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EP on EP Episode 40 - Update on LAA Closure
EP on EP Episode 40
EP on EP Episode 40
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Video Transcription
Hi, this is Eric Prystowski. Welcome to another episode of EP on EP. I'm thrilled today to have a buddy for years and really one of the leaders in this whole area of leptatrial appendage occlusion, Dr. DJ Laccaretti, who is now the executive medical director at the Kansas City Heart Rhythm Institute. DJ, welcome to the show. Eric, thank you. So you've had such an impact in this area, you've done so much of the research, so let's first start with what's available for leptatrial occlusions and then maybe we'll go into some of the indications. Well, I mean, as you pointed out, the leptatrial appendage has really, I mean, exploded in a sort of, from a research standpoint and a clinical activity standpoint in the last 15 years. And I think the amount of progress we made in the last five years is even more incredible. So there are at least 20 plus devices that are out there in different phases of development, and of which I would say about four or five technologies are probably more mature, and probably three or four of them have a lot amount of data that has already been published. So first of all, there is the Watchman device that is currently marketed by Boston Scientific that is approved in most of the places in the world, including the United States. And then we have the Amulet, a leptatrial appendage plug manufactured by Abbott Medical. It is mostly available in Europe, and it is only in a clinical study in the United States. And then you have the Lariat that has a soft tissue phytoncaine approval, and then the Atriclip, these are the two epicardial devices that are out there. And then you have a plethora of other things that are still in clinical trials and that haven't really hit the mainstream yet. So when you think about the leptatrial appendage, I think for the longest of the time, people didn't realize what was causing strokes in patients of atrial fibrillation. And then about, I mean, the early data, as early as 1949, when John Madden came up with this beautiful paper in JAMA describing how he could prevent a stroke in patients that have an appendage thrombus, I think really started off this insight into why we should do an appendage exclusion. So the surgeons did it for almost five to six decades, but then it kind of fell off of the sideways a little bit, and people got disinterested because the techniques of surgical exclusion did not really pan out. There were a lot of leaks, and there were incomplete exclusions. So people weren't really not sure if the appendage exclusion was ever really going to make it or not. And then Michael Esch came up with his invention in 2001, along with Horst Seward. They did the first percutaneous appendage closure with the PLATO device. And unfortunately, it had some early issues, design-wise and complications-wise. And then the IP was brought over by Atrotech, which led to the origins of WATCHMAN. So after two large pivotal trials, the PREVAIL and PROTECT-AFib, finally, after 10 years of iteration, FDA finally allowed to have an indication for this, which is patients who are very high risk for continued oral anticoagulation, and they have atrial fibrillation, a left atrial appendage occlusion may be a very reasonable option in getting them off of oral anticoagulation and potentially mitigating the risk of stroke. So when you look at the left atrial appendage, I think globally there are, I mean, four things that come to my mind. One is the whole thrombus issue, because when people go into AFib due to structural electrical functional remodeling, appendage loser ciscontractility becomes a site for thrombus. So mechanical exclusion or occlusion could potentially minimize the risk of thrombus. But then there is a whole thing about the neurohormonal angle of it, which is the... So let's stop with it just a moment, because that's kind of, before you get to that, let me make sure that we can summarize this right. So right now, at least in the United States, it's just the WATCHMAN, but Europe also has the AMULET. AMULET. We're lucky at our institution, we're on the trial, so we can use either one. And the major indication, before we get to the research part, the major indication is still patients who are at high risk for stroke. That's correct. Right? And really can't take an anticoagulant. So before you get to the neurohormone, which I definitely want to cover, would you please update me on where we stand if you're an ablation person and you do a left atrial appendage occlusion. They're at higher risk for stroke, right? That's correct. So I know you've done some work in this area. The question is, should you put an occlusive device in automatically afterwards or later or stage it? What are your thoughts on that? I think it's an excellent question, very relevant, because as the disease process evolves, as you're very aware, the non-pulmonary vein triggers, including the left atrial appendage, become very relevant. And there is data to show that a significant number of these non-pulmonary vein triggers are harbored in left atrial appendage. So the idea of endocardial isolation really became popular over the last decade or so, and more and more people are now adapting left atrial appendage to endocardial isolation. Even though it's relatively difficult, it takes more than one procedure oftentimes. And then what happens to this appendage, which is now achinitic. And there are also some differences, like some people isolate the appendage more close to the ostium, some people do a more wide anterior wall isolation. So in those cases, when you do a wide anterior wall isolation, the passive filling that helps to fill and empty the left atrial appendage is now gone, and so now the left atrial appendage becomes a sitting duck for thrombus formation. There are reports even from the European guys that despite anticoagulation, sometimes you have thrombus in it. So you should make this maybe part of your decision making before you do that kind of ablation. That's correct. I understand from talking to Dr. Natale, and you said the same, it often takes a couple of procedures. So I'm thinking that maybe you would plan this after you really feel it's isolated? That's correct. I think you've got to prepare the patient about the possibility of an appendage closure. And I think that preparation has to happen even before you decide that you want to isolate the left atrial appendage. Got you. And I think it's the right thing to do in the long term. So there are several new trials that are being looked at where you isolate the left atrial appendage and then go ahead and plug the left atrial appendage. So I think it's exciting some of the work you've published in the past year that a lot of people don't know about it. So tell us just briefly, because we're kind of getting to the end, tell us a little bit about this neurohormonal issue with the left atrial appendage. So the whole neurohormonal area is, I think, pretty exciting. We know that it's an important source of atrial natriuretic peptide. So the experience from the surgeons and the subsequent LARIT experience has shown us that there are significant changes in the ANP levels after you ligate off the appendage or when you put a clip on it. The same thing does not happen with an endocardial occluder. As a byproduct, we also noticed that there is a significant sustained drop in blood pressure stool. So there's an antihypertensive benefit. So this really provoked us to do a systematic assessment of the neurohormonal profile, looking at aldosterone, renin-angiotensin levels, epinephrine, norepinephrine levels, BNP, ANP, and all of this. And what you'll find is there is a significant downregulation of the renin-angiotensin activation system. By occluding it or by plugging it? By epicardially excluding it. Not plugging it? Not plugging it. But the tissue has to die. Oh, so the tissue has to die, right. So the periganglionic fat pad that exists around the left atrial appendage. I think has some primordial connections to the adrenergic system and the adrenals, because embryologically, they all develop around the same time. So there is a primordial connection to it. And in fact, the effect of the sustained drop in blood pressure is agnostic of the type of device that you use. Whether you resect it, you clip it, you lariat it. As long as you get rid of it. You want to get rid of it. So not to interrupt you, but because I know when people start talking about their research, it could be two hours. So me too. So here's what I'm going to do, I'm going to make you a deal. At some point, you're going to show us a prospective trial with this, with lowering the blood pressure. That's correct. We're actually working on it. Right. I figured that. So here's my promise to you, and you have to be okay with this. I'm going to bring you back for part two, because that's exciting. But since we know you're working on it, and we know you've published your original data, I'm going to wait on the, any more on this until you get some data on the blood pressure. Sound like a deal? Sounds like a plan. All right.
Video Summary
Dr. DJ Laccaretti, executive medical director at the Kansas City Heart Rhythm Institute, discusses the advancements in left atrial appendage occlusion. He mentions that there are currently several devices available, including the Watchman and Amulet devices. These devices are used for patients at high risk for stroke who cannot take anticoagulants. Dr. Laccaretti also discusses the use of left atrial appendage occlusion after ablation procedures, as well as the potential neurohormonal benefits of occluding the appendage. He mentions ongoing research on the impact of appendage closure on blood pressure.
Keywords
left atrial appendage occlusion
Watchman device
Amulet device
stroke risk
anticoagulants
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