Technology & Innovations
Lariat II Suture Delivery Device
by Steve S. Ryan, updated Oct. 2016
To address the increased risk of stroke, A-Fib patients are often put on anticoagulant drug therapy, such as warfarin. Because the Left Atrial Appendage (LAA) is the source of over 90% of A-Fib-related strokes, the Lariat II Suture, an occlusion device, can be used to close off the LAA, replacing the need for anticoagulants.
It is often used in cases where the patient cannot tolerate anticoagulants like Coumadin. (The Watchman device, another occlusion device, requires a patient be on anticoagulants for several months. See The Watchman™: Alternative to Blood Thinners.)
Placement of the Lariat Device
From the inside of the heart a balloon is placed inside the Left Atrial Appendage to expand it and make it accessible to the noose device which is inserted from the outside of the heart. The positioning balloon is withdrawn before the Lariat noose is closed around the base of the Left Atrial Appendage.
The noose completely closes off the Left Atrial Appendage which dies and is no longer electrically active. The Lariat II snare device has been approved by the FDA (Lariat II, SentreHeart, Inc., Palo Alto, CA).
A noose device to close off the Left Atrial Appendage is inserted from outside the heart, unlike for example the Watchman device which is inserted into the LAA from inside the heart.
The Lariat device was invented by Dr. William E. “Billy” Cohn, Director of Minimally Invasive Surgical Technology at the Texas Heart Institute at St. Luke’s Episcopal Hospital.
VIDEO: Closure of the Left Atrial Appendage Technique 2: The Lariat Procedure. Using doctor interviews and animated footage, explains the need for and use of the Lariat occlusion device.
For more about the Lariat, see Alert: Patients with Lariat Device for Left Atrial Appendage Closure.
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Last updated: Wednesday, October 12, 2016
By Steve S. Ryan, PhD, updated March 2015
Do you hate having to take Coumadin or other blood thinners? Hate the side effects? Or are you allergic to them? A replacement to taking blood thinners is the Watchman, an occlusion device.
The theory behind the WATCHMAN™ LAA closure technology is that most A-Fib clots originate in the Left Atrial Appendage (LAA). The Watchman closes off the LAA where 90-95% of A-Fib strokes come from. It’s a very low risk procedure that takes as little as 20 minutes to install. Afterward, you would usually not need to be on blood thinners.
How It Works
The Watchman device comes in multiple sizes from 21mm to 33mm to accommodate the different sizes of LAAs. Once a patient’s Left Atrial Appendage is measured, a wide-sheathed catheter with a spline is used to insert the Watchman device which has a self-expanding Nitinol (a special metal) open-ended circular frame.
The atrial surface of this frame is covered with a thin, permeable 160 μm (micron) pore filter made of polyester material (Polyethylene Terephthalate known as Dacron or PET). This filter allows blood to pass through while stopping clots. Little hooks or anchors called fixation barbs at the middle of the device make sure it is attached firmly to the LAA wall.
Before the catheter is removed (which fixes the Watchman in place), contrast agents are used to make sure the Watchman is stable and entirely closes off the LAA opening. Over time heart tissue grows over the polyester (PET) material so that it completely closes off the LAA with smooth heart tissue similar to other heart surfaces.
In this Occlusion image, heart tissue has completely covered the Watchman device after only nine months.
Patients on Coumadin continue to take it for six weeks after the Watchman device is inserted. They are then examined using a TEE (Transesophageal Echocardiogram) to make sure there is complete closure of the LAA. At that time they are taken off of Coumadin and put on a different type of blood thinner called clopidogrel (Plavix) until six months after the implant procedure.
Think of the Watchman as a replacement for blood thinners; both reduce but do not totally eliminate the risk of stroke. The stroke risk is reduced to that of a person with a normal heart.
Even while you are waiting for or trying to decide on having a Pulmonary Vein Ablation, you can have the Watchman inserted and reduce your stroke risk to that of a person without A-Fib.
Just as closing off the LAA is standard practice in the Cox Maze/Mini-Maze operations, in the future, the Watchman device could become part of most catheter ablation procedures. If included with the ablation procedure, the Watchman would protect the patient from blood clots even if the catheter ablation procedure was unsuccessful. The Watchman device may become standard therapy for anyone at risk of a stroke, not just for people with A-Fib.
For a list of US doctors installing the Watchman device, go to Steve’s Lists/Doctors Installing the Watchman Device.
Update: The U.S. Food and Drug Administration (FDA) approved Boston Scientific’s WATCHMAN™ LAA closure technology for use in the U.S. on March 13, 2015. It has been available internationally since 2009. The FDA approval of the WATCHMAN device is based on the clinical program which consists of numerous studies, with more than 2,400 patients and nearly 6,000 patient-years of follow-up. The Watchman device will be available first at U.S. centers where it has been used in clinical studies.
If you are at high risk for stroke but can’t take anticoagulants, your doctor may suggest closing off the Left Atrial Appendage using an occluder such as the Watchman Device.
Update: After extensive clinical studies, the FDA approved Boston Scientific’s WATCHMAN™ LAA closure technology for use in the U.S. on March 13, 2015 (it has been available internationally since 2009). Boston Scientific has an excellent web site which lists centers implanting the Watchman device http://www.bostonscientific.com/en-US/products/laac-system/watchman-device/implanting-hospitals.html. On the far right hit the button “Find Implanting Center”. Doctors are listed only by the hospitals they work at rather than by their office and their normal contact phone number. (I had to use a magnifying glass to read the copy.)
However, this Boston Scientific site doesn’t distinguish between Electrophysiologists (EPs) certified in “Clinical Cardiac Electrophysiology” and Internists/Interventionalists who normally do not work inside the heart. These doctors are usually only certified in “Cardiovascular Disease,” “Internal Medicine,” or “Interventional Cardiology.” (They usually work primarily with pacemakers and/or stents and usually don’t perform A-Fib ablations.)
The following table lists only EPs who have passed their “Clinical Cardiac Electrophysiology” (CCE) certification. Though installing the Watchman Device is normally a relatively simple procedure, it might be advisable to have the Watchman Device installed only by EPs who have their CCE. They are usually more experienced at working inside the heart.
|Alabama||Birmingham||Dr. Jose Osorio||205-939-0073||Alabama Cardiovascular|
|Arizona||Phoenix/Peoria/Chandler||Dr. Vijendra Swarup (Clinical Trial Participant)||602-456-2342||Arizona Heart Rhythm Center|
|Arizona||Phoenix||Dr. Marwan M. Bahu||602-952-0002||Biltmore Cardiology|
|Arizona||Phoenix||Dr. Ashish Sadhu||602-307-0070||Heart & Vascular Center|
|California||Santa Monica||Dr. Shephal Doshi (Clinical Trial Participant)||310-829-6889||St. John’s|
|California||Los Angeles||Dr. Michael Shehata||310-423-3336||Cedars-Sinai|
|California||Los Angeles||Dr. Ivan Ho||213-977-0419||Good Samaritan|
|Florida||Atlantis||Dr. Mark A. Freher||561-434-0353||Florida Electrophysiology Assoc.|
|Florida||Bradenton||Dr. Daniel E. Friedman||941-748-2277||Bradenton Cardiology|
|Forida||Lakeland||Dr. Neal G. Kavesh||863-680-7000||Watson Clinic|
|Florida||St. Petersburg||Dr. Robert C. Sheppard||727-490-2136||Heart & Vascular Institute|
|Florida||St. Petersburg||Dr. Shalin S. Shah||727-544-1441||Bay Area Heart Center|
|Florida||Sarasota||Dr. Robert E. Eckart||941-917-4250||Heart Specialists of Sarasota|
|Florida||Sarasota||Dr. Dilip J. Mathew (Lariat)||941-486-6758||Heart Rhythm Consultants|
|Florida||Tallahassee||Dr. Farhat S. Khairallah||850-216-0120||Southern Medical Group|
|Florida||Tampa||Dr. Kevin J. Makati (Lariat)||813-229-9292||Tampa Cardiac Specialists|
|Georgia||Atlanta||Dr. Angel Leon (Clinical Trial Participant)||404-686-2504||Emory Univ. Heart Center|
|Georgia||Atlanta||Dr. David DeLurgio (Clinical Trial Participant)||404-686-2504||Emory Univ. Heart Center|
|Georgia||Atlanta||Dr. Mikhael F. El-Chami||404-686-2504||Emory Univ. Heart Center|
|Georgia||Atlanta||Dr. Michael Hoskins||404-712-4063||Emory Univ. Hospital|
|Illinois||Naperville/Winfield||Dr. Moeen A. Saleem||630-687-9451||Midwest Heart Specialists|
|Illinois||Springfield||Dr. Ziad F. Issa (Clinical Trial Participant)||217-788-0706||Prairie Cardiovascular Consultants|
|Kentucky||Lexington||Dr. Gery Tomassoni (Clinical Trial Participant)||859-277-5887||Lexington Cardiology at Central Baptist|
|Massachusetts||Boston||Dr. Moussa Mansour (Clinical Trial Participant)||617-726-5557||Massachusetts General Hospital|
|Massachusetts||Burlington||Dr. Bruce G. Hook||781-744-8863||Lahey Clinic|
|Massachusetts||Burlington||Dr. Jonathan S. Silver||781-744-8863||Lahey Clinic|
|Massachusetts||Fall River||Dr. Nitesh A. Sood||508-679-7262||Southcoast Healthcare
|Michigan||Detroit||Dr. Claudio D. Schuger||313-916-2417||Henry Ford Hospital|
|Michigan||Grand Rapids||Dr. Musa I. Dahu||616-885-5000||Frederik Meijer Heart|
|Michigan||Royal Oak||Dr. David E. Haines||248-898-4198||William Beaumont Hospital|
|Minnesota||Minneapolis||Dr. William Katsiyiannis (Clinical Trial Participant)||612-863-3900||Minneapolis Heart Institute|
|Minnesota||Rochester||Dr. Douglas L. Packer||507-284-3994||Mayo Clinic|
|Minnesota||Rochester||Dr. Samuel J. Asirvatham||507-284-3994||Mayo Clinic|
|Minnesota||Rochester||Dr. Thomas M. Munger||507-284-3994||Mayo Clinic
|Mississippi||Tupelo||Dr. Karl J. Crossen||662-620-6800||Cardiology Assoc of Northern Mississippi|
|Mississippi||Tupelo||Dr. Keith Kyker||662-620-6800||Cardiology Assoc of Northern Mississippi|
|Missouri||Kansas City||Dr. Alan Wimmer (Clinical Trial Participant)||816-931-1883||Mid America Heart Institute|
|Missouri||Saint Louis||Dr. Amit A. Doshi||314-256-5240||Heart Health Center|
|Missouri||Saint Louis||Dr. J. Mauricio Sanchez||314-993-6969||Heart Health Center|
|New Hampshire||Manchester||Dr. Connor J. Haugh||603-669-0413||Catholic Medical Center|
|New Hampshire||Manchester||Dr. Jamie H. Kim||603-669-0413||Catholic Medical Center|
|New Jersey||Asbury Park||Dr. Ashish B. Patel||732-663-0300||Monmouth Cardiology|
|New Jersey||Camden||Dr. Zoltan Turi||856-968-7096||Cooper Univ. Hospital|
|New Jersey||Neptune||Dr. Mark A. Mascarenhas||732-776-8535||Monmouth Cardiology|
|New Jersey||Neptune||Dr. Mark J. Hansalia||732-776-8500||Shore Heart Group|
|New Jersey||Parlin||Dr. Zyan Younan||732-727-0400||K. George Younan, MD|
|New York||New York||Dr. Vivek Reddy (Clinical Trial Participant)||212-241-7114||Mount Sinai|
|New York||Manhasset||Dr. Stuart J. Beldner||516-562-2300||North Shore Univ. Hospital|
|New York||New Hyde Park||Dr. Bruce G. Goldner||718-470-7330||Long Island Jewish Medical|
|New York||New Hyde Park||Dr. Apoor Patel||718-470-7330||Long Island Jewish Medical|
|New York||New York||Dr. Srinivas R. Dukkipati||212-241-7114||Mount Sinai|
|New York||New York||Dr. Jacob Koruth||212-241-7114||Mount Sinai|
|New York||Staten Island||Dr. Marcin Kowalski||718-663-7000||Staten Island Univ. Hospital|
|North Carolina||Charlotte||Dr. John W. Holshouser||704-373-0212||Sanger Heart & Vascular|
|Ohio||Cleveland||Dr. Mohamed Kanj||216-444-9162||Cleveland Clinic|
|Ohio||Cleveland||Dr. Walid Saliba||216-444-9162||Cleveland Clinic|
|Ohio||Cleveland||Dr. Oussama M. Wazni||216-444-9162||Cleveland Clinic|
|Ohio||Columbus||Dr. James M. Kleman||614-262-6772||OhioHealth Heart|
|Tennessee||Nashville||Dr. Robert A. “Drew” Pickett||615-329-5144||Saint Thomas Midtown|
|Tennessee||Nashville||Dr. W. David Thompson||615-269-4545||Saint Thomas West|
|Tennessee||Nashville||Dr. Christopher R. Ellis||615-322-2318||Vanderbilt Heart Center for Atrial Fibrillation|
|Texas||Austin||Dr. Rodney Horton (Clinical Trial Participant)||512-807-3150||Texas Cardiac Arrhythmia Institute|
|Texas||Austin||Dr. Andrea Natale||512-807-3150||Texas Cardiac Arrhythmia Institute|
|Texas||Austin||Dr. J. David Burkhardt||512-807-3150||Texas Cardiac Arrhythmia Institute|
|Texas||Austin||Dr. Patrick M. Hranitzky||512-807-3150||Texas Cardiac Arrhythmia Institute|
|Texas||Austin||Dr. David R. Tshopp||512-458-1006||Austin Heart|
|Texas||Fort Worth||Dr. Syed Nayyar Shah||817-334-2800||Heart Center of North Texas|
|Texas||Fort Worth||Dr. Senthil K. Thambidorai||817-334-2800||Heart Center of North Texas|
|Texas||Houston||Dr. Nadim Nasir, Jr.||713-791-1978||Methodist DeBakey Heart|
|Texas||Houston||Dr. Miguel Valderrabano||713-791-1978||Methodist DeBakey Heart|
|Texas||San Antonio||Dr. Kiran N. Jayaram||210-614-5400||Cardiology Clinic of San Antonio|
|Utah||Murray||Dr. J. Peter Weiss||801-507-3513||Intermountain Heart|
|Virginia||Richmond||Dr. John R. Onufer (Clinical Trial Participant)||804-288-4494||Virginia Cardiovascular Specialists|
|Virginia||Norfolk||Dr. Ian Woollett||757-597-9294||Sentara Cardiovascular Research|
|Washington||Seattle||Dr. Adam Zivin||206-861-8550||Swedish Heart & Vascular|
|Washington||Seattle||Dr. Jordan Prutkin||206-598-4300||UW Medicine Regional Heart Clinic|
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Last updated: Saturday, May 21, 2016