EP News: Allied Professionals Erica S. Zado, PA-C, FHRS From the Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
Left atrial appendage occlusion for stroke prevention in atrial fibrillation review Percutaneous left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation is a relatively new procedure, and studies have been limited by small numbers of patients. Bajaj et al (J Am Coll Card Intv 2014;7:296-304, PMID 24650403) performed a systematic review of the available studies to pool data from more than 1000 patients in 17 observational studies to determine the rate of stroke in patients treated with LAAO devices. The authors note that to date there has only been 1 randomized trial, and this showed noninferiority to dose-adjusted warfarin. Results from other randomized trials are anticipated shortly. In review of the pooled data, the authors found an adjusted rate of stroke of 0.7 per 100 patient-years in these high-risk patients (average CHADS2 score of 2.7), which is similar to available preliminary results from these randomized trials and from the use of other anticoagulation strategies. The adjusted combined rate of complications was 16.2% with access site complications (8.6%) and pericardial effusion (4.3%), the most frequently encountered complications. The actual procedure failure rate was 4.9%. The authors conclude that LAAO is comparable to other anticoagulation strategies for stroke prevention in nonvalvular atrial fibrillation, but that further randomized trials are needed.
Percutaneous left atrial appendage occlusion Atrial fibrillation (AF) can lead to stroke because the atria are no longer contracting in an organized fashion, leading to stasis in the nooks and crannies of the left atrium. Stasis leads to clotting, and if the clots break off, they can cause stroke or lodge in the periphery, damaging other organs. Oral anticoagulation (OAC) has been the mainstay of preventing clots and emboli but carries with it the risk of bleeding, which can be prohibitive in certain patients. The left atrial appendage (LAA) is a pouch connected to the left atrium, and transesophageal echocardiography (TEE) studies have shown that more than 90% of clots in AF form in the LAA. Therefore, it has been a target for surgical and now percutaneous methods of occlusion to prevent stroke.
Patient selection for left atrial appendage occlusion (LAAO) currently includes those with nonvalvular AF at high risk for stroke (typically CHADS2 score Z2) and not candidates for long-term OAC (ie, prior bleeding or falls) or had prior embolic event on OAC. Currently, there are no Food and Drug Administration–approved devices for percutaneous LAAO. There are 2 devices that are deployed via endovascular access and are currently under investigation in the United States. In brief, a TEE is used to rule out LAA clot before the procedure. Femoral vein access is used with transseptal puncture into the left atrium to deploy the device in the LAA. TEE is used during the procedure to confirm that the orifice is completely occluded. Anticoagulation is continued for 45 days to allow for endothelialization of the device. There is an epicardial device to ligate the LAA using a snare available for use. This procedure requires femoral vein access with transseptal puncture to place a balloon in the opening of the LAA to be used as a guide and for angiography to ensure complete occlusion before releasing the snare. The snare is placed over the LAA from pericardial access. Because of the need for pericardial access, patients with prior cardiac surgery are not candidates. In addition, a computed tomography scan is done before the planned procedure to make sure that the LAA is not too large or complex to allow snaring. A Cardiology Patient Page by Shehata et al (Circulation 2014;129:e360-362. PMID 24589700) provides useful information regarding LAAO for you and your patients, and a recent publication by Koneru et al (Heart Rhythm 2014;11:911-921, PMID 24462524) provides “tips and tricks” to use the percutaneous epicardial LAA ligation device. It is important to note that in most studies so far, anticoagulation is continued at least in the short-term and follow-up TEE is recommended to ensure that the orifice of the LAA is occluded before discontinuing OAC. In addition, not all strokes in AF are from the LAA, so there may be patients who would be best served by continued anticoagulation. Patient selection, devices, and periprocedural care will all likely be refined as more information becomes available.
Address reprint requests and correspondence: Ms Erica S. Zado, Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Founders 9, 3400 Spruce St, Philadelphia, PA 19004. E-mail address: [email protected].
1547-5271/$-see front matter
http://dx.doi.org/10.1016/j.hrthm.2014.04.007
Left atrial appendage occlusion for stroke prevention in atrial fibrillation review Percutaneous left atrial appendage occlusion (LAAO) for stroke prevention in atrial fibrillation is a relatively new procedure, and studies have been limited by small numbers of patients. Bajaj et al (J Am Coll Card Intv 2014;7:296-304, PMID 24650403) performed a systematic review of the available studies to pool data from more than 1000 patients in 17 observational studies to determine the rate of stroke in patients treated with LAAO devices. The authors note that to date there has only been 1 randomized trial, and this showed noninferiority to dose-adjusted warfarin. Results from other randomized trials are anticipated shortly. In review of the pooled data, the authors found an adjusted rate of stroke of 0.7 per 100 patient-years in these high-risk patients (average CHADS2 score of 2.7), which is similar to available preliminary results from these randomized trials and from the use of other anticoagulation strategies. The adjusted combined rate of complications was 16.2% with access site complications (8.6%) and pericardial effusion (4.3%), the most frequently encountered complications. The actual procedure failure rate was 4.9%. The authors conclude that LAAO is comparable to other anticoagulation strategies for stroke prevention in nonvalvular atrial fibrillation, but that further randomized trials are needed.
Percutaneous left atrial appendage occlusion Atrial fibrillation (AF) can lead to stroke because the atria are no longer contracting in an organized fashion, leading to stasis in the nooks and crannies of the left atrium. Stasis leads to clotting, and if the clots break off, they can cause stroke or lodge in the periphery, damaging other organs. Oral anticoagulation (OAC) has been the mainstay of preventing clots and emboli but carries with it the risk of bleeding, which can be prohibitive in certain patients. The left atrial appendage (LAA) is a pouch connected to the left atrium, and transesophageal echocardiography (TEE) studies have shown that more than 90% of clots in AF form in the LAA. Therefore, it has been a target for surgical and now percutaneous methods of occlusion to prevent stroke.
Patient selection for left atrial appendage occlusion (LAAO) currently includes those with nonvalvular AF at high risk for stroke (typically CHADS2 score Z2) and not candidates for long-term OAC (ie, prior bleeding or falls) or had prior embolic event on OAC. Currently, there are no Food and Drug Administration–approved devices for percutaneous LAAO. There are 2 devices that are deployed via endovascular access and are currently under investigation in the United States. In brief, a TEE is used to rule out LAA clot before the procedure. Femoral vein access is used with transseptal puncture into the left atrium to deploy the device in the LAA. TEE is used during the procedure to confirm that the orifice is completely occluded. Anticoagulation is continued for 45 days to allow for endothelialization of the device. There is an epicardial device to ligate the LAA using a snare available for use. This procedure requires femoral vein access with transseptal puncture to place a balloon in the opening of the LAA to be used as a guide and for angiography to ensure complete occlusion before releasing the snare. The snare is placed over the LAA from pericardial access. Because of the need for pericardial access, patients with prior cardiac surgery are not candidates. In addition, a computed tomography scan is done before the planned procedure to make sure that the LAA is not too large or complex to allow snaring. A Cardiology Patient Page by Shehata et al (Circulation 2014;129:e360-362. PMID 24589700) provides useful information regarding LAAO for you and your patients, and a recent publication by Koneru et al (Heart Rhythm 2014;11:911-921, PMID 24462524) provides “tips and tricks” to use the percutaneous epicardial LAA ligation device. It is important to note that in most studies so far, anticoagulation is continued at least in the short-term and follow-up TEE is recommended to ensure that the orifice of the LAA is occluded before discontinuing OAC. In addition, not all strokes in AF are from the LAA, so there may be patients who would be best served by continued anticoagulation. Patient selection, devices, and periprocedural care will all likely be refined as more information becomes available.
Address reprint requests and correspondence: Ms Erica S. Zado, Section of Cardiac Electrophysiology, Cardiovascular Division, Hospital of the University of Pennsylvania, Founders 9, 3400 Spruce St, Philadelphia, PA 19004. E-mail address: [email protected].
1547-5271/$-see front matter
http://dx.doi.org/10.1016/j.hrthm.2014.04.007
