Left Atrial Appendage Exclusion for Prevention of Stroke in Atrial Fibrillation: Review of Minimally Invasive Approaches

Abstract

Stroke prevention is of vital importance in the management of atrial fibrillation (AF), though the proven strategy of systemic anticoagulation for thromboembolic prophylaxis is underutilized for a variety of reasons. The left atrial appendage (LAA) has long been suspected as the principal source of arterial emboli, particularly in nonvalvular AF, and a variety of techniques for its exclusion from the circulation have been developed. This review highlights the history of the LAA as a target of intervention, and the parallel advances in three minimally invasive strategies for its exclusion: percutaneous occlusion of the LAA orifice from within the left atrium, closed-chest ligation via a percutaneous pericardial approach, and minimally invasive thoracoscopic surgery. While further study is necessary, available evidence suggests that effective LAA exclusion is becoming a viable alternative to anticoagulation for stroke prevention in nonvalvular AF.

Progress toward the prevention and treatment of atrial fibrillation: A summary of the Heart Rhythm Society Research Forum on the Treatment and Prevention of Atrial Fibrillation, Washington, DC, December 9–10, 2013

“…143 The merits of intravascular vs intrapericardial devices have not yet been assessed. Progress in this field has been sparked by the composite surgical experience attesting to the efficacy of LAA exclusion in preventing cerebroembolic events.…”

Thoracoscopic Ablation with Appendage Ligation versus Medical Therapy for Stroke Prevention a Proof-of-Concept Randomized Trial

“…6,19,20 Furthermore, some patients with AF may elect a single interventional procedure to avoid the risks of lifelong anticoagulation therapy. 21…”

Thoracoscopic Ablation with Appendage Ligation versus Medical Therapy for Stroke Prevention a Proof-of-Concept Randomized Trial

“…6,19,20 Furthermore, some patients with AF may elect a single interventional procedure to avoid the risks of lifelong anticoagulation therapy. 21 The left atrial appendage is the major source of emboli in AF, and in this study, the AtriClip (AtriCure Inc, Westchester, OH USA), a dacron-covered nitinol clip, was placed epicardially to close the appendage at the same time pulmonary vein isolation was performed to restore NSR. Although the Watchman device (Boston Scientific Inc, Marlborough, MA USA) has shown promise for appendage closure via catheter delivery, it should be noted in the latest randomized PREVAIL trial that the Watchman device did not meet the end point for reduction in ischemic stroke or systemic embolism as compared with warfarin.…”