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Physician training, experience and imaging guidance: Key components for successful LAA closure procedures

At the session “All you need to know about left atrial appendage (LAA) closure”, on 18 May, participants learned that physician training, experience and imaging guidance are fundamental for achieving successful LAA closure procedures for stroke prevention in patients with non-valvular atrial fibrillation. The need to update current guidelines on LAA was also highlighted at the session.

Speaking on the take-home messages from the session, co-chair Ralf Birkemeyer said: “Endocardial device obstruction of the LAA orifice is feasible and safe if performed after appropriate training in an appropriate setting with appropriate imaging.”

Co-chair Eric Eeckhout shared R. Birkemeyer views on the importance of training, he commented: “We have learned that LAA is not an easy technique and that it should be done by experts who perform the procedure on a frequent basis. I would say that perhaps it is more complex than TAVI, for example, which means that it needs dedicated people who are really well-trained to reduce the complication rate.”

“Every patient is unique so you can never feel you are in a comfort zone, and I think that if you do not have a good number of cases it is not responsible to be doing this procedure,” session panellist Farrel Hellig noted.

Sergio Berti, who presented on imaging guidance for LAA closure, commented that because of the anatomical complexity of the left atrial appendage “imaging plays a pivotal role”.  At the moment, “there is no gold standard for imaging of the LAA so we have to use a multi-imaging approach pre- and post-procedure, including CT scan, angiography, 2D/3D ICE and 2D/3D TEE,” he said. For successful LAA procedures, “we need precise measurement of the left ostium and imaging helps us to achieve that.”  

A call to update the current guidelines on LAA was highlighted at the session. Olivier Muller, who presented about unresolved issues on LAA closure, said: “Nowadays, we have enough data on LAA closure to be able to change the current indications.” Amongst other studies, he referred to data from the five-year follow-up of the PROTECT AF trial which showed that closure of the LAA with the Watchman device (Boston Scientific) is non-inferior to warfarin therapy in stroke prevention, systemic embolism and cardiovascular death of atrial fibrillation patients.

In terms of safety of the procedure, Horst Sievert, also presenter at the session, said that the results are “getting better and better” referring to the recently published data on the EWOLUTION registry which showed a 2.8% procedure-related serious adverse event rate at seven days post implant with Watchman.    

Regarding the guidelines, E. Eeckhout commented: “The current guidelines basically tell us that we should talk twice to the patient and explain them the alternative (LAA closure) to warfarin. It is a IIbB indication, which place it in a grey zone. A consensus document on LAA occlusion, recently published by Apsotolos Tzikas et al in EuroIntervention, perhaps will help us to move in a different direction.” 

Physician training, experience and imaging guidance: Key components for successful LAA closure procedures