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For patients with atrial fibrillation, percutaneous left atrial appendage closure (LAAC) emerged as a valid alternative to oral anticoagulation. This activity reviews the evaluation, indications/contraindications, pre/post-procedural management of percutaneous LAAC and highlights the role of the interprofessional team in evaluating and treating this condition. Objectives: Identify indications and contraindications for percutaneous left atrial appendage closure. Describe pre-procedural planning and preparation to perform successful percutaneous left atrial appendage closure. Summarize the complications of percutaneous left atrial appendage closure. Explain the importance of collaboration and communication amongst the interprofessional team to ensure the appropriate selection of candidates for percutaneous left atrial appendage closure and to enhance post-procedural management. Access free multiple choice questions on this topic.

Atrial fibrillation (AF) is the most common type of heart arrhythmia affecting 33.5 million people worldwide.[1][2] The most dreaded complication of this disease is stroke, which is also the leading cause of disability in the United States.[3] AF increases the risk of ischemic stroke by 4 to 5 fold in all ages when left untreated.[3][4] Moreover, AF is correlated with a higher risk of extracranial thromboembolic aortic events and also in the mesenteric, renal, and peripheral arteries.[5] The number of strokes attributed solely to AF increases with age approaching 23.5%.[4][6] In AF patients, oral anticoagulants (OACs) remain the gold standard treatment. The role of OACs in preventing strokes is well established, yet it is contraindicated in patients with an increased risk of bleeding.[7][8] Hence, left atrial appendage occlusion (LAAO) has risen as an alternative approach in this subset of patients.

The most common complications are pericardial effusion or cardiac tamponade requiring intervention, device-related thrombus, device embolization, persistent atrial septal defect (ASD), cardiac perforation, and procedure-related stroke. The incidence of pericardial effusion/tamponade is about 1.2% to 5% and, in the majority of cases, is managed with pericardiocentesis.[25][48][24][49][50][51][52][53][29][54] The incidence of device embolization has been reported as high as 3.5%, requiring transcatheter removal or surgery. However, the incidence is much lower amongst experienced operators (much less than 1%).[25][48][24][49][51][52][53][29][54] Device-related thrombus can be encountered in up to 14% of patients and is managed with a longer course of anticoagulation with a success rate approaching 95% (median treatment duration of 45 days).[55][48][51][52][53][29] The majority of these patients are asymptomatic, with an overall incidence of neurological events attributed to device-associated thrombus being very low (0.28%).[55] Persistent ASD incidence accounts for about 11% at six months and 7% at 12 months post-procedure.[56] Usually, ASD is small and does not require treatment. Cardiac perforations occur in up to 0.4% of patients and require surgical intervention.[25] Up to 1.1% of patients develop procedure-related stroke requiring management.[25][48][24][50][51][52][53][54] Other less common complications are procedure-related death and vascular complications such as hematoma, bleeding, and AV fistula formation.

For AF patients, percutaneous LAAC has emerged as a valid alternative to OAC. Although randomized control trials have mostly been restricted to patients who can tolerate short-term OAC, registries have shown some benefit in patients at high risk of stroke and intolerance and/or contraindications to OAC, with consistent safety improvements as long-term efficacy of the procedure. Current recommendations from professional societies support the use of percutaneous LAAC in AF patients with high stroke risk and contraindication for long-term anticoagulation.[Level 1] Guidelines recommend 6 weeks of oral anticoagulation plus aspirin followed by aspirin plus clopidogrel up to 6 months post-procedure. Aspirin will subsequently be continued for the lifetime of the patient.[20][66] However, the post-procedural antithrombotic regimens are sometimes modified in select patients(especially in patients with recurrent bleeding after LAAC) to balance the risk of bleeding and device-associated thrombus. Patients undergo a transesophageal echocardiogram at 6 weeks to confirm adequate sealing of LAA and rule out device-related thrombus, as this might change the duration of oral anticoagulation. An interprofessional team including an interventional cardiologist, non-invasive cardiologist specialized in multimodality imaging, cardiac anesthesiologist, nurses, and catheterization laboratory technologists work together to provide an integrated and holistic approach to pre-procedural planning, intra-procedural support, and post-procedural care to ensure an optimal outcome for the patient. Communication, shared decision-making, and collaboration between the interprofessional team members are key elements for excellent outcomes. Interprofessional care also helps identify early and late complications of percutaneous LAAC and, therefore, improves patients' prognosis and improves patient outcomes while reducing adverse events. [Level 5]