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Textbook of Catheter-Based Cardiovascular Interventions pp 1707–1716Cite as

Left Atrial Appendage Occlusion: State of the Art

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Abstract

Percutaneous left atrial appendage occlusion (LAAO) is a new therapy for the prevention of systemic thromboembolism in patients with non-valvular atrial fibrillation. Currently, the most commonly used LAAO devices are the Watchman device (Boston Scientific, Natick, MA, USA) and the Amplatzer Amulet device (St Jude Medical, Plymouth, MN, USA). In this chapter, we describe the history and the most important clinical trials and registries related to LAAO, and some technical considerations, tips, and tricks around these devices. We also briefly cover some other newer LAAO devices. We discuss the challenges related to the anatomic variability of the left atrial appendage, pre- and periprocedural cardiac imaging, device sizing, and possible ways to prevent and manage complications.

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References

  1. Tzikas A, Sievert H, Holmes DR Jr. Percutaneous left atrial appendage occlusion in 2016. EuroIntervention. 2016;11(14):e1576–8.

    Article  PubMed  Google Scholar 

  2. Sievert H, Lesh MD, Trepels T, Omran H, Bartorelli A, Della Bella P, Nakai T, Reisman M, DiMario C, Block P, Kramer P, Fleschenberg D, Krumsdorf U, Scherer D. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation. 2002;105(16):1887–9.

    Article  PubMed  Google Scholar 

  3. Sick PB, Schuler G, Hauptmann KE, Grube E, Yakubov S, Turi ZG, Mishkel G, Almany S, Holmes DR. Initial worldwide experience with the WATCHMAN left atrial appendage system for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2007;49:1490–5.

    Article  PubMed  Google Scholar 

  4. Meier B, Palacios I, Windecker S, et al. Transcatheter left atrial appendage occlusion with Amplatzer devices to obviate anticoagulation in patients with atrial fibrillation. Catheter Cardiovasc Interv. 2003;60:417–22.

    Article  PubMed  Google Scholar 

  5. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minguez JR, Meerkin D, Valdés M, Ormerod O, Leithäuser B. Left atrial appendage closure with Amplatzer Cardiac Plug in atrial fibrillation: initial European experience. Catheter Cardiovasc Interv. 2011;77:700–6.

    Article  PubMed  Google Scholar 

  6. Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fi brillation: a randomised noninferiority trial. Lancet. 2009;374:534–42.

    Article  CAS  PubMed  Google Scholar 

  7. Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, Huber K, Reddy VY. 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.

    Article  PubMed  Google Scholar 

  8. Tzikas A, Shakir S, Gafoor S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Cruz-Gonzalez I, Sievert H, Tichelbäcker T, Kanagaratnam P, Nietlispach F, Aminian A, Kasch F, Freixa X, Danna P, Rezzaghi M, Vermeersch P, Stock F, Stolcova M, Costa M, Ibrahim R, Schillinger W, Meier B, Park JW. Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug. EuroIntervention. 2016;11:1170–9.

    Article  PubMed  Google Scholar 

  9. Holmes DR Jr, Doshi SK, Kar S, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation – a patient-level meta-analysis. J Am Coll Cardiol. 2015;65:2614–23.

    Article  PubMed  Google Scholar 

  10. Reddy VY, Mobius-Winkler S, Miller MA, et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix feasibility study with Watchman left atrial appendage closure technology). J Am Coll Cardiol. 2013;61:2551–6.

    Article  PubMed  Google Scholar 

  11. Boersma LV, Schmidt B, Betts TR, Sievert H, Tamburino C, Teiger E, Pokushalov E, Kische S, Schmitz T, Stein KM, Bergmann MW, investigators E. Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry. Eur Heart J. 2016;37(31):2465–74.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Reddy VY, Gibson DN, Kar S, O’Neill W, Doshi SK, Horton RP, Buchbinder M, Gordon NT, Holmes DR. Post-FDA approval, initial US clinical experience with Watchman left atrial appendage closure for stroke prevention in atrial fibrillation. J Am Coll Cardiol. 2016. pii: S0735–1097(16)36641–4. https://doi.org/10.1016/j.jacc.2016.10.010. [Epub ahead of print].

  13. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9.

    Article  CAS  PubMed  Google Scholar 

  14. Granger CB, Alexander JH, McMurray JJ, Lopes RD, Hylek EM, Hanna M, Al-Khalidi HR, Ansell J, Atar D, Avezum A, Bahit MC, Diaz R, Easton JD, Ezekowitz JA, Flaker G, Garcia D, Geraldes M, Gersh BJ, Golitsyn S, Goto S, Hermosillo AG, Hohnloser SH, Horowitz J, Mohan P, Jansky P, Lewis BS, Lopez-Sendon JL, Pais P, Parkhomenko A, Verheugt FW, Zhu J, Wallentin L. Apixaban versus warfarin in patients with atrial fi brillation. N Engl J Med. 2011;365:981–92.

    Article  CAS  PubMed  Google Scholar 

  15. Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, Breithardt G, Halperin JL, Hankey GJ, Piccini JP, Becker RC, Nessel CC, Paolini JF, Berkowitz SD, Fox KA, Califf RM. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.

    Article  CAS  PubMed  Google Scholar 

  16. Kefer J, Tzikas A, Freixa X, Shakir S, Gafoor S, Nielsen-Kudsk JE, Berti S, Santoro G, Aminian A, Landmesser U, Nietlispach F, Ibrahim R, Danna PL, Benit E, Budts W, Stammen F, De Potter T, Tichelbäcker T, Gloekler S, Kanagaratnam P, Costa M, Cruz-Gonzalez I, Sievert H, Schillinger W, Park JW, Meier B, Omran H. Impact of chronic kidney disease on left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation. Int J Cardiol. 2016;207:335–40.

    Article  PubMed  Google Scholar 

  17. Freixa X, Gafoor S, Regueiro A, Cruz-Gonzalez I, Shakir S, Omran H, Berti S, Santoro G, Kefer J, Landmesser U, Nielsen-Kudsk JE, Sievert H, Kanagaratnam P, Nietlispach F, Gloekler S, Aminian A, Danna P, Rezzaghi M, Stock F, Stolcova M, Costa M, Ibrahim R, Schillinger W, Park JW, Meier B, Tzikas A. Comparison of efficacy and safety of left atrial appendage occlusion in patients aged <75 to ≥75 years. Am J Cardiol. 2016;117:84–90.

    Article  PubMed  Google Scholar 

  18. Saw J, Tzikas A, Shakir S, Gafoor S, Omran H, Nielsen-Kudsk J, Kefer J, Aminian A, Berti S, Santoro G, Nietlispach F, Moschovitis A, Cruz-Gonzalez I, Stammen F, Tichelbacker T, Freixa X, Ibrahim R, Schillinger W, Meier B, Sievert H, Gloekler S. Incidence and clinical impact of device-associated thrombus and peri-device leak following LAA closure with the Amplatzer Cardiac Plug. J Am Coll Cardiol Intv. 2017;10(4):391–9.

    Article  Google Scholar 

  19. Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GY, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J. 2016;37(38):2893–962.

    Article  PubMed  Google Scholar 

  20. Tzikas A, Bergmann MW. Left atrial appendage closure: patient, device and post-procedure drug selection. EuroIntervention. 2016;12(Suppl X):X48–54.

    Article  PubMed  Google Scholar 

  21. Tzikas A, Holmes DR, Gafoor S, Ruiz CE, Blomström-Lundqvist C, Diener HC, Cappato R, Kar S, Lee RJ, Byrne RA, Ibrahim R, Lakkireddy D, Soliman OI, Nabauer M, Schneider S, Brachman J, Saver JL, Tiemann K, Sievert H, Camm J, Lewalter T. Percutaneous left atrial appendage occlusion: the Munich consensus document on definitions, endpoints and data collection requirements for clinical studies. EuroIntervention. 2016;12(1):103–11.

    Article  PubMed  Google Scholar 

  22. Veinot JP, Harrity PJ, Gentile F, Khandheria BK, Bailey KR, Eickholt JT, Seward JB, Tajik AJ, Edwards WD. Anatomy of the normal left atrial appendage: a quantitative study of age-related changes in 500 autopsy hearts: implications for echocardiographic examination. Circulation. 1997;96:3112–5.

    Article  CAS  PubMed  Google Scholar 

  23. Di Biase L, Santangeli P, Anselmino M, Mohanty P, Salvetti I, Gili S, Horton R, Sanchez JE, Bai R, Mohanty S, Pump A, Cereceda Brantes M, Gallinghouse GJ, Burkhardt JD, Cesarani F, Scaglione M, Natale A, Gaita F. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? Results from a multicenter study. J Am Coll Cardiol. 2012;60:531–8.

    Article  PubMed  Google Scholar 

  24. Freixa X, Tzikas A, Basmadjian A, Garceau P, Ibrahim R. The chicken-wing morphology: an anatomical challenge for left atrial appendage occlusion. J Interv Cardiol. 2013;5:509–14.

    Article  Google Scholar 

  25. Tzikas A, Gafoor S, Meerkin D, Freixa X, Cruz-Gonzalez I, Lewalter T, Saw J, Berti S, Nielsen-Kudsk JE, Ibrahim R, Lakkireddy D, Paul V, Arzamendi D, Nietlispach F, Worthley SG, Hildick-Smith D, Thambo JB, Tondo C, Aminian A, Kalarus Z, Schmidt B, Sondergaard L, Kefer J, Meier B, Park JW, Sievert H, Omran H. Left atrial appendage occlusion with the AMPLATZER Amulet device: an expert consensus step-by-step approach. EuroIntervention. 2016;11:1512–21.

    Article  PubMed  Google Scholar 

  26. Al-Kassou B, Tzikas A, Stock F, Neikes F, Völz A, Omran H. A comparison of two-dimensional and real time 3D transesophageal echocardiography and angiography for assessing the left atrial appendage anatomy for sizing a left atrial appendage occlusion system – impact of volume loading. EuroIntervention. 2016. pii: EIJ-D-15-00543. https://doi.org/10.4244/EIJ-D-15-00543.

  27. Berti S, Paradossi U, Meucci F, Trianni G, Tzikas A, Rezzaghi M, Stolkova M, Palmieri C, Mori F, Santoro G. Reply: intracardiac echocardiographic imaging of the left atrial appendage and detection of a peridevice leak after device occlusion. JACC Cardiovasc Interv. 2015;8(1 Pt A):126–7. https://doi.org/10.1016/j.jcin.2014.12.001.

    Article  PubMed  Google Scholar 

  28. Bergmann MW, Landmesser U. Left atrial appendage closure for stroke prevention in non-valvular atrial fibrillation: rationale, devices in clinical development and insights into implantation techniques. EuroIntervention. 2014;10(4):497–504.

    Article  PubMed  Google Scholar 

  29. Bellmann B, Schnupp S, Kühnlein P, Javernik C, Kleinecke C, Rillig A, Landmesser U, Brachmann J, Park JW. Left atrial appendage closure with the new Occlutech® device: first in man experience and neurological outcome. J Cardiovasc Electrophysiol. 2016. doi: https://doi.org/10.1111/jce.13141. [Epub ahead of print].

    Article  PubMed  Google Scholar 

  30. Lam YY. A new left atrial appendage occluder (Lifetech LAmbre device) for stroke preventionin atrial fi brillation. Cardiovasc Revasc Med. 2013;14:134–6.

    Article  PubMed  Google Scholar 

  31. Bartus K, Han F, Bednarek J, Myc J, Kapelak B, Sadowski J, Lelakowski J, Bartus S, Yakubov S, Lee R. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol. 2013;62:108–18.

    Article  PubMed  Google Scholar 

  32. Aminian A, Lalmand J, Tzikas A, Budts W, Benit E, Kefer J. Embolization of left atrial appendage closure devices: a systematic review of cases reported with the Watchman device and the Amplatzer Cardiac Plug. Catheter Cardiovasc Interv. 2015;86:128–35.

    Article  PubMed  Google Scholar 

  33. Viles-Gonzales J, Kar S, Douglas P, Dukkipati S, Fledman T, Horton R, Holmes D, Reddy V. The clinical impact of incomplete left atrial appendage closure with the Watchman device in patients with atrial fibrillation. J Am Coll Cardiol. 2012;59:923–9.

    Article  Google Scholar 

  34. Fassini G, Conti S, Moltrasio M, Maltagliati A, Tundo F, Riva S, Dello Russo A, Casella M, Majocchi B, Zucchetti M, Russo E, Marino V, Pepi M, Tondo C. Concomitant cryoballoon ablation and percutaneous closure of left atrial appendage in patients with atrial fibrillation. Europace. 2016;18(11):1705–10.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. AHEPA University Hospital of Thessaloniki, Aristotle University of Thessaloniki, Stilp. Kiriakidi 1, 54637, Thessaloniki, Greece

    Apostolos Tzikas MD, PhD

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  1. Apostolos Tzikas MD, PhD
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Correspondence to Apostolos Tzikas MD, PhD .

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  1. Middle German Heart Center and Health Care Center Bitterfeld-Wolfen, gGmbH, Bitterfeld-Wolfen, Germany

    Peter Lanzer

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Tzikas, A. (2018). Left Atrial Appendage Occlusion: State of the Art. In: Lanzer, P. (eds) Textbook of Catheter-Based Cardiovascular Interventions. Springer, Cham. https://doi.org/10.1007/978-3-319-55994-0_98

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  • DOI: https://doi.org/10.1007/978-3-319-55994-0_98

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