Left Atrial Appendage Closure

What is a left atrial appendage closure?

Left atrial appendage closure is a surgical or minimally invasive procedure to seal off your left atrial appendage (LAA). This is a small sac in the muscle wall of your left atrium (top left chamber of your heart). Removing it or closing it off can reduce your risk of stroke and end the need to take blood thinners.

Among people with atrial fibrillation (Afib) who don’t have valve disease, most of the blood clots that happen in the left atrium start in the LAA.

Normal hearts contract with each heartbeat, squeezing the blood in your left atrium and LAA out into your left ventricle (bottom left chamber of the heart). When you have Afib, the electrical impulses that control your heartbeat don’t travel in an orderly way. They can be fast and chaotic, which doesn’t give your atria time to squeeze blood into your ventricles.

Because the LAA is a pouch, blood collects there and can form clots. When your heart pumps out blood clots, they can cause a stroke. People with Afib are three to five times more likely to have a stroke than the general population. While this is unsettling, your provider can help you protect yourself with a solution that works for you. This can involve medications that make it more difficult for these blood clots to form or closing off the left atrial appendage.

Your heart can keep doing its job with a closed left atrial appendage.

Types of left atrial appendage closure devices

Thousands of people worldwide have had an LAA closure. Providers use different methods and devices, like:

• Devices that block the left atrial appendage’s opening: WATCHMAN™, Amulet™, WaveCrest™ (these keep blood clots that form in your LAA from going into your bloodstream)
• Devices that clamp the base of the LAA to close it off: AtriClip™(disclosure: Cleveland Clinic has the potential to receive a royalty payment as a result of the sale of this clip)
• Devices that use a band or suture loop to close off your LAA: Lariat™, Sierra™

What does a left atrial appendage closure treat?

LAA closure reduces the stroke risk associated with Afib. But it doesn’t treat the Afib itself. Left atrial appendage closure can benefit people who have an increased risk of stroke due to Afib. If you’re at risk of getting blood clots in your left atrium/left atrial appendage, your healthcare provider may recommend sealing off your LAA to reduce your risk of stroke from Afib. They can do this instead of prescribing a blood thinner like warfarin (Coumadin® or Jantoven®), apixaban (Eliquis®), rivaroxaban (Xarelto®) or dabigatran (Pradaxa®).

Many people have concerns about, or dislike, taking warfarin. Some of the reasons for this are:

• A provider needs to check your blood often to see how quickly it clots (they use blood tests to make sure you’re taking the right amount of medication)
• You need to be consistent and limit certain foods you eat that contain vitamin K
• The risk of bleeding is higher while taking warfarin (this is especially concerning for people at a high risk of falling or bleeding from their gastrointestinal tracts)
• Some people don’t tolerate warfarin or have trouble maintaining a normal clotting time

People with Afib who don’t have heart valve disease can take other medications — apixaban, dabigatran and rivaroxaban. But some people have concerns and problems with these medications:

• People who can’t take anticoagulants can’t tolerate these medications.
• Some people are concerned about the cost of the medication.
• These medications also increase the risk of bleeding.

How should I prepare for a left atrial appendage closure procedure?

Before an LAA closure, you’ll get a transesophageal echocardiogram (TEE) and/or cardiac CT. This gives your provider dimensions of your left atrial appendage. This matters because left atrial appendages vary from person to person. Researchers have compared the left atrial appendage’s shape to a chicken wing, cactus, windsock or cauliflower.

Your provider may also do three-dimensional printing to help choose the correct device and the right size.

You’ll need to fast (stop eating and drinking) at a certain time before your procedure. Your provider will tell you when to fast.

You’ll receive anesthesia of some type, depending on which procedure you’re having.

What happens during a left atrial appendage closure procedure?

If you’re having heart surgery for other reasons, like coronary artery disease or valve disease, your healthcare provider frequently can remove your left atrial appendage at the same time. They may sew or staple the area closed. This is a surgical left atrial appendage closure.

In a minimally invasive approach, they can use a catheter to insert a special device to close or block your left atrial appendage. These devices may act as a plug in your left atrial appendage’s opening to your left atrium. Other devices tie or clamp your left atrial appendage closed.

For a device your provider uses a catheter to implant, they will:

1. Insert a catheter into a vein near your groin
2. Advance the catheter to your right atrium and make a hole between your left and right atrium (the hole usually heals within six months)
3. Move the catheter through that hole and to your left atrial appendage
4. Confirm the device size you need
5. Put the device into your left atrial appendage to cover its opening (this seals off the left atrial appendage and keeps it from releasing clots)
6. Remove the catheter

Several types of imaging guide your provider while they work inside your heart. Types of imaging they use include:

• Fluoroscopy (video from X-rays)
• Transesophageal echo (TEE)
• Intracardiac ultrasound (using sound waves from a tiny transducer on a catheter)

What happens after a left atrial appendage closure procedure?

After your surgery or minimally invasive procedure, you may:

• Stay in the hospital overnight after the procedure (or longer after surgery)
• Have a transesophageal echo (TEE) within 48 hours of your procedure

What are the benefits of a left atrial appendage closure?

People who get an LAA closure can:

• Reduce their risk of stroke
• Stop taking blood thinners
• Have the procedure done during heart surgery for another issue
• Have a minimally invasive procedure for a left atrial appendage closure device

What are the risks or complications of this procedure?

Left atrial appendage closure complications may include:

• A problem with the device itself
• A reaction to anesthesia
• Bleeding
• Chest pain
• Cardiac arrest
• Abnormal heart rhythm (arrhythmia)
• Infection
• Pericardial effusion
• Stroke

What is the recovery time for left atrial appendage closure?

If you had your LAA closure as part of a heart surgery for another issue, your recovery time will vary depending on which other surgery you had.

If you had a minimally invasive procedure using a catheter to put in a left atrial appendage closure device, your recovery will be quicker. You may be able to go home the next day.

After getting a device, you’ll need to take an anticoagulant (blood thinner) and aspirin for 45 days. This is how long it takes your body’s tissue to form around the device so there aren’t any gaps around it. Then, you’ll stop taking an anticoagulant and switch to clopidogrel (Plavix®) and aspirin for six months.

You may be on aspirin for the long term.

Follow-up appointments

You’ll have another transesophageal echo (TEE) at a follow-up visit 45 days after your procedure. This helps your provider see if your left atrial appendage is fully blocked.

If the TEE shows that your left atrial appendage isn’t blocked, you’ll keep taking the anticoagulant and have another TEE and follow-up visit after six months.

Once your left atrial appendage is blocked, you’ll have an annual follow-up visit with your provider.

How successful is surgical left atrial appendage closure?

Researchers have linked LAA closure with suture to a 40% decrease in the risk of a blood clot, and over 90% with clip or surgical excision. They found an 80% decrease in strokes in device studies. Some devices have rates above 95% for successful placement.

While there’s no surefire way to prevent strokes, removing or blocking your left atrial appendage reduces your risk significantly. This is because 90% of strokes that start in an upper heart chamber start in your LAA.

When should I call my healthcare provider?

In addition to going to your scheduled visits, you should contact your provider if you have:

• Fever or other signs of infection
• Abnormal heart rhythms
• Chest pain
• Shortness of breath