Original title: Percutaneous Left Atrial Appendage Suture Ligation Using the Lariat Device In Patines UIT Atrial Fibrillation Reference: Krystof Bartus, et al. J Am Coll Cardiol 2013;62:108–18.
Atrial fibrillation (AF) is the most frequent arrhythmia and is associated with a 5 fold increase in stroke risk and the resulting morbimortality. Warfarin anticoagulation therapy can be effective but only 50 to 60% of patients achieve an adequate therapeutic range. A number of new drugs have recently been proved effective to prevent cardioembolic complications, such as Dabigatran; however, the bleeding risk persists and this limitation adds to the lack of antidote.
This analysis evaluated percutaneous left atrial appendage suture with the SentreHEART device, Redwood City, Ca and the LARIAT suture. Basically, during procedure, a magnet-tipped wire is introduced into the right atrium via a femoral venous sheath and is placed inside the LAA via the transseptal approach. A balloon catheter is then advanced over the wire and placed inside the LAA. Next, a guidewire fitted with a strong magnet is introduced into the pericardial space and toward the LAA. When the transpericardial magnetic wire “marries” or connects with the transseptal magnetic wire at the LAA, the LARIAT, a snare-like pre-tied suture loop, is advanced over the LAA and closed. After confirmation of closure, the suture is released and tightened.
119 candidates were evaluated and 89 patients were finally included (16 were excluded for LAA anatomy, 11 for thrombi presence and 3 for adherences). All patients presented high risk of cardio embolic stroke (CHADS2 ≥1) with non valvular AF, a >12 life expectancy and were no good candidates for anticoagulation therapy. Those who had a pericarditis background, pectus excavatum, AMI at 3 months, stroke at 30 days, CF IV cardiac insufficiency, <30% ejection fraction and thoracic radiation, were excluded. Compete occlusion was defined as a
Occlusion was successful in 85 patients that were taken off anticoagulation therapy after procedure. Excluding LAA was not possible in four patients: in one due to pericardial adherences, two presented complications associated to the pericardial access site and another patient had transseptal access complications.
In most of patients there was only one attempt at the the transseptal access. Cardiac rhythm was modified post procedure, except in one patient. Two patients evolved with pericarditis. An echocardiography at 30 and 90 days documented a complete occlusion in 95% of patients. Only one patient saw a leak increase from 3mm leak.
At 6 months two deaths were reported, and another two at 12 months, none of which were procedure related. At one year, 98% of patients presented complete occlusion. Only one thrombus was seen in the echocardiography, which was solved with anticoagulation.
Conclusion:
Percutaneous LAA suture with LARIAT device can be performed effectively with low chances of periprocedural adverse events, which makes this device investigational, to be tested in future randomized studies.
Editorial Comment:
This technique provides a viable alternative to treat AF patients. Its complexity and potential complications may limit its use, since it requires an important learning curve.
Courtesy of Dr Carlos Fava,
Interentional Cardiologist,
Favaloro Foundation, Buenos Aires, Argentina.
Dr. Carlos Fava para SOLACI.ORG