Matthew Earnest

Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications

BACKGROUND Watchman and Lariat left atrial appendage (LAA) occlusion devices are associated with LAA leaks postdeployment. OBJECTIVE The purpose of this study was to compare the incidence, characteristics, and clinical significance of these leaks. METHODS We performed a multicenter prospective observational study of all patients who underwent LAA closure. Baseline, procedural, and imaging variables along with LAA occlusion rates at 30-90 days and 1-year postprocedure were compared. RESULTS A total of 478 patients (219 with the Watchman device and 259 with the Lariat device) with successful implants were included. Patients in the Lariat group had a higher CHADS2 (congestive heart failure, hypertension, age >74 years, diabetes, stroke) score and a larger left atrium and LAA. A total of 79 patients (17%) had a detectable leak at 1 year. More patients in the Watchman group had a leak compared with those in the Lariat group (46 [21%] vs 33 [14%]; P = .019). All the leaks were eccentric (edge effect) in the Watchman group and concentric (gunny sack effect) in the Lariat group. The size of the leak was larger in the Watchman group than in the Lariat group (3.10 ± 1.5 mm vs 2.15 ± 1.3 mm; P = .001). The Watchman group had 1 device embolization requiring surgery and 2 pericardial effusions requiring pericardiocentesis. In the Lariat group, 4 patients had cardiac tamponade requiring urgent surgical repair. Three patients in each group had a cerebrovascular accident and were not associated with device leaks. CONCLUSION The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.

Impact of left atrial appendage exclusion using an epicardial ligation system (LARIAT) on atrial fibrillation burden in patients with cardiac implantable electronic devices

BACKGROUND The left atrial appendage (LAA) is a well-known source of atrial arrhythmia and atrial fibrillation (AF). OBJECTIVE The purpose of this study was to determine whether LAA exclusion using the LARIAT device would decrease AF burden. METHODS A total of 50 patients with AF and cardiac implantable electronic devices who underwent successful LAA exclusion were enrolled in this prospective observational study. AF burden before LAA exclusion (baseline) and 3 and 12 months after exclusion was assessed by device interrogation. RESULTS AF burden at 3-month follow-up (42% ± 34%) was significantly lower compared to baseline (76% ± 33%, P < .0001). The reduction in AF burden was sustained at 12 months (59% ± 26%, P < .001). Subgroup analysis revealed that AF burden at 3-month follow-up was similarly reduced in both paroxysmal AF (n = 19) and nonparoxysmal AF (n = 31). However, there was no reduction in AF burden in patients with paroxysmal AF at 12 months. AF burden in patients with known AF triggers in the LAA (n = 9) was significantly reduced at 3 months (52% ± 35%) and 12 months (42% ± 19%) compared to respective baseline (84 ± 31%, P < .0001). CONCLUSION LAA exclusion appears to reduce AF burden. The presence of AF triggers in the LAA appears to be the strongest predictor of AF reduction. The study underscores the role of the LAA in arrhythmogenesis for AF and highlights the complementary role of LAA exclusion in restoration of normal sinus rhythm.

IMPACT OF LEFT ATRIAL APPENDAGE EXCLUSION ON SYSTEMIC HOMEOSTASIS (THE LAA HOMEOSTASIS STUDY)

Left atrial appendage (LAA) a major source of ANP (atrial natriuretic peptide) which can influence the endocrine axis. The physiologic effects of LAA exclusion on systemic homeostasis have not been previously studied. 37 consecutive patients (7 women (19%)/30 men (81%); age 71±8; CHAD2 2.6±1.1;

Initial experience with post Lariat left atrial appendage leak closure with Amplatzer septal occluder device and repeat Lariat application

BACKGROUND Left atrial appendage (LAA) ligation with the Lariat device is a therapeutic option to prevent thromboembolic stoke in patients with nonvalvular atrial fibrillation (AF) at high risk for systemic thromboembolization and bleeding related to use of anticoagulation. In rare cases, this procedure could leave the LAA incompletely ligated with continued risk of stroke. OBJECTIVE The purpose of this study was to investigate the incidence and characteristics of LAA leak following ligation using the Lariat device and the feasibility of leak closure with the Amplatzer septal occluder device or a repeat Lariat application. METHODS Seventy-one consecutive patients who underwent LAA ligation by the Lariat device were followed-up with transesophageal echocardiography to evaluate for the presence of appendage leaks, characterization of the leaks, and the presence of any thrombus. Patients with LAA leaks underwent definite closure of the leak. RESULTS Six patients had LAA leaks with a mean leak size of 4.3 ± 0.6 mm. All leaks were concentric in nature. None of the patients had LAA thrombus. Leaks in 5 of these patients were successfully closed using an Amplatzer septal occluder device (St. Jude Medical); the leak in the sixth patient was closed using a repeat Lariat procedure. CONCLUSION LAA leaks from incomplete ligation of the LAA following the Lariat procedure are not uncommon and could be successfully closed with an Amplatzer septal occluder device or a repeat Lariat procedure.

Use of non-warfarin oral anticoagulants instead of warfarin during left atrial appendage closure with the Watchman device

BACKGROUND In the stroke prevention trials of left atrial appendage closure with the Watchman device (Boston Scientific), a postimplantation antithrombotic regimen of 6 weeks of warfarin was used. OBJECTIVE Given the clinical complexity of warfarin use, the purpose of this study was to study the relative feasibility and safety of using non-warfarin oral anticoagulants (NOACs) instead of warfarin during the peri- and initial postimplantation periods after Watchman implantation. METHODS This was a retrospective multicenter study of consecutive patients undergoing Watchman implantation and receiving peri- and postprocedural NOACs or warfarin. Transesophageal echocardiography or chest computed tomography was performed between 6 weeks and 4 months postimplant to assess for device-related thrombosis. Bleeding and thromboembolic events also were evaluated at the time of follow-up. RESULTS In 5 centers, 214 patients received NOACs (46% apixaban, 46% rivaroxaban, 7% dabigatran, and 1% edoxaban) in either an uninterrupted (82%) or a single-held-dose (16%) fashion. Compared to a control group receiving uninterrupted warfarin (n = 212), the rates of periprocedural complications, including bleeding events, were similar (2.8% vs 2.4%, P = 1). At follow-up, the rates of device-related thrombosis (0.9% vs 0.5%, P = 1), composite of thromboembolism or device-related thrombosis (1.4% vs 0.9%, P = 1), and postprocedure bleeding events (0.5% vs 0.9%, P = .6) also were comparable between the NOAC and warfarin groups. CONCLUSION NOACs proved to be a feasible peri- and postprocedural alternative regimen to warfarin for preventing device-related thrombosis and thromboembolic complications expected early after appendage closure with the Watchman device, without increasing the risk of bleeding.

LEFT ATRIAL APPENDAGE LIGATION AND ABLATION FOR PERSISTENT ATRIAL FIBRILLATION (LAALA-AF REGISTRY)

Left atrial appendage (LAA) isolation is known to be an important adjunctive therapy to improve outcomes of pulmonary vein isolation in patients with persistent AF. Percutaneous endo-epicardial LAA closure system (LARIAT) can result in both mechanical and electrical exclusion of the LAA and may

EFFECT OF ENDOEPICARDIAL PERCUTANEOUS LEFT ATRIAL APPENDAGE LIGATION (LARIAT) ON ARRHYTHMIA BURDEN IN PATIENTS WITH ATRIAL FIBRILLATION

Left atrial appendage is a very common non Pulmonary venous source of triggered activity. Electrical isolation of LAA seems to be effective in improving outcomes of RF ablation. It is not clear how ligation of the LAA impacts arrhythmia burden in patients with AF We prospectively followed AF

Safety profiles of percutaneous left atrial appendage closure devices: An analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database from 2009 to 2016

Percutaneous left atrial appendage closure (LAAC) is a viable option for AF patients who are unable to tolerate long‐term oral anticoagulation (OAC).

Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA-AF registry

The anatomical, electrical, and clinical impact of incomplete Lariat left atrial appendage ligation remains unclear.

Embryology and Anatomy of the Left Atrial Appendage: Why Does Thrombus Form?

The left atrial appendage (LAA) is a long tubular structure that opens into the left atrium. In patients with atrial fibrillation, the LAA develops mechanical dysfunction and fibroelastotic changes on the endocardial surface. The complex anatomy of the LAA makes it a good site for relative blood stasis. In addition, systemic factors exacerbate the hypercoagulable state, eventually resulting in endothelial dysfunction, release of tissue factor, and production of inflammatory cytokines and oxidative free radicals, and eventually initiating the coagulation cascade. Thus, the LAA is susceptible to thrombus formation and is the most common source of systemic thromboembolism.