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AtriClip device

International Symposium on Left Atrial Appendage (ISLAA) 2015

Internation Symposium LAA 2015 logoby Steve S. Ryan, PhD, February 2015

The heart’s Left Atrial Appendage (LAA) has emerged as an important factor in the source of A-Fib signals. So much so, that doctors and researchers from around the world gathered for a two-day Symposium devoted exclusively to the LAA on February 6-7 at the Marina del Rey Marriott Hotel in Marina del Rey, CA.

Overview—First Impressions & Brief Reports

“Closing Off the LAA Has No Adverse Effects”

This Symposium was unique in that Electrophysiologists, Interventionalists and Surgeons were featured speakers and attendees. Dr. James Cox, inventor of the original Cox Maze operation, both presented a report and participated in a debate “Who Should Perform LAA Occlusion/Exclusion Procedures? A 3-Way Debate with a Surgeon, EP and Interventionalist.” In Dr. Cox’s talk he stated that cutting out the LAA has no adverse effects. This is a very powerful statement coming from someone with his years of experience.

AtriClip In Action

AtriClip being positioned

Dr. Cox said that the AtriClip closure device was the safest compared to staples and sutures. We were privileged to see two recorded operations using the AtriClip which were fascinating to watch. The surgeon opened up the pericardium sack and inserted the AtriClip over the LAA. In the first case he used what looked like two pencil eraser probes to poke and prod the LAA into the jaws of the AtriClip.

In the second case the surgeon inserted sutures into the LAA and used them to pull the LAA through the AtriClip opening. Once the AtriClip closed off the LAA, the closure looked very complete and secure. Both surgeons did not sew up and close the pericardium opening they had made to get to the LAA. This was surprising to me, but I later learned that this is standard procedure during such surgery to not close or stitch up the pericardium sack.

The Watchman occlusion device

The Watchman occlusion device

Watchman May Win FDA Approval

In my earlier brief reports on the Orlando AF Symposium, based on the recent research and the FDA presentation, I said the Watchman device probably won’t be approved in the US.

I’m happy to say that I am most likely wrong. The Watchman may be approved by the middle of this year. One presenter described how the FDA chairman talked with several people who were going to Canada to have the Watchman device installed. He seemed embarassed that the Watchman was available everywhere in the world but not in the US and said that it has to be approved.

Other doctors I talked with at the LAA Symposium were of the same opinion. Presenters described how clinical trials for other LAA closure devices were on hold so that they could get approved in comparison to the Watchman (Non-Inferiority Trials). Dr. Dhanunjaya Lakkireddy of the University of Kansas Medical Center said that we are at a “tipping point” for the (A-Fib) industry.

Lariat II imageLariat Live Case

We were privileged to watch a live case from Cedars Sinai in which Dr. Saibal Kar and his colleagues inserted a Lariat device to close off the LAA in a patient. From outside the heart Dr. Kar inserted a magnet-tipped catheter through the diaphragm so that it arrived at the base of the LAA. Then from inside the heart he inserted another magnet-tipped catheter to the base of the LAA where the magnets joined and formed a rope-like structure.

Using this rope-like link he inserted a catheter with the Lariat II device which followed this rope-like link till it reached the LAA. He then unfurled the Lariat snare or noose-like device which he manipulated over the base of the LAA. But there were problems. It was hard to get all the folds or pouches of the LAA in the Lariat snare.

In most Lariat procedures, they use a balloon inside the heart to expand the LAA so that the lariat noose can more easily fit over it. Inserting the Lariat seemed like a somewhat tricky procedure to me, and is certainly more complicated than inserting a Watchman device.

Having to work from both outside and inside the heart and using balloons and catheters with magnet tips isn’t something the average EP or Interventionalist is used to doing. As Dr. Andrea Natale commented, the Lariat procedure needs skill and expertise. Though Dr. Natale didn’t say this, there are few centers and doctors with the experience, skill and expertise necessary to successfully insert the lariat device.

LAA Structures are Different and UniqueLAA 1.500 pix wide at 96 res

Previous research has postulated that the LAA has four basic structures:

1. Chicken-wing (48%)

2. Windsock (19%)

3. Cactus (30%)

4. Califlower (3%)

The Chicken-wing is the easiest to tie off with the Lariat, while the Califlower can be quite difficult. Also, sometimes the LAA is virtually inaccessible, because it is buried behind other heart structures.

LAA 3 500 pixel wide at 96 resDr. Jacqueline Saw of Vancouver General Hospital certainly surprised me by showing five more different LAA shapes which she named:

5. Elephant trunk

6. Serpiginous

7. Seahorse

8. Whale’s tail

9. Trousers

It seems that every LAA is different and unique in structure, like snowflakes. This may be very important in our understanding of the LAA.

Dr. Shaw also described how the LAA Orifice Opening can have very different shapes:

1. Oval (68.9%)LAA 2 500 pix wide at 96 res

2. Triangular (7.7%)

3. Foot-like (10%)

4. Waterdrop-like (7.7%)

5. Round (5.7%)

She also described how Cardiac Computed Tomography Angiography [CCTA]) imaging is used to measure the diameter and depth of the LAA. Addition measurements include the internal LAA structures such as lobes, muscle ridges, trebeculations and sharp bends.

These internal structures may influence or hinder the placement of LAA occlusion devices.

CCTA imaging can also be used after an occlusion device (i.e. Lariat or Watchman) is implanted to inspect and detect gaps or leaks.

References for this article

Return to Research & Innovations

Last updated: Friday, March 6, 2015

 

Role of the Left Atrial Appendage & Removal Issues

Left Atrial Appendage heart illustration; Source: Boston Scientific Inc. educational brochure

The Role of the Left Atrial Appendage (LAA) & Removal Issues

By Steve S. Ryan, PhD

In the first trimester or two of our time in the womb, The Left Atrial Appendage (LAA) was originally our left atrium (LA). When the final real Left Atrium (LA) formed gradually from the conjunction and evolutionary development of the four pulmonary veins, the actual LA chamber grew and ballooned out, pushing the smaller remnant LA up to the left top of the Left Atrium where it became became known as the Left Atrial Appendage (LAA) with its own functions and behaviors.

But as we age and as heart disease/A-Fib, etc. start to set in, the LAA can turn into “the most lethal, no longer essential appendage in the human anatomy.” (Thanks to Shannon Dickson for these insights about the LAA.)

One considered advantage of the Mini-Maze operations is that the Left Atrial Appendage (LAA) is closed or cut off. Most A-Fib blood clots which cause stroke come from the Left Atrial Appendage. By closing off the LAA, most but not all risk of stroke is eliminated even if you are still in A-Fib.

Failure to Completely Close Off the LAA is Common

However, in a study by Surgeon s, “both suture exclusion and stapler exclusion had extraordinarily low success rates. In fact, none of the patients with stapler exclusion had successful closure…This study presents clear evidence of the inadequacy of these techniques.”1

According to Dr. Marc Gillinov of the Cleveland Clinic, staplers “can be hard to apply to the appendage and tend to leave a little cul-de-sac and also cause bleeding and tearing, so they are not particularly safe or effective.”2

However, the AtriClip device (FDA approved June, 2010) makes it much easier for surgeons to close off the LAA during open heart surgery. The surgeon positions the rectangular-shaped device around the LAA and then closes it like a clamp. Blood no longer flows into and out of the Left Atrial Appendage.3 

AtriCure has developed a version of the AtriClip which can be used in Mini-Maze surgery.

Should the LAA be routinely cut out, stapled shut or closed off in all A-Fib patients?

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib.

The rationale for closing off the LAA is that, in case the operation fails which happens occasionally, the patient is still protected from having an A-Fib stroke. 90%-95% of A-Fib strokes come from clots which originate in the LAA. In A-Fib, blood stagnates in the LAA and clots tend to form.

Another important consideration, even if a person is no longer in A-Fib, is that closing off the LAA may still prevent a stroke. The LAA is where most clots originate. If a surgeon is already working on the heart, why not close off the LAA and reduce the patient’s chance of having a future stroke? (If a surgeon didn’t close off the LAA, they could be sued if a patient later had a stroke, even if the patient was no longer in A-Fib.) Life (no stroke) is more important for most people than a possible reduced exercise intolerance.

In the future even people without A-Fib may have their Left Atrial Appendage closed off if it prevents or reduces the risk of a stroke. This may become a way to prevent stroke in older people, particularly women, who are more at risk of stroke as we age. There are currently a variety of devices, surgical and non-surgical, which can do this. LAA closure may become an important new way to reduce strokes, particularly in the elderly.

Functions of the Left Atrial Appendage

Some question the need or benefit of removing the Left Atrial Appendage (LAA) if someone is no longer in A-Fib. For a patient made A-Fib free, would their heart function better or more normally if they still had their LAA?

The LAA functions like a reservoir or decompression chamber or a surge tank on a hot water heater to prevent surges of blood in the left atrium when the mitral valve is closed.4Without it there is increased pressure on the pulmonary veins and left atrium which might possibly lead to heart problems later.

Conclusion

Cutting out or stapling shut the LAA also reduces the amount of blood pumped by the heart and may result in exercise intolerance for people with an active life style. (In dogs the LAA provides 17.2% volume of blood pumped.5) This is usually not a problem for patients with Persistent (Chronic) A-Fib, whose LAA has stopped contracting along with the fibrillating atrium. Cutting out or stapling shut the LAA won’t affect their cardiac output. But this may not be the case for patients with Paroxysmal A-Fib who still have large amounts of normal rhythm and whose LAA still functions normally.

But would a non-functioning LAA return to normal when someone with, for example, longstanding persistent (Chronic) A-Fib becomes A-Fib free?

The author isn’t aware of any surgeons (or EPs) who do pre- and post-LAA closure measurements of exercise ability, heart pumping function, etc. with and without the LAA.

(When doctors do a TEE [Transesophageal Echocardiogram] of the LAA of someone in A-Fib, the LAA doesn’t move at all and blood does not move. Doctors refer to this as “SMOKE” which is shorthand for Spontaneous Echo Contrast. The blood not moving looks like smoke inside the LAA.)

The LAA also has a high concentration of Atrial Natriuretic Factor (ANF) granules which help to reduce blood pressure.6Some preliminary research indicates that when the LAA is closed or cut off, the Right Atrial Appendage produces more ANF to compensate for the lost of the LAA.

Editor’s comment: If you are thinking of having a Cox Maze or Mini-Maze, discuss removing the LAA with the surgeon. Ask if they close off the Left Atrial Appendage and with what: sutures, stapler or the AtriClip.

Posted June 2013

Back to top

Return to Index of Articles: Maze, Mini-Maze, Convergent, LAA Closure Surgeries

Last updated: Sunday, February 15, 2015

References    (↵ returns to text)
  1. Damiano, Jr., RJ. “What Is the Best Way to Surgically Eliminate the Left Atrial Appendage?” Journal of the American College of Cardiology 2008, Sept. 9; Vol. 52, No. 11:930-1.
  2. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010. 
  3. AtriCure’s AtriClip system receives FDA 510(k) clearance (press release). June 14, 2010.
  4. Al-Saady, N M, et al.  Left atrial appendage: structure, function, and role in thromboembolism
  5. Hondo T. et al. “The Role of the left atrial appendage. A volume loading study in open-chest dogs.” Jpn Heart J 1995 Mar;36(2):225-34.  http://www.ncbi.nlm.nih.gov/pubmed/7596042
  6. Atrial natriuretic peptide. Wikipedia.org. Last accessed April 13, 2014, URL: http://en.wikipedia.org/wiki/Atrial_natriuretic_peptide.

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