I’m pleased this has been brought to light. I was briefed on the device but frankly I didn’t want to undergo the procedure. A relative of mine had it and swears there is no leakage. He says that he can't tolerate a blood thinner. I think I will continue with Eliquis although I am not currently in afib since my last (four in all) cardio conversion in July 2023. I am 80.
Thanks. As to Vinay and COVID, it might be useful for you and I to have a substack discussion on some of the issues he is overly strident and mean-spirited about but upon which he makes good points.
I also utilize Up-To-Date but recognize that the subsection authors are subject to the same biases and limitations as the authors of review articles. My approach is to independently verify the recommendations by scanning the primary literature.
With respect to the indications it is heartening that they have only made it a 2B level recommendations and they recognize "thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA."
Up-to-date says LAA) might be considered in patients "who have a contraindication to long-term anticoagulation." Which patients have a contraindication is subject to interpretation. Those who are pushing LAAO have a very low bar for a contraindication. I've seen LAAO recommended and performed because "patient is young" or because of a GI bleed with correctible causes, or because the patient likes to ride his/her bike..
The indication for anticoagulation is also somewhat fuzzy. Does a CHADS2 woman with 10 seconds of afib on a Holter monitor from 10 years and no clinical AFIB since have an indication for anticoagulation? Does a 78 year old man, (CHADS3) with one episode of AFIB 5 years ago at a time when he was septic from a UTI have an indication? Those who are gungho on getting their LAAO experience and numbers up might say yes.
Anyway, thanks for the comments. Always appreciated. I 'm curious how often PCPs weigh in on this issue with their patients or whether they leave the recommendations up to their favorite cardiologist or EP doctor?
I have afib, though the instances are infrequent my cardiologist at Scripps Clinic in La Jolla says that, counterintuitively, the frequency of incidents isn’t correlated to risk of stroke. So I’ve been on Eliquis for a while. Recently had to stop it because bleeding hemorrhoids put me in the hospital with anemia. Got the bleeding stopped and am working assiduously on getting the hemorrhoids resolved. We’ll see if I can go back on the Eliquis again in a couple of months. The Watchman has been mentioned, but when I did the questionnaire at the Boston Scientific website it said I wasn’t a good candidate. Your summary of the problems and lack of solid RCT data is sobering, to say the least. Here’s hoping I can go back on an anticoagulant!
I agree this is a great post thank you! Leave Vinay out of the accolades though. Whatever good contributions he has made to the general conversation are far outweighed by the harmful, spiteful, and inflammatory writings he produces on long Covid, masking, updated covid vaccines, and continued prudence with Covid.
Getting back to this article, as a primary care doc I appreciate the counterpoints made here. I do consult UpToDate frequently (and pay handsomely for that access) so I’ll copy and paste the summary recommendations from their long chapter on LAAO. Do you agree with this for the most part?
SUMMARY AND RECOMMENDATIONS
●Rationale and limitations – Among patients with atrial fibrillation (AF), thrombus in the left atrial appendage (LAA) is the primary source for thromboemboli. This is the rationale for excluding the appendage in selected patients. (See 'Rationale and limitations' above.)
However, thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA.
●Indications
•Patients not undergoing cardiac surgery – For patients with AF with an indication for anticoagulation (based upon risk of stroke and other systemic thromboembolism (table 1)) but who have a contraindication to long-term anticoagulation, we suggest a percutaneous LAA occlusion (LAAO) procedure (Grade 2B). Among these devices, we prefer the WATCHMAN. (See 'Patients not undergoing cardiac surgery' above and 'WATCHMAN device' above.)
This approach does not apply to patients with an indication for anticoagulation other than AF (eg, an implanted mechanical valve). (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".)
•Patients with AF and a CHA2DS2-VASc score of at least 2 (table 1) who are undergoing cardiac surgery for another indication
For such patients, if there is no contraindication to long-term anticoagulation, we recommend concomitant surgical LAAO. (Grade 1B) (See 'Patients undergoing surgery' above.)
For such patients, if there is a contraindication to long-term anticoagulation, we suggest concomitant surgical LAAO (Grade 2C). (See 'Patients undergoing surgery' above.)
●Preprocedure planning – Specific LAA measurements can be useful for LAA closure planning; these can be obtained by transesophageal echocardiogram (TEE), cardiac computed tomography angiography, or cardiac magnetic resonance imaging. If cardiac imaging shows an LA/LAA thrombus, the LAAO procedure is contraindicated. (See 'Preprocedure planning' above.)
●Percutaneous devices – The WATCHMAN device is the most commonly implanted percutaneous LAAO device and has the most robust data to support its use (table 3). (See 'Percutaneous devices' above.)
●Surgical devices – Types of surgical closure include stapler occlusion, amputation and suture, and epicardial device closure (table 2). (See 'Surgical LAA closure' above.)
●Postprocedure management
•After percutaneous closure
We treat with short-term antithrombotic therapy (anticoagulant and antiplatelet therapy) after placement of the device. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy postprocedure.
We obtain a TEE between one and six months postprocedure. Device-related thrombus and/or peridevice leak ≥5 mm may be indications for continued anticoagulation. (See 'After percutaneous closure' above.)
•After surgical occlusion
Patients with a contraindication to long-term anticoagulation – These patients are treated with short-term anticoagulation (typically a DOAC) plus aspirin for six weeks to three months after the surgery, followed by TEE assessment of the completeness of occlusion. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy during the pre-TEE period of six weeks to three months.
If the TEE demonstrates that the LAA is completely occluded and long-term anticoagulation is contraindicated, only aspirin is continued indefinitely. If any leak is present postsurgical LAAO, oral anticoagulation should be continued. (See 'After surgical occlusion' above.)
Patients with no contraindication to anticoagulation – These patients are treated with anticoagulation indefinitely regardless of whether a rhythm control intervention is performed. (See 'Patients undergoing surgery' above.)
●Complications – These are rare but include pericardial effusion/tamponade, vascular injury, device erosion or embolization, stroke, death, and cardiac arrest.
AUTHORS:Ziyad M Hijazi, MD, MPH, FAAP, FACC, MSCAI, FAHA, FPICSJacqueline Saw, MD, FRCPC, FACCSECTION EDITOR:Bradley P Knight, MD, FACCDEPUTY EDITOR:Susan B Yeon, MD, JD
I’m pleased this has been brought to light. I was briefed on the device but frankly I didn’t want to undergo the procedure. A relative of mine had it and swears there is no leakage. He says that he can't tolerate a blood thinner. I think I will continue with Eliquis although I am not currently in afib since my last (four in all) cardio conversion in July 2023. I am 80.
Ryan,
Thanks. As to Vinay and COVID, it might be useful for you and I to have a substack discussion on some of the issues he is overly strident and mean-spirited about but upon which he makes good points.
I also utilize Up-To-Date but recognize that the subsection authors are subject to the same biases and limitations as the authors of review articles. My approach is to independently verify the recommendations by scanning the primary literature.
With respect to the indications it is heartening that they have only made it a 2B level recommendations and they recognize "thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA."
Up-to-date says LAA) might be considered in patients "who have a contraindication to long-term anticoagulation." Which patients have a contraindication is subject to interpretation. Those who are pushing LAAO have a very low bar for a contraindication. I've seen LAAO recommended and performed because "patient is young" or because of a GI bleed with correctible causes, or because the patient likes to ride his/her bike..
The indication for anticoagulation is also somewhat fuzzy. Does a CHADS2 woman with 10 seconds of afib on a Holter monitor from 10 years and no clinical AFIB since have an indication for anticoagulation? Does a 78 year old man, (CHADS3) with one episode of AFIB 5 years ago at a time when he was septic from a UTI have an indication? Those who are gungho on getting their LAAO experience and numbers up might say yes.
Anyway, thanks for the comments. Always appreciated. I 'm curious how often PCPs weigh in on this issue with their patients or whether they leave the recommendations up to their favorite cardiologist or EP doctor?
I have afib, though the instances are infrequent my cardiologist at Scripps Clinic in La Jolla says that, counterintuitively, the frequency of incidents isn’t correlated to risk of stroke. So I’ve been on Eliquis for a while. Recently had to stop it because bleeding hemorrhoids put me in the hospital with anemia. Got the bleeding stopped and am working assiduously on getting the hemorrhoids resolved. We’ll see if I can go back on the Eliquis again in a couple of months. The Watchman has been mentioned, but when I did the questionnaire at the Boston Scientific website it said I wasn’t a good candidate. Your summary of the problems and lack of solid RCT data is sobering, to say the least. Here’s hoping I can go back on an anticoagulant!
I agree this is a great post thank you! Leave Vinay out of the accolades though. Whatever good contributions he has made to the general conversation are far outweighed by the harmful, spiteful, and inflammatory writings he produces on long Covid, masking, updated covid vaccines, and continued prudence with Covid.
Getting back to this article, as a primary care doc I appreciate the counterpoints made here. I do consult UpToDate frequently (and pay handsomely for that access) so I’ll copy and paste the summary recommendations from their long chapter on LAAO. Do you agree with this for the most part?
SUMMARY AND RECOMMENDATIONS
●Rationale and limitations – Among patients with atrial fibrillation (AF), thrombus in the left atrial appendage (LAA) is the primary source for thromboemboli. This is the rationale for excluding the appendage in selected patients. (See 'Rationale and limitations' above.)
However, thrombogenesis in patients with AF may not be limited to the LA, and the procedure does not always result in complete occlusion of the LAA.
●Indications
•Patients not undergoing cardiac surgery – For patients with AF with an indication for anticoagulation (based upon risk of stroke and other systemic thromboembolism (table 1)) but who have a contraindication to long-term anticoagulation, we suggest a percutaneous LAA occlusion (LAAO) procedure (Grade 2B). Among these devices, we prefer the WATCHMAN. (See 'Patients not undergoing cardiac surgery' above and 'WATCHMAN device' above.)
This approach does not apply to patients with an indication for anticoagulation other than AF (eg, an implanted mechanical valve). (See "Atrial fibrillation in adults: Selection of candidates for anticoagulation".)
•Patients with AF and a CHA2DS2-VASc score of at least 2 (table 1) who are undergoing cardiac surgery for another indication
For such patients, if there is no contraindication to long-term anticoagulation, we recommend concomitant surgical LAAO. (Grade 1B) (See 'Patients undergoing surgery' above.)
For such patients, if there is a contraindication to long-term anticoagulation, we suggest concomitant surgical LAAO (Grade 2C). (See 'Patients undergoing surgery' above.)
●Preprocedure planning – Specific LAA measurements can be useful for LAA closure planning; these can be obtained by transesophageal echocardiogram (TEE), cardiac computed tomography angiography, or cardiac magnetic resonance imaging. If cardiac imaging shows an LA/LAA thrombus, the LAAO procedure is contraindicated. (See 'Preprocedure planning' above.)
●Percutaneous devices – The WATCHMAN device is the most commonly implanted percutaneous LAAO device and has the most robust data to support its use (table 3). (See 'Percutaneous devices' above.)
●Surgical devices – Types of surgical closure include stapler occlusion, amputation and suture, and epicardial device closure (table 2). (See 'Surgical LAA closure' above.)
●Postprocedure management
•After percutaneous closure
We treat with short-term antithrombotic therapy (anticoagulant and antiplatelet therapy) after placement of the device. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy postprocedure.
We obtain a TEE between one and six months postprocedure. Device-related thrombus and/or peridevice leak ≥5 mm may be indications for continued anticoagulation. (See 'After percutaneous closure' above.)
•After surgical occlusion
Patients with a contraindication to long-term anticoagulation – These patients are treated with short-term anticoagulation (typically a DOAC) plus aspirin for six weeks to three months after the surgery, followed by TEE assessment of the completeness of occlusion. Patients with an absolute contraindication to oral anticoagulants instead receive dual antiplatelet therapy during the pre-TEE period of six weeks to three months.
If the TEE demonstrates that the LAA is completely occluded and long-term anticoagulation is contraindicated, only aspirin is continued indefinitely. If any leak is present postsurgical LAAO, oral anticoagulation should be continued. (See 'After surgical occlusion' above.)
Patients with no contraindication to anticoagulation – These patients are treated with anticoagulation indefinitely regardless of whether a rhythm control intervention is performed. (See 'Patients undergoing surgery' above.)
●Complications – These are rare but include pericardial effusion/tamponade, vascular injury, device erosion or embolization, stroke, death, and cardiac arrest.
AUTHORS:Ziyad M Hijazi, MD, MPH, FAAP, FACC, MSCAI, FAHA, FPICSJacqueline Saw, MD, FRCPC, FACCSECTION EDITOR:Bradley P Knight, MD, FACCDEPUTY EDITOR:Susan B Yeon, MD, JD
https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion