Occluder therapy with Atrial Fibrillation: Left Atrial Appendage occlusion prevents stroke – an alternative to anticoagulant medication?
Atrial Fibrillation increases the risk of stroke. If coagulation-inhibiting medications (blood thinners) cannot be used, then occlusion of the heart’s left atrial appendage can significantly reduce the risk of stroke.
Usually, blood-thinning medications (anticoagulation tablets) are given to atrial fibrillation patients as a preventive measure against stroke. However, for patients who cannot take these medications, e.g. due to a high bleeding risk or because of a previous bleeding, occlusion of the left atrial appendage (LAA) with an implanted plug device provides an alternative treatment option. A guiding sheath is introduced via the femoral vein and advanced towards the heart, to the entrance of the cavernous LAA structure that protrudes from the left atrium. At the Osypka Heart Center this procedure is essentially guided by 3D echocardiography. Each individual step of the procedure is supported by 3D imaging, which makes the procedure very accurate and safe. The previously folded occluding device is released into the LAA structure where it unfolds by itself due to its nitinol (memory metal) structure.
Implantation with 3D Echocardiography
We use 3D echocardiography to optimally choose the appropriate size of the occluding device that will be implanted. 3D echocardiography is also used at each step during the implantation procedure, aiding the guiding sheath and operator, possibly further supported by x-ray, to optimally place and implant the device. The correct place and positioning of the occluder can thus be optimally assessed before and after implantation. Until the final dislodgement, the device can be repositioned and even removed at any time. The majority of blood clots build up in the left atrial appendage (LAA) (Atrial Fibrillation/Stroke risk). The occluding device acts like a mechanical plug that seals off the LAA structure, thus preventing any possible build-up of thrombi (blood clots). After implantation the patient has to take, for a short time, thrombocyte aggregation inhibitor medication in order to prevent clot build-up on the freshly implanted device. However, after a short time period the plug will be covered with the heart’s own endothelial tissue, such that the medication will only have to be taken for about 3-6 months.
Modern Imaging (Fusion Imaging) at the OHC
X-ray imaging in the cath lab only allows depiction of the LAA in two dimensions (2D). The LAA itself is not even directly visible, it can only be made visible through injection of contrast medium using a so-called pig-tail catheter. This is in contrast to 3D echocardiography: here the LAA structure can be visualized in great detail and real time using harmless ultrasound energy. This does not require any x-ray imaging. At the OHC we have an additional tool called the Echo-navigator-technique, which allows to overlay and fuse the images of both imaging modalities. This way the physician can optimally use the advantages of both imaging systems in one depiction. This also allows particularly short x-ray exposure times and short operator times at the OHC. Thanks to this technological advancement the possibly dangerous anesthesia of very ill patients can be avoided. Our team of experts has an exceptional amount of experience with these minimally-invasive implantation techniques as they have been the pioneers performing the world’s first implantation of an occluding device many years ago. Additionally, our physicians are internationally active in proctoring other doctors, and are leaders in the establishment of new standards and the development of new treatment options.
Please ask us for any further information regarding the Occluder Device Program
Which examinations are required before undergoing an LAA occluder implantation?
In case you are being referred by your family physician or medical specialist for LAA occluder implantation, we will first evaluate whether plug implantation is technically and anatomically feasible. Please bring to your appointment at our arrhythmia outpatient office hours any recent documentation (doctor’s letters, laboratory results, examination reports, etc.), if possible. At the Osypka Heart Center we will examine via 3D echocardiography (3D TEE), to make sure that there are no blood clots already situated in the left atrial appendage, that the implantation of an occluding device is technically feasible, and which occluding device may be most appropriate for You.
Please bring, if possible, any lab tests and possibly anticoagulant card (e.g. Marcumar passport) with you. If occluder device implantation is the appropriate treatment option for You, we will already in the same appointment give You the medical briefing, to make your in-hospital stay as short as possible. If additional examinations are required we will organize those for You beforehand.
What is an LAA occluding device?
A left atrial appendage (LAA) occluding device is a kind of „plug“ device, that is implanted to occlude the entrance of the LAA, a protrusion on the left atrial wall. The devices are made of thin mesh wires out of flexible material (nitinol). This material has a special memory effect: it can be folded into a very small structure and upon release finds its original shape on its own. This allows transportation within a narrow catheter sheath via a small insertion in the femoral vein, all the way to the heart and the left atrium. Inside the heart the device is released from the sheath and takes up its original structure, which is much larger than the catheter in which it was delivered. There are several systems with some technical differences that are currently available in Germany. With the Amplatzer occluding device, e.g. the plug consists of two connected parts, a body portion and a closure disc. In the video animation in the upper left side You can see the successive release and unfolding of the body and the disc one after the other.
How is closure of the LAA achieved?
Implantation of an LAA device is usually performed via general anesthesia, or a short sedation. After a small puncture of the femoral vein in the groin area (usually on the right side), a catheter sheath system is being advanced into the right atrium, followed by a transseptal passage into the left atrium. The image on the left shows the different phases of the unfolding of the occluding device.
Upper left: partial opening of the body part. Under ultrasound vision the device is guided into its final position.
Upper right: unfolding of the body, ultrasound-check of appropriate positioning.
Lower Left: unfolding of disc portion. Ultrasound-check of the complete system.
Lower Right: implanted device in final position after removal of catheter. The animation video shows the complete procedure (Video animation by Abbott Laboratories.)
What happens after the implantation?
After implantation of the occluder there is a final check in the cath lab regarding the position and impermeability of the device. An additional ultrasound (TEE) check is performed before the patient is released from the hospital. Anticoagulation medication has to be continued until the occluder is completely grown in and an endothelial layer covers the device. In any case a dual antiplatelet inhibitor is indicated, usually for about 3 months. Regular out-patient check ups are required in case of high bleeding risk.
At our cardiac arrhythmia office hours we will take care of You in close consultation with your attending physician.
Mrs. Monika Haberland
Mrs. Petra Peulic
+49 89 72400 4343
+49 89 72400 4391
089 72400 4399
Peter Osypka Herzzentrum
München Süd GmbH
Am Isarkanal 36