Atrial Appendage Closure

What is Atrial Appendage Closure?

Atrial appendage closure is a way to treat atrial fibrillation, a common cardiac arrhythmia in which there is a disturbance in the electrical excitation propagation in the heart. This results in an increased contraction frequency of the atria or one of the atria. Atrial fibrillation keeps the atria from emptying, increasing the risk of blood clots. These blood clots can be washed through the bloodstream into the arteries of the head, causing a stroke.

Blood flow is slowed in atrial fibrillation, particularly in the left atrium, a bulge called the heart's auricle. Blood hardly flows at this point, and blood clots can easily form. To prevent a stroke, this heart auricle can be closed by a particular system so that blood clots can no longer form there.

What Methods Are Available?

One method of atrial appendage closure is through a right heart catheter. The catheter is a thin wire that is forwarded through the inguinal vein into the right atrium. The position of the catheter is checked in small intervals by X-ray. The atrial septum is then pierced in the right atrium, and the catheter is forwarded further into the left atrium. From there, the catheter tip is placed in the left atrial auricle. Next, a threaded small screen made of plastic is forwarded over the catheter to the catheter tip and then opened. This occluder now remains in the atrial auricle and acts as a barrier to block possible blood clots from entering the atrium. The catheter is then removed, and the puncture site in the groin is dressed in a pressure bandage. The occluder grows over the following weeks.

Another option is to place an LAA clip. LAA stands for Left Atrial Appendage. This option is carried out under general anesthesia with the heart beating. Three small incisions are made in the chest, through which a camera and two tools are inserted into the chest cavity. The pericardium is cut open, and the left atrial auricle is accessed. A clip is subsequently inserted through a chest incision and placed over the entire atrial auricle like a sling. At the same time, a cable with an ultrasound probe is inserted over the esophagus so that real-time images of the atrium can be seen during the procedure. Once the correct position of the clip is verified, it can be finally placed. The pericardium is sutured, and the tools are removed. The three incisions in the chest are also sutured and dressed in a bandage.

Who Is Eligible for Atrial Appendage Closure?

Standard drug therapy is used to prevent stroke in atrial fibrillation patients, which involves prescribing tablets that inhibit blood clotting, making it more difficult for blood clots to form. However, this form of treatment also has side effects. The most common and severe side effect is the increased risk of bleeding. Therefore, this anticoagulation with tablets is not an option for some people, and atrial appendage closure can be used as an alternative.

Procedure and Duration

In both variants, the closure is carried out during an inpatient stay. The occlusion procedure can be carried out under light sedation without general anesthesia. After disinfection and covering the groin region, a local anesthetic is injected. The occluder can be inserted via the catheter procedure described above. During and after the procedure, a check with transesophageal echocardiography is carried out. The treatment takes about 20 minutes to 1 hour. Closure with a clip is performed as cardiac surgery. General anesthesia is necessary for this. The procedure takes about 1 hour.

Side Effects & Risks

Every medical procedure has risks, including, among others, secondary bleeding at the puncture site, injury to the tissue the catheter passes, infection of the puncture site, and allergic reaction to material or the contrast agent. In addition, in rare cases, atrial appendage occlusion can result in injury leading to bleeding into the pericardium.

Aftercare

Anticoagulation with tablets must be administered for the following weeks while the occluder is growing in. After the intervention, the patient is hospitalized for about 3 days. After 30 days, another transesophageal echocardiography is carried out to check the fit of the clip. Subsequently, anticoagulation can be reduced or completely discontinued.

The surgical procedure is followed by a short period in the intensive care unit or recovery room, followed by 3 to 4 days in the hospital for monitoring. After the closure with a clip, doctors decide whether anticoagulation is necessary. No significant physical exertion should be performed for the initial 10 to 14 days after the procedure. The fit of the clip is rechecked after 6 months with transesophageal echocardiography.

Which Doctors and Clinics Are specialized?

Atrial appendage closure procedures are not offered at all heart clinics. Instead, occlusion by an occluder is carried out in clinics with interventional cardiology, while the treatment with a clip is used in the field of cardiac surgery.

We can help you find an expert for your condition. All doctors and clinics listed have been reviewed by us for their outstanding specialization in atrial appendage closure and are awaiting your inquiry or treatment request.

Sources:

• Herold et al.: Innere Medizin. Eigenverlag 2012, ISBN 978-3-981-46602-7.
• Schnabel et al.: Prävalenz und Risikofaktoren von Vorhofflimmern in Deutschland. In: Herz. Band 40, Nummer 1, 2015, doi: 10.1007/s00059-014-4199-6, S. 8–15.
• Gillinov et al.: Rate Control versus Rhythm Control for Atrial Fibrillation after Cardiac Surgery. In: New England Journal of Medicine. Band 374, Nummer 20, 2016, doi: 10.1056/nejmoa1602002, S. 1911–1921.
• Karow, Lang-Roth: Allgemeine und Spezielle Pharmakologie und Toxikologie 2010.
• Scherr: Katheterablation bei persistierendem Vorhofflimmern. In: Herz. Band 40, Nummer 1, 2015, doi: 10.1007/s00059-015-4204-8, S. 31–36.
• Sultan et al.: Interventionelle Therapie von paroxysmalem Vorhofflimmern. In: Herz. Band 40, Nummer 1, 2015, doi: 10.1007/s00059-014-4195-x, S. 25–30.
• Metzner et al.: Innovative Verfahren der Vorhofflimmertherapie. In: Herz. Band 40, Nummer 1, 2015, doi: 10.1007/s00059-014-4194-y, S. 37–44.
• Camm et al.: 2012 focused update of the ESC Guidelines for the management of atrial fibrillation: An update of the 2010 ESC Guidelines for the management of atrial fibrillation. In: European Heart Journal. Band 33, Nummer 21, 2012, doi: 10.1093/eurheartj/ehs253, S. 2719–2747.
• Bedeir K, Warriner S, Kofsky E, Gullett C, Ramlawi B. Left Atrial Appendage Epicardial Clip (AtriClip): Essentials and Post-Procedure Management. J Atr Fibrillation. 2019;11(6):2087. Published 2019 Apr 30. doi:10.4022/jafib.2087