Left atrial appendage closure with amplatzer cardiac plug in atrial fibrillation: Initial European experience

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

“…37,40,42,64,67 Two alternative concepts to achieve LAA occlusion are obstruction of the LAA orifice with an occlusion device 41,45,48,68 or percutaneous suture ligation using an endocardial/epicardial approach. 47 Currently, three entirely catheter-based devices are commercially used for mechanical orifice obstruction, the Watchman and WaveCrest devices and the ACP.…”

“…The safety and feasibility of this drug regimen was shown in initial registry data for the ACP. 48 In a recently published study using the Lariat device among 89 patients, those with a contraindication to warfarin remained off warfarin, while patients with a CHADS 2 score of 2 who could tolerate warfarin but had been non-compliant or had labile INR continued warfarin. Warfarin use in patients with a CHADS 2 score of 1 was left to the discretion of the referring physician.…”

Left Atrial Appendage Morphology in Patients with Non-Valvular Atrial Fibrillation

“…Despite the utility of TOE for thrombus detection in the LAA [13], a small number of thromboembolic events continue to occur even when no thrombus is detected in a pre-cardioversion [8] or LAA-occlusion setting (1-2%) [5,6]. Possible causes include absent or sub-therapeutic anticoagulation [14] and air embolism due to insufficient venting during LAA occlusion [5].…”

“…The ranges and frequencies of orientation were similar between sexes, with a slightly higher frequency of retroverted LAAs in women (16%) than in men (6%), device design and procedural technique. As the thin walls of the LAA (muscular wall ≤1 mm) are vulnerable, device maneuvering during the procedure [18] together with anatomical variation in the LAA may partly explain the most common (4-5%) [5,6] risk of perforation and pericardial hemorrhage. Malalignment of the delivery system with the central axis of the LAA may cause tension/stress on the LAA or may result in suboptimal device positioning, leading to more manipulations including device recapturing and redeployment.…”

“…Furthermore, regardless of the LAA closure device used, co-axial alignment of the delivery sheath within the appendage is crucial for safe and successful implantation, and this depends on the orientation of the LAA. Suboptimal alignment of the delivery system within the appendage may cause perforation [5,6] and poor final device position, potentially promoting residual leaks [7] and thrombus formation. These complications remain the Achilles heel of the procedure, partially offsetting its potential benefits.…”