Left atrial appendage closure to prevent stroke in patients with atrial fibrillation: a call for the heart team approach

With great interest we read the EHRA/EAPCI expert consensus statement on catheter-based left atrial appendage (LAA) occlusion.¹ It is important to emphasize that the seminal efforts to address the LAA originate from open-heart surgery, specifically Madden's seminal report on surgical LAA amputation in 1949, which has driven innovation and the development of less invasive catheter-based approaches to achieve LAA closure.

Current data have led to early clinical adoption of this seemingly attractive therapy. In this regard, the incorporation of surgically applied epicardial closure devices may offer an interesting adjunct for selected patients. Unfortunately, the expert panel just states that ‘…. In addition, a number of other minimally invasive surgical and percutaneous devices including the AtriClip, Cardioablate, and Aegis, are at various stages of advanced animal studies or first in man experiments …’.¹

We believe it is important to also include the surgical devices in this statement. The clinical experience with these surgically placed devices is substantial and can be found in many peer reviewed journals. First, the AtriClip has been implanted in humans since 2007. Over 40 000 devices have been sold since CE mark and FDA approval. Data on this effective device are substantial.^2,3 Next, the long-term imaging controlled data on the AtriClip further substantiate these positive results of complete and durable closure, presenting the first data on durability of LAA closure.³ Second, there is an another epicardial closure device, the Tiger-Paw (MAQUET Medical Systems USA, Wayne, NJ, USA) approved by the FDA yielding similar short-term safety and efficacy results as the aforementioned AtriClip (Atricure, West Chester, OH, USA).⁴ Third, and most importantly, thoracoscopic LAA amputation with 3 months computed tomography control with a linear stapler has been reported in a stand-alone fashion by Ohtsuka et al.⁵ LAA stapler amputation has long been an integral part of surgical minimal invasive atrial fibrillation ablation. The results are summarized in two review papers, reporting on over 1000 patients also highlight feasibility, safety and efficacy of routine surgical LAA amputation.⁶

Before any type of intervention, important anatomical and morphological considerations are mandatory to more accurately predict in which patients a complete and durable transcatheter closure is not likely to be achieved. In these cases, referral for minimally invasive surgical LAA closure should be considered as an option. We believe that only a more focused collaboration between cardiologists and cardiothoracic surgeons (the heart team approach) in regard to device and patient selection would enable a 100% successful LAA closure in all-comers. In regards to stroke prevention obviously more data, and ideally a prospective randomized trial would be necessary.

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