Epicardial ligation of the left atrial appendage: Long-term results in patients with high stroke and bleeding risk

Author(s): Karin Nentwich, Nuki Kazaishvili, Elena Ene, Artur Berkovitz, Julian Müller, Sebastian Barth, Thomas Deneke

Introduction: Left atrial appendage (LAA) closure may be performed in atrial fibrillation (AF) patients with contraindications for anticoagulation and high stroke risk. Multiple trials have proven non inferiority of endocardial LAA occlusion in terms of total stroke events versus oral anticoagulation, while epicardial LAA exclusion at the time of open heart surgery has led to a decrease in embolic stroke events. In our center percutaneous LAA ligation using the Lariat device is the primary technique for LAA closure since long-term antithrombotic medication is not needed. Long-term safety and efficacy of percutaneous epicardial ligation appears favorable, but there is a lack of evidence of stroke prevention. We present follow-up data up to 6 years of a large single center group of AF patients with contraindications to oral anticoagulation (OAC) therapy undergoing the LARIAT procedure.

Method: 125 patients out of 211 screened patients (59%) were eligible for percutaneous epicardial ligation between December 2015 and August 2023. Standardized follow up (FUP) with transesophageal echo (TOE) was performed at 6 weeks, 12 weeks and 12 months. Clinical (death, hemorrhagic stroke, embolic event, readministration of anticoagulation) FUP was performed every 12 months thereafter. If possible, TOE data after 12 months were documented.

Results: LAA ligation using the LARIAT system was successful in 118 (50,4% male) of 125 patients (93%). Mean age was 74.3 years, mean CHA2DS2VASC score 4,1, mean HASBLED score was 3. Procedure associated major complication was recorded in 1 patient with LAA laceration and need for surgical revision, procedure associated minor complications were recorded in 3 patients. 6 weeks FUP was available in 92 patients, 12 weeks FUP in 66 patients and 12 months FUP in 40 patients. 6 patients developed pericarditis, 7 patients developed devicerelated thrombus (1 patient had a stroke), 110 patients had complete LAA closure and 7 patients had a documented gap of a mean of 2 mm (all ≤ 3 mm). During long term clinical FUP after 12 months (mean 37,7 ± 18 months) 20 patients died (6,7% per year), 4 patients had an embolic event (1 peripheral embolic event, 3 strokes) meaning a stroke rate of 0,98%/y. In 13 patients anticoagulation was restarted for different reasons. In 74 patients T0E was available mean 32 months after ligation documenting no late development of thrombus or gap.

Conclusion: Long-term follow-up of percutaneous epicardial ligation of the LAA shows high LAA closure efficacy and safety. No late ligationassociated complications were noted, no new thrombus or gap formation could be detected after 3 months. Percutaneous epicardial ligation of the LAA results in an absolute risk reduction of 3%/y and a relative risk reduction of 76 % for a CHA2DS2VASC 4 AF population.