Korean Circ J.  2021 Jan;51(1):1-14. 10.4070/kcj.2020.0416.

Interventional Treatment for Stroke Prevention

• Gianni C
• Rocca DGD
• Natale A
• Horton RP

• KMID: 2509900
• DOI: http://doi.org/10.4070/kcj.2020.0416

Abstract

Closure of the left atrial appendage using percutaneous transcatheter occlusion devices is used for stroke prevention as an alternative for patients with a high risk or contraindications for long-term oral anticoagulation use. Herein, we will discuss the practical aspects of five among the available devices used for interventional left atrial appendage occlusion: Watchman, Amulet, WaveCrest, LAmbre, and Lariat.

Keyword

Left atrial appendage occlusion; Stroke

Figure

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  Figure 1 Principal devices for left atrial appendage closure.

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  Figure 2 Transesophageal echocardiography for sizing of intravascular LAAO devices. Examples of different LAA measurements on a 90° TEE view. Solid and dashed lines represent LAA landing zone and depth, respectively; grey solid line represents the anatomical ostium while the red dashed circle is the left circumflex coronary artery. Reproduced with permission from Gianni et al.19)LAA = left atrial appendage; LAAO = left atrial appendage occlusion; TEE = transesophageal echocardiography.

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  Figure 3 Importance of a low mid-to-anterior transseptal puncture. For LAAO the transseptal puncture should be low, in the mid to anterior septum to facilitate engagement of the LAA. On ICE (rightmost), the LAA and MV should be in view. Reproduced with permission from Gianni et al.19)IAS = interatrial septum; ICE = intracardiac echocardiography; LAA = left atrial appendage; LAAO = left atrial appendage occlusion; MV = mitral valve.

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  Figure 4 Watchman FLX deployment. Step-by-step procedure as seen on fluoroscopy. See text for description.

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  Figure 5 Watchman deployment. Step-by-step procedure as seen on fluoroscopy. See text for description. Reproduced with permission from Gianni et al.19)

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  Figure 6 Amulet deployment. Step-by-step procedure as seen on fluoroscopy. See text for description. Reproduced with permission from Gianni et al.19)

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  Figure 7 WaveCrest deployment. Step-by-step procedure as seen on fluoroscopy. See text for description. Reproduced with permission from Gianni et al.19)

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  Figure 8 Lariat deployment. Step-by-step procedure as seen on fluoroscopy. See text for description.

Reference

1. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke. 1991; 22:983–988. PMID: 1866765.

2. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg. 2000; 17:718–722. PMID: 10856866.

3. Madden JL. Resection of the left auricular appendix; a prophylaxis for recurrent arterial emboli. J Am Med Assoc. 1949; 140:769–772. PMID: 18152330.

4. Beal JM, Longmire WP Jr, Leake WH. Resection of the auricular appendages. Ann Surg. 1950; 132:517–530. PMID: 15433218.

5. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014; 63:2438–2488. PMID: 24603192.

6. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines and the Heart Rhythm Society. Circulation. 2014; 130:e199–267. PMID: 24682347.

7. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines and the Heart Rhythm Society. J Am Coll Cardiol. 2019; 74:104–132. PMID: 30703431.

8. Glikson M, Wolff R, Hindricks G, et al. EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion – an update. Europace. 2019; euz258. PMID: 31504441.

9. Asmarats L, Rodés-Cabau J. Percutaneous left atrial appendage closure: current devices and clinical outcomes. Circ Cardiovasc Interv. 2017; 10:e005359. PMID: 29146668.

10. Reddy VY, Doshi SK, Kar S, et al. 5-year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017; 70:2964–2975. PMID: 29103847.

11. 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 fibrillation: a randomised non-inferiority trial. Lancet. 2009; 374:534–542. PMID: 19683639.

12. Viles-Gonzalez JF, Kar S, Douglas P, 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; 59:923–929. PMID: 22381428.

13. Holmes DR Jr, Kar S, Price MJ, 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; 64:1–12. PMID: 24998121.

14. Doshi SK, Sadhu A, Horton RP, et al. Primary outcome evaluation of a next generation left atrial appendage closure device: the PINNACLE FLX trial. Heart Rhythm. 2020; 17:S74.

15. Landmesser U, Tondo C, Camm J, et al. Left atrial appendage occlusion with the AMPLATZER Amulet device: one-year follow-up from the prospective global Amulet observational registry. EuroIntervention. 2018; 14:e590–7. PMID: 29806820.

16. Stone GW. WaveCrest: device description, data, and future directions [Internet]. New York: TCTMD;2017. cited 2020 October 5. Available from: https://www.tctmd.com/slide/wavecrest-device-description-data-and-future-directions.

17. Huang H, Liu Y, Xu Y, et al. Percutaneous left atrial appendage closure with the LAmbre device for stroke prevention in atrial fibrillation: a prospective, multicenter clinical study. JACC Cardiovasc Interv. 2017; 10:2188–2194. PMID: 29122133.

18. Price MJ, Gibson DN, Yakubov SJ, et al. Early safety and efficacy of percutaneous left atrial appendage suture ligation: results from the U.S. transcatheter LAA ligation consortium. J Am Coll Cardiol. 2014; 64:565–572. PMID: 25104525.

19. Gianni C, Anannab A, Sahore Salwan A, Della Rocca DG, Natale A, Horton RP. Closure of the left atrial appendage using percutaneous transcatheter occlusion devices. J Cardiovasc Electrophysiol. 2020; 31:2179–2186. PMID: 32249473.

20. Hur J, Kim YJ, Lee HJ, et al. Left atrial appendage thrombi in stroke patients: detection with two-phase cardiac CT angiography versus transesophageal echocardiography. Radiology. 2009; 251:683–690. PMID: 19366905.

21. Enomoto Y, Gadiyaram VK, Gianni C, et al. Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device. Heart Rhythm. 2017; 14:19–24. PMID: 27771552.

22. Korsholm K, Jensen JM, Nielsen-Kudsk JE. Intracardiac echocardiography from the left atrium for procedural guidance of transcatheter left atrial appendage occlusion. JACC Cardiovasc Interv. 2017; 10:2198–2206. PMID: 28866042.

23. Della Rocca DG, Horton RP, Di Biase L, et al. First experience of transcatheter leak occlusion with detachable coils following left atrial appendage closure. JACC Cardiovasc Interv. 2020; 13:306–319. PMID: 31954677.

24. Imazio M, Brucato A, Ferrazzi P, et al. Colchicine for prevention of postpericardiotomy syndrome and postoperative atrial fibrillation: the COPPS-2 randomized clinical trial. JAMA. 2014; 312:1016–1023. PMID: 25172965.

25. Gunda S, Reddy M, Nath J, et al. Impact of periprocedural colchicine on postprocedural management in patients undergoing a left atrial appendage ligation using LARIAT. J Cardiovasc Electrophysiol. 2016; 27:60–64. PMID: 26515657.

26. Chahar P, Cummings KC. Liposomal bupivacaine: a review of a new bupivacaine formulation. J Pain Res. 2012; 5:257–264. PMID: 23049275.