Utilization of percutaneous left atrial appendage closure in patients with atrial fibrillation: an update on patient outcomes

ABSTRACT

Introduction

Atrial fibrillation (AF) is associated with an increased risk of stroke, morbidity and overall mortality. So far, oral anticoagulation (OAC) is the standard of care for stroke prevention, either with vitamin K antagonists or with non-vitamin K oral anticoagulants (NOACs). The left atrial appendage (LAA) can be eliminated by epicardial or endocardial exclusion. Left atrial appendage closure (LAAC) represents a mechanical thromboprophylaxis – which has also been termed mechanical vaccination – against stroke, bleeding and death.

Areas covered

Studies show that LAAC provides stroke prevention comparable to (N)OAC. Additionally, a notable reduction of bleeding events and its associated mortality is achieved by LAAC. With accruing experience and advances in patient selection, procedural planning, implantation techniques and devices, contemporary LAAC registries report high rates of success and low rates of complications.

Expert opinion

The decision to provide the most appropriate stroke prevention for patients with AF (OAC, NOAC or LAAC) needs to be individualized to patients’ thromboembolic and bleeding risk and life expectancy. This review on LAAC provides an update on contemporary devices and techniques, as well as recommendations for patient selection and management.

KEYWORDS:

• Atrial fibrillation
• left atrial appendage closure
• stroke prevention
• oral anticoagulation
• bleeding

Article highlights

• Cardio-embolic stroke from left atrial appendage clots due to atrial fibrillation often hits large brain areas in a sudden manner, preventing timely formation of collaterals, and thus causes considerable disability and high mortality rates.

• Oral anticoagulation by non-vitamin K antagonists or vitamin K antagonists is the standard of care for stroke prevention in patients with atrial fibrillation, but this may change.

• In selected patients, left atrial appendage closure is comparable to oral anticoagulation for prevention of stroke with additional reduction in bleeding events, as well as cardiovascular and overall mortality.

• Current guidelines recommend left atrial appendage closure only for patients with atrial fibrillation and contraindications to oral anticoagulation and such as prior bleeds or an elevated bleeding risk. This is in contrast to the fact that the only randomized data available pertain to patients without these attributes and show a survival benefit of left atrial appendage closure.

• The Amplatzer (Abbott, USA) and Watchman (Boston Scientific, USA) occluders are the market leading devices for percutaneous left atrial appendage closure. Their effectiveness and safety have been demonstrated in randomized trials and large, real-word registries.

• A dual antiplatelet therapy with acetylsalicylic acid and clopidogrel for 3–6 months is a common postoperative treatment; however, for Watchman oral anticoagulation for 6 weeks is recommended and the optimal strategy should be adapted to the patients’ individual thromboembolic and bleeding risk.

• Routine follow-up assessment by transesophageal echocardiography or computed tomography is recommended at 1–6 months after percutaneous left atrial appendage closure, mainly to exclude device-related thrombi or significant peri-device leaks.

Declaration of interest

B Meier has disclosed that he received speaker fees from Abbott. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.