Heart Team for Left Appendage Occlusion without the Use of Antithrombotic Therapy: The Epicardial Perspective

Abstract

Background: Left atrial appendage occlusion is an increasingly proposed treatment for patients with atrial fibrillation and poor tolerance to anticoagulants. All endovascular devices require antithrombotic therapy. Anatomical and clinical variables predisposing to device-related thrombosis, as well as post-procedural peri-device leaks, could mandate the continuation or reintroduction of aggressive antithrombotic treatment. Because of the absence of foreign material inside the heart, epicardial appendage closure possibly does not necessitate antithrombotic therapy, but data of large series are missing. Methods: Multidisciplinary team evaluation for standalone totally thoracoscopic epicardial appendage closure was done in 180 consecutive patients with atrial fibrillation and poor tolerance to antithrombotic therapy. One hundred and fifty-two patients consented (male 66.1%, mean age 76.1 ± 7.4, CHA2DS2VASc mean 5.3 ± 1.6, HASBLED mean 3.8 ± 1.1). Indications were cerebral hemorrhage (48%), gastro-intestinal bleeding (33.3%), and other bleeding (20.7%). No antithrombotic therapy was prescribed from the day of surgery to the latest follow up. Results: Procedural success was 98.7%. At a mean follow up of 38.2 ± 18.8 months, cardioembolic and bleeding events were 1.3% and 0.6%, respectively. Among patients with a history of blood transfusions (41.1%), none needed further transfusions or treatment post procedure. Conclusion: Epicardial appendage occlusion without any antithrombotic therapy appears to be safe and effective. This strategy could be advised when minimization of bleeding risk concomitant to stroke prevention is needed.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

“…Several studies have established the safety and long-term efficacy of stand-alone minimally invasive or thoracoscopic LAA occlusion with the AtriClip (AtriCure, Inc.) device in patients who either cannot be anticoagulated or who are not candidates for a transcatheter approach. 1329–1334 , 1450 , 1451 The role of concomitant surgical LAA occlusion, in addition to OAC use, is best supported by a large RCT on LAA occlusion (LAAOS III). 1335 Over 4800 patients with AF undergoing cardiac surgery were randomized to LAA occlusion (amputation, stapling, or suturing) or no treatment and were followed for a mean period of 3.8 years, with 76.8% of the participants continuing their OAC treatment.…”

Left atrial appendage therapies: a new topic for the Heart Team

“…If rate control strategy is chosen managing anticoagulation is even more a critical issue. In these patients, LAA occlusion is a valid option, achievable endo- or epi-cardially both with non-overlapping anatomical and technical restrictions but similar excellent outcomes ( 1 , 8 , 9 ). If adhesions and severe diastolic dysfunction are drawback for epicardial devices, the Achille’s heel of all endovascular devices are: device thrombosis, peridevice leaks and mandatory antithrombotic therapy.…”

“…If adhesions and severe diastolic dysfunction are drawback for epicardial devices, the Achille’s heel of all endovascular devices are: device thrombosis, peridevice leaks and mandatory antithrombotic therapy. Endocardial approach plays the role of the lion but requires post procedure antiplatelet therapy ( 1 ), and in case of device thrombosis/leak more aggressive pharmacological therapy: the clinical dilemma is represented as bleeding remains an issue with any antiplatelet regime ( 1 , 8 ).…”

“…Standalone totally thoracoscopic epicardial, lacks randomized controlled trials (RCTs) but is supported by continuously upcoming papers of larger series ( 8 ). Since no foreign material is implanted inside the heart, potentially no antithrombotic therapy is required filling the gap left by off label endovascular implantation without/reduced/shortened period of antiplatelets agents in frail patients, such as those with gastrointestinal (GI) bleeding disorders not amenable of definitive treatment always associated with chronic bleeding on aspirin, cerebral amyloid angiopathy, some intracranial hemorrhages, hematologic diseases with thrombocytopenia and clotting disorders.…”

“…In high volume LAA management centers it is common to equate the physician-patient goal of anticoagulant discontinuation with the “least invasive” but this approach may not necessarily be the optimal strategy especially in the long term. Given the ideal device and technique for LAA occlusion is not available, a joint discussion might have the great merit of transcending the limitation of an established care offering the most up to date treatment options allowing proper patient recruitment ( 1 , 8 , 9 ). There seems not to be evidence to support off label/suboptimal transcatheter implantation if an epicardial approach is available or a multicenter networking is set up in the patient interest.…”