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Review
. 2014 Jul 8;130(2):202-12.
doi: 10.1161/CIRCULATIONAHA.114.009060.

Left atrial appendage closure to prevent stroke in patients with atrial fibrillation

Matthew J Price  1 , Miguel Valderrábano  2
Affiliations
Review

Left atrial appendage closure to prevent stroke in patients with atrial fibrillation

Matthew J Price et al. Circulation. .
No abstract available

Keywords: anticoagulants; atrial appendage; atrial fibrillation; heart disease; prevention and control.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr. Price reports receipt of consulting and speaking honoraria from Boston Scientific, Daiichi-Sankyo, and St Jude Medical; consulting fees from Janssen Pharmaceutical, W.L. Gore, and Terumo Corporation; research support (to institution) from SentreHeart; and has or will serve as a proctor for Boston Scientific, St. Jude, W.L. Gore, and SentreHeart. Dr. Valderrábano is supported by NIH/NHLBI R21HL097305 and R01 HL115003. He reports receiving consulting and speaking honoraria and research support from Boston Scientific, St Jude Medical, and Medtronic; and consulting and proctoring honoraria from SentreHeart.

Figures

Figure 1
Figure 1
WATCHMAN device. The WATCHMAN device is comprised of a self-expanding nitinol frame with a polyethylene terephthalate fabric cap. Distal tines secure the device within the LAA trabeculae. The device is fully retrievable prior to release from the delivery cable. Device length is approximately equal to its diameter. Device size is selected based upon the largest diameter of the LAA ostium, which is measured by drawing a line from the mitral valve annulus across to the ridge of left upper pulmonary vein, perpendicular to the planned axis of the delivery sheath. Alternatively, the LAA ostium can be measured from the mitral valve annulus to a point approximately 2cm distal from the tip of the left upper pulmonary vein ridge.
Figure 2
Figure 2
WATCHMAN implantation. (A) LAA angiography through a diagnostic pigtail catheter introduced through the delivery sheath within the left atrium. (B) Delivery sheath is advanced deeply within the LAA over the pigtail catheter to avoid traumatizing the thin-walled appendage. (C) WATCHMAN deployed, and angiography demonstrates appropriate position and seal. Contrast material penetrates through the WATCHMAN since the membrane cap is a 160-micron filter. (D) Final fluoroscopy after release.
Figure 3
Figure 3
Amplatzer Cardiac Plug (ACP). The ACP is a self-expanding, nitinol device consisting of a distal lobe and proximal disk with sewn-in polyester fabric connected by a central waist. The distal lobe has hooks around its circumference and anchors the device within the appendage, while the disk is positioned proximally along the plane of the tip of the left upper pulmonary venous ridge and the mitral valve annulus, thereby occluding the mouth of the LAA. Device size is selected based upon the maximal diameter of the distal lobe landing zone, measured approximately 10mm distal to the LAA orifice. A second-generation device has a slightly longer distal lobe, more stabilizing hooks, a longer central waist and a larger diameter proximal disk in order to facilitate implantation and improve LAA sealing.
Figure 4
Figure 4
Transcatheter LAA ligation with the Lariat. (A) A magnetic-tipped wire has been advanced through a trans-septal sheath into the anterior lobe of the LAA and connected to a complementary magnetic tipped wire that has been advanced through a pericardial sheath, forming a rail over which the Lariat snare has been opened and advanced to the base of the LAA. (B) The Lariat is closed and appropriate position and occlusion confirmed by angiography and TEE. The endocardial (inner) wire and catheter are then removed, and an actuator deploys a pre-tied surgical suture from within the Lariat snare and ligates the LAA.
Figure 5
Figure 5
Outcomes in clinical trials of novel oral anticoagulants (NOACs) (top panel) and WATCHMAN (lower panel), compared with warfarin. The primary safety endpoint in PROTECT-AF included both bleeding and procedural complications (including procedure-related stroke). TT: terminal therapy (i.e., landmark analysis after discontinuation of protocol-directed post-procedural warfarin and dual antiplatelet therapy in WATCHMAN group).
Figure 6
Figure 6
Net clinical benefit of WATCHMAN compared with warfarin therapy. Benefit was defined as a weighed sum of outcome differences between warfarin and WATCHMAN. Due to procedural complications with device implantation, net benefit was achieved at approximately 9 months post-procedure in PROTECT-AF (blue line), while the time to positive net clinical benefit was shorter in CAP (red line), since the rate of procedural complications with device implantation was significantly lower. Adapted from Gangireddy et al.
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