Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper

Outcomes of Left Atrial Appendage Occlusion Treatment With Amulet After Unsuccessful Watchman FLX Device: A Multicenter Observational Study

INTRODUCTION

Watchman FLX (W-FLX) is the most widely used left atrial appendage occlusion (LAAO) device to prevent atrial fibrillation (AF) related strokes in the United States. However, successful LAAO with W-FLX can be challenging in patients with complex left atrial appendage (LAA) anatomies. This analysis aimed to assess the procedural success rates of LAA occlusion (immediate and short-term outcomes) using the Amulet device, in patients with prior failed LAAO with W-FLX device.

METHODS AND RESULTS

This was a multicentric retrospective analysis of 62 consecutive patients with unsuccessful LAAO with W-FLX, who subsequently underwent an attempted Amulet occluder placement. The primary endpoint was successful Amulet implantation. Secondary endpoints included peri-device leak (PDL) and device-related thrombus assessed by transesophageal echocardiography (TEE) at 45 days, safety end point through 7 days or hospital discharge (whichever was later) and major adverse events (MAEs) through 45 days. The Amulet occluder was successfully implanted in 98.38% of patients (n = 61/62). No clinically relevant PDL or device-related thrombus was noted at 45 days. There was one pericardial effusion noted a week after Amulet implant that underwent successful percutaneous pericardiocentesis. The reasons for W-FLX failure were all anatomical in nature. We identified five distinct anatomical patterns that posed challenges for W-FLX deployment but were amenable to successful Amulet implantation.

CONCLUSION

The disc-lobe design of Amulet allows a high degree of successful LAAO in challenging anatomical variants (whale-tail, bilobed LAA, shallow vertical chicken-wing or seahorse, oval wide with posterior sloping trabeculations, and extensively trabeculated broccoli morphologies) with prior failed W-FLX implants. These findings may help guide device selection on pre-LAAO imaging, thereby enhancing resource utilization and contributing to more efficient and safer LAAO procedures.

Left atrial appendage occlusion in atrial fibrillation: shaping the future of stroke prevention

Atrial fibrillation (AF) is the most common cardiac arrhythmia, significantly increasing the risk of thromboembolic events, particularly ischemic stroke. The left atrial appendage (LAA) is the predominant site of thrombus formation in patients with AF, making it a crucial target for stroke prevention strategies. Left atrial appendage occlusion (LAAO) has emerged as an important therapeutic alternative to oral anticoagulation, particularly in patients with contraindications to long-term anticoagulant therapy. This review examines the role of LAAO in AF management, discussing current indications, patient selection, procedural techniques, and clinical outcomes. We also explore the latest evidence from major clinical trials and real-world studies, highlighting the efficacy and safety of LAAO compared to standard anticoagulation. Additionally, we consider the unresolved questions and the potential future directions for this intervention, including emerging technologies and the integration of LAAO into broader AF management protocols. Our review underscores the growing importance of LAAO in reducing thromboembolic risk in AF patients, particularly those unable to tolerate traditional anticoagulation, and offers insights into the ongoing evolution of this treatment modality in clinical practice.

Left atrial appendage occlusion and radiofrequency ablation in a patient with atrial fibrillation and dextrocardia: a case report

Background

Dextrocardia is a rare congenital condition, affecting approximately 1 in 10,000-12,000 individuals. When combined with atrial fibrillation (AF), it becomes even rarer. "One-stop" surgery, including combined radiofrequency ablation (RFA) and left atrial appendage occlusion (LAAO), has become a common clinical treatment for patients with AF who develop cerebral infarction despite regular oral anticoagulants. To date, no cases have been reported of patients with AF and dextrocardia undergoing the "one-stop" procedure, making this surgery particularly challenging.

Case presentation

An 85-year-old dextrocardia male with total visceral inversion and persistent AF developed cerebral infarction despite regular oral anticoagulation therapy. He was referred to our hospital for RFA of AF and LAAO. The procedure was successfully performed using a three-dimensional electroanatomical mapping system (Carto3, Biosense Webster, Diamond Bar, CA, USA), intracardiac echocardiography (ICE), and x-ray, with no complications.

Conclusion

This is the first reported case of a "one-stop" surgery for dextrocardia with AF. This procedure is safe and feasible with the assistance of advanced technologies such as ICE and the VIZIGO bidirectional adjustable bent sheath.

An International Consensus Practical Guide on Left Atrial Appendage Closure for the Non-implanting Physician: Executive Summary

Many patients with atrial fibrillation (AF) who are in need of stroke prevention are not treated with oral anticoagulation or discontinue treatment shortly after its initiation. Despite the availability of direct oral anticoagulants (DOACs), such undertreatment has improved somewhat but is still evident. This is due to continued risks of bleeding events or ischemic strokes while on DOAC, poor treatment compliance, or aversion to anticoagulant therapy. Because of significant improvements in procedural safety over the years left atrial appendage closure (LAAC), using a catheter-based, device implantation approach, is increasingly favored for the prevention of thromboembolic events in AF patients who cannot have long-term oral anticoagulation. This article is an executive summary of a practical guide recently published by an international expert consensus group, which introduces the LAAC devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. This practical guide, aligned with published guideline/guidance, is aimed at those non-implanting physicians who may need to refer patients for consideration of LAAC.

The 2024 European Society of Cardiology Guidelines for Diagnosis and Management of Atrial Fibrillation: A Viewpoint from a Practicing Clinician's Perspective

Atrial fibrillation (AF) is a complex disease requiring a multidomain and (usually) long-term management, thus posing a significant burden to patients with AF, practitioners, and health care system. Unlike cardiovascular conditions with a narrow referral pathway (e.g., acute coronary syndrome), AF may be first detected by a wide range of specialties (often noncardiology) or a general practitioner. Since timely initiated optimal management is essential for the prevention of AF-related complications, a concise and simple guidance is essential for practitioners managing AF patients, regardless of their specialty. Guideline-adherent management of patients with AF has been shown to translate to improved patient outcomes compared with guideline-nonadherent treatment. To facilitate guideline implementation in routine clinical practice, a good guideline document on AF should introduce only evidence-based new recommendations, while avoiding arbitrary changes, which may be confusing to practitioners. Herein, we discuss the main changes in the 2024 European Society of Cardiology (ESC) AF Guidelines relative to the previous 2020 ESC document. Whether the updates and new recommendations issued by the new guidelines will translate in high adherence in clinical practice (and hence improved prognosis of patients with AF) will need to be addressed in upcoming years.

Device-Assisted Left Atrial Appendage Exclusion: From Basic Sciences to Clinical Applications

Device-assisted left atrial appendage exclusion plays a crucial role in the prevention of fatal ischemic complications in patients with atrial fibrillation and contraindications to anticoagulation treatment. Various devices with different safety profiles and device-related complications are available in daily practice to perform this procedure. In this review, the anatomy, physiology, and functions of the left atrial appendage were detailed, and all available devices used for epicardial and endocardial exclusion of the left atrial appendage and their clinical outcomes were discussed. Future research should aim to further investigate the long-term effects of left atrial appendage exclusion on body homeostasis, blood coagulation, and cardiac function.

Treatment strategies of the thromboembolic risk in kidney failure patients with atrial fibrillation

The incidence and prevalence of atrial fibrillation (AF) in patients affected by kidney failure, i.e. glomerular filtration rate <15 ml/min/1.73 m2, is high and probably underestimated. Numerous uncertainties remain regarding how to prevent thromboembolic events in this population because both cardiology and nephrology guidelines do not provide clear recommendations. The efficacy and safety of oral anticoagulant therapy (OAC) in preventing thromboembolism in patients with kidney failure and AF has not been demonstrated for either vitamin K antagonists (VKAs) or direct anticoagulants (DOACs). Moreover, it remains unclear which is more effective and safer, because estimated creatinine clearance <25-30 ml/min was an exclusion criterion in the randomized controlled trials (RCTs). Three RCTs comparing DOACs and VKAs in kidney failure failed to reach the primary endpoint, as they were underpowered. The left atrial appendage is the main source of thromboembolism in the presence of AF. Left atrial appendage closure (LAAC) has recently been proposed as an alternative to OAC. RCTs comparing the efficacy and safety of LAAC versus OAC in kidney failure were terminated prematurely due to recruitment failure. A recent prospective study showed a reduction in thromboembolic events in haemodialysis patients with AF and undergoing LAAC compared with patients taking or not taking OAC. We review current treatment standards and discuss recent developments in managing the thromboembolic risk in kidney failure patients with AF. The importance of shared decision-making with the multidisciplinary team and the patient to consider individual risks and benefits of each treatment option is underlined.

Incidence and predictors of 2-year mortality following percutaneous left atrial appendage occlusion in the EWOLUTION trial

AIMS

Sufficient survival time following left atrial appendage occlusion (LAAO) is essential for ensuring the efficacy and cost-effectiveness of this strategy for stroke prevention. Understanding prognostic factors for early mortality after LAAO could optimize patient selection. In the current study, we perform an in-depth analysis of 2-year mortality after LAAO, focusing particularly on potential predictors.

METHODS AND RESULTS

The EWOLUTION registry is a real-world cohort comprising 1020 patients that underwent LAAO. Endpoint definitions were pre-specified, and death was categorized as cardiovascular, non-cardiovascular, or unknown origin. Mortality rates were calculated from Kaplan-Meier estimates. Baseline characteristics significantly associated with death in univariate Cox regression analysis were incorporated into the multivariate analysis. All multivariate predictors were included in a risk model. Two-year mortality rate was 16.4% [confidence interval (CI): 14.0-18.7%], with 50% of patients dying from a non-cardiovascular cause. Multivariate baseline predictors of 2-year mortality included age [hazard ratio (HR) 1.05, CI: 1.03-1.08, per year increase], heart failure (HR 1.73, CI: 1.24-2.41), vascular disease (HR 1.47, CI: 1.05-2.05), valvular disease (HR 1.63, CI: 1.15-2.33), abnormal liver function (HR 1.80, CI: 1.02-3.17), and abnormal renal function (HR 1.58, CI: 1.10-2.27). Mortality rate exhibited a gradual rise as the number of risk factors increased, reaching 46.1% in patients presenting with five or six risk factors.

CONCLUSION

One in six patients died within 2 years after LAAO. We identified six independent predictors of mortality. When combined, this model showed a gradual increase in mortality rate with a growing number of risk factors, which may guide appropriate patient selection for LAAO.

CLINICAL TRIAL REGISTRATION

The original EWOLUTION registry was registered at clinicaltrials.gov under identifier NCT01972282.

Feasibility study on atrial fibrillation ablation with pulsed field ablation and concomitant occlusion of the left atrial appendage

AIMS

Atrial fibrillation (AF) ablation and left atrial appendage occlusion (LAAO) are increasingly performed as individual procedures. Pulsed field ablation (PFA) has significantly reduced procedure duration and may be advantageous for the combined approach.

METHODS AND RESULTS

We have launched a programme for simultaneous AF ablation using PFA and LAAO for patients qualifying for both treatments and excluding those with a complex anatomy. We compare procedure duration and fluoroscopy time against individual procedures (either AF ablation or LAAO alone), all performed by the same operators and using consistent technologies. We performed the combined procedure in 10 patients (50% males; median age 70 years) and excluded 2 patients (17%) because of a complex left atrial appendage anatomy. No death, stroke, or major bleeding events, including pericardial effusion, occurred. For single-procedure comparison, 207 AF ablation procedures and 61 LAAO procedures were available. The total median procedure duration was 79 min (range 60-125) for the combined procedure, 71 min (25-241) for individual AF ablation (51 min without and 78 min with 3-dimensional electroanatomic mapping), and 47 min (15-162) for individual LAAO. The respective fluoroscopy times were 21 (15-26), 15 (5-44), and 10 (3-50) min. For the combined procedure, femoral vein access to last PFA application lasted 49 min (34-93) and LAAO added 20 min (15-37).

CONCLUSION

Simultaneous PFA-based AF ablation and LAAO in carefully selected patients is feasible and safe and can be executed within a short overall procedure duration.

Incidence and predictors of device-related thrombus after left atrial appendage closure with Watchman device

Introduction

Left atrial appendage closure (LAAC) with Watchman device prevents thromboembolism in patients with atrial fibrillation (AF). However, thrombus may develop on the atrial surface of the device.

Aim

To investigate the incidence and predictors of device-related thrombus (DRT) in patients with AF who were treated with LAAC.

Material and methods

Ninety-one consecutive patients with AF underwent LAAC procedure using first-generation Watchman 2.5 device followed by antiplatelet therapy. In our analysis we have included all patients (n = 78) who had clinical follow-up visits with transesophageal echocardiography (TEE) after the procedure.

Results

The median (IQR) CHA2DS2-VASc score was 4 (4.0-6.0) and HAS-BLED score was 3 (3.0-4.0). DRTs were observed in 5 (6.4%) patients. When compared with patients without DRT, those with DRT presented more often with lower median ejection fraction (40% (23.5-45.5) versus 55% (48.0-60.0); p = 0.005), lower emptying velocity of LAA (25 cm/s (17.5-27.0) versus 53 cm/s (26.5-78.0); p = 0.009), and with greater depth of implantation (18 mm (14.0-20.5) versus 8 mm (5.0-11.0); p < 0.001). Furthermore, patients with DRT had greater depth of LAA (35 mm (29.5-41.0) versus 29 mm (25.5-31.0); p = 0.003), greater mean (SD) dimension in 900 (22.4 mm (3.2) versus 19 mm (2.7); p = 0.02). Patients with DRT were also younger than those without DRT (67.4 years (7) versus 75 years (8.3), p = 0.045).

Conclusions

The DRT after Watchman device implantation remains a rare complication. Its formation was related to several patient and procedural characteristics, which need to be confirmed in larger studies.