations as to the number of procedures for training, as well as for maintenance of skills over two-year periods.
Other recommendations include having onsite cardiovascular surgery backup available for new programs and for implanting physicians who are early in their LAAC experience. Baseline imaging with transesophageal echocardiography (TEE) or cardiac computed tomography (CCT) is recommended before LAAC, as well as at 45 to 90 days after LAAC for device surveillance to assess for peridevice leak and device-related thrombus. Use of TEE or intracardiac echocardiography is recommended for intraprocedural imaging guidance. The statement also calls for predischarge imaging to be performed with two-dimensional transthoracic echocardiography to rule out pericardial effusion and device embolization.
Of note, the statement recommends that routine closure of iatrogenic atrial septal defects associated with LAAC not be performed. Additionally, with the clinical impact and management of peridevice leaks not fully understood, the authors stress that all efforts should be made to minimize such leaks at the time of implantation. Similarly, with several ongoing randomized controlled trial still pending, the statement recommends against routinely performing combined procedures with LAAC (e.g., structural interventions, pulmonary vein isolation).
“The field of transcatheter LAAC has evolved tremendously in its first two decades, with marked improvements in safety, efficacy, and device iterations,” the statement says. “Ongoing trials and evolving practices indicate significant future advancements to come. … Given the rapid developments in this field, this consensus document acknowledges important areas where further evidence is needed to be developed including but not restricted to the type and duration of post-LAAC antithrombotic therapy, standardization of post-LAAC imaging surveillance and time points; duration of OAC after DRT detection and follow-up imaging; management of PDL; and head-to-head comparison of LAAC vs DOAC in OAC-eligible patients.”
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Imaging, Angiography, Nuclear Imaging
Keywords: Iatrogenic Disease, Reference Standards, Physicians, Professional Competence, Angiography, Anticoagulants, Thrombosis, Thromboembolism, Atrial Fibrillation, Follow-Up Studies, Pericardial Effusion, Fibrinolytic Agents
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