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  • Review Article
  • Published:

Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation

Key Points

  • Oral anticoagulation, using apixaban, dabigatran, rivaroxaban, or warfarin is the first-line therapy for stroke prevention in patients with atrial fibrillation (AF), an approach limited by an increased risk of haemorrhage

  • Percutaneous transcatheter occlusion of the left atrial appendage (LAA), where >90% of thrombi form in patients with nonrheumatic AF, is an attractive nonpharmacological option for individuals intolerant to oral anticoagulants

  • Limited evidence suggests that mechanical LAA occlusion can be superior to oral anticoagulation therapy with warfarin in preventing stroke, systemic embolism, and cardiovascular-related or unexplained death in patients with AF

  • Echocardiographic imaging of the LAA has an important role in the occlusion procedure by guiding device sizing, delivery, and deployment

  • Operator experience is crucial in influencing the rate of procedure-related complications associated with percutaneous transcatheter LAA occlusion

  • Evidence is emerging, but substantial efforts are warranted to understand better the role of LAA occlusion in stroke prevention, especially in patients with AF and contraindications for oral anticoagulation therapy

Abstract

Stroke in patients with atrial fibrillation (AF) is often associated with substantial morbidity and mortality. Oral anticoagulation remains the first-line approach to stroke prevention in such individuals; however, for a considerable proportion of patients, traditional treatment using warfarin is limited by a number of factors, such as the inconvenience of frequent therapeutic monitoring and the risk of haemorrhage. The development of new oral anticoagulants with improved efficacy and safety profiles has provided viable options for oral anticoagulation therapy in patients with nonvalvular (nonrheumatic AF). Nonetheless, in patients who have an increased risk of major haemorrhage, a nonpharmacological approach to antithrombotic therapy remains an attractive alternative. The left atrial appendage (LAA) has been found to be the source of >90% of thrombi in patients with nonvalvular AF; thus, prevention of thrombus formation via transcatheter mechanical LAA occlusion is a novel therapeutic target for stroke prevention in this patient population. In this Review, we present the rationale for LAA occlusion in patients with AF, the available occlusion devices and their clinical evidence to date. We also discuss the roles of various imaging techniques in device implantation and the management strategy for associated procedural complications.

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Figure 1: Transcatheter mechanical left atrial appendage occlusion devices.
Figure 2: The role of TEE in determining suitability of mechanical LAA occlusion and in guiding device sizing.
Figure 3: Morphology of the LAA.
Figure 4: Intraprocedural and follow-up imaging assessment of LAA occlusion.
Figure 5: Complications of transcatheter mechanical LAA occlusion.

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Yu, CM., Khattab, A., Bertog, S. et al. Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation. Nat Rev Cardiol 10, 707–722 (2013). https://doi.org/10.1038/nrcardio.2013.158

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