Left atrial appendage closure

Overview

Left atrial appendage closure is a medical procedure, often performed minimally invasively, that involves sealing off the left atrial appendage (LAA), a small sac located within the muscular wall of the left atrium, which is the upper left chamber of the heart. This procedure is primarily undertaken to reduce the risk of stroke and eliminate the necessity for blood-thinning medications. Research indicates that in individuals with atrial fibrillation who do not have valve disease, a significant portion of blood clots that can lead to strokes originate in the LAA.

The specific function of the left atrial appendage remains uncertain. However, closing or removing it does not hinder the heart’s ability to perform its vital functions. In a healthy heart, each heartbeat is characterized by coordinated contractions, allowing blood to flow from the left atrium and LAA into the left ventricle, the bottom left chamber of the heart.

In atrial fibrillation, an irregular heart rhythm, electrical impulses responsible for controlling the heartbeat become disordered. This results in multiple impulses occurring simultaneously and spreading chaotically through the atria. Consequently, the atria do not contract effectively, and blood can accumulate in the LAA and atria, potentially forming clots. These clots, when ejected from the heart, pose a significant risk of causing strokes. Individuals with atrial fibrillation are at a significantly higher risk, three to five times more so, for experiencing strokes compared to the general population.

Types of left atrial appendage closure devices

There are several types of left atrial appendage closure devices designed to prevent blood clots from escaping the LAA into the bloodstream:

• Blocking devices: These seal the LAA opening to prevent clot migration.
• Clamping devices: These secure the base of the LAA to close it off.
• Band or suture loop devices: These use bands or sutures to close off the LAA.

Reasons for undergoing the procedure

If you are at risk of developing blood clots in your left atrium or left atrial appendage, your healthcare provider might suggest a procedure to close off the LAA as an alternative to using blood thinners like warfarin to reduce the risk of stroke associated with atrial fibrillation.

Many individuals have reservations about or dislike taking warfarin due to various reasons, including:

• Frequent blood tests are necessary to monitor your international normalized ratio (INR) or clotting time to ensure the correct medication dosage.
• Certain vitamin K-rich foods must be limited while on warfarin.
• The risk of bleeding is higher when using warfarin.
• Some individuals may not tolerate warfarin well or struggle to maintain a normal clotting time.

There are other medications, such as dabigatran and rivaroxaban, available for people with atrial fibrillation who do not have heart valve disease. However, some individuals have concerns and encounter issues with these medications, including:

• People who cannot take anticoagulants may not tolerate these medications.
• Cost concerns may arise for some individuals.
• These medications also carry an increased risk of bleeding.

LAA closure is effective in lowering the stroke risk linked to atrial fibrillation, but it does not address the underlying AFib condition itself. This procedure is advantageous for individuals who require heart surgery and have atrial fibrillation as a concurrent condition. Additionally, it proves beneficial for individuals with atrial fibrillation, who do not have any other heart surgery-related issues, and opt for a Maze procedure to manage their atrial fibrillation.

Risks

Possible complications associated with left atrial appendage (LAA) closure can include:

• Device-related issues.
• Anesthesia-related reactions.
• Bleeding.
• Cardiac failure.
• Thoracic discomfort.
• Irregular heart rhythms.
• Infections.
• Accumulation of fluid around the heart (pericardial effusion).

Before the procedure

Your healthcare provider will perform either a transesophageal echocardiogram (TEE) or a cardiac computed tomography (CT) scan to gather precise dimensions of your left atrial appendage. This is a crucial step as these structures exhibit significant variations among individuals, resembling shapes such as a chicken wing or cauliflower. Additionally, three-dimensional printing may be utilized to aid in selecting the appropriate device and determining its size. The procedure will also involve anesthesia tailored to the specific technique being used.

During the procedure

During surgery to address conditions such as coronary artery disease or valve disease, medical professionals have the option to address the left atrial appendage by either surgically removing it and suturing or stapling the area closed, or by employing a minimally invasive approach using a catheter to insert a specialized device for closure.

For the minimally invasive catheter-based method, the procedure typically involves the following steps:

• Your healthcare provider will insert a catheter containing the closure device through a vein near your groin.
• The catheter is advanced to your right atrium, and a small opening is created between your left and right atrium.
• The catheter is then threaded through this opening and directed to your left atrial appendage.
• The closure device is positioned within your left atrial appendage to cover its opening, effectively sealing it off and preventing the release of blood clots.
• Once the device is in place, the catheter is removed.

Throughout the procedure, imaging techniques such as fluoroscopy (real-time X-ray video), transesophageal echo (TEE), or intracardiac ultrasound (ICE) may be used to guide the healthcare provider in accurately placing the closure device.

This approach aims to reduce the risk of blood clots forming in the left atrial appendage and potentially causing stroke or other complications.

After the procedure

Following your surgery or minimally invasive procedure, you may need to spend a night or more in the hospital. Additionally, it might be necessary to undergo a transesophageal echo (TEE) within the first 48 hours post-procedure as part of your follow-up care.

Outcome

Recovering from LAA closure surgery after another heart procedure varies based on the type of surgery you had:

• Minimally invasive catheter procedure: If you had a minimally invasive catheter-based LAA closure, you might go home the next day.
• Medications: After the LAA device insertion, you’ll take warfarin and aspirin for 45 days to allow tissue formation around the device. Then, you switch to clopidogrel and aspirin for six months, and aspirin may continue long-term.
• Follow-up: A follow-up TEE is done at 45 days to check if the LAA is fully blocked. If not, you’ll stay on warfarin with another TEE in six months.
• Annual follow-ups: Once your LAA is blocked, you’ll have yearly follow-up appointments, possibly with an echocardiogram within 60 days of the procedure.
• Important signs: Contact your healthcare provider if you experience fever, abnormal heart rhythms, or chest pain.