Left Atrial Occlusion Device Implantation: the Role of the Echocardiographer
- 46 Downloads
Purpose of Review
Atrial fibrillation is the most common arrhythmia worldwide and is a major risk factor for embolic stroke. For patients with atrial fibrillation who are unable to tolerate systemic anticoagulation, left atrial appendage (LAA) occlusion has been shown to mitigate stroke risk. In this article, we describe the vital role of the echocardiographer in intraprocedural guidance of percutaneous LAA occlusion procedures as well as in the pre- and post-procedure assessment of these patients.
A few percutaneously delivered devices for LAA exclusion from the systemic circulation are available in contemporary practice. These devices employ an either exclusive endocardial LAA occlusion approach, such as the Watchman (Boston Scientific, Maple Grove, MN) and Amulet (St. Jude Medical, Minneapolis, MN), or both an endocardial and pericardial (epicardial) approach such as the Lariat procedure (SentreHEART, Palo Alto, CA).
Two- and three-dimension transesophageal echocardiography is critical for patient selection, procedure planning, procedural guidance, and ensuring satisfactory immediate as well as long-term LAA occlusion/exclusion efficacy. This review will provide an overview of the role of the echocardiographer in all aspects of LAA occlusion/exclusion procedures for the most commonly used commercially available devices in current practice.
KeywordsLeft atrial appendage Echocardiography 3D Percutaneous closure
Compliance with Ethical Standards
Conflict of Interest
David Altszuler, Alan F. Vainrib, Daniel G. Bamira, and Ricardo J. Benenstein declare that they have no conflict of interest.
Anthony Aizer reports grants for research support from Abbott, Inc., Biosense Webster, Inc., Sentreheart, Inc.; and fellowship support grants from Abbott, Inc., Biosense Webster, Inc., and Boston Scientific, Inc.
Larry A. Chinitz reports personal fees and nonfinancial support from Medtronic, Abbott, and St. Jude Medical; grants, personal fees, and nonfinancial support from Biotronik; and personal fees from Pfizer, Biosense Webster, and Boston Scientific.
Muhamed Saric reports being on the Speakers’ bureau for Philips and Medtronic and being on the Advisory board for Siemens.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 11.Healey JS, Crystal E, Lamy A, Teoh K, Semelhago L, Hohnloser SH, et al. Left Atrial Appendage Occlusion Study (LAAOS): results of a randomized controlled pilot study of left atrial appendage occlusion during coronary bypass surgery in patients at risk for stroke. Am Heart J. 2005;150(2):288–93.CrossRefGoogle Scholar
- 12.Emmert MY, Puippe G, Baumuller S, Alkadhi H, Landmesser U, Plass A, et al. Safe, effective and durable epicardial left atrial appendage clip occlusion in patients with atrial fibrillation undergoing cardiac surgery: first long-term results from a prospective device trial. Eur J Cardiothorac Surg. 2014;45(1):126–31.CrossRefGoogle Scholar
- 13.•• Vainrib, AF HSC, Jaber W, Benenstein RJ, Aizer A, Chinitz LA, et al. Left atrial appendage occlusion / exclusion: procedural image guidance with transesophageal echocardiography. J Am Soc Echocardiogr. 2018;31:454–74 Recent review of LAA occlusion/exclusion procedures with focus on procedural imaging and equipment. CrossRefGoogle Scholar
- 14.• Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, et al. Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv. 2011;77(5):700–6 The initial left atrial appendage closure trial in humans with the Amplatzer cardiac plug. CrossRefGoogle Scholar
- 15.Ostermayer SH, Reisman M, Kramer PH, Matthews RV, Gray WA, Block PC, et al. Percutaneous left atrial appendage transcatheter occlusion (PLAATO system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials. J Am Coll Cardiol. 2005;46(1):9–14.CrossRefGoogle Scholar
- 16.• Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374(9689):534–42 Landmark randomized controlled trial demonstrating non-inferiority of percutaneous LAA occlusion compared with warfarin. CrossRefGoogle Scholar
- 17.• Bartus K, Han FT, Bednarek J, Myc J, Kapelak B, Sadowski J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol. 2013;62(2):108–18 Initial clinical experience with the Lariat device in a non-randomized study. CrossRefGoogle Scholar
- 22.• Vainrib AF, Bamira DG, Saric M. Percutaneous Left Atrial Appendage Closure Devices. Current Cardiovascular Imaging Reports 2017, 10:40. Review of the percutaneous devices used for LAA occlusion/exclusion with focus on procedural imaging. Google Scholar
- 25.Nucifora G, Faletra FF, Regoli F, Pasotti E, Pedrazzini G, Moccetti T, et al. Evaluation of the left atrial appendage with real-time 3-dimensional transesophageal echocardiography: implications for catheter-based left atrial appendage closure. Circ Cardiovasc Imaging. 2011;4(5):514–23.CrossRefGoogle Scholar
- 28.Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure: results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation. 2011;123(4):417–24.CrossRefGoogle Scholar
- 30.Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of the watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1–12.CrossRefGoogle Scholar
- 31.Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, et al. The clinical impact of incomplete left atrial appendage closure with the watchman device in patients with atrial fibrillation: a PROTECT AF (percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation) substudy. J Am Coll Cardiol. 2012;59(10):923–9.CrossRefGoogle Scholar
- 38.Massumi A, Chelu MG, Nazeri A, May SA, Afshar-Kharaghan H, Saeed M, et al. Initial experience with a novel percutaneous left atrial appendage exclusion device in patients with atrial fibrillation, increased stroke risk, and contraindications to anticoagulation. Am J Cardiol. 2013;111(6):869–73.CrossRefGoogle Scholar