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Cardiology
Left Atrial Appendage Exclusion
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
7 sections · 77 slides
Overview
- Scope of this presentation
Rationale for targeting the appendage
- Thromboembolism in atrial fibrillation
- Left atrial appendage as the source of thrombus
- Left atrial appendage anatomy
- Atrial fibrillation on the surface electrocardiogram
- Surgical proof of concept: LAAOS III
- From surgical to percutaneous occlusion
Randomised trials of percutaneous occlusion
- PROTECT AF: design
- PROTECT AF: exclusions
- PROTECT AF: antithrombotic algorithm
- PROTECT AF: outcomes
- PREVAIL: design and higher-risk cohort
- PREVAIL: exclusions
- PREVAIL: three endpoints at 18 months
- Pooled five-year outcomes of PREVAIL and PROTECT AF
- PRAGUE-17: comparison against direct oral anticoagulants
- PRAGUE-17: entry criteria
- PRAGUE-17: exclusions
- PRAGUE-17: procedural and imaging findings
- PRAGUE-17: risk profile of the cohort
- PRAGUE-17: outcomes
- Turagam meta-analysis: pooled randomised data
- Turagam meta-analysis: efficacy and bleeding
- Turagam meta-analysis: mortality
- EWOLUTION registry: real-world performance
- What the randomised evidence supports
Current percutaneous devices
- Devices approved in the United States
- Watchman device construction
- Amplatzer Amulet device construction
- Amulet IDE: design
- Amulet IDE: antithrombotic strategy by arm
- Amulet IDE: outcomes
Patient selection and procedure
- Patients unlikely to benefit
- Pre-procedural imaging
- Procedural setting and guidance
- Immediate post-procedural care
- Post-procedural antithrombotic therapy
- Imaging surveillance after implantation
- Endocarditis prophylaxis after implantation
- Electrical isolation of the appendage during ablation
- HRS, ACC and AHA 2023 consensus: Class IIa
- HRS, ACC and AHA 2023 consensus: Class IIb
- Drivers of referral not formally tested in trials
Complications
- Periprocedural complications
- Peri-device leak: definition and uncertainty
- Peri-device leak: reported incidence
- Mechanisms of peri-device leak
- Management of peri-device leak
- Device-related thrombus: incidence and risk factors
- Mechanism of device-related thrombus
- Management of device-related thrombus
Ongoing work and future directions
- Active areas of investigation
- Rationale for concomitant ablation and occlusion
- Concerns with concomitant ablation and occlusion
- Single-centre concomitant ablation and occlusion series
- Leak and thrombus outcomes in the concomitant series
- WATCH-TAVR: occlusion at the time of aortic valve replacement
- WATCH-TAVR: outcomes and caveats
- OPTION: occlusion after ablation in patients who tolerate anticoagulation
- OPTION: outcomes
- Cautions in interpreting OPTION
- Limitations of the evidence base as a whole
- Maintaining discipline as volumes expand
- Occlusion in addition to anticoagulation: LAAOS IV
- Key points
- Key points continued
- References
- References (continued)
- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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