Abstract
Atrial fibrillation (AF) is a common cardiac arrhythmia with an estimated prevalence of 1% in the general population. It is associated with an increased risk of ischemic stroke, silent cerebral ischemia, and cognitive impairment. Due to the blood flow stasis and morphology, thrombus formation occurs mainly in the left atrial appendage (LAA), particularly in the setting of nonvalvular AF (NVAF). Previous studies have shown that >90% of emboli related to NVAF originate from the LAA, thus prevention of systemic cardioembolism is indicated. According to the current guidelines, anticoagulant therapy with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs), represents the standard of care in AF patients, in order to prevent ischemic stroke and peripheral embolization. Although these drugs are widely used and DOACs have shown, compared to VKAs, non-inferiority for stroke prevention with significantly fewer bleeding complications, some issues remain a matter of debate, including contraindications, side effects, and adherence. An increasing number of patients, indeed, because of high bleeding risk or after experiencing life-threatening bleedings, must take anticoagulants with extreme caution if not contraindicated. While surgical closure or exclusion of LAA has been historically used in patients with AF with contradictory results, in the recent years, a novel procedure has emerged to prevent the cardioembolic stroke in these patients: The percutaneous left atrial appendage occlusion (LAAO). Different devices have been developed in recent years, though not all of them are approved in Europe and some are still under clinical investigation. Currently available devices have shown a significant decrease in bleeding risk while maintaining efficacy in preventing thromboembolism. The procedure can be performed percutaneously through the femoral vein access, under general anesthesia. A transseptal puncture is required to access left atrium and is guided by transesophageal echocardiography (TEE). Evidence from the current literature indicates that percutaneous LAAO represents a safe alternative for those patients with contraindications for long-term oral anticoagulation. This review summarizes scientific evidences regarding LAAO for stroke prevention including clinical indications and an adequate patient selection.
Highlights
Atrial fibrillation (AF) is the most frequent cardiac arrhythmia in elderly, affecting up to the 15% of patients older than 80 years
These changes may explain in part why the source of an embolic events in AF patients is often a thrombus localized in the left atrial appendage (LAA) [10,17]: it is probably the result of the interaction between three components: blood stasis, changes in the inner layer of the atrium and hemostasis abnormalities as for Virchow triad [18,19]
Percutaneous left atrial appendage occlusion (LAAO) can be performed through an endocardial approach, less often using a hybrid epicardial/endocardial approach, under transesophageal echocardiography (TEE) guidance with general anesthesia, that ensures complete immobility of patients to reduce the risk of mechanical complications [24]
Summary
AF is the most frequent cardiac arrhythmia in elderly, affecting up to the 15% of patients older than 80 years. Anticoagulation is the gold standard strategy for stroke prevention: DOACs are recommended as a first-line therapy in NVAF patients, while VKAs are used in AF patients with mechanical heart valves or moderate-to-severe mitral stenosis [1]. In AF patients with mechanical heart valves or moderate-to-severe mitral stenosis, VKAs therapy represents the gold standard since thrombus formation occurs outside the LAA and percutaneous LAAO may not provide an adequate protection from embolic stroke. The growing experience accumulated in the last five years, supported by recent clinical trials reporting the safety and the non-inferiority of percutaneous LAAO in the prevention of cardioembolic stroke compared to long-term anticoagulation, indicate that this therapeutic approach is becoming an important alternative in the management of the cardioembolic risk in AF patients. In the present narrative review, we will discuss the emerging role of percutaneous LAAO in stroke prevention focusing on technical aspects of the procedure and current indications
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