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Mechanistic Rationale for LAA Closure with AF and Stroke Prevention

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Left Atrial Appendage Closure

Part of the book series: Contemporary Cardiology ((CONCARD))

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Abstract

Ischemic embolic stroke occurring secondary to atrial fibrillation is a devastating complication with significant morbidity and mortality. The functional impairment of the left atrium and left-atrial appendage in combination with specific anatomical characteristics results in altered hemodynamics and a prothrombotic environment. This scenario sets the stage for subsequent systemic and often cerebral emboli. In addition to the well-established approach of systemic anticoagulation, the restriction or separation of the LAA from the systemic cardiovascular space can provide a local solution with reduction of stroke, however, with limited systemic adverse events. This approach has particular attraction to the subgroup of patients at high risk of stroke as well as complications from systemic anticoagulation.

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References

  1. Beeri R. Left atrial appendages from adult hearts contain a reservoir of diverse cardiac progenitor cells. PLoS One. 2013;8:e59228.

    Article  PubMed Central  PubMed  Google Scholar 

  2. Sakellaridis T, Argiriou M, Charitos C, Tsakiridis K, Zarogoulidis P, Katsikogiannis N, Kougioumtzi I, Machairiotis N, Tsiouda T, Arikas S, Mpakas A, Beslevis T, Koletas A, Zarogoulidis K. Left atrial appendage exclusion—where do we stand? J Thorac Dis. 2014;6 Suppl 1:S70–7. doi:10.3978/j.issn.2072-1439.2013.10.24.

    PubMed Central  PubMed  Google Scholar 

  3. Cruz-Gonzalez I, Yan BP, Lam YY. Left atrial appendage exclusion: state-of the art. Catheter Cardiovasc Interv. 2010;75:806–13.

    Article  PubMed  Google Scholar 

  4. Singh IM, Holmes D. Left atrial appendage closure. Curr Cardiol Rep. 2010;12:413–21.

    Article  CAS  PubMed  Google Scholar 

  5. Leal S, Moreno R, de Sousa AM, et al. Evidence-based percutaneous closure of the left atrial appendage in patients with atrial fibrillation. Curr Cardiol Rev. 2012;8:37–42.

    Article  PubMed Central  PubMed  Google Scholar 

  6. Al-Saady NM, Obel OA, Camm AJ. Left atrial appendage: structure, function, and role in thromboembolism. Heart. 1999;82:547–54.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  7. Yamaji K, Fujimoto S, Yutani C, Hashimoto T, Nakamura S. Is the site of thrombus formation in the left atrial appendage associated with the risk of cerebral embolism? Cardiology. 2002;97(2):104–10.

    Article  PubMed  Google Scholar 

  8. Pollick C, Taylor D. Assessment of left atrial appendage function by transesophageal echocardiography: implications for the development of thrombus. Circulation. 1991;84:223–31.

    Article  CAS  PubMed  Google Scholar 

  9. Mikael Kortz RA, Delemarre BJ, van Dantzig JM, Bot H, Kamp O, Visser CA. Left atrial appendage blood flow determined by transesophageal echocardiography in healthy subjects. Am J Cardiol. 1993;71:976–81.

    Article  CAS  PubMed  Google Scholar 

  10. Tabata T, Oki T, Yamada H, Iuchi A, Ito S, Hori T, Kitagawa T, Kato I, Kitahata H, Oshita S. Role of left atrial appendage in left atrial reservoir function as evaluated by left atrial appendage clamping during cardiac surgery. Am J Cardiol. 1998;81:327–32.

    Article  CAS  PubMed  Google Scholar 

  11. Davis 3rd CA, Rembert JC, Greenfield Jr JC. Compliance of left atrium with and without left atrium appendage. Am J Physiol. 1990;259:H1006–8.

    PubMed  Google Scholar 

  12. Shirani J, Alaeddini J. Structural remodeling of the left atrial appendage in patients with chronic non-valvular atrial fibrillation: implications for thrombus formation, systemic embolism, and assessment by transesophageal echocardiography. Cardiovasc Pathol. 2000;9:95–101.

    Article  CAS  PubMed  Google Scholar 

  13. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61(2):755–9.

    Article  CAS  PubMed  Google Scholar 

  14. Kimura T, Takatsuki S, Inagawa K, Katsumata Y, Nishiyama T, Nishiyama N, Fukumoto K, Aizawa Y, Tanimoto Y, Tanimoto K, Jinzaki M, Fukuda K. Anatomical characteristics of the left atrial appendage in cardiogenic stroke with low CHADS2 scores. Heart Rhythm. 2013;10(6):921–5.

    Article  PubMed  Google Scholar 

  15. Nunes MCP, Handschumacher MD, Levine RA, Barbosa MM, Vinicius T, Carvalho VT, Esteves WA, Zeng X, Guerrero JL, Zheng H, Tan TC, Hung J. Role of LA shape in predicting embolic cerebrovascular events in mitral stenosis: mechanistic insights from 3D echocardiography. JACC Cardiovasc Imaging. 2014;7(5):453–61.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Acar J, Cormier B, Grimberg D, Kawthekar G, Iung B, Scheuer B, Farah E. Diagnosis of left atrial thrombi in mitral stenosis—usefulness of ultrasound techniques compared with other methods. Eur Heart J. 1991;12(Suppl B):70–6.

    Article  PubMed  Google Scholar 

  17. Aberg H. Atrial fibrillation. I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Med Scand. 1969;185:373–9.

    Article  CAS  PubMed  Google Scholar 

  18. Beppu S, Park YD, Sakakibara H, Nagata S, Nimura Y. Clinical features of intracardiac thrombosis based on echocardiographic observation. Jpn Circ J. 1984;48:75–82.

    Article  CAS  PubMed  Google Scholar 

  19. Tsai LM, Chen JH, Yang YJ. Role of transesophageal echocardiography in detecting left atrial thrombus and spontaneous echo contrast in patients with mitral valve disease and non-rheumatic atrial fibrillation. J Formos Med Assoc. 1990;89:270–4.

    CAS  PubMed  Google Scholar 

  20. Aschenberg W, Schlüter M, Kremer P, Schröder E, Siglow V, Bleifeld W. Transesophageal two-dimensional echocardiography for the detection of left atrial appendage thrombus. J Am Coll Cardiol. 1986;7:163–6.

    Article  CAS  PubMed  Google Scholar 

  21. Shrestha NK, Moreno FL, Narciso FV, Torres L, Calleja HB. Two-dimensional echocardiographic diagnosis of left-atrial thrombus in rheumatic heart disease. A clinicopathologic study. Circulation. 1983;67:341–7.

    Article  CAS  PubMed  Google Scholar 

  22. Lin SL, Hsu TL, Liou JY, Chen CH, Chang MS, Chiang HT, Chen CY. Usefulness of transesophageal echocardiography for the detection of left atrial thrombi in patients with rheumatic heart disease. Echocardiography. 1992;9:161–8.

    Article  CAS  PubMed  Google Scholar 

  23. Kronzon I, Tunick PA, Glassman E, Slater J, Schwinger M, Freedberg RS. Transesophageal echocardiography to detect atrial clots in candidates for percutaneous transseptal mitral balloon valvuloplasty. J Am Coll Cardiol. 1990;16:1320–2.

    Article  CAS  PubMed  Google Scholar 

  24. Manning WJ, Reis GJ. Douglas PS Use of transoesophageal echocardiography to detect left atrial thrombi before percutaneous balloon dilatation of the mitral valve: a prospective study. Br Heart J. 1992;67:170–3.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  25. Cormier B, Serafini D, Grimberg D, Scheuer B, Acar J. Detection of thrombosis of the left atrium in mitral valve stenosis. Particular value of transesophageal echography. Arch Mal Coeur Vaiss. 1991;84:1321–6.

    CAS  PubMed  Google Scholar 

  26. Jordan RA, Scheifley CH, Edwards JE. Mural thrombis and arterial embolism in mitral stenosis. Circulation. 1951;3:363–7.

    Article  CAS  PubMed  Google Scholar 

  27. Hwang JJ, Kuan P, Lin SC, Chen WJ, Lei MH, Ko YL, Cheng JJ, Lin JL, Chen JJ, Lien WP. Reappraisal by transesophageal echocardiography of the significance of left atrial thrombi in the prediction of systemic arterial embolization in rheumatic mitral valve disease. Am J Cardiol. 1992;70:769–73.

    Article  CAS  PubMed  Google Scholar 

  28. Sharma S, Kumar MV, Aggarwal S, Reddy VM, Kaul U, Rajani M, Venugopal P. Chest radiographs are unreliable in predicting thrombi in the left atrium or its appendage in rheumatic mitral stenosis. Clin Radiol. 1991;43:337–40.

    Article  CAS  PubMed  Google Scholar 

  29. Wallach JB, Lukash L, Angrist AA. An interpretation of the incidence of mural thrombi in the left auricle and appendage with particular reference to mitral commissurotomy. Am Heart J. 1953;45:252–4.

    Article  CAS  PubMed  Google Scholar 

  30. Stoddard MF, Dawkins PR, Prince CR, Ammash NM. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study. J Am Coll Cardiol. 1995;25:452–9.

    Article  CAS  PubMed  Google Scholar 

  31. Manning WJ, Silverman DI, Keighley CS, et al. Transesophageal echo (TEE) facilitated early cardioversion for patients with new atrial fibrillation: a 4-year experience. Circulation. 1994;90:1–21a.

    Article  Google Scholar 

  32. Brown J, Sadler DB. Left atrial thrombi in non-rheumatic atrial fibrillation: assessment of prevalence by transesophageal echocardiography. Int J Card Imaging. 1993;9:65–72.

    Article  CAS  PubMed  Google Scholar 

  33. Manning WJ, Waksmonski CA, Haering JM, et al. Sensitivity and specificity of transesophageal echo for left atrial thrombi: a prospective consecutive surgical study. Circulation. 1994;90:1202a.

    Article  Google Scholar 

  34. Klein AL, Grimm RA, Black IW et al. for the ACUTE Investigators. Assessment of cardioversion using transesophageal echocardiography compared to conventional therapy: The ACTE Randomized Pilot Study. Circulation. 1994;90 (Suppl 1):21a

    Google Scholar 

  35. Leung DY, Black IW, Cranney GB, Hopkins AP, Walsh WF. Prognostic implications of left atrial spontaneous echo contrast in nonvalvular atrial fibrillation. J Am Coll Cardiol. 1994;24:755–62.

    Article  CAS  PubMed  Google Scholar 

  36. Hart RG, Halperin JL. Atrial fibrillation and stroke. Revisiting the dilemmas. Stroke. 1994;25:1337–41.

    Article  CAS  PubMed  Google Scholar 

  37. Whitlock R, Healey J, Vincent J, Brady K, Teoh K, Royse A, Shah P, Guo Y, Alings M, Folkeringa RJ, Paparella D, Colli A, Meyer SR, Legare JF, Lamontagne F, Reents W, Böning A, Connolly S. Rationale and design of the left atrial appendage occlusion study (LAAOS) III. Ann Cardiothorac Surg. 2014;3:45–54.

    PubMed Central  PubMed  Google Scholar 

  38. Capodanno D, Capranzano P, Giacchi G, Calvi V, Tamburino C. Novel oral anticoagulants versus warfarin in non-valvular atrial fibrillation: a meta-analysis of 50,578 patients. Int J Cardiol. 2013;167:1237–41.

    Article  PubMed  Google Scholar 

  39. Apostolakis E, Papakonstantinou NA, Baikoussis NG, et al. Surgical strategies and devices for surgical exclusion of the left atrial appendage: a word of caution. J Card Surg. 2013;28:199–206.

    Article  PubMed  Google Scholar 

  40. Aryana A, Saad EB, d’avila A. Left atrial appendage occlusion and ligation devices: what is available, how to implement them, and how to manage and avoid complications. Curr Treat Options Cardiovasc Med. 2012;14:503–19.

    Article  PubMed  Google Scholar 

  41. Holmes DR, Reddy VY, Turi ZG, Doshi SK, Sievert H, Buchbinder M, Mullin CM, Sick P, Investigators PROTECTAF. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374:534–42.

    Article  CAS  PubMed  Google Scholar 

  42. Meerkin D, Butnaru A, Dratva D, Bertrand OF, Tzivoni D. Early safety of the amplatzer cardiac plug™ for left atrial appendage occlusion. Int J Cardiol. 2013;168:3920–5.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. Structural and Congenital Heart Disease Unit, Shaare Zedek Medical Center, 3235, Jerusalem, 91031, Israel

    David Meerkin M.B.B.S.

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  1. David Meerkin M.B.B.S.
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Correspondence to David Meerkin M.B.B.S. .

Editor information

Editors and Affiliations

  1. Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada

    Jacqueline Saw

  2. Cardiovascular Intervention Center Research, Cedars-Sinai Medical Center, Los Angeles, California, USA

    Saibal Kar

  3. Scripps Translational Science Institute, Division of Cardiovascular Diseases, Scripps Clinic, La Jolla, California, USA

    Matthew J. Price

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Meerkin, D. (2016). Mechanistic Rationale for LAA Closure with AF and Stroke Prevention. In: Saw, J., Kar, S., Price, M. (eds) Left Atrial Appendage Closure. Contemporary Cardiology. Humana Press, Cham. https://doi.org/10.1007/978-3-319-16280-5_3

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  • DOI: https://doi.org/10.1007/978-3-319-16280-5_3

  • Publisher Name: Humana Press, Cham

  • Print ISBN: 978-3-319-16279-9

  • Online ISBN: 978-3-319-16280-5

  • eBook Packages: MedicineMedicine (R0)

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