Pulmonary Artery Perforation by Plug Anchoring System After Percutaneous Closure of Left Appendage

Key Findings▪Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative strategy to oral anticoagulants in selected patients with atrial fibrillation.▪The landmark trials comparing LAA occlusion to an oral anticoagulation strategy enrolled patients with no apparent contraindications to the use of warfarin.▪LAA occlusion has limited head-to-head comparison against the direct-acting oral anticoagulants.▪Observational data to date have generally shown specific adverse events after LAA occlusion in specific subgroups of patients (women, patients with kidney disease and heart failure, patients belonging to racial/ethnic subgroups and with advanced age), but further large-scale studies are necessary to elucidate reasons for increased adverse events associated with LAA occlusion in these subgroups of patients before recommending this modality as first-line therapy in all patient groups. ▪Percutaneous left atrial appendage (LAA) occlusion has emerged as an alternative strategy to oral anticoagulants in selected patients with atrial fibrillation.▪The landmark trials comparing LAA occlusion to an oral anticoagulation strategy enrolled patients with no apparent contraindications to the use of warfarin.▪LAA occlusion has limited head-to-head comparison against the direct-acting oral anticoagulants.▪Observational data to date have generally shown specific adverse events after LAA occlusion in specific subgroups of patients (women, patients with kidney disease and heart failure, patients belonging to racial/ethnic subgroups and with advanced age), but further large-scale studies are necessary to elucidate reasons for increased adverse events associated with LAA occlusion in these subgroups of patients before recommending this modality as first-line therapy in all patient groups.

Intracardiac echocardiography for implantation of LAA occlusion devices: A further step toward the ICE era?

Comparison of Transesophageal Echocardiography Versus Computed Tomography for Detection of Left Atrial Appendage Filling Defect (Thrombus)

Malignant left atrial appendage morphology and embolization risk in atrial fibrillation

To the Editor: Percutaneous left atrial appendage (LAA) transcatheter occlusion (PLAATO) has been suggested to prevent stroke in high-risk patients with atrial fibrillation (AF).1 PLAATO is performed by implanting a novel device via transseptal catheterization into the LAA to seal it.1 Because more than 90% of thrombi are located within the LAA in AF, occlusion of the LAA seems an attractive alternative to oral anticoagulation (OAC), especially in AF patients who are not suitable candidates for OAC. However, performing PLAATO in patients with AF raises several concerns: 1) it is not known whether LAA thrombi are responsible for the increased number of thromboembolic events in patients with AF; atrial, ventricular, or aortic thrombi might also be important sources of arterial embolism; 2) hypercoagulability reported in patients with AF2 will not be treated by the PLAATO technique; 3) it …

Reply to the Editor

Atrial fibrillation (AF) is consider to be the most common cardiac arrhythmia with an increasingly prevalence. It is postulated that the source of thromboembolism in 90% of patients with non-valvular AF arises from the left atrial appendage (LAA). Stroke is the most feared and life threatening consequence of thromboembolism. Oral anticoagulation (OAC) with vitamin-K-antagonists is the standard medical therapy for stroke prevention in patients with AF. Unfortunately, chronic therapy with vitamin-K-antagonists is contraindicated in 14% to 44% of patients with AF who are at risk for stroke, and its benefits are limited by underutilization, narrow therapeutic window and increased risk for bleeding, making it often undesired. Therefore, mechanical LAA exclusion is a means of preventing thrombus formation in the appendage and subsequent thromboembolic events in these patients. The LAA can be excluded from the systemic circulation via surgical, percutaneous, or thoracoscopic approaches. Several studies of percutaneous transcatheter delivery of dedicated LAA exclusion devices, such as the percutaneous left atrial appendage transcatheter occlusion (PLAATO) device, Watchman device and the Amplatzer cardiac plug, have shown encouraging results as an alternative to vitamin-K-antagonists therapy for selected patients, good feasibility and efficacy, with a high rate of successful implantation. We discuss the current evidence for LAA exclusion in patients and review their results.

Successful Percutaneous Left Atrial Appendage Closure in the Presence of a Nonobstructive Appendage Membrane

Commentary: The appendage strikes back: The last surgeon

Bioprosthetic Valve Thrombosis while on a Novel Oral Anticoagulant for Atrial Fibrillation

Warfarin Sensitivity Genotyping: A Review of the Literature and Summary of Patient Experience

Left Atrial Reduction Plasty: A Novel Technique

Rationale, considerations, and goals for atrial fibrillation centers of excellence: A Heart Rhythm Society perspective

The European PLAATO (Percutaneous Left Atrial Appendage Transcatheter Occlusion) study was performed to determine the safety and efficacy of left atrial appendage occlusion by catheter technique. Embolic stroke due to atrial fibrillation is a common observation, especially in the elderly. Most thrombi in atrial fibrillation form in the left atrial appendage (LAA), its occlusion may therefore reduce the incidence of stroke in these patients.One hundred and eighty patients with non-rheumatic atrial fibrillation and contraindication to warfarin therapy were enrolled in the PLAATO study. Patients were eligible if they had a?history of transient ischaemic attack (TIA) or stroke or at least two independent risk factors for stroke such as age > or =75 years, hypertension, congestive heart failure or diabetes. The primary endpoint was LAA closure as determined by transesophageal echocardiography (TEE) two months after the procedure and stroke rate at 150 patient years. Left atrial appendage occlusion was successful in 162/180 patients (90%, 95% CI 83.1% to 92.9%). Two patients died within 24 hours of the procedure (1.1%, 95% CI 0.3% to 4%). Six cardiac tamponades were observed (3.3%, 95% CI 1.5% to 7.1%). In two cases, surgical drainage of the tamponade was necessary (1.1%, 95% CI 0.3% to 4%). In one patient, the device that was chosen was too small and embolised into the aorta after its release (0.6%, 95% CI 0.1% to 3.1%). It was snared and replaced without further complications. Successful occlusion of the LAA was achieved in 126/ 140 (90%, 95% CI 83.5% to 94.2%) of patients as noted by TEE at the two months follow-up. In a follow-up time of 129 documented patient years, three strokes occurred (2.3% per year). The expected incidence of stroke according to the CHADS2-Score was 6.6% per year. The trial was halted prematurely during the follow-up phase for financial considerations.Left atrial appendage closure is relatively safe and effective. However, severe complications can occur. It might become an alternative for atrial fibrillation patients who are ineligible for long-term anticoagulation therapy.

Trans–coronary sinus puncture for catheter ablation and left atrial appendage closure device implantation in a patient with dextrocardia and persistent right superior vena cava