Transcatheter Left Atrial Appendage Closure (LAAC)

Publication Date: March 27, 2023
Last Updated: March 31, 2023

Summary of Recommendations

1

Transcatheter left atrial appendage closure (LAAC) is appropriate for patients with nonvalvular atrial fibrillation with high thromboembolic risk who are not suited for long-term oral anticoagulation and who have adequate life expectancy (minimum >1 year) and quality of life to benefit from LAAC. There should be patient-provider discussion for shared decision making.
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2.1

Physicians performing LAAC should have a prior experience, including ≥50 prior left-sided ablations or structural procedures and ≥25 transseptal punctures (TSPs). Interventional imaging physicians should have experience in guiding ≥25 TSPs before supporting any LAAC procedures independently.
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2.2

For maintenance of skills, implanting physicians should perform ≥25 TSPs and >12 LAACs over each 2-year period.
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2.3

New programs and implanting physicians early in their LAAC experience should have on-site cardiovascular surgery backup.
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3

Baseline imaging with transesophageal echocardiography (TEE) or cardiac computed tomography is recommended before LAAC.
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4

Intraprocedural imaging guidance with TEE or intracardiac echocardiography is recommended.
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5

Technical aspects of the procedure, including venous access, anticoagulation, transseptal puncture, delivery sheath selection and placement, left atrial pressure measurement, and device deployment, should be performed in accordance with the labeling of each specific LAAC device.
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6

Operators need to be familiar with avoidance, recognition, and management of procedural complications associated with LAAC.
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7

Predischarge imaging should be performed with 2-dimensional transthoracic echocardiography to rule out pericardial effusion and device embolization. Same-day discharge may be appropriate after several hours of observation demonstrating no complications or pericardial effusion after LAAC.
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8

Device-related thrombus should be treated with anticoagulation. Repeat imaging at 45- to 90-day intervals can be performed to assess for resolution with eventual cessation of anticoagulation.
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9

Routine closure of iatrogenic atrial septal defects associated with LAAC should not be performed.
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10

The clinical impact and management of peridevice leaks are not fully understood, and all efforts should be made to minimize such leaks at the time of implantation.
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11

Patients should be prescribed antithrombotic therapy with warfarin, direct oral anticoagulants, or dual antiplatelet therapy after LAAC according to the studied regimen and instructions for use for each specific device and tailored to the bleeding risks of each patient.
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12

TEE or cardiac computed tomography is recommended at 45 to 90 days after LAAC for device surveillance to assess for peridevice leak and device-related thrombus.
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13

Combined procedures with LAAC (eg, structural interventions, pulmonary vein isolation) are not routinely recommended, as data are pending from ongoing randomized controlled trials.
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Procedural and Late Postprocedural Complications of Left Atrial Appendage Occlusion

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Periprocedural Complications Postprocedural Complications
Death (<0.2%) Late pericardial effusion & tamponade (∼1%)
Stroke (<0.2%): Peridevice leak:
Stroke (<0.2%): Peridevice leak:
Ischemic: air or thromboembolism >5 mm on TEE: 1%-3%
Hemorrhagic >3 mm on TEE: 10%-25%
Systemic embolism (rare) Device-related thrombus (3%-5%)
Pericardial tamponade (∼1%) Late device migration/embolization (infrequent)
Device embolization (∼0.2%) Device erosion (rare)
Vascular complications: retroperitoneal bleed, arteriovenous fistula, pseudoaneurysm Iatrogenic atrial septal defects (rare to require intervention)
Other: major bleeding, renal failure, respiratory failure, sepsis, MI, endotracheal/esophageal damage, interfering surrounding structures, device/contrast allergy, pericarditis

Imaging Surveillance Modality and Optimal Imaging at Different Postdevice Implantation Time Points

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Imaging Timing Immediate Postdevice Implant Prehospital Discharge 45-d Follow-Up 1-y Follow-Up (optional)
Transthoracic echocardiogram − +++ − −
Transesophageal echocardiogram +++ − ++ ++
CCTA − − +++ +++
Complication surveillance Pericardial effusion Device embolization Peridevice leak Device-related thrombus
Transthoracic echocardiogram +++ + − −
Transesophageal echocardiogram +++ +++ ++ +++
CCTA +++ +++ +++ +++
+++, strongly recommended; ++, less strongly recommended; +, recommended; −, not required.

Recommendation Grading

Abbreviations

  • AF: Atrial Fibrillation
  • LAA: Left Atrial Appendage
  • LAAC: Left Atrial Appendage Closure
  • TEE: Transesophageal Echocardiography

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Transcatheter Left Atrial Appendage Closure

Authoring Organizations

Publication Month/Year

March 27, 2023

Last Updated Month/Year

February 14, 2024

Supplemental Implementation Tools

Document Type

Consensus

Country of Publication

US

Document Objectives

Exclusion of the left atrial appendage to reduce thromboembolic risk related to atrial fibrillation was first performed surgically in 1949. Over the past 2 decades, the field of transcatheter endovascular left atrial appendage closure (LAAC) has rapidly expanded, with a myriad of devices approved or in clinical development. The number of LAAC procedures performed in the United States and worldwide has increased exponentially since the Food and Drug Administration approval of the WATCHMAN (Boston Scientific) device in 2015. The Society for Cardiovascular Angiography & Interventions (SCAI) has previously published statements in 2015 and 2016 providing societal overview of the technology and institutional and operator requirements for LAAC. Since then, results from several important clinical trials and registries have been published, technical expertise and clinical practice have matured over time, and the device and imaging technologies have evolved. Therefore, SCAI prioritized the development of an updated consensus statement to provide recommendations on contemporary, evidence-based best practices for transcatheter LAAC focusing on endovascular devices.

Target Provider Population

Cardiologists, including interventional cardiologists and electrophysiologists

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D020517 - Atrial Appendage, D016279 - Atrial Function, Left

Keywords

LAA, WATCHMAN, Device-related thrombus, LAAC, left atrial appendage, left atrial appendage closure, transcatheter left atrial appendage, Peridevice leak, Non-valvular atrial fibrillation, CHA(2)DS(2)-VASc, nonvalvular AF

Source Citation

Saw J, Holmes DR, Cavalcante JL, Freeman JV, Goldsweig AM, Kavinsky CJ, Moussa ID, Munger TM, Price MJ, Reisman M, Sherwood MW, Turi ZG, Wang DD, Whisenant BK. SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure. Heart Rhythm. 2023 Mar 20:S1547-5271(23)00011-5. doi: 10.1016/j.hrthm.2023.01.007. Epub ahead of print. PMID: 36990925.

Supplemental Methodology Resources

Data Supplement