Percutaneous management of late leak after lariat transcatheter ligation of the left atrial appendage in patients with atrial fibrillation at high risk for stroke

Mosley, William J.; Smith, Michael; Price, Matthew J.

doi:10.1002/ccd.25251

Cited by 32 publications

(11 citation statements)

References 10 publications

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“…Incomplete surgical LAA ligation has been associated with subsequent thrombus formation and clinical events (21). The clinical consequences of residual leaks after the Lariat procedure, if any, are unknown, but leaks can be treated successfully with percutaneous approaches (22,23), although the safety and efficacy of such leak closure are unproven.…”

Section: Discussionmentioning

confidence: 99%

Early Safety and Efficacy of Percutaneous Left Atrial Appendage Suture Ligation

Price

Gibson

Yakubov

et al. 2014

Journal of the American College of Cardiology

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BACKGROUND Transcatheter left atrial appendage (LAA) ligation may represent an alternative to oral anticoagulation for stroke prevention in atrial fibrillation.. OBJECTIVES This study sought to assess the early safety and efficacy of transcatheter ligation of the LAA for stroke prevention in atrial fibrillation.. METHODS This was a retrospective, multicenter study of consecutive patients undergoing LAA ligation with the Lariat device at 8 U.S. sites. The primary endpoint was procedural success, defined as device success (suture deployment and <5 mm leak by post-procedure transesophageal echocardiography), and no major complication at discharge (death, myocardial infarction, stroke, Bleeding Academic Research Consortium bleeding type 3 or greater, or cardiac surgery). Post-discharge management was per operator discretion. RESULTS A total of 154 patients were enrolled. Median CHADS2 score (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke, transient ischemic attack, or thromboembolism [doubled]) was 3 (interquartile range: 2 to 4). Device success was 94%, and procedural success was 86%. A major complication occurred in 15 patients (9.7%). There were 14 major bleeds (9.1%), driven by the need for transfusion (4.5%). Significant pericardial effusion occurred in 16 patients (10.4%). Follow-up was available in 134 patients at a median of 112 days (interquartile range: 50 to 270 days): Death, myocardial infarction, or stroke occurred in 4 patients (2.9%). Among 63 patients with acute closure and transesophageal echocardiography follow-up, there were 3 thrombi (4.8%) and 13 (20%) with residual leak. CONCLUSIONS In this initial multicenter experience of LAA ligation with the Lariat device, the rate of acute closure was high, but procedural success was limited by bleeding. A prospective randomized trial is required to adequately define clinical efficacy, optimal post-procedure medical therapy, and the effect of operator experience on procedural safety.

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Section: Discussionmentioning

confidence: 99%

Early Safety and Efficacy of Percutaneous Left Atrial Appendage Suture Ligation

Price

Gibson

Yakubov

et al. 2014

Journal of the American College of Cardiology

Self Cite

194

107

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“…Additionally, recurrent LA-LAA communication after initial successful LARIAT LAAO can result from knot-loosening and tissue necrosis at the suture site and is another mechanism of thrombo-embolic complication. In case reports, late leaks have been treated successfully with alternate LAAO devices as repeat LARIAT ligation is not typically pursued due to potential pericardial adhesions developed after the initial procedure (Yeow et al 2013 ; Mosley et al 2014 ; Di Biase et al 2013 ; Pillai et al 2014 ). The implications of residual leak are unknown, however in a review of 259 patients who underwent LARIAT ligation, 14 % were noted to have recurrent LA-LAA communication at 1 year, compared with 21 % in patients undergoing WATCHMAN endocardial occlusion.…”

Section: Discussionmentioning

confidence: 99%

A review of the LARIAT device: insights from the cumulative clinical experience

et al. 2015

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Atrial fibrillation (AF) is the most common arrhythmic disorder world-wide, accounting for 15 % of all strokes. Management of stroke risk in AF is complicated by intolerance of anti-coagulation (AC) therapy and difficulty maintaining therapeutic range in patients treated with warfarin. The left atrial appendage (LAA) is a source of thrombus in AFrelated thrombo-embolic events and surgical LAA exclusion (LAAO) is commonly performed during cardiac surgery in AF patients. Surgical approaches are limited by a high incidence of incomplete closure with a potential for consequent thrombo-embolic events as well as the morbidity of an open-heart procedure. More recently, percutaneous approaches to LAAO have been developed. The LARIAT device is an epicardial LAA exclusion system that enables percutaneous suture ligation of the LAA via combined, pericardial and trans-septal access. The device has 510k Federal Drug Administration (FDA) clearance for soft-tissue ligation and has been studied in canine models in pre-clinical studies as well as published series of clinical experience with LARIAT LAAO. The history, patient selection, procedural technique and complications of LARIAT LAAO are reviewed here. Additionally, insights and procedural improvements that have been elucidated from clinical series and outcomes from the collective experience are discussed. The LARIAT’s epicardial approach to LAA ligation is unique compared with other percutaneous LAA exclusion devices, however more data regarding device safety and efficacy is needed for the LARIAT to emerge as an established therapy for stroke prevention in AF.

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“…After the Lariat procedure, concentric leaks can be closed with an atrial septal occluder (ASO) device or a repeat Lariat suture. 32, 33 We described our experience where 6 patients with concentric leaks associated with the Lariat device were successfully closed with an ASO device and repeat Lariat applications. 32 However, leaks postdeployment of a Watchman device are more difficult to treat because of the eccentric jets.…”

Section: Device Leak Management: Clinical Implicationsmentioning

confidence: 98%