EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage occlusion

Atrial Fibrillation and Stroke in Elderly Patients

“…9 However, incomplete closure of the LAA has been documented in a large number of patients who continue to be at risk for thromboembolic events. 72 Stand-alone thoracoscopic left atrial appendectomy in patients with AF and prior thromboembolism who had contraindications to oral anticoagulation demonstrated the feasibility of this approach along with reduction in thromboembolism.…”

“…2 Very elderly patients (age > 85 years) have a higher risk-adjusted mortality and risk of disability, have longer hospitalizations, receive less evidencedbased care and are less likely to be discharged to their original place of residence. 9 According to analyses from the U.S. Nationwide Inpatient Sample, over the past decade, in-hospital mortality rates after stroke have declined for every age except men older than 84 years. Over the next 40 years (2010-2050), the number of incident strokes is expected to more than double, with the majority of the increase among patients aged ≥ 75 years as well as in minority groups.…”

“…84 The long-term effectiveness of the Lariat with respect to reducing stroke or its safety relative to other approaches needs to be defined in randomized controlled trials. 82 In patients with AF who have a high risk of stroke and contraindication to long-term anticoagulation, percutaneous LAA closure by the Watchman device 9 or surgical excision at the time of cardiac surgery 1 are reasonable options to reduce the risk of stroke in lieu of taking long-term anticoagulation. Since a significant proportion of strokes in AF patients may originate from aortic arch plaques, the risk of stroke with LAA occlusion may persist; in select patients, carotid diverters aimed at diverting emboli from intracranial circulation may be helpful but require further investigation.…”

“…This risk could be unacceptably high, highlighting the need for approaches to reduce the risk of stroke without increasing the risk of bleeding. Based on observations that left atrial clots are localized to the LAA more than 90% of the time, 9 surgical excision of the LAA or mechanical devices that occlude or exclude the LAA from circulation by ligating its opening into the left atrium have been developed for reduction in thromboembolic risk.…”

“…9 Among these, the Watchman ™ device (Boston Scientific Corp., Marlborough, MA), a selfexpandable nitinol cage deployed in the LAA using a transseptal approach, was assessed in two randomized trials (PROTECT AF and PREVAIL) in patients with nonvalvular AF eligible for oral anticoagulation (CHADS2 score > 1). 79,80 A comparable efficacy and safety of the Watchman device to warfarin for the prevention of stroke and systemic embolization was demonstrated in PROTECT AF.…”