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. 2021 Nov 2;10(21):e022274.
doi: 10.1161/JAHA.121.022274. Epub 2021 Oct 20.

Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation

Fareed Moses S Collado  1 , Claudia M Lama von Buchwald  1 , Christina K Anderson  1 , Nidhi Madan  1 , Hussam S Suradi  1 , Henry D Huang  1 , Hani Jneid  2 , Clifford J Kavinsky  1
Affiliations

Left Atrial Appendage Occlusion for Stroke Prevention in Nonvalvular Atrial Fibrillation

Fareed Moses S Collado et al. J Am Heart Assoc. .

Abstract

The majority of embolic strokes in patients with nonvalvular atrial fibrillation are caused by thrombi in the left atrial appendage. It is projected that strokes related to atrial fibrillation will markedly increase in the future unless effective mitigation strategies are implemented. Systemic anticoagulation has been known to be highly effective in reducing stroke risk in patients with atrial fibrillation. However, bleeding complications and nonadherence are barriers to effective anticoagulation therapy. Surgical and percutaneous left atrial appendage occlusion devices are nonpharmacologic strategies to mitigate the challenges of drug therapy. We present a contemporary review of left atrial appendage occlusion for stroke prevention in nonvalvular atrial fibrillation. A thorough review of the history of surgical and percutaneous left atrial appendage occlusion devices, recent trials, and US Food and Drug Administration milestones of current left atrial appendage occlusion devices are discussed.

Keywords: atrial fibrillation; left atrial appendage; left atrial appendage occlusion; stroke.

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Conflict of interest statement

None.

Figures

Figure 1
Figure 1. Explanted hearts showing different left atrial appendage morphology.
(A) chicken wing, (B) windsock, (C) cauliflower, (D) cactus. Reprinted from Beigel et al with permission. Copyright ©2014, Elsevier.
Figure 2
Figure 2
The AtriClip device. Copyright Atricure 2021.
Figure 3
Figure 3. Percutaneous left atrial appendage occlusion devices.
(A) Watchman, (B) Watchman FLX, (C) fluoroscopic image of the Watchman, (D) TEE image showing a deployed Watchman, (E) Amplatzer Cardiac Plug (ACP), (F) Amulet, (G) Fluoroscopic image of the ACP device, (H) transesophageal echocardiogram image showing a deployed Amulet device, (I) PLAATO, (J) WaveCrest, (K) Occlutech, (L) LAmbre, (M) Sideris Patch, (N) Ultraseal, (O) Pfm, (P) LARIAT, (Q) Sierra Ligation System. Reprinted from Asmarats and Rodés‐Cabau with permission. Copyright ©2017 American Heart Association, Inc. ACP indicates Amplatzer Cardiac Plug; and PLAATO, percutaneous left atrial appendage transcatheter occlusion.
Figure 4
Figure 4. The Watchman (A) and the Watchman FLX device (B).
Image provided courtesy of Boston Scientific ©2021 Boston Scientific Corporation or its affiliates. All rights reserved.
Figure 5
Figure 5. Timeline showing important dates of left atrial appendage occlusion trials and US FDA milestones in the United States.
AF indicates atrial fibrillation; ASAP, ASA Plavix Feasibility Study With WATCHMAN Left Atrial Appendage Closure Technology; ASAP TOO, The Assessment of the Watchman Device in Patients Unsuitable for Oral Anticoagulation; CAP, Continued Access to PROTECT AF; CAP2, Continued Access to PREVAIL; CE, conformité européenne; EXCLUDE, Exclusion of Left Atrial Appendage with AtriClip Exclusion Device in Patients Undergoing Concomitant Cardiac Surgery; FDA, Food and Drug Administration; LAA, left atrial appendage; LAAOS I, Left Atrial Appendage Occlusion During Cardiac Surgery to Prevent Stroke; and PLAATO, percutaneous left atrial appendage transcatheter occlusion.
Figure 6
Figure 6. Contrast injection using a pigtail catheter and Watchman access sheath showing a multilobed left atrial appendage (LAA).
Figure 7
Figure 7. Fluoroscopic image of a Watchman FLX device released using intracardiac echo guidance (ICE).
Figure 8
Figure 8. Intracardiac echocardiogram image of a deployed Watchman FLX device (27 mm).
See this image and copyright information in PMC

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