Left atrial appendage occlusion

The placement of a LAA occlusion device requires a large-bore venous access, general anesthesia, and transseptal puncture of left atrial access.

The Watchman device has a high device implant success of 95.6% and low rate of major complications including: pericardial tamponade at 1%, procedure related stroke at 0.078%, device embolization at 0.24% and procedure related death at 0.078%.

Left atrial appendage occlusion also known as Left atrial appendage closure.

It reduces the risk of left atrial appendage blood clots from entering the bloodstream and causing a stroke in patients with non-valvular atrial fibrillation (AF).

The left atrial appendage originates from the left atrium.

In non-valvular AF, over 90% of stroke-causing clots are formed in the left atrial appendage.

Oral anticoagulants reduce the chance for blood clots to form.

Because of risks of bleeding complications with oral anticoagulants, and the fact that 45% of patients who are eligible for anticoagulants are not being treated an alternative treatment is needed.

Left atrial appendage closure is an implant-based alternative.

It does not cure AF.

The WATCHMAN Implant is a one-time implant typically performed under general anesthesia with Transesophageal echo guidance (TEE).

A catheter is inserted through the femoral vein and is introduced into the right atrium and is then passed into the left atrium through a puncture hole.

The iatrogenic atrial septal defect that is formed usually disappears within six months.

The implant is then released and is left permanently fixed in the heart.

Recovery typically takes twenty-four hours.

Anticoagulants and aspirin are continued for 45 days post implantation at which point in time they return for a transesophageal echocardiography to judge completeness of the closure and the presence of blood clots.

If there are no gaps around the device larger than 5mm with communication to the appendage, then the patient can stops the oral anticoagulants and clopidogrel and aspirin for 6 months after implant is started.

Aspirin should be continued in definitely.

A number of other devices exist to occlude the left atrial appendage as well: Wavecrest device, and Lariat device.

The LAA can also be surgically removed, during other cardiac procedures.

The left atrial appendage has been closed in a limited number of patients using a chest keyhole surgery approach.

Adverse events related to LAAO are: pericardial effusion, incomplete LAA closure, dislodgement of the device, blood clot formation on the device requiring prolonged oral anticoagulation, and the general risks of catheter-based techniques.

Percutaneous left atrial appendage ligation as an adjunct to pulmonary vein isolation did not increase freedom from atrial arrhythmias at 12 months compared with pulmonary vein isolation alone in patients with  with non-paroxysmal atrial fibrillation. (aMAZE, investigators).

Among patients with AF who had undergone cardiac surgery, most of whom continued to receive ongoing anti thrombotic therapy, the risk of ischemic stroke or systemic embolism was lower with concomitant left atrial appendage occlusion  performed during surgery than  without it (LAAOS III investigators).

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