Skip to main content
SpringerLink
Log in

Review on Future Targets and Current Trends in Transcatheter Left Atrial Appendage Closure

  • Secondary Prevention and Intervention (D. Steinberg, Section Editor)
  • Published:
Current Cardiovascular Risk Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Atrial fibrillation is cause for a growing burden of thromboembolic stroke. Transcatheter left atrial appendage closure is an alternative to lifelong oral anticoagulation for many patients with nonvalvular atrial fibrillation. Reviewed here are three commonly used devices (Watchman, Amplatzer Cardiac Plug/Amulet, and Lariat) and their key clinical trials, special candidate patient populations, and recent investigations of the impact of post-procedure antithrombotic strategies.

Recent Findings

Transcatheter left atrial appendage closure devices provide noninferior thromboembolic stroke risk reduction and superior bleeding risk reduction compared with oral anticoagulation in nonvalvular atrial fibrillation. Very recent studies of post-procedure antithrombotic regimens describe a variety of anticoagulant and antiplatelet pharmacotherapies without clear impact on device-associated thrombus or post-procedure embolic stroke though more study is needed.

Summary

Transcatheter left atrial appendage closure is a viable alternative to lifelong oral anticoagulation to decrease thromboembolism and bleeding in patients with nonvalvular atrial fibrillation who are at increased risk of adverse event with anticoagulants. Patient populations at risk of bleeding on anticoagulants have been demonstrated to benefit from this technology, but there are several additional benefits of left atrial appendage closure unrelated to bleeding risks for specific patient populations. Data on the optimal short-term (weeks to months) post-procedure antithrombotic regimens is emerging and will play a significant role in how to best treat patients and which patients will benefit most from left atrial appendage closure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Haim M, Hoshen M, Reges O, Rabi Y, Balicer R, Leibowitz M. Prospective national study of the prevalence, incidence, management and outcome of a large contemporary cohort of patients with incident non-valvular atrial fibrillation. J Am Heart Assoc. 2015;4(1):e001486.

    Article  Google Scholar 

  2. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142–7.

    Article  Google Scholar 

  3. Kishore A, Vail A, Majid A, Dawson J, Lees KR, Tyrrell PJ, et al. Detection of atrial fibrillation after ischemic stroke or transient ischemic attack: a systematic review and meta-analysis. Stroke. 2014;45(2):520–6.

    Article  CAS  Google Scholar 

  4. Benjamin EJ, Virani SS, Callaway CW, Chamberlain AM, Chang AR, Cheng S, et al. Heart disease and stroke statistics-2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67–e492.

    Article  Google Scholar 

  5. January CT, Wann LS, Calkins H, Chen LY, Cigarroa JE, Cleveland JC Jr, et al. 2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation. Circulation. 2019:CIR0000000000000665.

  6. Fauchier L, Clementy N, Bisson A, Ivanes F, Angoulvant D, Babuty D, et al. Should atrial fibrillation patients with only 1 nongender-related CHA2DS2-VASc risk factor be anticoagulated? Stroke. 2016;47(7):1831–6.

    Article  CAS  Google Scholar 

  7. Aberg H. Atrial fibrillation. I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Med Scand. 1969;185(5):373–9.

    CAS  PubMed  Google Scholar 

  8. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61(2):755–9.

    Article  CAS  Google Scholar 

  9. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is frequently incomplete: a transesophageal echocardiograhic study. J Am Coll Cardiol. 2000;36(2):468–71.

    Article  CAS  Google Scholar 

  10. 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(9689):534–42.

    Article  CAS  Google Scholar 

  11. •• 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(24):2614–23 The meta-analysis of the PROTECT-AF and PREVAIL trials and their respective continued access registries is a landmark study of left atrial appendage closure versus anticoagulation for patients with nonvalvular atrial fibrillation at increased risk for thromboembolic stroke and bleeding reporting outcomes of stroke, death, and bleeding. Patients undergoing left atrial appendage closure were found to have marked reductions in hemorrhagic stroke, cardiovascular death, and nonprocedural bleeding compared with warfarin-treated patients. The reduction in hemorrhagic stroke was countered by a trend toward increase in ischemic strokes (procedural or nonprocedural).

    Article  Google Scholar 

  12. •• 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):1–12 The PREVAIL trial was a randomized, controlled clinical trial comparing the Watchman device for left atrial appendage closure with anticoagulation alone, much like the PROTECT-AF trial. Unlike PROTECT-AF, it did not meet noninferiority compared with warfarin. Notably, there was a significantly lower-than-expected event rate in the warfarin arm (despite enrolling older patients with higher CHADS 2 scores than the PROTECT-AF cohort). This trial was initiated at the behest of the U.S. Food and Drug Administration's concerns about periprocedural safety outcomes seen in PROTECT-AF trial. The PREVAIL trial showed improved and acceptable 7-day periprocedural safety outcomes, specifically less procedural-related strokes and pericardial effusion requiring surgery.

    Article  Google Scholar 

  13. •• 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(19):1988–98 Reddy VY et al. published 3.8-year outcomes from the PROTECT-AF trial which was the first large randomized controlled clinical trial examining left atrial appendage closure versus warfarin anticoagulation in nonvalvular atrial fibrillation patients. Patients in the device arm received the Watchman device which was found to be noninferior (like the earlier 18-month and 2.3-year follow-up findings) and superior to warfarin for the composite primary outcome of stroke, systemic embolism, cardiovascular, or unexplained death.

    Article  Google Scholar 

  14. Parashar A, Tuzcu EM, Kapadia SR. Cardiac plug I and amulet devices: left atrial appendage closure for stroke prophylaxis in atrial fibrillation. J Atr Fibrillation. 2015;7(6):1236.

    PubMed  PubMed Central  Google Scholar 

  15. • 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(10):1170–9 Tzikas A et al. examined 1,024 patients undergoing implant of the Amplatzer Cardiac Plug making this the largest systematic observational series of experience with this specific device. They describe the procedural events and clinical outcomes of a "real-world" application of left atrial appendage closure with this techonology.

    Article  Google Scholar 

  16. Bartus K, Bednarek J, Myc J, Kapelak B, Sadowski J, Lelakowski J, et al. Feasibility of closed-chest ligation of the left atrial appendage in humans. Heart Rhythm. 2011;8(2):188–93.

    Article  Google Scholar 

  17. 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(2):108–18.

    Article  Google Scholar 

  18. Musat D, Mittal S. LARIAT trial updates. J Atr Fibrillation. 2018;11(1):1806.

    Article  Google Scholar 

  19. • Lakkireddy D, Afzal MR, Lee RJ, Nagaraj H, Tschopp D, Gidney B, et al. Short and long-term outcomes of percutaneous left atrial appendage suture ligation: results from a US multicenter evaluation. Heart Rhythm. 2016;13(5):1030–6 Lakkireddy et al. described the largest published series on the safety and efficacy of left atrial appendage ligation with the Lariat device in 712 patients with improved procedural success, and significantly lower complication rates compared with prior series with this device, employing micropuncture pericardial access techniques and routine colchicine and nonsteroidal anti-inflammatory drugs.

    Article  Google Scholar 

  20. Litwinowicz R, Bartus M, Burysz M, Brzezinski M, Suwalski P, Kapelak B, et al. Long term outcomes after left atrial appendage closure with the LARIAT device-stroke risk reduction over five years follow-up. PLoS One. 2018;13(12):e0208710.

    Article  CAS  Google Scholar 

  21. 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(7):1501–7.

    Article  Google Scholar 

  22. O'Brien EC, Simon DN, Thomas LE, Hylek EM, Gersh BJ, Ansell JE, et al. The ORBIT bleeding score: a simple bedside score to assess bleeding risk in atrial fibrillation. Eur Heart J. 2015;36(46):3258–64.

    CAS  PubMed  PubMed Central  Google Scholar 

  23. Pisters R, Lane DA, Nieuwlaat R, de Vos CB, Crijns HJ, Lip GY. A novel user-friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro Heart Survey. Chest. 2010;138(5):1093–100.

    Article  Google Scholar 

  24. Winkelmayer WC, Liu J, Setoguchi S, Choudhry NK. Effectiveness and safety of warfarin initiation in older hemodialysis patients with incident atrial fibrillation. Clin J Am Soc Nephrol. 2011;6(11):2662–8.

    Article  CAS  Google Scholar 

  25. Bonde AN, Lip GY, Kamper AL, Hansen PR, Lamberts M, Hommel K, et al. Net clinical benefit of antithrombotic therapy in patients with atrial fibrillation and chronic kidney disease: a nationwide observational cohort study. J Am Coll Cardiol. 2014;64(23):2471–82.

    Article  CAS  Google Scholar 

  26. Poterucha TJ, Goldhaber SZ. Warfarin and vascular calcification. Am J Med. 2016;129(6):635 e1-4.

    Article  Google Scholar 

  27. Holmes DR Jr, Lakkireddy DR, Whitlock RP, Waksman R, Mack MJ. Left atrial appendage occlusion: opportunities and challenges. J Am Coll Cardiol. 2014;63(4):291–8.

    Article  Google Scholar 

  28. Martinez C, Katholing A, Wallenhorst C, Freedman SB. Therapy persistence in newly diagnosed non-valvular atrial fibrillation treated with warfarin or NOAC. A cohort study. Thromb Haemost. 2016;115(1):31–9.

    Article  Google Scholar 

  29. Bergmann MW, Betts TR, Sievert H, Schmidt B, Pokushalov E, Kische S, et al. Safety and efficacy of early anticoagulation drug regimens after WATCHMAN left atrial appendage closure: three-month data from the EWOLUTION prospective, multicentre, monitored international WATCHMAN LAA closure registry. EuroIntervention. 2017;13(7):877–84.

    Article  Google Scholar 

  30. • 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;14(9):1302–8 The EWOLUTION trial is the largest prospective registry of 1005 patients scheduled to undergo left atrial appendage closure with the Watchman device. Importantly, the trial observed outcomes in this large number of patients who were treated with several different antithrombotic pharmacotherapy regimens post-procedure. A major proportion received antiplatelet therapy during the months following implant rather than an anticoagulant with similar efficacy seen in prior randomized trials with mandated short-term post-procedure anticoagulation. The evidence from this trial questions the utility of standard pharmacotherapies and the clinical significance of observed device-related thrombus.

    Article  Google Scholar 

  31. Sharma D, Reddy VY, Sandri M, Schulz P, Majunke N, Hala P, et al. Left atrial appendage closure in patients with contraindications to oral anticoagulation. J Am Coll Cardiol. 2016;67(18):2190–2.

    Article  Google Scholar 

  32. Weise FK, Bordignon S, Perrotta L, Konstantinou A, Bologna F, Nagase T, et al. Short-term dual antiplatelet therapy after interventional left atrial appendage closure with different devices. EuroIntervention. 2018;13(18):e2138–e46.

    Article  Google Scholar 

  33. • Pracon R, Bangalore S, Dzielinska Z, Konka M, Kepka C, Kruk M, et al. Device thrombosis after percutaneous left atrial appendage occlusion is related to patient and procedural characteristics but not to duration of postimplantation dual antiplatelet therapy. Circ Cardiovasc Interv. 2018;11(3):e005997 Pracon R et al. studied clinical factors associated with thromboembolic risk after left atrial appendage closure. Notably, they found device-related thrombus was not significantly predictive.

    Article  Google Scholar 

  34. Korsholm K, Nielsen KM, Jensen JM, Jensen HK, Andersen G, Nielsen-Kudsk JE. Transcatheter left atrial appendage occlusion in patients with atrial fibrillation and a high bleeding risk using aspirin alone for post-implant antithrombotic therapy. EuroIntervention. 2017;12(17):2075–82.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Cardiology, Department of Medicine, Medical University of South Carolina, 30 Courtenay Drive, MSC 592, BM 205, Charleston, SC, 29425, USA

    Nicholas S. Amoroso

Authors
  1. Nicholas S. Amoroso
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicholas S. Amoroso.

Ethics declarations

Conflict of Interest

Nicholas S. Amoroso declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Secondary Prevention and Intervention

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Amoroso, N.S. Review on Future Targets and Current Trends in Transcatheter Left Atrial Appendage Closure. Curr Cardiovasc Risk Rep 13, 15 (2019). https://doi.org/10.1007/s12170-019-0609-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s12170-019-0609-x

Keywords

Search

Navigation