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Published on: August 16, 2021
Epicardial Ligation of the Left Atrial Appendage in Octogenarians: Safety and Long-Term Efficacy
Karin Nentwich1,2, Nuki Kazaishvilli1, Elena Sauer1
1Department of Invasive Electrophysiology, Campus Bad Neustadt, Von Guttenbergstrasse 11, 97616 Bad Neustadt a. d. Saale, Germany.
Insights
Epicardial ligation of the left atrial appendage (LAA) using the LARIAT device is a safe and effective stroke prevention method for octogenarians. Early transesophageal echocardiography follow-up is crucial for managing thrombi and optimizing anticoagulation.
Area of Science:
- Cardiology
- Interventional Cardiology
- Geriatric Medicine
Background:
- The aging population presents a growing number of elderly patients with atrial fibrillation who have contraindications for anticoagulation due to bleeding risks.
- Epicardial ligation of the left atrial appendage (LAA) offers an alternative to anticoagulation for stroke prevention.
Purpose of the Study:
- To evaluate the safety and long-term efficacy of LARIAT device-based epicardial LAA ligation in octogenarians.
- To assess the incidence of thromboembolic events and procedural complications in this high-risk population.
Main Methods:
- A single-center analysis of 45 octogenarian patients (age > 80 years) who underwent LARIAT LAA ligation.
- Follow-up included transesophageal echocardiography (TOE) at 6 weeks, 12 weeks, and 12 months, along with clinical event monitoring for stroke and death.
Main Results:
- The procedure was successful in 93% of patients, with a mean CHA 2DS2VASC score of 4.6 and HASBLED score of 3.7.
- Early TOE revealed leaks and thrombi in some patients, with most resolving over time. Long-term follow-up (mean 38 months) showed no new gaps or thrombi, with a stroke rate of 1%/year.
- One major complication (LAA laceration) occurred. Eleven patients died during the follow-up period.
Conclusions:
- Epicardial LAA ligation with the LARIAT device is a safe and effective strategy for stroke prevention in octogenarians.
- Early and regular TOE follow-up is essential for detecting and managing potential thrombi post-procedure.
- The LARIAT procedure demonstrates durable LAA closure with a low long-term risk of thromboembolic events in this elderly cohort.
Abstract:
Introduction: Due to the aging population, the number of elderly patients with atrial fibrillation and contraindications for anticoagulation due to bleeding complications is growing. After the epicardial ligation of the left atrial appendage (LAA), anticoagulation can be omitted. We present the single-center procedure data and long-term data of octogenarians being treated with LARIAT®. Method: Out of 145 patients eligible for the epicardial ligation of the LAA, 45 were older than 80 y and included in this analysis. After successful ligation, patients were screened at 6 weeks of follow-up (FUP), at 12 weeks and after 12 months for transesophageal echocardiography (TOE) and clinical events. During long-term FUP, TOE sessions and clinical events for embolic events and death were documented. Results: The procedure was successful in 93% of patients, with a mean CHA2DS2VASC score of 4.6 and HASBLED score of 3.7 and a mean age of 82 y. One major complication occurred, with the laceration of the LAA and surgical closure of the LAA with an Atriclip. The 6-week FUP data were available in 39 patients, with the detection of four leaks (1-3 mm, median 2 mm) and three thrombi; one thrombus occurred at the site of a leak. The 12-week FUP (in 26 patients) showed that three leaks were closed, one leak persisted and one new thrombus developed at the site of the leak. All thrombi were resolved. The 12-month FUP showed the persistent resolution of three thrombi; one thrombus recurred after the withdrawal of the anticoagulant, and no new gap or thrombus could be detected. The long-term FUP (mean 38 months) was documented in 30 patients, with no new gaps and no new thrombi; one patient suffered from a stroke, with a good long-term result of LAA closure in TOE (stroke rate 1%/y, absolute risk reduction of 4.4% to a stroke rate of 5.4% related to the score, relative CHA2DS2VASC risk reduction of 88%). Eleven patients died: four in the first year of ligation and seven during long-term FUP. Conclusions: The epicardial ligation of the LAA for stroke prevention in octogenarians is highly safe and effective. Early TOE FUP is crucial for the detection of thrombi and establishing an optimal anticoagulation regime. No late development of thrombi or gaps can be observed at up to 5 years.
