Review
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Feb 26, 2019; 11(2): 57-70
Published online Feb 26, 2019. doi: 10.4330/wjc.v11.i2.57
Percutaneous devices for left atrial appendage occlusion: A contemporary review
Homam Moussa Pacha, Yasser Al-khadra, Mohamad Soud, Fahed Darmoch, Abdulghani Moussa Pacha, M Chadi Alraies
Homam Moussa Pacha, Mohamad Soud, MedStar Washington Hospital Center, Washington, DC 20010, United States
Yasser Al-khadra, Cleveland Clinic, Medicine Institute, Cleveland, OH 44195, United States
Fahed Darmoch, Beth Israel Deaconess Medical center/Harvard Medical School, Boston, MA 02215, United States
Abdulghani Moussa Pacha, University Hospital of Mainz, Mainz 55122, Germany
M Chadi Alraies, Wayne State University, Detroit Medical Center, Detroit Heart Hospital, Detroit, MI 48201, United States
Author contributions: All authors equally contributed to this paper with conception and design of the study, literature review and analysis, drafting and critical revision and editing, and final approval of the final version.
Conflict-of-interest statement: No potential conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: M Chadi Alraies, MD, Wayne State University, Detroit Medical Center, Detroit Heart Hospital, 311 Mack Ave, Detroit, MI 48201, United States. makraies@dmc.org
Telephone: +1-216-2550008 Fax: +1-313-7453500
Received: October 16, 2018
Peer-review started: October 16, 2018
First decision: October 26, 2018
Revised: December 12, 2018
Accepted: December 17, 2018
Article in press: December 17, 2018
Published online: February 26, 2019
Abstract

Patient with atrial fibrillation (AF) are at risk of developing stroke with the left atrial appendage (LAA) being the most common site for thrombus formation. If left untreated, AF is associated with 4 to 5 folds increase in the risk of ischemic stroke in all age groups. About 5% to 15% of AF patients have atrial thrombi on transesophageal echocardiography, and 91% of those thrombi are located in the LAA in patient with nonrheumatic AF. Although oral anticoagulants are the gold-standard treatment for stroke prevention in patients with non-valvular AF, some patients are at high risk of bleeding and deemed not candidates for anticoagulation. Therefore, LAA occlusion (LAAO) has emerged as alternative approach for stroke prevention in those patients. Surgical LAAO is associated with high rate of unsuccessful closure and recommended only in patients with AF and undergoing cardiac surgery. Percutaneous LAAO uses transvenous access with trans-septal puncture and was first tested using the PLAATO device. Watchman is the most common and only Food and Drug Administration (FDA) approved device for LAAO. LAAO using Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Amplatzer is another successful LAAO device that has CE mark and is waiting for FDA approval. Optimal antithrombotic therapy post LAAO is still under debate and highly patient-specific. The aim of this paper is to systematically review the current literature to evaluate the efficacy and safety of different LAAO devices.

Keywords: Left atrial appendage, Atrial fibrillation, Anticoagulation, Stroke, Mortality

Core tip: Left atrial appendage occlusion (LAAO) is a reasonable alternative approach that is used in patients with atrial fibrillation who are not candidates for anticoagulation. A number of key trials have shown that Watchman device is non-inferior to warfarin therapy in preventing ischemic stroke/systemic thromboembolism. However, it is associated with lower rates of hemorrhagic stroke, bleeding and death. Multiple retrospective and prospective studies of Amplatzer device (ACP and Amulet) reported high success rates in device implantation and stroke prevention. Our objective is to consolidate the current literature to better delineate the safety, efficacy and indication of LAAO for stroke prevention.