The left atrial appendage (LAA) of the heart may be a small structure, but it plays an outsized role in caring for patients with atrial fibrillation (AFib). Joshua Meskin, MD, cardiologist and MCW faculty member, and Mario Gasparri, MD, cardiothoracic surgeon and MCW faculty member, reviewed the latest strategies for LAA management.
The LAA is like a small, “blind” pouch on the side of the atrium, a developmental remnant that research suggests does not have an important function. Blood flow within it tends to stagnate. AFib only accentuates that and stagnant blood is more likely to clot. For that reason, it is the largest source of clots that can lead to strokes in people with AFib.
“The traditional first-line treatment for patients with AFib and an LAA that puts them at risk for stroke is blood thinners, but not everyone is a candidate for anticoagulation long term,” Dr. Meskin said. “Some patients can’t maintain control of their INR (warfarin levels) or they have a bleeding problem like a lower GI bleed or other disorder. It may also be a lifestyle issue — a downhill skier, for example, who faces increased risk of injury and doesn’t want to be on a blood thinner.”
“For these patients, there has been an effort to address this mechanically if we can’t address it with blood thinners,” Dr. Gasparri said. “Through our multidisciplinary team, we are able to provide referred patients with multiple options to successfully manage the LAA.”
Umbrella-Like WATCHMAN Device Seals the LAA From Inside
“For many patients, the preferred choice for LAA occlusion is the WATCHMAN™ device, an expandable device placed inside the appendage to block it off,” Dr. Meskin said.
Froedtert Hospital, the academic medical center of the Froedtert & the Medical College of Wisconsin health network, has been performing WATCHMAN device procedures since 2015 and is a leading implanter in the state.
“To implant the WATCHMAN device, we enter through a vein in the groin, go up into the heart, cross from one side to the other, place a catheter into the LAA and deploy the WATCHMAN device,” Dr. Meskin said. “It’s like an umbrella that we open at the orifice of the appendage, closing it off. Placement of the WATCHMAN device is critical. I provide imaging support using transesophageal echocardiography, giving direction to the other cardiologist at the table for positioning the catheter.”
Different sizes of the WATCHMAN device are available to fit a variety of LAA anatomies. Sizing is critical as the WATCHMAN device must be large enough so that compression will hold it in place. It can’t be too small that it comes loose and risks tearing tissue.
The WATCHMAN device itself is a combination of metal and fabric. It starts out like a filter and eventually the body grows endothelial tissue over it and seals it. Patients usually go home the same or next day and take anticoagulants for 45 days, followed by aspirin long-term.
“The WATCHMAN device has a very good track record and there’s data that supports better outcomes at higher volume centers like ours where we perform more than 30 implants a year,” Dr. Meskin said.
Robotic-Installed Clip Occludes the LAA From the Outside
While the WATCHMAN device has proven to be effective for many patients, about 10% of patients aren’t candidates because of the anatomy of their LAA or other issues. “Some patients with atrial fibrillation can’t get the WATCHMAN device and can’t take blood thinners,” Dr. Gasparri said. “For them, we offer a robotic clip called AtriClip.”
Instead of blocking the LAA from the inside like the WATCHMAN device, the clip does it from the outside of the heart. The Froedtert & MCW cardiology team has two options — one that looks like a bobby pin and another that looks like an O. Both procedures are performed robotically with three small incisions for the scope and instruments.
“Once near the heart, we open the pericardium so we can see the LAA, dissect it from adjoining structures and then deploy the clip from a delivery device,” Dr. Gasparri said. “Intraoperative echocardiography guides us to make sure the clip is at the base of the appendage before we secure it.”
“It’s a perfect application for the robot, which gives us exceptional visualization,” Dr. Gasparri said. “I sit at the console controlling the robotic arms, while a cardiothoracic surgeon stands at the table and 'fires' the clip. It’s a true collaborative effort where we have both thoracic and cardiac expertise in the room. We check with echocardiography to make sure the clip is in the right place and also do follow-up studies. Patients usually go home the next day and are back to regular activities within 10 to 14 days.”
An Option for Every Patient
“If a physician in the community has concerns about a patient whose anticoagulation is difficult to manage because of risk factors, they don’t have to choose a device on their own,” Dr. Meskin said. “Our cardiologists can help them navigate that and figure out the best option for the patient.”
“With these available procedures, every AFib patient now has an option,” Dr. Gasparri said. “If a patient can’t take blood thinners, the WATCHMAN device should be the first choice. If they can’t have the WATCHMAN device, then we have a successful, minimally invasive clip approach.”
“Shared decision-making governs our choices,” Dr. Meskin said. “Our multidisciplinary team discusses all the options, collaborating to ensure we recommend the right type of procedure for the right patient. Our program is not one-size-fits-all, but rather one stop for all different options.”
