What Is the Role of Left Atrial Appendage Closure in the Rhythm Control of Atrial Fibrillation?
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Interventional catheter ablation approaches to the rhythm control of atrial fibrillation (AF) have advanced significantly in the past decade. The foundation of the catheter ablation in AF is electrical isolation of the pulmonary veins (PVI). However, PVI only in more advanced stages of AF (persistent AF) has only modest to poor success rates prompting a search for alternative and adjunctive procedures to improve the outcomes of ablation in persistent AF. The left atrial appendage (LAA) is well understood to be a primary source of emboli in AF but less well known be a trigger or driver for AF. Therefore, LAA exclusion is an attractive target to potentially improve AF ablation outcomes in more advanced stages of AF and possibly as an alternative to chronic oral anticoagulation in the prevention of stroke and systemic embolism in AF. However, the precise role of LAA closure in the interventional approach to AF is still to be elucidated with ongoing clinical investigations.
KeywordsAtrial fibrillation Arrhythmia Stroke Systemic embolism
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- 8.Krul SP, Berger WR, Smit NW, et al. Atrial fibrosis and conduction slowing in the left atrial appendage of patients undergoing thoracoscopic surgical pulmonary vein isolation for atrial fibrillation. Circ Arrhythm Electrophysiol. 2015;8(2):288–95. https://doi.org/10.1161/CIRCEP.114.001752.CrossRefPubMedGoogle Scholar
- 9.Hocini M, Shah AJ, Nault I, Sanders P, Wright M, Narayan SM, et al. Localized reentry within the left atrial appendage: arrhythmogenic role in patients undergoing ablation of persistent atrial fibrillation. Heart Rhythm. 2011;8(12):1853–61. https://doi.org/10.1016/j.hrthm.2011.07.013.CrossRefPubMedPubMedCentralGoogle Scholar
- 10.• Di Biase L, Burkhardt JD, Mohanty P, et al. Left atrial appendage isolation in patients with longstanding persistent atrial fibrillation undergoing catheter ablation: BELIEF trial. J Am Coll Cardiol. 2016;68:1929–40. First randomized trial using LAAEI as the “adjunctive” addition to AF ablation demonstrating improved outcomes in LSPAF. This is reasonable evidence that the LAA or adjacent structures are an important AF trigger or driver.CrossRefPubMedGoogle Scholar
- 12.Reddy VY, Holmes D, Doshi SK, et al. 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;123:417–24.CrossRefPubMedGoogle Scholar
- 18.• Lakkireddy D, Mahankali A, Kanmanthareddy A, et al. Left atrial appendage ligation and ablation for persistent atrial fibrillation: the LAALA-AF Registry. J Am Coll Cardiol EP. 2015;1:153–60. First observational trial suggesting that suture-snare LAA exclusion may have an anti-arrhythmic effect similar to LAAEI by catheter ablation.Google Scholar
- 19.• Lakkireddy D, Afzal MR, Lee RJ, Nagaraj H, Tschopp D, Gidney B, et al. Acute and long-term outcomes of percutaneous left atrial appendage suture ligation: results from a United States multicenter evaluation. Heart Rhythm. 2016;13(5):1030–6. Largest multicenter registry of LARIAT suture-snare LAA exclusion success rates and complication rates. First published data on the improved safety of a microneedle approach to pericardial puncture. https://doi.org/10.1016/j.hrthm.2016.01.022.CrossRefPubMedGoogle Scholar
- 21.Romanov A, Pokushalov E, Elesin D, Bogachev-Prokophiev A, Ponomarev D, Losik D, et al. Effect of left atrial appendage excision on procedure outcome in patients with persistent atrial fibrillation undergoing surgical ablation. Heart Rhythm. 2016;13(9):1803–9. https://doi.org/10.1016/j.hrthm.2016.05.012.CrossRefPubMedGoogle Scholar