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Left atrial appendage closure for stroke prevention in atrial fibrillation: state of the art and current challenges

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 428–435 (2007)Cite this article

Abstract

Atrial fibrillation (AF) is a major risk factor for disabling ischemic strokes. Anticoagulation is highly effective for stroke prevention in patients with AF, but a substantial number of patients are unable to sustain chronic therapy with warfarin. Most strokes in patients with AF are thought to arise from thrombus formation in the left atrial appendage (LAA); therefore, occlusion of the orifice of the LAA provides a theoretically appealing option for stroke prevention. Surgical exclusion of the LAA is increasingly performed in patients undergoing open-heart surgery, and thoracoscopic epicardial occlusion of the LAA has yielded promising early results. Percutaneous LAA occlusion devices have shown some success initial trials, but additional safety and efficacy data are required before this approach can be routinely considered. Here we discuss the LAA in relation to AF-related embolic stroke, and how LAA occlusion devices could be used in stroke prevention in patients who cannot tolerate chronic anticoagulant therapy.

Key Points

  • Atrial fibrillation is an important risk factor for ischemic stroke

  • Oral anticoagulation is highly effective in preventing atrial-fibrillation-related stroke, but is underused and often cannot be administered because of the inherent limitations of available agents and the associated risk of bleeding

  • Patients with contraindications to warfarin therapy are often at particularly high risk of stroke because of advanced age and associated comorbidities

  • Closure of the left atrial appendage using investigational percutaneous devices and surgical techniques shows promise, but more data are required to confirm the safety and efficacy of these procedures and to clarify the appropriate indications for their use

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Figure 1: Adjusted stroke rate stratified by CHADS2 score in patients with nonvalvular atrial fibrillation not taking warfarin13
Figure 2: Three-dimensional volume-rendered CT image of the heart showing anatomical correlation of the left atrial appendage
Figure 3: The PLAATO® device (ev3 Endovascular, Inc., North Plymouth, MN)
Figure 4: The WATCHMAN® device (Atritech, Inc., North Plymouth, MN)
Figure 5: The AMPLATZER® device (AGA Medical Corporation, Golden Valley, MN)

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Authors and Affiliations

  1. TM Syed is a third-year Fellow in Cardiology and JL Halperin is the Robert and Harriet Heilbrunn Professor of Medicine, at the Zena and Michael A Wiener Cardiovascular Institute and Center for Cardiovascular Health, Mount Sinai School of Medicine, New York, NY, USA.,

    Tariqshah M Syed & Jonathan L Halperin

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Correspondence to Jonathan L Halperin.

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Competing interests

TM Syed declared he has no competing interests. JL Halperin has received consultancy fees from the following companies: Astellas Pharma, AtriCure, Bayer Healthcare, Boehringer Ingelheim, Daiichi Sanyo Pharma, GlaxoSmithKline, Johnson & Johnson and sanofi-aventis.

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Syed, T., Halperin, J. Left atrial appendage closure for stroke prevention in atrial fibrillation: state of the art and current challenges. Nat Rev Cardiol 4, 428–435 (2007). https://doi.org/10.1038/ncpcardio0933

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