Consensus Statement on Transcatheter LA Appendage Closure: Key Points

Saw J, Holmes DR, Cavalcante JL, et al.
SCAI/HRS Expert Consensus Statement on Transcatheter Left Atrial Appendage Closure. JACC Cardiovasc Interv 2023;Mar 27:[Epub ahead of print].

Editor’s Note: This Expert Consensus Statement was endorsed by the American College of Cardiology.

The following are key points to remember from a Society for Cardiovascular Angiography & Interventions/Heart Rhythm Society (SCAI/HRS) Expert Consensus Statement on transcatheter left atrial appendage closure (LAAC):

  1. Atrial fibrillation (AF) is associated with a four- to five-fold increased risk of ischemic stroke and accounts for 25% of the 700,000 cerebrovascular accidents that occur in the United States annually.
  2. Historically, the standard of care for stroke prevention in AF has been oral anticoagulation (OAC); however, there are many patient, prescriber, and health care resource issues that limit OAC use in this setting. This treatment gap has created an unmet clinical need for an effective and safe nonpharmacologic therapy for stroke prevention in patients with nonvalvular AF and has fueled the field of LAAC.
  3. Transcatheter LAAC is appropriate for patients with nonvalvular AF with high thromboembolic risk who are not suited for long-term OAC and who have adequate life expectancy (minimum >1 year) and quality of life to benefit from LAAC. There should be patient-provider discussion for shared decision making. Over the past two decades, the field of transcatheter endovascular LAAC has rapidly expanded, with a myriad of devices approved or in clinical development.
  4. Physicians performing LAAC should have prior experience, including ≥50 prior left-sided ablations or structural procedures and ≥25 transseptal punctures (TSPs). Interventional imaging physicians should have experience in guiding ≥25 TSPs before supporting any LAAC procedures independently.
  5. For maintenance of skills, implanting physicians should perform ≥25 TSPs and >12 LAACs over each 2-year period. New programs and implanting physicians early in their LAAC experience should have on-site cardiovascular surgery backup.
  6. Baseline imaging with transesophageal echocardiography (TEE) or cardiac computed tomography (CCT) is recommended before LAAC. Intraprocedural imaging guidance with TEE or intracardiac echocardiography is also recommended.
  7. Technical aspects of the procedure, including venous access, anticoagulation, transseptal puncture, delivery sheath selection and placement, left atrial pressure measurement, and device deployment, should be performed in accordance with the labeling of each specific LAAC device. Operators need to be familiar with avoidance, recognition, and management of procedural complications associated with LAAC.
  8. Predischarge imaging should be performed with two-dimensional transthoracic echocardiography to rule out pericardial effusion and device embolization. Same-day discharge may be appropriate after several hours of observation demonstrating no complications or pericardial effusion after LAAC.
  9. Device-related thrombus should be treated with anticoagulation. Repeat imaging at 45- to 90-day intervals can be performed to assess for resolution with eventual cessation of anticoagulation. Routine closure of iatrogenic atrial septal defects associated with LAAC should not be performed.
  10. Patients should be prescribed antithrombotic therapy with warfarin, direct oral anticoagulants, or dual antiplatelet therapy after LAAC according to the studied regimen and instructions for use for each specific device and tailored to the bleeding risks of each patient.
  11. TEE or CCT is recommended at 45-90 days after LAAC for device surveillance to assess for peridevice leak and device-related thrombus.
  12. Combined procedures with LAAC (e.g., structural interventions, pulmonary vein isolation) are not routinely recommended, as data are pending from ongoing randomized controlled trials.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Pericardial Disease, Prevention, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Interventions, Interventions and Imaging, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Appendage, Atrial Fibrillation, Heart Septal Defects, Atrial, Diagnostic Imaging, Echocardiography, Echocardiography, Transesophageal, Embolization, Therapeutic, Endovascular Procedures, Fibrinolytic Agents, Iatrogenic Disease, Ischemic Stroke, Pericardial Effusion, Platelet Aggregation Inhibitors, Punctures, Quality of Life, Secondary Prevention, Stroke, Thromboembolism, Thrombosis, Tomography, X-Ray Computed, Warfarin

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