Objective Percutaneous left atrial appendage (LAA) occlusion can be an interventional alternative to oral anticoagulation for stroke prevention in patients with atrial fibrillation.
Methods We delivered LAA occlusion therapy using a standardised approach to patient referral, multidisciplinary team assessment, implant criteria, imaging and follow-up. We analysed patient characteristics, efficacy and safety of the implant procedure, and 12-month outcomes.
Results Of 143 referrals from October 2014 to December 2016, 83 patients (age 76±8 years, 32.5% female, mean CHAD2S2-VASc score 4±1) were offered LAA occlusion. Eighty (95.3%) had previous major bleeding (intracranial in 59%). LAA occluder implantation with an Amulet device was successful in 82 (98.8%), with periprocedural major adverse events occurring in 5 (6.0%) patients (2 device embolisations including 1 death, 2 major bleeds). Cardiac imaging in 75 (94%) patients 2 months following implant showed device-related thrombus in 1 case (1.3%) and minor (<5 mm) device leaks in 13 (17.1%). Over a median 12-month follow-up, 3 (3.8%) ischaemic strokes, 2 (2.5%) haemorrhagic strokes and 5 (6.3%) major extracranial bleeds occurred. All-cause mortality was 10%, with most deaths (7, 87.5%) due to non-cardiovascular causes.
Conclusions LAA occlusion may be a reasonable option for stroke prevention inhigh-risk patients with atrial fibrillation ineligible for anticoagulation. However, procedural complication rates are not insignificant, and patients remain at risk of serious adverse events and death even after successful implant.
- atrial fibrillation
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Contributors DG, AyK, PV, WLM, SA were personally involved in the procedures of LAA occlusion. TF, AfK, NS were members of the multidisciplinary team involved in the patient selection for LAA occlusion. AM, SB acted as main data collectors, performed the statistical analysis and wrote the different versions of the manuscript. DG, PK reviewed different versions of the manuscript and submitted the final version for publication.
Competing interests DG is on the proctors’ panel for St Jude Medical (now Abbott) for implantation of Amulet devices, and has received honoraria for proctoring activities. PK receives research support from European Union, British Heart Foundation, Leducq Foundation, Medical Research Council (UK) and German Centre for Cardiovascular Research, from several drug and device companies active in atrial fibrillation, and has received honoraria from several such companies. All other authors do not have relevant conflicts of interest to declare.
Ethics approval Ethics approval was obtained from Liverpool Heart and Chest Hospital. An institutional review board-approved registry of patient selection, procedural success and follow-up (including appropriate imaging) was established where data were prospectively captured.
Provenance and peer review Not commissioned; externally peer reviewed.
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