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Abstract
Atrial fibrillation (AF) is the most common arrhythmic disorder world-wide, accounting for 15 % of all strokes. Management of stroke risk in AF is complicated by intolerance of anti-coagulation (AC) therapy and difficulty maintaining therapeutic range in patients treated with warfarin. The left atrial appendage (LAA) is a source of thrombus in AFrelated thrombo-embolic events and surgical LAA exclusion (LAAO) is commonly performed during cardiac surgery in AF patients. Surgical approaches are limited by a high incidence of incomplete closure with a potential for consequent thrombo-embolic events as well as the morbidity of an open-heart procedure. More recently, percutaneous approaches to LAAO have been developed. The LARIAT device is an epicardial LAA exclusion system that enables percutaneous suture ligation of the LAA via combined, pericardial and trans-septal access. The device has 510k Federal Drug Administration (FDA) clearance for soft-tissue ligation and has been studied in canine models in pre-clinical studies as well as published series of clinical experience with LARIAT LAAO. The history, patient selection, procedural technique and complications of LARIAT LAAO are reviewed here. Additionally, insights and procedural improvements that have been elucidated from clinical series and outcomes from the collective experience are discussed. The LARIAT’s epicardial approach to LAA ligation is unique compared with other percutaneous LAA exclusion devices, however more data regarding device safety and efficacy is needed for the LARIAT to emerge as an established therapy for stroke prevention in AF.
Highlights
Atrial fibrillation (AF) is the most common arrhythmic disorder worldwide, affecting approximately 2.3 million people in the United States and 4.5 million in the European Union (January et al 2014)
AC after LARIAT LAA exclusion (LAAO) is not required as only an epicardial suture is retained, in the cumulative published experience, a TIA/cerebrovascular accident (CVA) was observed in 1.8 % of patients in follow-up (Table 5) and AC or anti-platelet therapy was continued in 55 % of patients in the controlled Bartus et al series, reflecting uncertainty regarding residual thrombo-embolic risk in the absence of randomized trial data (Bartus et al 2013)
The LARIAT device is an epicardial approach to left atrial appendage (LAA) ligation, with safety and efficacy studied in small clinical series
Summary
Atrial fibrillation (AF) is the most common arrhythmic disorder worldwide, affecting approximately 2.3 million people in the United States and 4.5 million in the European Union (January et al 2014). Oral anti-coagulation (AC) is the mainstay of stroke prevention therapy but is complicated by bleeding events and prescribing complexity, with only 50–60 % of patients treated with warfarin consistently in therapeutic range (Go et al 1999). New oral anti-coagulants (NOACs) such as the direct thrombin inhibitor, dabigatran, and factor Xa inhibitors, The left atrial appendage (LAA) has a narrow-orifice with a tubular, trabeculated structure that fibrillates rather than contracts in AF, resulting in blood stasis and predisposition to thrombus formation (Al-Saady et al 1999; Kanmanthareddy 2014). The implication of the LAA as a primary source of thrombus for thrombo-embolic events in non-valvular AF has made it a veritable target for stroke reduction
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