LAA Closure: Best Practices and How Do We Make it Mainstream Therapy?

6.3 / IAGS 2019
Session 6: Structural Session 3
LAA Closure: Best Practices and How Do We Make it Mainstream Therapy?
Problem Presenter: Brian O’Neill, MD

Statement of the problem

The hallmark of stroke prevention in the treatment of atrial fibrillation is anti-coagulation (AC). However, registry studies have demonstrated that there are a substantial proportion of patients who are not offered this therapy. For these patients, particularly with high CHADS2Vasc scores, the annual stroke rate can be unacceptably high. Left atrial appendage closure (LAAO) is an important alternative to anticoagulation in these patients.

 

Gaps in knowledge

Real world registries have demonstrated increasing success and decreasing complication rates with the dissemination of LAAO technology. This is despite the introduction of the technology to many operators who have not previously performed LAAO. It is because of this that LAAO has now been incorporated into the most recent guidelines for the treatment of atrial fibrillation as a Class IIB indication for those patients who have contraindications to long-term AC. Currently, it is recommended that patients who undergo LAAO should be anticoagulated for 45 days. Although several registries have suggested the efficacy of dual-antiplatelet therapy (DAPT) in patients with absolute contraindications to AC, larger randomized trials are lacking.

 

Possible solutions and future directions

Newer devices and trials are currently in development for LAAO which will require DAPT only. The use of cardiac CT to accurately size the LAA is replacing transesophageal echo (TEE) in the preprocedural work-up of these patients. CT has previously been shown to allow more appropriate device sizing of the LAA and to reduce the amount of devices used per case. Implantation success rates are likely to increase as this imaging modality continues to disseminate. LAAO still requires general anesthesia and TEE. Operators are gaining experience with mini TEE probes and intracardiac echo (ICE) to help eliminate the need for general anesthesia. However, these techniques remain in their infancy, and enhanced imaging technology is needed for this practice to become mainstream, particularly for ICE. Device related thrombus occurs in 3.7% of patients who undergo LAAO. Risk factors for this phenomenon have been described, and further study is needed to identify patients pre-procedure who are at risk and may benefit from prolonged AC post LAAO. Finally, further study is needed to assess the efficacy of the LAAO technology with the further adoption of direct oral anticoagulants (DOAC).