Left Atrial Appendage and Closure
- 1 May 2016
- journal article
- research article
- Published by Ovid Technologies (Wolters Kluwer Health) in Circulation: Cardiovascular Interventions
- Vol. 9 (5), e002942
- https://doi.org/10.1161/circinterventions.115.002942
Abstract
Patients with nonvalvular atrial fibrillation have a 4- to 5-fold increase in strokes and that rhythm may be responsible for 15% to 20% of all strokes, particularly in the elderly. In this setting, thrombus in the left atrial appendage has been found to be the source of stroke in 90% of cases. Although oral anticoagulants have been found effective in reducing stroke rates, for a variety of issues, they may only be used in 40% to 50% of patients at increased risk for stroke. Given pathophysiology of stroke, site-specific therapy directed at left atrial appendage occlusion has been now studied for stroke prevention, and one device is FDA approved (Watchman). A meta-analysis of 2 randomized clinical trials and 2 registries with this device documented the following: (1) patients receiving the device had significantly fewer hemorrhagic strokes (hazard ratio 0.22, P =0.004); (2) a significant reduction in cardiovascular or unexplained death (hazard ratio 0.48, P =0.004); (3) more ischemic strokes in the device group; however, when periprocedural events were excluded, the difference was not significant; and (4) a significant reduction in nonprocedural bleeding with the device (hazard ratio 0.51, P =0.006) versus control. At present, the only device approved in the United States is indicated in patients with nonvalvular atrial fibrillation with acceptable anatomy who are at increased risk for stroke and would be candidates for anticoagulation in whom there is concern about the risk/benefit ratio for chronic anticoagulation. Unresolved issues include optimal patient selection criteria, the role of devices in patients in whom anticoagulation is contraindicated, and the relative role of novel oral anticoagulants versus the device which has not been tested in randomized trials.Keywords
This publication has 50 references indexed in Scilit:
- Association of atrial fibrillation with mortality and disability after ischemic strokeNeurology, 2013
- Predictors of Early and Late Case-Fatality in a Nationwide Danish Study of 26 818 Patients With First-Ever Ischemic StrokeStroke, 2011
- Atrial Fibrillation and Stroke Management: Present and FutureSeminars in Neurology, 2010
- Left atrial appendage closure with amplatzer cardiac plug in atrial fibrillation: Initial european experienceCatheterization and Cardiovascular Interventions, 2010
- Stroke in paroxysmal atrial fibrillation: report from the Stockholm Cohort of Atrial FibrillationEuropean Heart Journal, 2009
- Polypharmacy and the Geriatric PatientClinics in Geriatric Medicine, 2007
- Lifetime Risk for Development of Atrial FibrillationCirculation, 2004
- Short- and long-term prognosis for very old stroke patients. The Copenhagen Stroke StudyAge and Ageing, 2004
- Age and National Institutes of Health Stroke Scale Score Within 6 Hours After Onset Are Accurate Predictors of Outcome After Cerebral IschemiaStroke, 2004
- Atrial fibrillation as an independent risk factor for stroke: the Framingham Study.Stroke, 1991