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The left atrial appendage prophylactic closure (occluder)  for stroke prevention: 


For cases of atrial fibrillation it is often an alternative to medication treatment with anticoagulants (e.g., warfarin) as a way of preventing stroke (cerebrovascular apoplexy), "says Prof. Th. Lewalter of The Isar Heart Center , Munich
Atrial fibrillation, the most common heart rhythm disorder in advanced age, is a condition in which there is a disturbance of the normal contraction of the antechamber. This can cause dangerous blood clots to form in the heart, particularly in the so-called atrial appendage, an appendage of the antechamber. If these clots pass into the bloodstream, they are then called embolisms. If these clots then reach blood vessels located in the brain they can cause a stroke. While anticoagulants (e.g., Warfarin) can often prevent clot formation, not all patients can be treated with such a drug as there are some significant side effects and risks with type of therapy.If the patient has a low tolerance to oral anticoagulants, or an unacceptably high risk of bleeding, this medication for stroke prevention cannot be taken. In such cases a platelet inhibitors treatment, such as with aspirin, is insufficient.
Since the risk of thrombi formation in the left atrium is particularly high in patients with persistent atrial fibrillation, one option is a new method of treatment: the implantation of a left atrial appendage occluder.  In the simplest terms, a left atrial appendage occluder is a sort of "plug" which closes the atrial appendage permanently. The principle is similar to other closure systems (ASD or PFO Occluder). The procedure calls for a long sheath to be advanced through a vein in the groin up to the right atrium, the atrial septum is illuminated by fluoroscopic means and, guided by continuous echocardiography, the closure system is introduced into the atrial appendage. Clinical studies have shown that after a successful sealing of the atrial appendage, the decrease in the stroke rate was even lower than that of patients who had been treated with an anticoagulant (warfarin®).

Verschluss des Vorhofohres bei Vorhofflimmern mittels Katheter Occluder

Left: A representation of the steps of implantation.
A guide-catheter is introduced into the left atrial appendage. The closure device (in the middle) is unfolded and then released from the catheter (right).

What are the risks of atrial appendage closure?

As with any type of catheter intervention, there is some risk associated with a closure in the left atrial appendage. During the implantation, there is the possibility the catheter may cause injury to the heart walls, which are very thin in the area of the atria. Another risk is the induction of stroke or embolization of the closure system. These risks can be reduced by the use of a high-resolution ultrasound system in the context of a TEE exam. An experienced physician can estimate in advance whether an implant in the left atrial appendage can be taken into consideration. During the exam itself, a continuous monitoring of the position of the closure system is important. Here, the examiner and the echocardiographic operator (specialist) must work closely together in order to ensure that the position of the closing system is on target. After the release of the system, an echocardiographic assessment is made. Modern ultrasound systems today allow a representation of the closure system in 3D. Control over the placement and positioning of the occluder system has been greatly simplified.
Following the implantation, the occluder system becomes integrated into the surrounding tissue. A new vascular endothelium (a layer of cells) forms on the surface. Following this process, the risk of stroke is permanently reduced and the patient can dispense with the use of anticoagulants. Whether this form of treatment is suitable for every patient must be decided on an individual basis.  Factors such as medical indicators and anatomical conditions must be taken into consideration.
The Isar Heart Center recently had a live report on such implantation procedures during the PCI-Congress here in Munich.

Implantation of an Amplatzer™ – Atrial Occluder system. The left atrial appendage is sealed by means of the closure system so that can a blood clot can no longer form in this area. Video SJM

Our team of experts will be glad to advise you about atrial appendage closure. You can find answers to questions and information concerning our other areas of focus here.