Transcatheter Left Atrial Appendage Research Articles

GW27-e0209 Application of echocardiographic three-dimensional printed left atrial appendage model to guide transcatheter left atrial appendage occlusion

This study aimed to determine the feasibility of three dimensional (3D) printed left atrial appendage (LAA) models based on 3D transesophageal echocardiography (3D TEE) data and its application value in the interventional LAA closure. Eighteen patients who had interventional LAA occlusion underwent

Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation.

BackgroundTranscatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost-effectiveness of LAAO for stroke prophylaxis in NVAF.MethodsA Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One-way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty.ResultsLAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115, $2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24 % of 10,000 simulations using a threshold of US$50,000/QALY.ConclusionsTranscatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies.Condensed abstractThe transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management.

A meta-analysis for efficacy and safety evaluation of transcatheter left atrial appendage occlusion in patients with nonvalvular atrial fibrillation.

This meta-analysis was conducted to evaluate the efficacy and safety of transcatheter left atrial appendage (LAA) occlusion in patients with nonvalvular atrial fibrillation. The randomized controlled trials (RCT) or observational studies with any transcatheter LAA occlusion devices were searched in PubMed, Embase, and Cochrane library from inception to November 2015. The incidence rates from individual studies were combined to evaluate the procedural efficacy and safety, including all-cause death, cardiac/neurological death, stroke, transient ischemic attack (TIA), thrombosis, hemorrhagic complications, and pericardial effusion/tamponade. Thirty-eight studies involving 3585 patients and 6 different occlusion devices were eligible for our inclusion criteria. The procedural failure rate for LAA closure was 0.02 (95% CI: 0.02-0.03). The all-cause mortality was 0.03 (95% CI: 0.02-0.03) and cardiac/neurological mortality was 0 (95% CI: 0.00-0.01). The stroke/TIA rate was estimated only 0.01 (95% CI: 0.01-0.01). The incidence of thrombus on devices was 0.01 (95% CI: 0.01-0.02). The major hemorrhagic complication rate was estimated 0.01 (95% CI: 0.00-0.01). Pericardial effusion/tamponade was estimated 0.02 (95% CI: 0.02-0.03). No heterogeneity was observed for above pooled estimates (I = 0). In devices subgroups analysis, the all-cause mortality and cardiac/neurological mortality of PLAATO group were the highest (P = 0.01 and P < 0.01 respectively), whereas the incidence of thrombus on devices in the ACP group was the highest (P < 0.01). In follow-up period subgroups analysis, there were significant differences in all-cause death, stroke/TIA, major hemorrhage, and pericardial effusion/tamponade events between the shorter and longer follow-up period subgroups (P < 0.05). However, the differences among the subgroups were numerically small. the pooled data demonstrated that transcatheter LAA occlusion was effective and safe in the patients with nonvalvular atrial fibrillation who were not suitable for lifelong antithrombotic therapy.

Transcatheter left atrial appendage occlusion: patient selection and perspectives

Transcatheter left atrial appendage occlusion: patient selection and perspectives

Safety and efficacy of transcatheter left atrial appendage closure using the Watchman device in Egyptian patients with nonvalvular atrial fibrillation

Abstract Background Atrial fibrillation (AF) is considered the major cause of stroke in the elderly. Alternative therapies to the anticoagulant therapy are warranted, particularly in patients who are ineligible or at high risk of bleeding. The left atrial appendage (LAA) is a prominent source of thrombi in nonvalvular AF, accounting for 90% of thrombi. As a result, surgical and transcatheter techniques have been explored to reduce the risk of stroke in patients with AF by occluding the LAA. Objectives To assess the safety and efficacy of LAA closure in patients with nonvalvular atrial fibrillation (AF) ineligible for warfarin therapy. Methods A prospective study that evaluated LAA closure with the Watchman device (Boston Scientific, Natick, MA; group A) in fifteen patients with nonvalvular AF and CHADS2 (congestive heart failure, hypertension, age ⩾75 years, diabetes mellitus, and prior stroke or transient ischemic attack) score ⩾1, who were considered ineligible for warfarin therapy. The primary efficacy endpoint was the combined events of ischemic/hemorrhagic stroke, systemic embolism and cardiovascular/unexplained death during a period of six months follow-up. Results Successful closure of the LAA using the Watchman device was achieved in 15 patients (100%). The mean age was found to be 67.9 ± 9 years with 40% of them being males. No device or procedure related adverse events were detected. The mean CHADS2 score was 2.4 ± 0.8, while the mean CHA2DS2-VASC score was 4.4 ± 1.0. After a mean period of 8 ± 2 months of follow-up, no device dislodgement or device-related thrombi were documented. The all-cause stroke (ischemic and hemorrhagic) and systemic embolism were 0%. The device and procedure related mortality was found to be 0%. Only one patient died after 8 months of device implantation from pneumonia. Conclusion LAA closure with the Watchman device can be safely performed, and may be a reasonable alternative to consider for patients at high risk for stroke but with contraindications to systemic oral anticoagulation or with high risk of bleeding.

First in vivo evaluation of a flexible self‐apposing left atrial appendage closure device in the canine model

Aimed to evaluate the feasibility of deployment and healing response of a novel transcatheter left atrial appendage (LAA) occlusion device in the canine model LAA occlusion is proposed to reduce the risk of stroke in atrial fibrillation patients Transseptal puncture and device deployment was guided under fluoroscopy and transesophageal echocardiography (TEE) in five dogs. First, a distal cylindrical bulb occluder was released and secured to the appendage wall with hooks. Subsequently, a proximal sail was unfolded, covering the LAA ostium. Rotational angiography, TEE, and histology outcomes were assessed 30 days following implantation Pre-operative TEE revealed the mean diameter of the LAA ostium to be 17.2 ± 1.6 mm with a depth of 18.5 ± 1.7 mm. The landing zone for the distal bulb was measured to be 12.8 ± 1.3 mm. The mean bulb diameter at implant was 16.8 ± 1.8 mm. Post-operative TEE showed adequate positioning and successful LAA occlusion with all implanted devices. Pericardial effusion requiring pericardiocentesis was seen in one animal following device implantation. At 30 days, TEE revealed full occlusion of all LAA ostia with the exception of a minimal peri-device leak (<3 mm) observed in one animal. No pericardial effusion or device-related thrombus formation was found at termination. Histological analysis confirmed circumferential occlusion of all appendages and complete neointimal coverage on the luminal aspect of the occluder The percutaneous delivery of a novel self-positioning LAA occlusion device is feasible and safe in a canine model. At 30 days, all devices displayed complete healing and occlusion of the LAA without any device related adverse events.

Transcatheter Left Atrial Appendage Closure Using Intracardiac Echocardiographic Guidance From the Left Atrium

BackgroundMost commonly, left atrial appendage (LAA) occlusion procedures are performed using transesophageal echocardiography (TEE) guidance and general anaesthesia. Intracardiac echocardiography (ICE) offers potential advantages over TEE, however, ICE-guided LAA occlusion experience is limited and has been typically performed from a right-sided location where LAA visualization might be suboptimal. We sought to evaluate the efficacy and safety of percutaneous LAA occlusion using ICE guidance performed from the left atrium. MethodsThirty-seven patients with atrial fibrillation, significant risk for stroke, and long-term contraindication to anticoagulation underwent LAA closure with the Amplatzer Cardiac Plug (St Jude Medical, Inc, St Paul, MN) with mild sedation and ICE guidance. The ICE catheter was introduced in the left atrium through a second transseptal puncture. Patients underwent preprocedural TEE to rule out thrombus and 3-month follow-up TEE to assess occlusion grade. Patient characteristics, procedural data, effectiveness of ICE imaging, quality of occlusion, and complications were prospectively recorded. ResultsProcedural success was achieved in 36 of 37 patients (97%). Closure was complete or near complete (grade ≥3 according to ICE and angiography) in all cases where the device was released. In all cases, ICE imaging yielded good LAA and surrounding structure visualization and adequate procedural guidance. Three major procedural or in-hospital complications occurred. Median length of stay was 1 day. Follow-up TEE documented the absence of any residual peri-device leak in all but 1 (29 of 30) case. ConclusionInitial experience suggests LAA occlusion with the Amplatzer Cardiac Plug using ICE guidance from the left atrium is feasible, reproducible, and safe.

Overlay Technique for Transcatheter Left Atrial Appendage Closure

The Overlay technique is popular in peripheral artery interventions, but not in coronary or cardiac structural procedures. We present an initial experience using three-episode overlays during a transcatheter left atrial appendage closure. The first overlay was applied to facilitate advancement of the delivery sheath into left atrium. The second overlay was used to navigate the advancement of prepped delivery system containing the compressed occluder into its optimal position in the left atrium. The third overlay facilitated the real-time deployment of the closure device. This case report demonstrates the effectiveness of the overlay technique in facilitating each step of the transcatheter left atrial appendage closure.

Transcatheter Left Atrial Appendage Ligation Therapy Update

We have read the recent review by Saw and Lempereur [(1)][1] with interest because it provides a comprehensive overview of the currently available therapies for transcatheter left atrial appendage (LAA) closure, with a particular emphasis on procedural imaging and techniques [(1)][1]. However, the

EFFICACY AND SAFETY OF TRANSCATHETER LEFT ATRIAL APPENDAGE LIGATION WITH LARIAT: A META-ANALYSIS

LARIAT is an endo-epicardial transcatheter left atrial appendage (LAA) exclusion technique that is increasingly being used for LAA exclusion. We searched for studies that reported the safety and outcomes of LAA exclusion using the LARIAT technique in PubMed, EBSCO and Google Scholar databases. Data

Percutaneous left atrial appendage closure-An alternative strategy for anticoagulation in atrial fibrillation and hereditary hemorrhagic telangiectasia?

Many patients with hereditary hemorrhagic telangiectasia (HHT) are unable to sustain oral anticoagulation (OAC) because of severe epistaxis, gastrointestinal (GI) bleeding and the risk of life-threatening bleeding from cerebral arteriovenous malformations (CAVMs) or pulmonary arteriovenous malformations (PAVMs). In patients with atrial fibrillation (AF), most thromboembolic complications arise from the left atrial appendage (LAA) and percutaneous transcatheter LAA closure proved to be non-inferior to OAC at mid-term follow-up. We report our experience with LAA closure in HHT with a follow-up of 12 months. Percutaneous LAA closure was performed in five patients with both HHT and high thromboembolic risk AF (CHA2DS2-VASc score ≥2) without peri-procedural complications. At 3 months no thromboembolic event occurred. After 12 months one patient had a transient ischemic attack while another patient had recurrence of stroke, this latter patient had a significant stenosis of the carotid artery and an incomplete closure of the LAA without any signs of thrombus on echocardiogram. Both patients had a non-treatable pulmonary right-to-left shunt (RLS). Percutaneous closure of the LAA may provide an alternative strategy to long-term OAC therapy in HHT patients with AF induced high stroke risk and intolerance for OAC.

Left atrial appendage closure for thromboembolism prevention in patients with atrial fibrillation: advances and perspectives.

Atrial fibrillation (AF) is a frequent cause of stroke. More than 90% of thrombi were found in the left atrial appendage (LAA) in non-valvular AF. Transcatheter LAA closure has been developed as a novel approach to reduce the risk of stroke in patients with AF over the last decade. In this article, we review the recent advances and propose the possible challenges regarding the LAA closure for thromboembolism prevention in patients with AF.

How to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Pracoń R, Demkow M. EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2015;11(1):5-8. doi:10.5114/pwki.2015.49177. APA Pracoń, R., & Demkow, M. (2015). EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 11(1), 5-8. https://doi.org/10.5114/pwki.2015.49177 Chicago Pracoń, Radosław, and Marcin Demkow. 2015. "EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 11 (1): 5-8. doi:10.5114/pwki.2015.49177. Harvard Pracoń, R., and Demkow, M. (2015). EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 11(1), pp.5-8. https://doi.org/10.5114/pwki.2015.49177 MLA Pracoń, Radosław et al. "EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 11, no. 1, 2015, pp. 5-8. doi:10.5114/pwki.2015.49177. Vancouver Pracoń R, Demkow M. EditorialHow to walk the tightrope between harm and protection in selecting the optimal antiplatelet treatment strategy after transcatheter left atrial appendage occlusion. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2015;11(1):5-8. doi:10.5114/pwki.2015.49177.

Percutaneous left atrial appendage closure: Technical aspects and prevention of periprocedural complications with the watchman device.

Transcatheter closure of the left atrial appendage has been developed as an alternative to chronic oral anticoagulation for stroke prevention in patients with atrial fibrillation, and as a primary therapy for patients with contraindications to chronic oral anticoagulation. The promise of this new intervention compared with warfarin has been supported by several, small studies and two pivotal randomized trial with the Watchman Device. The results regarding risk reduction for stroke have been favourable although acute complications were not infrequent. Procedural complications, which are mainly related to transseptal puncture and device implantation, include air embolism, pericardial effusions/tamponade and device embolization. Knowledge of nature, management and prevention of complications should minimize the risk of complications and allow transcatheter left atrial appendage closure to emerge as a therapeutic option for patients with atrial fibrillation at risk for cardioembolic stroke.

TCT-170 Cost-effectiveness Analysis Of Left Atrial Appendage Occlusion Device Compared With 7 Oral Anticoagulants For Stroke Prevention In Atrial Fibrillation

Transcatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. A Markov decision analytic model was used to compare cost-effectiveness of LAAO with 7 alternative

Early Safety and Efficacy of Percutaneous Left Atrial Appendage Suture Ligation: Results From the U.S. Transcatheter LAA Ligation Consortium

BackgroundTranscatheter left atrial appendage (LAA) ligation may represent an alternative to oral anticoagulation for stroke prevention in atrial fibrillation. ObjectivesThis study sought to assess the early safety and efficacy of transcatheter ligation of the LAA for stroke prevention in atrial fibrillation. MethodsThis was a retrospective, multicenter study of consecutive patients undergoing LAA ligation with the Lariat device at 8 U.S. sites. The primary endpoint was procedural success, defined as device success (suture deployment and <5 mm leak by post-procedure transesophageal echocardiography), and no major complication at discharge (death, myocardial infarction, stroke, Bleeding Academic Research Consortium bleeding type 3 or greater, or cardiac surgery). Post-discharge management was per operator discretion. ResultsA total of 154 patients were enrolled. Median CHADS2 score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism [doubled]) was 3 (interquartile range: 2 to 4). Device success was 94%, and procedural success was 86%. A major complication occurred in 15 patients (9.7%). There were 14 major bleeds (9.1%), driven by the need for transfusion (4.5%). Significant pericardial effusion occurred in 16 patients (10.4%). Follow-up was available in 134 patients at a median of 112 days (interquartile range: 50 to 270 days): Death, myocardial infarction, or stroke occurred in 4 patients (2.9%). Among 63 patients with acute closure and transesophageal echocardiography follow-up, there were 3 thrombi (4.8%) and 13 (20%) with residual leak. ConclusionsIn this initial multicenter experience of LAA ligation with the Lariat device, the rate of acute closure was high, but procedural success was limited by bleeding. A prospective randomized trial is required to adequately define clinical efficacy, optimal post-procedure medical therapy, and the effect of operator experience on procedural safety.

Left atrial appendage closure to prevent stroke in patients with atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained arrhythmia and is associated with substantial morbidity. The prevalence of AF in the United States is expected to rise to between 5.6 and 12 million in 2050.1 AF is associated with a 4- to 5-fold increased risk of ischemic stroke after adjustment for other risk factors,2 and paroxysmal, persistent, or permanent AF increases stroke risk to a similar degree. Oral anticoagulants (OACs) reduce the risk of thromboembolism, yet they are underused.3–6 Novel OACs are noninferior or superior to warfarin for the prevention of stroke and systemic embolism and are more convenient because they do not require ongoing monitoring.7–10 However, major challenges to long-term therapy with vitamin K antagonists and novel OACs include a substantial ongoing hazard of major bleeding, noncompliance, side effects, and, in the case of the novel OACs, lack of an available antidote. The left atrial appendage (LAA) is the predominant nidus for thrombus formation in AF, and transcatheter LAA closure has emerged as a potential alternative to oral anticoagulation in at-risk AF patients. AF is associated with mechanical dysfunction of atrial tissue. Loss of contractile function in the LAA can lead to local stasis and thrombus formation, which may then embolize into the systemic circulation. The observation that >90% of thrombi found in patients with nonvalvular AF and stroke are in the LAA supports this mechanistic sequence.11 In addition, low Doppler inflow velocities, spontaneous echocardiographic contrast, and the presence of thrombus in the LAA have been associated with high stroke rates in AF patients.12 These data lend support to the hypothesis that the elimination of the LAA may serve as a preventive strategy for AF-related stroke. Morphological features of the LAA may influence stroke risk. Larger LAA neck diameter …

Left atrial appendage occlusion with the WATCHMAN™ for stroke prevention in atrial fibrillation.

Atrial fibrillation (AF) is a major cause of stroke and systemic embolism. Although warfarin and the novel oral anticoagulants reduce thromboembolic risk, they are associated with an ongoing bleeding hazard, in addition to other limitations that deter their use. The left atrial appendage (LAA) appears to be the primary source of thrombus in AF; therefore, LAA closure represents a mechanical strategy for stroke prevention in these patients. The WATCHMAN™ LAA closure device (Boston Scientific, Natick, MA) is a nitinol-framed occluder that is implanted percutaneously under echocardiographic and fluoroscopic guidance. Data from two randomized clinical trials support the clinical efficacy of transcatheter LAA occlusion with the WATCHMAN and demonstrate that procedural safety has improved significantly since initial experience. This article summarizes the rationale, procedural technique, safety, and clinical efficacy of the WATCHMAN device in patients with AF at high risk for thromboembolic events.

Transcatheter left atrial appendage occlusion in the prevention of stroke and death in patients with atrial fibrillation.

Transcatheter left atrial appendage occlusion in the prevention of stroke and death in patients with atrial fibrillation.

Real-time 3D transesophageal echocardiography assisted the percutaneous transcatheter left atrial appendage closure

Real-time 3D transesophageal echocardiography assisted the percutaneous transcatheter left atrial appendage closure