Left atrial appendage occlusion for stroke prevention in patients with atrial fibrillation

Abstract

The most severe consequence of atrial fibrillation (AF) is a cardioembolic stroke. The incidence of cardioembolic stroke increases significantly in patients with AF. Although warfarin has been the mainstay of the prevention of cardioembolic stroke, there are several limitations to the use of warfarin that hinder its effectiveness. This article provides the historical development of devices that exclude the left atrial appendage, their effectiveness and potential patient selection, as an alternative to warfarin and the novel oral anticoagulation therapy for the prevention of cardioembolic stroke in patients with AF.

Keywords:

• atrial fibrillation
• cardioembolic stroke
• LARIAT
• left atrial appendage
• occlusion devices

Financial & competing interests disclosure

RJ Lee is a consultant for and equity holder in SentreHeart Inc. 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.

Key issues

• Atrial fibrillation is the most prevalent arrhythmia worldwide.

• Atrial fibrillation is associated with an increased risk of cardioembolic events.

• Warfarin therapy for the prevention of cardioembolic events is limited due to noncompliance, food and drug interactions, labile therapeutic range and bleeding.

• The PLAATO device was the first left atrial appendage (LAA) implant used in man and is the prototype for all LAA implants.

• The Protect AF study on the Watchman LAA occlusion device demonstrated non-inferiority to warfarin therapy in stroke reduction in patients with atrial fibrillation.

• Long-term results from the Protect AF study reveal a decrease in cardiovascular and all-cause death.

• Long-term results of the Prevail study demonstrates the potential for long-term embolic events and is not as efficacious as warfarin in preventing stroke.

• The Watchman device may be considered in warfarin eligible patients that have intolerances to or unable to take long-term warfarin therapy.

• Novel oral anticoagulants demonstrate either non-inferiority or superiority to warfarin therapy with less bleeding risks.

• Patients with contraindications to oral anticoagulation therapy should be considered for percutaneous epicardial LAA exclusion with the LARIAT device or surgical LAA exclusion.

• LAA electrical isolation during catheter ablation may lead to LAA mechanical standstill and promote thrombus formation in the LAA.

• LAA ligation with the LARIAT device produces LAA electrical isolation and LA debulking which may be beneficial as adjunctive therapy to catheter ablation for patients with persistent atrial fibrillation.