Left Atrial Appendage Closure

Left atrial appendage closure (also known as LAA closure or LAAC) is a minimally invasive procedure that is used to reduce the risk of stroke that comes as a result of atrial fibrillation (also known as Afib or AF.) Atrial fibrillation is a common form of arrhythmia, a condition in which the heart beats out of rhythm.
To understand the LAAC procedure and why your doctor may recommend it for you, it is important to learn why Afib increases the risk for stroke.

Atrial Fibrillation, Stroke and LAA Closure

In atrial fibrillation, the heart beats erratically, which results in it being unable to effectively circulate blood out of the heart and through the body. This leads to blood collecting, or pooling, in the heart where clots can form. If a clot travels to the brain, a stroke can occur.
When blood collects in the heart, the place where it tends to pool is the left atrial appendage (LAA). The LAA is a small sac found at the top of the heart’s upper left chamber (the left atria). If your doctor believes you are at risk for a stroke because of blood clots in your LAA, then you may be treated with blood-thinner medications (anticoagulants) and other medications that help regulate your heartbeat. If these medications are ineffective or if you cannot tolerate them, then your doctor may recommend an LAA closure procedure.

How Does LAA Closure Reduce the Risk of Stroke?

By reducing the risk of blood clots, LAA closure can prevent stroke, or at least reduce the risk of stroke. The procedure works by sealing off the left atrial appendage (the sac where blood clots form in the heart). The type of stroke brought about by a blood clot (including a blood clot caused by Afib) is known as an ischemic stroke. Ischemic strokes account for nearly 90% of all strokes. You can learn more about Afib-related stroke here.

LAA Closure Does Not Cure Atrial Fibrillation

While LAA closure reduces the risk of blood clots in the heart it is not a cure for Afib. It does not stop the irregular or erratic heartbeat, nor does it address the cause of the Afib. You will need to discuss with your doctor options for controlling your Afib and keeping your heart in normal sinus rhythm. Successful treatment and control of Afib will depend on following medical recommendations, including implementing any specific medications or any additional procedures, as well as diet, exercise or other lifestyle changes.

Who Is Eligible for LAA Closure?

No treatment is right for everyone. If you are considering LAA closure to reduce the risk of stroke, your healthcare team will talk with you about the benefits and risks of the procedure considering your specific condition and history. You will also need to know whether your health insurance will cover this procedure.
In general, LAA closure is an option for patients who have been unable to take blood-thinning medications to prevent blood clots caused by atrial fibrillation. The blood-thinner may have caused new bleeding. Or, with warfarin (Coumadin), the dosage may be difficult to regulate. Despite being on blood-thinner medications, some people still have problems with blood clots. However, LAA closure is not the best treatment option for every patient. Your doctor will discuss the various treatment options with you and make recommendations.
All procedures include risks, such as infection, damage to the heart or heart valves, blood clots, blood pressure changes and rare side effects. Your doctor can discuss these concerns with you and explain how they affect you in particular.

How Does LAA Closure Work?

LAA closure is a procedure your doctor will perform while you are under general anesthesia. In LAA closure, small flexible tubes (catheters) will be used to deliver a tiny device into the heart. The device is used to seal off the left atrial appendage, keeping blood from reaching that area. By preventing blood from entering the LAA, the risk of clots forming in the heart is significantly reduced.
Methods of LAA Closure
There are several devices and methods available for sealing off the left atrial appendage. Your medical team will discuss the various options with you and make a recommendation based on your specific situation. As with all surgical procedures, your physician or surgeon will make you aware of the possible risks and complications. These treatments will be reserved for people whose risk for the procedure is less than their risk of stroke or bleeding without the procedure.

  1. LARIAT: The LARIAT procedure involves guiding catheters through the blood vessels to the heart’s left atrial appendage. The catheters are used to tighten a loop around the mouth of the left atrial appendage, tying it off from the rest of the heart.
  2. WATCHMAN or AMPLATZER Cardiac Plug: The WATCHMAN is a tiny, umbrella-shaped device that is delivered to the heart through a catheter. Once the catheter is in place at the opening to the left atrial appendage, the WATCHMAN is implanted in the LAA so that it blocks blood from entering the LAA. The AMPLATZER Cardiac Plug, while shaped differently, is impanted much like the WATCHMAN, also to prevent blood flow into the LAA.
  3. Surgical removal: In some cases, your medical team may recommend that the left atrial appendage should be removed. This requires open-heart surgery and is usually performed during another operation, such as coronary bypass surgery or valve surgery.

If you undergo an LAA procedure with the LARIAT or WATCHMAN device, you will have a test called a transesophageal echocardiogram (TEE) which checks to make sure the closure is complete and also rules out the presence of any remaining blood clots. You will need to take blood-thinner medications for a period of time following the procedure, until your medical team is certain that your body is able to tolerate the device. Your team will also recommend taking aspirin indefinitely to reduce the risk of blood clots forming anywhere else in your heart and blood vessels.

Talk with Your Healthcare Team

If you have atrial fibrillation, it is important to talk openly with your doctors and nurses about your concerns, including any symptoms you may be experiencing or issues with your medications. You should be open and honest about any side effects that you are experiencing or other problems that could prevent you from taking your medications as prescribed. You should always tell your team about any other medications, supplements, vitamins or other products you are taking, because your doctor will want to ensure there are no dangerous interactions.
If you have atrial fibrillation, there are a variety of treatment options. The one that is right for you depends on your condition, how well lifestyle changes and medications are working for you, how you feel about undergoing procedures or surgeries, as well as how much your condition is affecting your quality of life. There is no “one-size-fits-all” treatment plan for atrial fibrillation or for stroke prevention. Working with your healthcare team, you will develop a treatment plan for your specific symptoms, lifestyle and the other factors that make your situation unique.

Some important information about the WATCHMAN procedure:

  • You will stay in the hospital overnight after the procedure.
  • You will need to take aspirin and warfarin until you have your follow-up appointment.
  • You will have a transesophageal echo (TEE) within 48 hours of the procedure.
  • Your first follow-up appointment is 45 days after the procedure. Another TEE will be done at this appointment. If the TEE shows that the LAA is blocked, you will be able to stop taking warfarin and start taking clopidogrel (Plavix) for 6 months.
  • After 6 months, you will stop taking clopidogrel, unless you need to take it for another reason. You will continue daily treatment with aspirin.
  • If the TEE shows that the LAA is not blocked, you will continue taking warfarin and have another TEE and follow-up appointment after 6 months.
  • Once the LAA is blocked, you will have a yearly follow-up appointment in the clinic.
  • You will need an echocardiogram (echo) within 60 days of your procedure.