Left atrial appendage occlusion in patients with atrial fibrillation: focus on current evidence and commercially available devices

Abstract

Atrial fibrillation is the most common cardiac arrhythmia and is associated with morbidity and mortality due to cerebral or systemic embolization, with cardiac thrombi mainly forming in the left atrial appendage (LAA). Anticoagulation is the treatment of choice; however, in patients who do not tolerate anticoagulation, LAA occlusion (LAAO) is a valid alternative. Over the last decade, many different LAAO devices have been developed and tested in trials, providing good clinical results. The purpose of this paper is to make an overview of the current state of the art of LAAO procedure, with a focus on available devices and future perspectives.

Keywords

Left atrial appendage / left atrial appendage occlusion / atrial fibrillation / stroke prevention

References

[1] Pritchett EL.Management of atrial fibrillation.N Engl J Med1992;326:1264-71

[2] Corley SD,DiMarco JP.AFFIRM InvestigatorsRelationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study.Circulation2004;109:1509-13

[3] Nielsen-Kudsk JE,Damgaard D.Clinical outcomes associated with left atrial appendage occlusion versus direct oral anticoagulation in atrial fibrillation.JACC Cardiovasc Interv2021;14:69-78

[4] Ezekowitz MD,James KE.Warfarin in the prevention of stroke associated with nonrheumatic atrial fibrillation. Veterans Affairs Stroke Prevention in Nonrheumatic Atrial Fibrillation Investigators.N Engl J Med1992;327:1406-12

[5] Blackshear JL.Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation.Ann Thorac Surg1996;61:755-9

[6] Shoeb M.Assessing bleeding risk in patients taking anticoagulants.J Thromb Thrombolysis2013;35:312-9 PMCID:PMC3888359

[7] Lip GY,Pisters R,Crijns HJ.Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: the euro heart survey on atrial fibrillation.Chest2010;137:263-72

[8] Pisters R,Nieuwlaat R,Crijns HJ.A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey.Chest2010;138:1093-100

[9] Hindricks G,Dagres N.ESC Scientific Document Group2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the Task Force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.Eur Heart J2021;42:373-498

[10] January CT,Alpert JS.American College of Cardiology/American Heart Association Task Force on Practice Guidelines2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol2014;64:e1-76

[11] January CT,Calkins H.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society.J Am Coll Cardiol2019;74:104-32

[12] Glikson M,Hindricks G.EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion - an update.EuroIntervention2020;15:1133-80

[13] Holmes DR,Turi ZG.Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial.Lancet2009;374:534-42

[14] Holmes DR Jr,Price MJ.Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.J Am Coll Cardiol2014;64:1-12

[15] Lakkireddy D,Ellis CR.Amulet IDE InvestigatorsAmplatzer™ Amulet™ left atrial appendage occluder versus watchman™ device for stroke prophylaxis (Amulet IDE): a randomized controlled trial.Circulation2021;

[16] Reddy VY,Kar S.PREVAIL and PROTECT AF Investigators5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials.J Am Coll Cardiol2017;70:2964-75

[17] Reddy VY,Miller MA.Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with Watchman left atrial appendage closure technology).J Am Coll Cardiol2013;61:2551-6

[18] Tzikas A,Gafoor S.Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug.EuroIntervention2016;11:1170-9

[19] Hildick-Smith D,Camm AJ.Left atrial appendage occlusion with the Amplatzer™ Amulet™ device: full results of the prospective global observational study.Eur Heart J2020;41:2894-901 PMCID:PMC7421773

[20] Huang H,Xu Y.Percutaneous left atrial appendage closure with the LAmbre device for stroke prevention in atrial fibrillation: a prospective, multicenter clinical study.JACC Cardiovasc Interv2017;10:2188-94

[21] Pagnotta PA,Pllaha E.Left atrial appendage closure with the Ultraseal device: initial experience and mid-term follow-up.J Interv Cardiol2018;31:932-8

[22] Sabiniewicz R,Wańczura P,Curzytek A.First-in-human experience with the Cardia Ultraseal left atrial appendage closure device: the feasibility study.Cardiol J2016;23:652-4

[23] Briosa E Gala A,Monteiro C.Long-term outcomes and periprocedural safety and efficacy of percutaneous left atrial appendage closure in a United Kingdom tertiary center: an 11-year experience.Heart Rhythm2021;18:1724-32

[24] Bartus K,Bednarek J.Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience.J Am Coll Cardiol2013;62:108-18

[25] Miller MA,Doshi SK.Multicenter study on acute and long-term safety and efficacy of percutaneous left atrial appendage closure using an epicardial suture snaring device.Heart Rhythm2014;11:1853-9

[26] Price MJ,Yakubov SJ.Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the U.S. transcatheter LAA ligation consortium.J Am Coll Cardiol2014;64:565-72 PMCID:PMC4524558

[27] Vos LM,Geuzebroek GSC.Totally thoracoscopic ablation for atrial fibrillation: a systematic safety analysis.Europace2018;20:1790-7 PMCID:PMC6212776

[28] Di Biase L,Mohanty P.Left atrial appendage isolation in patients with longstanding persistent AF undergoing catheter ablation: BELIEF trial.J Am Coll Cardiol2016;68:1929-40

[29] Caliskan E,Yilmaz M.Epicardial left atrial appendage AtriClip occlusion reduces the incidence of stroke in patients with atrial fibrillation undergoing cardiac surgery.Europace2018;20:e105-14

[30] Whitlock RP,Paparella D.LAAOS III InvestigatorsLeft atrial appendage occlusion during cardiac surgery to prevent stroke.N Engl J Med2021;384:2081-91

[31] Handke M,Hetzel A,Bode C.Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk: determinants and relationship to spontaneous echocontrast and thrombus formation--a transesophageal echocardiographic study in 500 patients with cerebral ischemia.J Am Soc Echocardiogr2005;18:1366-72

[32] Wang DD,Kupsky D.Application of 3-dimensional computed tomographic image guidance to WATCHMAN implantation and impact on early operator learning curve: single-center experience.JACC Cardiovasc Interv2016;9:2329-40

[33] Goitein O,Hay I.Cardiac CT angiography (CCTA) predicts left atrial appendage occluder device size and procedure outcome.Int J Cardiovasc Imaging2017;33:739-47

[34] Mo BF,Alimu A.Image fusion of integrating fluoroscopy into 3D computed tomography in guidance of left atrial appendage closure.Eur Heart J Cardiovasc Imaging2021;22:92-101

[35] Reddy VY,Doshi SK,Kar S.Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry.Circulation2011;123:417-24

[36] Landmesser U,Camm J.Left atrial appendage occlusion with the AMPLATZER Amulet device: one-year follow-up from the prospective global Amulet observational registry.EuroIntervention2018;14:e590-7

[37] Aminian A,Mazzone P.Incidence, characterization, and clinical impact of device-related thrombus following left atrial appendage occlusion in the prospective global AMPLATZER Amulet observational study.JACC Cardiovasc Interv2019;12:1003-14

[38] Simard T,Lehenbauer K.Predictors of device-related thrombus following percutaneous left atrial appendage occlusion.J Am Coll Cardiol2021;78:297-313

[39] Sedaghat A,Al-Kassou B.Device-related thrombus after left atrial appendage closure: data on thrombus characteristics, treatment strategies, and clinical outcomes from the EUROC-DRT-registry.Circ Cardiovasc Interv2021;14:e010195

[40] Sedaghat A,Schrickel JW.EWOLUTION study groupIncidence, predictors and outcomes of device-related thrombus after left atrial appendage closure with the WATCHMAN device-Insights from the EWOLUTION real world registry.Catheter Cardiovasc Interv2021;97:E1019-24

[41] Viles-Gonzalez JF,Douglas P.The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation) substudy.J Am Coll Cardiol2012;59:923-9

[42] Lempereur M,Freixa X.Device-associated thrombus formation after left atrial appendage occlusion: a systematic review of events reported with the Watchman, the Amplatzer Cardiac Plug and the Amulet.Catheter Cardiovasc Interv2017;90:E111-21

[43] Godino C,Bellini B.Percutaneous left atrial appendage closure versus non-vitamin K oral anticoagulants in patients with non-valvular atrial fibrillation and high bleeding risk.EuroIntervention2020;15:1548-54

[44] Osmancik P,Neuzil P.PRAGUE-17 Trial InvestigatorsLeft atrial appendage closure versus direct oral anticoagulants in high-risk patients with atrial fibrillation.J Am Coll Cardiol2020;75:3122-35

[45] Duthoit G,Marijon E.Reduced rivaroxaban dose versus dual antiplatelet therapy after left atrial appendage closure: ADRIFT a randomized pilot study.Circ Cardiovasc Interv2020;13:e008481