Left Atrial Appendage Occlusion (LAAO)
What is the left atrial appendage?
The left atrial appendage (LAA) is a small, ear-shaped sac in the muscle wall of the left atrium (top left chamber of the heart). It is unclear what function, if any, the LAA performs.
Why is the LAA so important?
In normal hearts, the heart contracts with each heartbeat, and the blood in the left atrium and LAA is squeezed out of the left atrium into the left ventricle (bottom left chamber of the heart)
When a patient has atrial fibrillation (AF), the electrical impulses that control the heartbeat do not travel in an orderly fashion through the heart. Instead, many impulses begin at the same time and spread through the atria. The fast and chaotic impulses do not give the atria time to contract and/or effectively squeeze blood into the ventricles. Because the LAA is a little pouch, blood collects there and can form clots in the LAA and atria. Studies have shown that, among patients who do not have valve disease, the majority of blood clots that occur in the left atrium start in the LAA. When blood clots are pumped out of the heart, they can cause a stroke. People with atrial fibrillation are 5 to 7 times more likely to have a stroke than the general population.
How can I prevent stroke from atrial fibrillation?
Taking a blood thinner, such as warfarin (Coumadin), Eliquis, Xarelto, or Pradaxa reduces the risk of stroke in patients with atrial fibrillation. This is known as anti-coagulation therapy.
Why do patients dislike warfarin/coumadin/newer blood thinners?
Many patients have concerns about, or dislike taking warfarin. Some of the reasons for this are:
Frequent blood draws are needed to measure the patient’s international normal ratio (INR), or clotting time. The tests are needed to make sure the patient takes the right amount of medication.
While taking warfarin, you need to limit your intake of certain foods that contain vitamin K.
Some patients do not tolerate warfarin or have trouble maintaining a normal INR.
Increased bleeding risk, including older adults who are at a high risk for falls.
New medications are available for patients with atrial fibrillation who do not have heart valve disease. These medications are dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis). However, like warfarin, some patients have concerns and problems with these medications, such as:
Patients who cannot take anticoagulants cannot tolerate these medications.
Some patients are concerned about the cost of the medication.
Increased bleeding risk, including older adults who are at a high risk for falls.
What is left atrial appendage occlusion?
If you are at risk of developing clots in the left atrial appendage, your doctor may recommend a procedure to seal off your LAA. This can reduce your risk of stroke and eliminate the need to take blood-thinning medication.
There are several options and devices available for closure of the LAA. Your doctor will talk to you about the best options for your individual needs.
LAA Occlusion with Watchman Implantation
The Watchman procedure used to close the left atrial appendage is a self-expanding, parachute-shaped device with an attached woven plastic cap called the WATCHMAN device. This device is approved by the FDA to reduce the risk of thromboembolism from the LAA in patients with nonvalvular atrial fibrillation who are not good candidates for long-term anti-coagulation.
How does the Watchman implant work?
The Watchman implant acts as a barrier to prevent left atrial appendage blood clots from entering the bloodstream.
The WATCHMAN device is implanted percutaneously (through the skin) in the electrophysiology (EP) lab. The implant procedure does not require surgery; however, general anesthesia may be used during the procedure.
The physician inserts the delivery catheter into the body through a vein in the leg. The catheter is advanced through the bloodstream until it reaches the upper right chamber of the heart. The physician makes a small hole through the wall between the two upper chambers of the heart so that the catheter reaches the left atrium. The physician then pushes the device through the delivery catheter into the left atrial appendage, where it opens like an umbrella and is permanently implanted. Once the device is in place, a thin layer of tissue grows over it in about 45 days. This keeps blood clots in the left atrial appendage from entering the bloodstream.
LAA Occlusion with Amplatzer Amulet Implantation
The Amplatzer Amulet LAA occlusion procedure used to close the left atrial appendage is a self-expanding, double disk device. This device is approved by the FDA to reduce the risk of thromboembolism from the LAA in patients with nonvalvular atrial fibrillation who are not good candidates for long-term anti-coagulation.
How does the Amplatzer Amulet implant work?
The Amplatzer Amulet implant acts as a barrier to prevent left atrial appendage blood clots from entering the bloodstream.
The Amplatzer Amulet device is implanted percutaneously (through the skin) in the electrophysiology (EP) lab. The implant procedure does not require surgery; however, general anesthesia may be used during the procedure.
The physician inserts the delivery catheter into the body through a vein in the leg. The catheter is advanced through the bloodstream until it reaches the upper right chamber of the heart. The physician makes a small hole through the wall between the two upper chambers of the heart so that the catheter reaches the left atrium. The physician then pushes the device through the delivery catheter into the left atrial appendage, where it opens like an umbrella and is permanently implanted. This keeps blood clots in the left atrial appendage from entering the bloodstream.
How does the Left Atrial Appendage Occlusion implant (LAAO) compare to blood thinners?
As some patients should not take blood thinners because of their risk of bleeding, the LAAO implant may be an alternative for people who cannot take blood thinners over the long term. In studies of the LAAO implant in patients with atrial fibrillation, the safety and effectiveness of the implant has been compared to taking blood thinners and is an acceptable alternative in the right patient.
What does the Left Atrial Appendage Occlusion (LAAO) implant not do?
Stroke can be caused by factors other than blood clots, including high blood pressure and narrowing of the blood vessels to the brain. The LAAO implant will not prevent these other potential causes of stroke. Like blood thinners, the LAAO implant does not cure or reduce the frequency of atrial fibrillation episodes.
How do I know if the Left Atrial Appendage Occlusion (LAAO) implant is right for me?
The Left Atrial Appendage Occlusion (LAAO) devices have been approved by the FDA to reduce the risk of thromboembolism from the LAA in patients with nonvalvular atrial fibrillation who:
Are at increased risk of stroke and systemic embolism and for whom anticoagulation therapy is recommended
Have physician approval to take short term anticoagulation
Have an appropriate reason to want treatment with a non-medication alternative to warfarin or other blood thinners, taking into account the safety and effectiveness of the device compared to warfarin
Be sure to talk with your doctor so that you thoroughly understand all of the risks and benefits associated with blood thinners compared to implanting the LAAO device.
What can I expect after the Left Atrial Appendage Occlusion (LAAO) procedure in the hospital?
You will stay in the hospital for few hours/overnight after the procedure. Most patients are able to go home the same day or the next day.
You will need to Warfarin/Eliquis/Xarelto/Pradaxa for 45 days after the procedure in case of Watchman Implant. You can stop Warfarin/Eliquis/Xarelto/Pradaxa immediately after Amplatzer Amulet implant and start Aspirin 81 mg and Clopidogrel(Plavix) 75 mg daily.
You are able to walk within a few hours after the procedure.
No heavy weight lifting/swimming for 1 week after the procedure.
You can shower from second day after the procedure.
Call the doctor if you have swelling, heat, or redness in the area, as these can be signs of infection.
What is the follow-up after the Left Atrial Appendage Occlusion (LAAO) procedure?
You will have a transesophageal echo (TEE) at 45 days after the procedure.
If the TEE shows that the LAA is blocked with Watchman device, you will be able to stop taking Warfarin/Eliquis/Xarelto/Pradaxa and start taking Aspirin 81 mg and Clopidogrel (Plavix) for another 4.5 months. After that, you will stop taking Clopidogrel (Plavix), unless you need to take it for another reason. You will continue daily treatment with aspirin.
If the TEE shows that the LAA is blocked with Amulet device, you will continue to take Aspirin 81 mg and Clopidogrel (Plavix) for another 4.5 months. After that, you will stop taking Clopidogrel (Plavix), unless you need to take it for another reason. You will continue daily treatment with aspirin.
If the TEE shows that the LAA is not blocked, you will continue taking Warfarin/Eliquis/Xarelto/Pradaxa and have another TEE and follow-up appointment after 3 months.
Once the LAA is blocked, you will have a yearly follow-up appointment in the clinic.
What are the risks?
Although the device is a permanent solution, there is a small incidence of complications associated with the implantation procedure. Your doctor can go over the risks and benefits of this procedure with you in detail.
Left Atrial Appendage Occlusion (LAAO) Procedure Discharge Instructions
Follow Up
You will need a 1-2-week post-procedure follow-up appointment with us. Please call us at (602) 698-5820 to schedule this appointment if one was not made for you at the time of your discharge from the hospital.
What To Expect At Home:
Bruising of the trunk, groin and leg around the puncture site is normal and should resolve in a few days.
You will be sent home with a bandage over the area which can typically be removed the day after the procedure.
Shower as usual after the bandages are removed. You may gently wash the area with soap and water but do not scrub the puncture site.
If you discontinued any medications pre-procedure, resume taking them unless told otherwise by your physician upon discharge from the hospital
Do not lift over 10 lbs. for 5 days post-procedure.
You may resume physical activity after 1-2 days but avoid any strenuous activity such as exercise for 1 week post-procedure.
Do not take a tub bath, Jacuzzi or swim for 7 days.
Discuss with your physician prior to discharge about when it is appropriate for you to return to work.
Call If You Experience:
Significant redness, heat, swelling, drainage or severe pain at your puncture site. If any bleeding occurs, hold direct pressure at the site with gauze or a band-aid. If the bleeding continues past 10 minutes, call your physician and seek immediate medical attention.
Fever of 100 degrees or higher. A high temperature can be early signs of infection.