Yonsei Med J.  2012 Jan;53(1):83-90. 10.3349/ymj.2012.53.1.83.

Early Experience Using a Left Atrial Appendage Occlusion Device in Patients with Atrial Fibrillation

• Kim YL
• Joung B
• On YK
• Shim CY
• Lee MH
• Kim YH
• Pak HN

• KMID: 1779690
• DOI: http://doi.org/10.3349/ymj.2012.53.1.83

Abstract

PURPOSE
Atrial fibrillation (AF) is one of the major risk factors for ischemic stroke, and 90% of thromboembolisms in these patients arise from the left atrial appendage (LAA). Recently, it has been documented that an LAA occlusion device (OD) is not inferior to warfarin therapy, and that it reduces mortality and risk of stroke in patients with AF.
MATERIALS AND METHODS
We implanted LAA-ODs in 5 Korean patients (all male, 59.8+/-7.3 years old) with long-standing persistent AF or permanent AF via a percutaneous trans-septal approach.
RESULTS
1) The major reasons for LAA-OD implantation were high risk of recurrent stroke (80%), labile international neutralizing ratio with hemorrhage (60%), and 3/5 (60%) patients had a past history of failed cardioversion for rhythm control. 2) The mean LA size was 51.3+/-5.0 mm and LAA size was 25.1x30.1 mm. We implanted the LAA-OD (28.8+/-3.4 mm device) successfully in all 5 patients with no complications. 3) After eight weeks of anticoagulation, all patients switched from warfarin to anti-platelet agent after confirmation of successful LAA occlusion by trans-esophageal echocardiography.
CONCLUSION
We report on our early experience with LAA-OD deployment in patients with 1) persistent or permanent AF who cannot tolerate anticoagulation despite significant risk of ischemic stroke, or 2) recurrent stroke in patients who are unable to maintain sinus rhythm.

Keyword

Atrial fibrillation; left atrial appendage; occlusion device; thromboembolism

MeSH Terms

Aged
Anticoagulants/contraindications
Atrial Appendage/*physiopathology
Atrial Fibrillation/epidemiology/*physiopathology/*surgery
Humans
Male
Middle Aged
Risk Factors
*Septal Occluder Device
Stroke/epidemiology/*prevention & control
Treatment Outcome
Warfarin/contraindications

Figure

• 

  Fig. 1 LAA occlusion device. (A, B and C) Delivery catheter (A) including folded WATCHMAN device inside the catheter lumen (B) connected to the deployment knob (C) and detachable by being unscrewed. (D) Trans-septal sheath has multiple radio-opaque marker bands that indicate the locations of delivery catheter and LAA ostium. (E and F) WATCHMAN device is unfolded by elastic recoil outside of delivery sheath (E) and remains in LAA after being detached from the delivery catheter (F). LAA, left atrial appendage.

• 

  Fig. 2 Intra-procedural TEE images before (A, B and C) and after (D) deployment of LAA occlusion device. Diameter of LAA ostium and depth of LAA were measured from 4 different angles of TEE images to determine the appropriate size of WATCHMAN device. (D) Successful deployment of device should be confirmed using a tug test and color Doppler. (E) RAO 45° fluoroscopic view after deployment of WATCHMAN device. (F) Eight week follow-up 3-D TEE showed complete sealing off of LAA by WATCHMAN device. TEE, trans-esophageal echocardiography; LAA, left atrial appendage; RAO, right anterior oblique.

• 

  Fig. 3 Warfarin dosage and INR values of case 1. INR values were extremely labile, and ischemic stroke occurred 9 months after switching to clopidogrel. INR, international neutralizing ratio; MCA, middle cerebral artery.

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