left atrial appendage occlusion interesting paper

[MummyLuv]

there a differences of views on left atrial appendage closure primarily due to the purpose of the left appendage not being known. This is an interesting research paper bringing together all the studies

- study looks at LAA closure alone and not with a mini maze or catheter ablation specifically

- both appendages use to be occluded but they help flush fluid and caused difficulty so now only the left where 90% of strokes occur are occluded.

- interesting overview of different left appendage shapes and which have highest risk of thrombosis

- surgical exclusion safe especially the atriclip which has very high occlusion rates and no fatalities. Almost halved the risk of stroke vs anticoagulants alone

- sadly EP placed devices such at the watchman had higher complication rates including death

- a lot of discussion in here about EP placed devices and the next phase of watchman

- research ongoing

ahajournals.org/doi/full/10...

[MummyLuv]

Uk study which concludes ‘The findings of our study suggest that LAAO is not without procedural risk, but that this risk may be justified in high-risk patients with AF who cannot take an anticoagulant. Moreover, the data do not provide support for more widespread use of LAAO as the complication rate was relatively high and would be difficult to justify in many patients with AF who tolerate anticoagulation’.

This is for an EP placed device and NOT for surgical clip which is considerably safer

academic.oup.com/ehjqcco/ar...

[MummyLuv]

more risks associated with the watchman device

openheart.bmj.com/content/9...

[Angie06 in reply to MummyLuv]

That was really interesting for me as I had an LAAO device fitted in 2018 due to not being able to take anticoagulants. It was an Amplatzer amulet which it seems is still undergoing trials in the US which won't be complete until 2024. Well I hope it comes up trumps as it's a bit late now for me 🤣 especially as there hasn't been any follow up since my post op TOE. Angie

[MummyLuv in reply to Angie06]

that’s a less well known device, not long for that paper 🤞 sure it will be fine, things are improving all the time 😍

[MummyLuv in reply to Angie06]

I had no idea there were so many different EP devices

Devices

[DawnTX in reply to MummyLuv]

I hate hearing this because it was an option for some people. The new model will need time to see how that goes. I was never considered a candidate they say it’s not for everyone.

[MummyLuv in reply to DawnTX]

hate hearing about the risks? That’s why I went looking factually as someone on here mentioned that there were long term risks of LAAO and as someone who has had this done I wanted to understand more

[MummyLuv]

surgical left appendage occlusion conclusion ‘In conclusion, S-LAAO (surgical left atrial appendage occlusionj was associated with lower events of ischemic stroke or systemic embolism and all-cause mortality when compared to the non-LAAO group.’

In conclusion, S-LAAO was associated with lower events of ischemic stroke or systemic embolism and all-cause mortality when compared to the non-LAAO group.

[MummyLuv]

a bit about increased pressure in left atrium after left appendage closure in here as well at the diuretic impact

heart.bmj.com/content/82/5/547

[Cat04]

Thank you MummyLuv -very interesting. 😊

I received an LAAe clip earlier this year whilst having AVR and PVI by OHS. I had previous had ganglionated plexi catheter ablation for PAF as part of an ICL trial. I had progressed 4 years later into atypical atrial flutter lasting >6 months.

I think I have received the Atriclip but am currently trying to confirm this having requested my hosp documents. The surgeon explained to me about the springs closing on the LAA but this was approx 12 hours pre-op and as you can imagine I didn't fully take in all the details!

I intend to ask more at my post-op follow-up appts and I'm fortunate that I have both a cardiac surgeon and a cardiologist happy to explain everthing in as much detail as I want.

Thanks again for the time & effort you have put into this post after yesterday's comment on another post about LAAO. xx

[MummyLuv in reply to Cat04]

Certainly sounds like the Articlip. I’ve never come across another make of clip only stapling as an alternative. No other mentioned in the main paper I posted. Got to say I was slightly nervous after reading the comment as I thought I had researched within an inch of my life before my surgery and had found the atriclip to be very safe at and after surgery as long as a TEE was used to check it’s placing is accurate. I knew that left appendage flushes fluid and so removing it means short term diuretics until right appendage takes over. BUT new studies are released all the time so I went and looked so I knew any new risks 👀 will be interesting if more is ever done on left atrial pressure.

[Cat04 in reply to MummyLuv]

My hosp discharge notes say LAAe clip & from the surgeon's description and my own research, I have assumed it's an Atriclip. I would still like confirmation as I do like to know what I'm carrying around in my chest. I refer to it as being like a scrap yard now - polyester, nickel, titanium, cobalt chromium, silicon rubber, cow, polypropylene and possibly stainless steel.

I had diuretics for 2 weeks post-op. Hopefully at some point I will have a follow up echo to see whether my dilated left atrium has decreased in size/volume.

It's certainly an interesting topic.

[4chickens]

wow thanks for the links to the papers, although a weighty Sunday morning read. As someone who wants to get back on a horse, plus various other high risk activities ( not my definition of risky)plus allergic to aspirin, The option to avoid anticoagulants was always attractive for me personally.

[MarkS]

That is an excellent set of papers you've put together, Mummyluv. Also I like your conclusions, such as that an LAAO is only really suitable for high risk AF-ers who can't take OACs. The surgical clip is safer but then we are only part way through identifying the benefits of the LAA.

[MummyLuv in reply to MarkS]

yes. for EP placed occlusions only for those who can’t take anticoagulants due to the higher risks, surgical left appendage closure by clip has been studied and found to be a safe and effective way of reducing stroke risk so does not carry that restriction. BUT as you say they are understanding more about the left appendage but still a way to go. There is currently only 13 years of use history for the Atriclip.

[JefferyW]

I am part of the Protect trial looking at the relative merits of Watchman compared to long term anticoagulants. My EP is based as University of Oxford Hospitals JOhn Radcliffe and carried out the procedure. The paper makes interesting reading and will discuss with him as I go in for review and monitoring every 6 months for next 5 years.

All I can say is that I had no ill effects from the procedure or subsequently. There had been no incidents arising from the procedure at this hospital with my EP. The EP went to great lengths to stress that the procedure was quite routine with very limited risk. I guess we don’t know the exact risk until it’s been tried - that’s what the trial is trying to assess.

Personally and on balance I am happy I did it and the risk of stroke and long term associated risk from taking anticoagulants seem worth it.

Regards

Jeff

[MummyLuv in reply to JefferyW]

brilliant to read! I suspect you will have the new watchman, excited to see those results as hopefully they’ll mitigate the risks associated with the old watchman device 🤞. The more options we all have the better.

[Abbyroza]

Electrofysiologist John Mandrola just issued a stern warning for the use of of left atrial appendage devices: “I am afraid. Really afraid that my colleagues will begin implanting these devices at the time of AF ablation. We do hundreds of thousands of AF ablation procedures per year in the US

Yet the evidence from the OPTION-study does not come close to supporting placing a permanent foreign body in the heart. We could easily be wrong.

Our profession should demand stronger evidence before doing something so aggressive. Be warned. This could be one of the worse chapters in modern cardiology”.