• Interventional Techniques & Devices
• Cerebrovascular Disease
• Arrhythmias

• Interventional Techniques & Devices
• Cardiology & Cardiovascular Medicine
• Cerebrovascular Disease
• Arrhythmias

In patients with atrial fibrillation (AF), ∼90% of emboli are thought to form within the left atrial appendage (LAA). Since AF is the number one cause of stroke in older adults, some physicians have hypothesized that removing or isolating the LAA may an effective treatment option to reduce the risk of embolic stroke. This is especially applicable to those patients who are poor candidates for anticoagulants, according to Hakop Hrachian-Haftevani, MD, Baptist Health System, South Miami, Florida, USA.

The United States Food and Drug Administration (FDA)-approved LARIAT device is used for percutaneous LAA closure. This device has been used in more than 1400 patients with a closure rate of 98%.

The device is deployed in a series of steps. First, a wire/catheter system is used to cross the atrial septum and place a special wire containing a deflated balloon into the LAA. At the same time, a silk tie (ie, the lariat) is placed around the neck of the LAA from the outside, by a small device inserted via a small incision made in the chest wall. Next, the balloon is inflated inside the LAA to allow placement and tightening of the lariat around the neck of the LAA (proximal to the inflated balloon). The lariat is then further tightened, tied, and cut resulting in isolation of the appendage from the left atrium.

After the procedure, the surgical area is permitted to drain for 24 hours with monitoring and/or management of pericarditis. Periprocedural antibiotics are used in some cases and anticoagulation is continued for a few months after implantation. Isolation of the appendage results in atrophy of the appendage within a year.

The use of preoperative imaging is essential for assessment of the neighboring anatomy in patients planned for this procedure. Unique anatomical characteristics of the appendage must also be taken into account, such as whether it has a single lobe or windsock morphology (technically easier) or whether it has a chicken wing, broccoli, or cauliflower-like morphology. These latter appendage morphologies tend to be larger and are associated with advanced age and existing blood clots.

Despite its benefits, the LARIAT procedure is not for everyone. Patients who should not have the LARIAT procedure include those who have had prior chest radiation, heart surgery, or have developed scars around the LAA and surrounding pericardial region for any other reason. This is because the device requires freedom of movement within the pericardial space. In addition, the upper size limit of the appendage is for this procedure is 4 cm.

For patients with AF that cannot take anticoagulant drugs, the LARIAT device offers an FDA-approved intervention that may be a permanent option to reduce the risk of associated embolic stroke.

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