Abstract
Purpose of Review
Left atrial appendage closure (LAAC) emerged as a promising site-directed therapy to mitigate stroke risk in patients ineligible for long-term oral anticoagulation. We sought to summarize the current evidence regarding the role of LAAC on long-term risk of ischemic stroke and systemic thromboembolism.
Recent Findings
Data from EWOLUTION registry provides real world evidence on the 1-year outcomes of LAAC by WATCHMAN device. The annual ischemic stroke rate was 1.1 per 100 patient-years, as opposed to the CHADS2VASC score-predicted stroke rate of 7.2% (84% relative risk reduction). No differences in death, stroke, or bleeding rates were observed between patients with or without a contraindication for anticoagulation or based on type of anticoagulant used. Pooled registry data in patients who underwent Amplatzer Cardiac Plug (ACP) demonstrate an observed stroke rate of 2.0–2.7% as opposed to CHADS2VASC score-predicted stroke rate of 5.6–8.3% over a median follow-up ~ 5 years. Recent studies evaluating efficacy of LARIAT over a median follow of ~3 years demonstrate that the observed ischemic stroke rate was 1% as opposed to the expected stroke rate of 6.2%. A recent propensity score matched observational study by Melduni RM et al. demonstrated that patients with AF who underwent routine LAAC during elective cardiac surgery (CABG/valvular surgery) were found to have higher risk (OR = 2.83) of postoperative AF with no effect on long-term stroke risk (OR 0.80, 95% CI 0.53–1.22) or mortality (OR 0.99, 95% CI 0.80–1.22).
Summary
LAAC device studies have shown promising results in patients ineligible for long-term oral anticoagulation (OAC). Patients who develop stroke while being on OAC should also be considered for LAAC. But, caution must be executed while interpreting the current evidence as these devices may only offer benefit in decreasing LAA-dependent cardio-embolic stroke and non-LAA-dependent thrombi contribute to a small but significant portion of stroke risk. Currently, WATCHMAN device and ACP are being used extensively, and other LAA closure devices are being studied in clinical trials (Amulet IDE, WaveCrest II, Amaze, LAAOS III) which will be available for clinical use in near future. Further studies with long-term follow-up data utilizing prospective registries (LAAO registry, ACP registry) are needed to determine their safety/efficacy profile in comparison with newer oral anticoagulants that are currently available for stroke prevention.
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References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Reiffel JA. Atrial fibrillation and stroke: epidemiology. Am J Med. 2014;127:e15–6.
• Calenda BW, Fuster V, Halperin JL, Granger CB. Stroke risk assessment in atrial fibrillation: risk factors and markers of atrial myopathy. Nat Rev Cardiol. 2016;13:549–59. Provides a state of the art review on stroke risk associated with atrial myopathies, risk prediction models, and available prevention strategies including left atrial appendage occlusion.
Iwasaki Y-K, Nishida K, Kato T, Nattel S. Atrial fibrillation pathophysiology: implications for management. Circulation. 2011;124:2264–74.
Koneru JN, Badhwar N, Ellenbogen KA, Lee RJ. LAA ligation using the LARIAT suture delivery device: tips and tricks for a successful procedure. Heart Rhythm. 2014;11:911–21.
Nielsen PB, Larsen TB, Skjøth F, Gorst-Rasmussen A, Rasmussen LH, Lip GYH. Restarting anticoagulant treatment after intracranial hemorrhage in patients with atrial fibrillation and the impact on recurrent stroke, mortality, and bleeding: a nationwide cohort study. Circulation. 2015;132:517–25.
Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61:755–9.
Holmes DR Jr, Doshi SK, Kar S, Price MJ, Sanchez JM, Sievert H, et al. Left atrial appendage closure as an alternative to warfarin for stroke prevention in atrial fibrillation: a patient-level meta-analysis. J Am Coll Cardiol. 2015;65:2614–23.
Reddy VY, Holmes D, Doshi SK, Neuzil P, Kar S. Safety of percutaneous left atrial appendage closure clinical perspective. Circulation; American Heart Association, Inc. 2011;123:417–24.
• Piccini JP, Sievert H, Patel MR. Left atrial appendage occlusion: rationale, evidence, devices, and patient selection. Eur Heart J. 2017;38:869–76. Provides a succinct summary of current evidence on available left atrial appendage closure strategies along with a decision algorithm for choosing pharmacological versus mechanical intervention and type of mechanical therapy for stroke prevention.
Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374:534–42.
Holmes DR Jr, Kar S, Price MJ, Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of the Watchman left atrial appendage closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64:1–12.
Connolly SJ, Ezekowitz MD, Yusuf S, Eikelboom J, Oldgren J, Parekh A, et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med. 2009;361:1139–51.
Granger CB, Alexander JH, McMurray JJV, Lopes RD, Hylek EM, Hanna M, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365:981–92.
Patel MR, Mahaffey KW, Garg J, Pan G, Singer DE, Hacke W, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365:883–91.
Jazayeri M-A, Vuddanda V, Parikh V, Lavu M, Atkins D, Reddy YM, et al. Five years of keeping a watch on the left atrial appendage—how has the WATCHMAN fared? J Thorac Dis. 2016;8:E1726–33.
Sohaib SMA, Fox KF. A meta-analysis of left atrial appendage closure for stroke prevention in atrial fibrillation—adding to the debate but elements remain unresolved. J Thorac Dis; AME Publications. 2015;7:E226.
Reddy VY, Sievert H, Halperin J, Doshi SK, Buchbinder M, Neuzil P, et al. Percutaneous left atrial appendage closure vs warfarin for atrial fibrillation: a randomized clinical trial. JAMA. 2014;312:1988–98.
Wiebe J, Franke J, Lehn K, Hofmann I, Vaskelyte L, Bertog S, et al. Percutaneous left atrial appendage closure with the Watchman device. JACC Cardiovasc Interv. 2015;8:1915–21.
Boersma LV, Ince H, Kische S, Pokushalov E, Schmitz T, Schmidt B, et al. Efficacy and safety of left atrial appendage closure with WATCHMAN in patients with or without contraindication to oral anticoagulation: 1-year follow-up outcome data of the EWOLUTION trial. Heart Rhythm. 2017; doi:10.1016/j.hrthm.2017.05.038.
Reddy VY, Möbius-Winkler S, Miller MA, Neuzil P, Schuler G, Wiebe J, et al. Left atrial appendage closure with the Watchman device in patients with a contraindication for oral anticoagulation: the ASAP study (ASA Plavix Feasibility Study With Watchman Left Atrial Appendage Closure Technology). J Am Coll Cardiol; Elsevier. 2013;61:2551–6.
Saw J, Lempereur M. Percutaneous left atrial appendage closure. JACC Cardiovasc Interv. 2014;7:1205–20.
Bartus K, Han FT, Bednarek J, Myc J, Kapelak B, Sadowski J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: initial clinical experience. J Am Coll Cardiol. 2013;62:108–18.
Sievert H, Rasekh A, Bartus K, Morelli RL, Fang Q, Kuropka J, et al. Left atrial appendage ligation in nonvalvular atrial fibrillation patients at high risk for embolic events with ineligibility for oral anticoagulation. JACC Clin Electrophysiol. 2015;1:465–74.
Boersma LVA, Schmidt B, Betts TR, Sievert H, Tamburino C, Teiger E, et al. Implant success and safety of left atrial appendage closure with the WATCHMAN device: peri-procedural outcomes from the EWOLUTION registry. Eur Heart J. 2016;37:2465–74.
Tzikas A, Shakir S, Gafoor S, Omran H, Berti S, Santoro G, et al. Left atrial appendage occlusion for stroke prevention in atrial fibrillation: multicentre experience with the AMPLATZER Cardiac Plug. EuroIntervention. 2016;11:1170–9.
López Mínguez JR, Asensio JMN, Gragera JE, Costa M, González IC, de Carlos FG, et al. Two-year clinical outcome from the Iberian registry patients after left atrial appendage closure. Heart. 2015;101:877–83.
Santoro G, Meucci F, Stolcova M, Rezzaghi M, Mori F, Palmieri C, et al. Percutaneous left atrial appendage occlusion in patients with non-valvular atrial fibrillation: implantation and up to four years follow-up of the AMPLATZER Cardiac Plug. EuroIntervention. 2016;11:1188–94.
Lewalter T, Kanagaratnam P, Schmidt B, Rosenqvist M, Nielsen-Kudsk JE, Ibrahim R, et al. Ischaemic stroke prevention in patients with atrial fibrillation and high bleeding risk: opportunities and challenges for percutaneous left atrial appendage occlusion. Europace. 2014;16:626–30.
Stone D, Byrne T, Pershad A. Early results with the LARIAT device for left atrial appendage exclusion in patients with atrial fibrillation at high risk for stroke and anticoagulation. Catheter Cardiovasc Interv. 2015;86:121–7.
Miller MA, Gangireddy SR, Doshi SK, Aryana A, Koruth JS, Sennhauser S, et al. Multicenter study on acute and long-term safety and efficacy of percutaneous left atrial appendage closure using an epicardial suture snaring device. Heart Rhythm. 2014;11:1853–9.
Pillarisetti J, Reddy YM, Gunda S, Swarup V, Lee R, Rasekh A, et al. Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm. 2015;12:1501–7.
Gianni C, Di Biase L, Trivedi C, Mohanty S, Gökoğlan Y, Güneş MF, et al. Clinical implications of leaks following left atrial appendage ligation with the LARIAT device. JACC Cardiovasc Interv. 2016;9:1051–7.
Suradi HS, Hijazi ZM. Left atrial appendage closure: outcomes and challenges. Neth Heart J. 2017;25:143–51.
Parikh V, Bartus K, Reddy M, Lee R, Lakkireddy D. Long term safety and efficacy of left atrial appendage closure with Lariat in atrial fibrillation: is it still working at 5 years? J Am Coll Cardiol. 2017;69:388.
Syed FF, DeSimone CV, Friedman PA, Asirvatham SJ. Left atrial appendage exclusion for atrial fibrillation. Heart Fail Clin. 2016;12:273–97.
Whitlock RP, Vincent J, Blackall MH, Hirsh J, Fremes S, Novick R, et al. Left Atrial Appendage Occlusion Study II (LAAOS II). Can J Cardiol. 2013;29:1443–7.
Garcya-Fernandez MA, Perez-David E, Quiles J. Role of left atrial appendage obliteration in stroke reduction in patients with mitral valve prosthesis: a transesophageal echocardiographic study. ACC Curr J Rev. 2004;13:60–1.
Tsai Y-C, Phan K, Munkholm-Larsen S, Tian DH, La Meir M, Yan TD. Surgical left atrial appendage occlusion during cardiac surgery for patients with atrial fibrillation: a meta-analysis. Eur J Cardiothorac Surg. 2015;47:847–54.
January CT, Samuel Wann L, Alpert JS, Calkins H, Cigarroa JE, Cleveland JC, et al. 2014 AHA/ACC/HRS Guideline for the management of patients with atrial fibrillation: executive summary. J Am Coll Cardiol. 2014;64:2246–80.
Melduni RM, Schaff HV, Lee H-C, Gersh BJ, Noseworthy PA, Bailey KR, et al. Impact of left atrial appendage closure during cardiac surgery on the occurrence of early postoperative atrial fibrillation, stroke, and mortality: a propensity score-matched analysis of 10 633 patients. Circulation. 2017;135:366–78.
AMPLATZER™ Amulet™ LAA Occluder Trial—full text view - ClinicalTrials.gov [Internet]. [cited 2017 May 25]. Available from: https://clinicaltrials.gov/ct2/show/NCT02879448?term=AMulet+IDE&rank=1.
Left Atrial Appendage Occlusion Study III—full text view - ClinicalTrials.gov [Internet]. [cited 2017 May 25]. Available from: https://clinicaltrials.gov/ct2/show/NCT01561651?term=LAAOS&rank=1.
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Drs Vuddanda, Turagam, and Lakkireddy declare no conflicts of interests.
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Vuddanda, V., Turagam, M.K. & Lakkireddy, D. Left Atrial Appendage Closure: Is the Strategy Enough to Lower Long-Term Stroke Risk?. Curr Cardiovasc Risk Rep 11, 28 (2017). https://doi.org/10.1007/s12170-017-0555-4
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DOI: https://doi.org/10.1007/s12170-017-0555-4