Question

Left atrial appendage closure: technique, device, indications and contraindications.

Hint:

Left atrial appendage closure is particularly useful for stroke prevention in patients with atrial fibrillation who are at high risk for bleeding or unable to take anticoagulants long-term.

Answer 1

Step 1: Understanding Left Atrial Appendage Closure (LAAC).
Left atrial appendage closure (LAAC) is a procedure used to prevent stroke in patients with atrial fibrillation (AF) who are at high risk of thromboembolism. The left atrial appendage is a pouch-like structure in the left atrium where blood clots can form in patients with AF. Closing this appendage reduces the risk of stroke by preventing clot formation and embolization.

Step 2: Technique of LAAC.
LAAC can be performed percutaneously or surgically. The percutaneous approach is the most common and involves the use of a catheter to insert a device into the left atrial appendage through a vein. A common device used for LAAC is the WATCHMAN device, which is a self-expanding plug that occludes the appendage. The procedure is typically performed under general anesthesia and requires the use of fluoroscopy and echocardiography to guide device placement. After implantation, the device permanently seals the appendage, and the patient can begin anticoagulation therapy.

Step 3: Indications for LAAC.
The main indication for LAAC is stroke prevention in patients with non-valvular atrial fibrillation who are not candidates for long-term anticoagulation therapy due to bleeding risks. It is also considered for patients with persistent AF who are at high risk for stroke and have failed or are not candidates for other forms of rhythm control, including ablation or medication therapy. Other indications may include patients with mechanical heart valves or those with recurrent thromboembolic events despite anticoagulation therapy.

Step 4: Contraindications for LAAC.
LAAC is not recommended for patients with significant left atrial thrombus, as the device may dislodge existing clots, leading to a stroke. It is also contraindicated in patients with active infection or endocarditis, severe mitral stenosis, or those with other significant valvular diseases. In addition, patients who are unable to comply with post-procedure anticoagulation therapy or who have contraindications to anticoagulants should not undergo LAAC.

Step 5: Conclusion.
LAAC is a safe and effective procedure for reducing stroke risk in high-risk AF patients who cannot tolerate long-term anticoagulation. It offers a permanent solution to reduce the risk of stroke without the need for lifelong anticoagulant therapy. However, careful patient selection is essential to ensure optimal outcomes.