2020 AF Symposium Abstract: Combination Device to Both Electrically Isolate and Occlude the LAA
2020 AF Symposium Abstract
Combination Device to Both Electrically Isolate and Occlude the Left Atrial Appendage (LAA)
by Steve S. Ryan

Heart showing location of Left Atrial Appendage (LAA)
Researchers in this study described the Left Atrial Appendage (LAA) as the 5th Pulmonary Vein. It plays a similar role as the PVs in generating A-Fib signals, but is the source of many clots that lead to stroke. Currently implanting an LAA occlusion device is a stand-alone procedure.
How the AuriGen Combination Device Works
An abstract by AuriGen Medical described a study with dogs of a very innovative device which both closes off and electrically isolates the Left Atrial Appendage (LAA) in a one-shot procedure.
The AuriGen Ablation, Delivery and Occlusion System consists of an LAA implant which closes off the LAA with a PET (polyethylene terephthalate) membrane, and an RF Ablation System to circumferential ablate the ostium of the LAA with an RF electrical array. Once implanted, the catheter electrodes are removed through a self-closing access conduit, leaving the occluder in play.
On day 7, the dogs underwent surgery to open the chest (thoracotomy) and observed that the LAA occluder device hadn’t moved. This also indicated that the ablation may have resulted in permanent electrical isolation of the LAA.
Editor’s Comments:
One can’t help but admire how A-Fib researchers and device manufacturers are developing innovative devices to improve A-Fib patient treatment.
From a patient’s perspective, it’s important that doctors and researchers recognize the importance of the LAA as a source of A-Fib signals (potentials). It seems to me that all too many EPs either ignore or put a low priority on mapping and ablating the LAA. Whereas other EPs such as Dr. Andrea Natale, after ablating the PVs, then focus on the LAA before examining any other areas of the heart. They recognize that the LAA often plays a major role in triggering A-Fib signals
Brilliant Idea to Combine LAA Closure with Electrical Isolation: The AuriGen combination occluder/LAA ablation device probably won’t be used in simple, recent onset, paroxysmal A-Fib cases because just isolating the PVs is usually enough to return patients to normal sinus rhythm (NSR).
Instead, the AuriGen combination device would be very useful in more complex cases where patients have had A-Fib for longer periods or who are more at risk of developing LAA clots. The AuriGen device can both close off and isolate the LAA in one procedure.
Practical Use by EPs: It’s is a long way from being available for A-Fib patients.
When and if the AuriGen device becomes available for patients, in practice EPs will probably first do a PVI to isolate the PVs, then proceed to use the AuriGen combination device to close off and isolate the LAA in the same procedure.
This will increase the effectiveness of ablation particularly in cases of persistent A-Fib. And, more importantly for patients, both procedures can be done at the same time.
If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020
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2020 AF Symposium Live Case: LAA Closure with New Generation Device

John Foran MD
AF Symposium 2020
Live Case: LAA Closure with New Generation Device
In this live case Dr. John Foran from Royal Brompton Hospital in London, implanted the Watchman FLX to close off the Left Atrial Appendage (LAA) (Boston Scientific). It was in conjunction with several presentations on Left Atrial Appendage Closure (LAAC) devices.
The moderator for this live case was Dr. Walid Saliba of the Cleveland Clinic. The Panelists were Dr. Jacqueline Saw of Vancouver General Hospital and Dr. Dhanunjaya Lakkireddy of the Kansas City Heart Rhythm Institute.
Patient History
This male patient with persistent A-Fib had recently suffered a hemorrhagic (bleeding) stroke. He had been in A-Fib for 20 years and had a long history of hypertension. He had a CHADS-VASc score of 4 and a HAS-BLED score of 3. He was formerly on warfarin for 17 years, then switched to edoxaban (Savaysa) for one year when he had his “catastrophic” cerebral bleed. Happily, he eventually made a good recovery.
Dr. Foran would not state that his patient’s hemorrhagic stroke came from his years of being on anticoagulants. He raised the alternative possibility that the man’s stroke could have come from a hypertension bleed. Dr. Foran said he tries to insert a Watchman device as soon as possible after a cerebral stroke.
Patient Drug Treatments
His doctors stopped his anticoagulant when he was approved for Left Atrial Appendage Closure. He was put on Apixaban (Eliquis) 2/day for a short period of time.
As of April 2020, the Watchman FLX device is not yet approved for use in the U.S.
Dr. Foran said, “we always anticoagulate in the lead-up to an implant procedure.” The apixaban was continued through the procedure.
Post-op, the patient will be given apixaban as well as aspirin during six weeks after the procedure. Then he will be on apixaban for 6 months.
The Next Generation: Watchman FLX Occlusion Device
Dr. Foran displayed the earlier Watchman 2.5 version (left) and compared it to the new Watchman FLX (right).

Comparison of Watchman 2.5 (left) and Watchman FLX (right)
The Watchman FLX has a closed cell architecture with no sharp points at the top. The threaded insert is much smaller with less metal visible. (In the older Watchman device, it was found that thrombi (clots) could form on the metal insert visible after the Watchman was inserted.)
The Watchman FLX is designed to conform better to individual anatomies.

Watchman FLX -18 J-hooks in 2 rows
It uses 18 hooks offset in two different planes as compared to the older Watchman 2.5 which had 10 hooks. This allows the FLX to hook deeper into the LAA.
Dr. Foran said the older Watchman had sharp points at the top which meant you couldn’t push it forward very hard into the heart tissue̶-particularly in someone with a small LAA (like this patient).
Because the Watchman FLX is more flexible, he no longer uses the earlier Watchman 2.5 version.
Inserting the Watchman FLX
When the Symposium audience joined the live ablation, the patient had already been prepped in the EP lab. The catheters were already in place in the heart.

Illustration of Watchman inserted into Left Atrial Appendage
We watched as Dr. Foran, using fluoroscopy (x-ray) and echocardiogram, inserted the Watchman FLX into the opening of the LAA. He used saline and color flow for contrast to show where the sheath was.
Dr. Foran showed how there were air bubbles inside the sheath which he flushed out with saline.
Next, he opened up the Watchman FLX inside the LAA. He pushed in the Watchman FLX for 10 seconds to better imbed the device’s hooks. He then tugged on it a couple of times to make sure the anchors were well seated.
To complete the procedure, he then released the Watchman FLX and withdrew the sheath.
Editor’s Comments
My own electrophysiologist (EP), Dr. Shephal Doshi at Pacific Heart in Santa Monica, CA, told me it normally takes him only around 20 minutes to insert a Watchman. The new Watchman FLX appears to be even easier to install.
The biggest improvement in the Watchman FLX, in my opinion, is the smaller threaded insert with much less metal visible. Patients will likely have significantly reduced risk of clots forming on metal, which was an annoying problem that sometimes occurred with the earlier Watchman.
Approved in Europe but Not in U.S.: In Europe, Boston Scientific received CE Mark certification in March 2019 and initiated a limited market release of the Watchman FLX™ in the European Economic Area (EEA).
In the U.S., clinical trials of the Watchman FLX are under way in 29 U.S. medicals centers. The trials close in Feb. 2021. I expect eventual approval by the U.S. Food and Drug Administration (FDA).About 85% of A-Fib strokes are ischemic strokes; this A-Fib patient had a hemorrhagic stroke which is less common.
The Patient’s Hemorrhagic Stroke: Did anticoagulants cause or contribute significantly to this patient’s bleeding stroke?
We simply can’t say for sure whether being on anticoagulants for so many years caused or contributed to this patient’s cerebral hemorrhage (bleeding stroke).
As Dr. Foran pointed out, the patient’s hypertension may have been a factor in his stroke.
But anticoagulants are not like taking vitamins. They work by causing or increasing bleeding. However, they are certainly better than having an A-Fib ischemic (blocking blood flow) clot and stroke.
A-Fib Patients and Hemorrhagic Stroke: Recent research indicates that the risk of a hemorrhagic stroke, particularly in older A-Fib patients, should be considered carefully and can be very dangerous. For more about A-Fib and Hemorrhagic stroke, see my article, Anticoagulants Increase Risk of Hemorrhagic-Type Strokes
If you find any errors on this page, email us. Y Last updated: Wednesday, August 26, 2020
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Considering a LAA Occlusion Closure? Watch Out for Nickel Allergy
Approximately 8% of us have a nickel allergy. If you’ve had your ears pierced (or some other body part) and had to use “hypoallergenic” jewelry, you most likely have a nickel allergy. (My wife, Patti, says gold earrings also work for her nickel allergy but are more costly.) It is one of the most common causes of metal sensitivities in people. It’s estimated that 15% to 20% of women in the U.S. are allergic to nickel due to jewelry exposure.
If you’re one of the many A-Fib patients looking to close off their Left Atrial Appendage, be aware if you have a nickel allergy, you have limited choices of an occlusion device.
Thanks to Frances Koepnick for alerting us to this problem. She had to cancel having a Watchman implanted because of her nickel allergy.
Nickel in Occlusion Devices

Heart illustration showing the Left Atrial Appendage
Watchman occlusion device (Boston Scientific): The Watchman contains Nitinol, a metal that is approximately 50% nickel and 50% titanium. The manufacturer states that individuals with a nickel allergy are ineligible for a Watchman implant.
Amplatzer Amulet occlusion device (St. Jude Medical-Abbott): The Amulet also contains nitinol and, therefore, has the same implications for nickel allergy.
Hyper-sensitivity Diagnostic Test Results
Standard skin/patch testing is considered unreliable for metal allergy testing. “Metal-LLT (Lymphocyte Transformation Testing)” is a diagnostic test used by allergists to measure hypersensitivity responses.
Below is a sample of test results showing nickel sensitivity:
Metal Challenge | Stimulation Index | Range (percentile based) |
Aluminum | 0.9 | Normal (Non-Reactive) |
Nickel | 4.2 | Reactive |
Iron | 0.7 | Normal |
For LAA Closure: What To Do About a Nickel Allergy?
Right now Frances seems to have two options: the Lariat II device (SentraHEART Inc) and a surgical approach using the second generation AtriClip which does not contain nickel, and as such, is suitable for LAA closure in individuals with nickel allergies.
The Lariat II does contain Nitinol, but it is gold plated. The gold plating acts as a barrier to nitinol/nickel exposure. Though formerly approved by the FDA, the Lariat II device is currently in a second (extended) “Amaze”clinical trial which is due to be completed in December 2019. For more about the SentraHeart Lariat device, see my article, Lariat II Suture Delivery Device.
The AtriClip is traditionally used during open-heart, Maze, or Mini-Maze surgery to close off the LAA. But it can be used as a stand-alone secondary heart surgery, which is traumatic and risky. The first generation AtriClip is essentially a “rectangle” placed around the LAA. Then it’s collapsed to close off the LAA. It does contain nitinol (50% titanium + 50% nickel) to provide felxibility for insertion. One major advantage of the AtriClip is it removes (closes off) the LAA which also eliminates electrical activity (A-Fib signals) that the LAA may have been producing.
The second generation AtriClip is more like a “hair clip”. Once the clip is correctly placed around the LAA, it’s then “triggered” by a type of spring-loading which doesn’t require the flexibility of nitinol.
Additional warning: today’s pacemaker leads may also contain nickel.
Be very careful selecting a surgeon to install the AtriClip. As a stand-alone surgery, it can be somewhat challenging. Make sure your surgeon has a lot of experience and verifiable success results.
The Watchman Occlusion Device and Risk of Device-Related Blood Clot
The Watchman is an occlusion device that closes off the Left Atrial Appendage (LAA) to prevent clots from getting into the heart. For those with A-Fib, 90%–95% of clots and strokes come from the LAA.
The Watchman device is considered an alternative or an improvement to a lifetime of taking anticoagulants including warfarin and the NOACs. See Watchman Alternative to Coumadin and Watchman Better Than Warfarin.
2018 HRS Report: Clots Can Form on the Watchman
A new meta-analysis of clinical trials and registries of the Watchman device is believed to be the largest to date of Device-Related Thrombi (blood clot) following left atrial appendage closure.

Size comparison of the Watchman occlusion device
The study shows that in about 3.7 percent of patients a blood clot forms on a metal screw on the face of the device. The clot can form many months, even a year after installation.
“While not frequent, when present, thrombus on the face of an LAA occluder is associated with a high rate of ischemic stroke,” said study presenter Vivek Y. Reddy of Mount Sinai Hospital in New York City. (Dr. Reddy was one of the original investigators of the Watchman clinical trials.) These findings were presented at the 2018 Heart Rhythm Society meeting.
Device-related thrombi (DRTs) are troublesome because they increase the risk of ischemic stroke by over 3 fold. However, no significant association with mortality emerged.
This risk, Dr. Reddy said, calls for aggressive management of patients at risk for device-related blood clots.
The Study: Finds Device-Related Thrombi (DRTs)
To better understand the mechanism of stroke after LAA closure, Dr. Vivek Reddy and his colleagues, looked at the incidence, predictors and clinical outcomes of device-related thrombus (DRT).

Watchman device: inserted (L) and progression of proper tissue growth (R)
The meta-analysis study looked at data on 1,739 patients who were successfully implanted with the Watchman device as part of four prior clinical studies. Patient follow-ups included a transesophageal echocardiography (TEE).
Findings: Among those patients receiving a Watchman, the investigators found 65 patients (3.74%) had DRT. Most were detected after anticoagulation had been discontinued at 45 days post-insertion. Some DRTs first showed up at the 1-year TEE.
Dr. Reddy reported that despite these findings, a majority of Watchman patients with an identified DRT (74% of the 65 patients) did not have a stroke. And in Watchman patients who did have stroke, 87% occurred in the absence of a DRT.
Implications: There is a strong case for rethinking the timing of planned follow-up TEE examinations of Watchman patients. The standard protocol is a TEE at 45 days after placement, when routine anticoagulation usually stops, and then a second TEE 12 months after placement.
Dr. Reddy suggests a better schedule might be to perform the first TEE at 3-4 months after placement when oral anticoagulant therapy stops. This gives time for a potential DRT to form.
What this Means For Those Patients With a Watchman
“Prevention and management of DRT may require that each [Watchman] patient receive a tailored regimen of anticoagulation and surveillance,” said B. De Lurgio, MD, a cardiac electrophysiologist at Emory Healthcare commenting on Reddy’s report.
If you have a Watchman device, you and your EP should discuss “aggressive surveillance” to find any clots on the face of your Watchman. Usually these can be resolved by taking a course of anticoagulants.
If Closing the LAA: An Alternative Occlusion Device

Lariat placement: lasso around opening to LAA
With no metal involved, another occlusion device is the Lariat II noose-like device which is slipped around the LAA. This ‘lasso’ is then tightened, and eventually the tissue dies and shrivels up (like a grape into a raisin).
But there has been a reported problem with the Lariat, too. For more on the Lariat see my article: Alert: Patients with Lariat Device for Left Atrial Appendage Closure.
A Challenge to Install: Compared to the Watchman, the Lariat is more challenging to install and is currently used less often than the Watchman. Not all EPs install and have experience with the Lariat II. You may need to do research to find an EP experienced and good at installing the Lariat. For more about the Lariat, see Lariat II Suture to Close the Left Atrial Appendage.
Watchman Still As Effective As Warfarin
Regarding this DRT data, Dr. Reddy said he didn’t think this data takes away from the argument that the Watchman is a reasonable strategy. “It doesn’t add or detract from the previous data.”
Comparing stroke risks: In cases where no treatment was applied (neither anticoagulants nor the Watchman), the overall ischemic stroke rate is 6.0% per year.
Contrast that 6% rate to the stroke rates of 1.77% per year in people with the Watchman device and 1.71% per year for those on oral anticoagulation.
The Watchman is still a viable option against stroke risk.
FAQ: I am considering closure of the LAA. What do I need to know?”
FAQ: Closure of the LAA
“I don’t want to be on a blood thinner for years and years. My doctor is talking about closure of the Left Atrial Appendage. What is an occlusion device?”
An occlusion device, like the FDA approved Watchman., is used to close off the Left Atrial Appendage (LAA), the source of most clots (90%-95%) and A-Fib-related strokes.
The Watchman is inserted in a very low risk procedure that takes as little as 20 minutes. Afterward, you would usually not need to be on a blood thinner (anticoagulant).
Closure of the LAA is often included in a Maze/Mini-Maze surgery and sometimes as part of a catheter ablation.
Side Effects: Closure of the LAA may compromise the ability of the Left Atrium to function fully. Serious athletes would probably miss the reduced blood flow from the left atrium. But most A-Fib patients would hardly notice.

Catheter placing Watchman in LAA
Long-Term Effects: What are the long-term effects of leaving a mechanical device like the Watchman inside the heart? We know that, after a few months, heart tissue grows over the Watchman device so that the LAA is permanently closed off from the rest of the heart.
It seems unlikely that complications would develop after a long period of time (compared to long-term use of the blood thinner, warfarin). But we can’t say that for sure until enough time has passed. The first clinical trials installation of the Watchman device in the US was in 2009 and in Europe in 2004. So far, no long-term complications have developed.
Other Occlusion Devices: Besides the Watchman from Boston Scientific, other occlusion devices include the Amplatz Amulet from St. Jude Medical and the LAmbre from LifeTech Scientific.
EPs Installing the Watchman Device: To find EPs installing the Watchman or other occlusion devices, I highly recommend selecting an electrophysiologist (EP) who is certified in “Clinical Cardiac Electrophysiology”. For a list of EPs meeting this criteria, see Steve’s Lists of A-Fib Doctors by Specialty: Doctors Installing the Watchman.
Reference Articles: To learn more about the removal of the LAA, and the Watchman, see my articles, The Role of the Left Atrial Appendage (LAA) & Removal Issues and The Watchman™ Device: The Alternative to Blood Thinners.
2018 AF Symposium Live Case: CryoBalloon Catheter for Isolation of the LAA
by Steve S. Ryan, PhD.

B. Knight MD
During this live streaming video, Dr. Bradley Knight from Northwestern Un. in Chicago, IL demonstrated the use of a CryoBalloon Catheter to isolate the Left Atrial Appendage (an off-label use, i.e. a new use not described in the FDA approved device labeling.).
Patient background: His patient was a 72-year-old man with hypertension and persistent A-Fib. He had an ablation in 2013. His ejection fraction was low but improved after a cardioversion to 40%. July 15, 2017 he had a right atrium Flutter ablation. He was on amiodarone which had to be stopped because of thyroid problems.
He developed severe Left Atrium enlargement and his ejection fraction went down to 30%. His PVs was were very large and hard to isolate. It was recommended to do both a repeat PVI and to isolate the LAA.
Isolating the Left Atrial Appendage
To isolate the Non-PV triggers originating in the patient’s Left Atrial Appendage, Dr. Knight used a 28 mm CryoBalloon catheter in order to penetrate deeper into the LAA.
A second freeze was performed and then a third freeze was necessary because the LAA was still generating A-Fib signals. Before we could see this third freeze, the allotted time slot ran out.
The use of the CryoBalloon catheter appeared to be an effective treatment (though an off-label use) to isolate the LAA.
Editor’s comments:
I was surprised that two CryoBalloon lesions didn’t effectively isolate the patient’s LAA and a third lesion was necessary.
On the other hand, the use of the CryoBalloon catheter to isolate the LAA is in the very preliminary stage of research.
From watching Dr.Knight’s live case, it doesn’t seem like the CryoBalloon catheter will emerge as a viable method of electrically isolating the LAA.
If you find any errors on this page, email us. Y Last updated: Saturday, February 16, 2019
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2018 AF Symposium Live Case: Installing a Coherex WaveCrest LAA Occlusion Device
by Steve S. Ryan, PhD.
Background: The Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device is not yet approved by the FDA for use in the U.S. The WaveCrest is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved).

Tom De Potter MD
Dr. Tom De Potter of Aalst, Belgium, presented a live case in which he installed a Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device in an 84-year-old female with longstanding A-Fib and a bleeding problem.
The WaveCrest has roll-out anchors which are then fixed into the sides of the LAA. It comes in three sizes to fit different LAA openings.
He spent a good deal of time and attention washing and immersing the WaveCrest in water to make sure there were no bubbles.
When the device is expanded inside the LAA, it can be repositioned and recaptured. Dr. Potter seemed to tug and firmly push and pull the device to anchor it. After insertion, it requires 2 months of dual antiplatelet therapy.
WaveCrest is from Coherex Medical, Inc., a subsidiary of Biosense Webster/Johnson & Johnson.
Coherex WaveCrest Video
Video animation is available: The Coherex Medical website has a short (35-second) showing the installation of the Coherex WaveCrest Left Atrial Appendage (LAA) occlusion device. Go to video on the Coherex website->
Editor’s Comments:
To me the WaveCrest seemed similar to Boston Scientific Watchman LAA Closure Device which did all the heavy lifting to be the first LAA occlusion device to get U.S. FDA approval.
I didn’t see major significant advantages of the WaveCrest. Though it’s always good for EPs to have a choice of devices when closing off the LAA.
For more on the Watchman, see my article, The Watchman™ Device: An Alternative to Blood Thinners.
If you find any errors on this page, email us. Y Last updated: Wednesday, February 28, 2018
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2018 AF Symposium Live Case: Installing an Amplatzer™ Amulet™ LAA Occluder
by Steve S. Ryan, PhD.

Illustration: Amplatzer Amulet in LAA
On the Thursday session on Left Atrial Appendage Closure, two live cases were presented via streaming video from around the world.
Here, I cover the first live case featuring the Amplatzer™ Amulet™ Left Atrial Appendage (LAA) occlusion device. (For my report on the other occluder, see: Installing a Coherex WaveCrest LAA Occlusion Device.)
Note: The Amplatzer™ Amulet™ Left Atrial Appendage (LAA) Occluder, is not yet approved by the FDA for use in the U.S. It is similar in purpose to the Boston Scientific Watchman™ LAA Closure Device (which is FDA approved). The Amplatzer™ Amulet™ is from Abbott (formerly St. Jude Medical).
Patient Background: An 81-year-old lady with acute hypertension was in permanent A-Fib since 2016. Her CHADS2VASc score was 5 (at the top of the risk range), her HAS-BLED score was 4 (high for one year risk of major bleeding). She had suffered syncope (fainting) episodes and had a history of major bleeding on anticoagulants (the reason for the LAA closure). On the positive side, her Ejection Fraction was a healthy 61%.
Live From Milan, Italy

Claudio Tondo, MD
Dr. Claudio Tondo from Milan, Italy, demonstrated an LAA Closure by inserting an Amplatzer LAA closure device.
In Europe, a LAA occluder can be inserted at the same time as a PVI (catheter ablation). But for the AF Symposium live session, only the Amplatzer Amulet™ was inserted. (Because of her history of major bleeding, Dr. Tondo decided to close off her LAA first while postponing a PVI till later.)
Amplatzer Amulet Features

Amplatzer™ Amulet™
The Amplatzer has two lips which close over both the outside and the inside of the LAA―like a sandwich. It comes in different sizes to fit better into different sized LAAs.
One advantage of the Amplatzer is less risk of leaking because the inside and outside lips overlap the opening of the LAA. Over time, heart tissue grows over the implant, becoming part of the heart.
Inserting the Amplatzer LAA Occluder
The primary imaging technology used to insert the Amplatzer was Intracardiac Echo, though fluoroscopy was used as an adjunct to help the audience follow the procedure. In the Echo you could see the Amplatzer being positioned and inserted into the LAA. (I could follow the fluoroscopy but found it hard to follow the Echo.)
Dr. Tondo described her LAA shape as “chicken wing” which is usually an LAA shape easier to close off. It appeared relatively easy to insert the device into the patient’s LAA, then fit it snugly into the LAA opening.
Dr. Tondo and his team used a type of dye pumped in behind the Amplatzer to see if there was any blow back or leaking. Once that was done, they simply disconnected the catheter used to insert the Amplatzer.
Amplatzer™ Amulet™ Video
A short animation from Abbott (formerly St. Jude Medical) illustrates insertion of the Amplatzer™ Amulet™ LAA Occluder (1:14). To watch the video, go to Abbott webpage->
Editor’s Comments:
About this patient: This 81-year-old lady was in a very difficult, risky situation. Her stroke risk was very high, but she couldn’t take anticoagulants to prevent a stroke because they caused her bleeding. By inserting the Amplatzer Amulet device to close off her Left Atrial Appendage (LAA), Dr. Tondo would significantly lower her risk of an A-Fib stroke which mostly comes from the LAA.
Her persistent A-Fib was very symptomatic with dangerous fainting episodes. She needed a catheter ablation to get her back into normal sinus rhythm. Dr. Tondo planned to perform the PVI as soon as possible after her LAA closure.

Two LAA occluder devices
About the Amplatzer Amulet: Having previously watched the Watchman Device procedure, to me the Amplatzer Amulet seemed simpler to insert. Though both are relatively easy to install.
One potential problem with an Amulet might occur if a subsequent catheter ablation requires the LAA to be mapped and isolated. It will be harder to do so because the lips of the Amulet cover the LAA opening.
In Europe, the Amplatzer Amulet is used to close holes in the septum (called ‘patent foramen ovale’, i.e. a hole in the heart that didn’t close the way it should after birth.).
Once approved in the U.S. by the FDA, it will probably become a competitor or an alternative to the Watchman Device.
If you find any errors on this page, email us. Y Last updated: Saturday, February 16, 2019
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2018 AF Symposium Live Case: Isolating the Left Atrial Appendage using RF Energy
by Steve S. Ryan, PhD.

Rodney Horton MD
Dr. Rodney Horton from the Texas Cardiac Arrhythmia Institute in Austin, TX, demonstrated in a live case how to isolate the Left Atrial Appendage (LAA) using Radio Frequency (RF) energy.
Side note: If you been in the EP lab before, the first thing you notice when viewing Dr. Horton at work is no one is wearing the lead aprons and protectors required when using fluoroscopy (x-ray). That’s because he uses 3D non-fluoroscopy (no radiation) imaging techniques.
Patient background: An 82-year old male with persistent A-Fib had a previous PVI but still had Flutter. He was also hypertensive. He also had a dual chamber pacemaker. Previously Dr. Horton had isolated the patient’s Coronary Sinus but hadn’t worked on his LAA.
Before the live case, Dr. Horton found that the patient had re-connection in one vein which he isolated before the live case demonstration began.
The Live Case: Mapping and Isolating the LAA

Live Streaming Video at AF Symposium
Dr. Horton used a mapping catheter in the Left Atrial Appendage (LAA).
To isolate the LAA, he used 40 watts radio frequency (RF) energy and a contact force sensing catheter with pressure readings above 10 but not higher than 25. The pressure readings indicate how hard the EP is pressing on the RF catheter to make a particular burn.
He discussed that if the LAA wasn’t contracting properly after the ablation, the patient would have to be on anticoagulation for life. (He, of course, discussed this possibility with the patient before the ablation.)
Dr. Horton rarely isolates the LAA during a first ablation unless he is absolutely sure it needs to be done. He stressed that the phrenic nerve often drops over the top of the LAA. For that reason, he doesn’t ablate too deep into the LAA but ablates at the base of the LAA.
Applause, Applause
There was excitement and clapping when he isolated the LAA and the Flutter disappeared as we watched.
Dr. Horton demonstrated for all the attendees that the LAA should also be mapped and isolated. And that isolating the LAA can be very effective in returning a patient to normal sinus rhythm.
Editor’s Comments:
No, no to Fluoroscopy: It’s a type of X-ray and its effect is cumulative. Therefore it should be avoided if possible. (Hence, the need for the staff to wear the lead aprons.)
Instead of fluoroscopy, Dr. Horton uses a non-radiation 3D imaging technique called Intracardiac Echocardiography (ICE), a form of ultrasound.
On a personal note, Dr. Horton has said that not having to wear those heavy lead aprons would probably add 5-10 years to his ablation career.
Importance of the LAA in Isolating A-Fib: More and more EPs are realizing how important the LAA is in mapping and isolating non-PV triggers. Many Master EPs after isolating the PVs, now go right to the LAA as their second isolation target.
What this means for patients: When selecting an EP for your catheter ablation, discuss the Left Atrial Appendage (LAA) as a possible site of non-PV A-Fib triggers. Ask your EP:
“During my ablation, when you’re looking for non-PV triggers, will you also map and isolated the LAA, if necessary?” (You want an affirmative answer to your question.)
If you find any errors on this page, email us. Y Last updated: Sunday, February 25, 2018
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