Left atrial appendage occlusion (LAAO)
What is a Left atrial appendage occlusion (LAAO)?
A left atrial appendage closure (LAAO) is a keyhole procedure that involves closing off an area of the top chamber of the heart called the left atrial appendage. This is to prevent blood entering, pooling and forming a clot that can lead to a stroke. The watchman is a plug -like device, that ultimately becomes part of the heart structure.
WHY DO I NEED TO HAVE A LAAO?
LAAO may be offered to you if you have a history of a condition called atrial fibrillation and have problems taking blood thinners that are required to prevent stroke.
Atrial fibrillation is a condition whereby the top chambers of the heart do not contract regularly and can cause blood to pool in the left atrial appendage. Approximately 90% of strokes are caused by clots that form in this area.
You will be prescribed strong blood thinners “anticoagulants” to prevent clotting if you have had a prior stroke or TIA “mini stroke” or have two of the following risk factors: aged 65 or over, diabetes, high blood pressure, heart muscle weakness or cardio/vascular disease.
Not all people can take blood thinners due to an increased risk of bleeding such as bleeding from the gastrointestinal or urinary tract, bleeding into the brain or anaemia of unknown cause. Additional conditions such as Parkinson’s disease, the frail and elderly with poor balance and at an increased risk of falls, are also suitable.
The LAAO is therefore an alternative treatment option to reduce your risk of having a stroke. Peninsula Heart Centre offer two types of LAOO devices- Amulet ® and Watchman ®. The doctor will decide which one best suits your anatomy.
LAAO begins with establishing your indication and suitability for the procedure. Why do you need the device and is your anatomy suitable?
Obtaining a thorough history including stroke and bleeding risks assists us in determining this.
Routine blood tests are ordered to check for anaemia or renal impairment.
A CT scan of the heart structure or a Transoesophageal echocardiogram (link) is needed to measure the size and shape of the left atrial appendage and to exclude the presence of clot. This allows for optimal preparation and planning prior to putting a patient on the table.
It is an invasive procedure performed in the angiography hybrid lab, under a general anaesthetic and guided by a transoesogeal echo (link ).
The procedure will take approximately one hour and you will remain in hospital overnight for monitoring purposes.
Can I eat or drink before my procedure?
You should fast at least 6 hours before your procedure.
Do I take my medications on the day of the procedure?
Unless advised by your doctor, you should continue to take your usual medications.
If you are taking anticoagulants, you will be asked to stop them 2 full days prior to your procedure. You may be required to have blood thinning injections (Clexane) until the day before the procedure as a bridge to stroke protection.
Where do I go to have the procedure?
Watchman LAAO is performed at Peninsula Private Hospital in the cardiac hybrid laboratory (‘cath lab’) which converts to an operating theatre.
Present to the cardiac admissions area of the hospital at the time recorded on your admission paperwork.
What do I need to bring?
It is recommended that you bring the following with you to the hospital:
- Your hospital admission paperwork with a signed consent form, health insurance details and Medicare /DVA card.
- Your current medications in their original containers.
An overnight bag with your belongings, as you will be required to stay overnight in hospital for monitoring after the procedure.
What happens during the procedure?
The procedure is performed under a general anaesthetic and guided by a transoesophageal echocardiogram. This is always performed by a specialist cardiac anaesthetist. You will have an intravenous line inserted into your arm for IV fluids and drugs and arterial line for monitoring you blood pressure during the procedure.
The right groin vein is punctured with a needle and a sheath (tube) with a one way valve is inserted into the vein, enabling us to carry the wires and catheter holding the device, to the heart.
The septum/muscle dividing the upper chambers is punctured with a needle which allows us entry into the left upper chamber (atrium) and toward the left atrial appendage. Xray images are taken and measurements repeated via the TOE probe to re-confirm the size, suitability and absence of clot. The catheter carrying the device is passed into the left atrial appendage and under TOE guidance, the device is slowly manipulated to sit into the appendage and deployed carefully to cover the appendage opening. A series of images are taken and a “tug” test is made to ensure the security of the device. Once confirmed, the catheter is released from the device and removed via the groin leaving the device behind “plugging’ the left atrial appendage.
Firm pressure is applied to the groin puncture site to stop any oozing of blood. The TOE probe and breathing tube will be removed and once awake and orientated, you will be transferred to the coronary care unit for overnight observation.
How long does the procedure take?
The procedure takes approximately 1 hour to perform, 1 hour in theatre recovery and you will remain in hospital overnight for monitoring.
What are the risks and complications?
All efforts are made to mitigate any risks associated with the procedure.
A cardiothoracic surgeon is available to support our cases should the rare need arise.
The risks associated with LAAO are:
- There is a 1-2% risk of tearing the left atrial appendage or puncturing the back of the atrial wall during septal puncture resulting in a pericardial effusion (blood trapped in the heart sac) requiring urgent pericardial drainage with a needle. There is a 1% chance of urgent surgical repair and drainage by a cardiac surgeon.
- Trauma to teeth, trachea (wind pipe) or oesophagus including a tear to oesophagus during passage of the transoesophageal probe requiring urgent surgical repair.
- Risks associated with general anaesthetic – vomiting, nausea etc
- Contrast related allergic response and rarely renal (kidney) impairment if a high volume of contrast is required.
- Pleuritic/sharp chest pain related to sternal puncture.
Your doctor will explain the risks to you prior to the procedure. You are encouraged to discuss any questions or concerns with your doctor, the structural heart nurse and your family prior to proceeding.
AFTER THE PROCEDURE
Your heart rate and rhythm, blood pressure and groin access site will be monitored in the coronary care unit.
You should have minimal discomfort however report any pain or discomfort in your chest, throat or groin following your procedure. This can be treated with antinflammatory or pain relief medications.
You will be able to get out of bed and mobilise within 4 hours of arriving into your room.
You will be discharged on the following day after a repeat echo to confirm there is no latent collection of fluid around the heart (pericardial effusion) You will be provided with the appropriate paperwork for a transoesophageal echocardiogram or CT scan in 6-8 weeks time. This is required to check for the complete sealing of the device by the body’s own cells “endothelialisation”. The review with your cardiologist will follow approximately 2 weeks after the test.
What will I need to do after I go home?
You can resume most gentle activities with exception of driving for 48hrs.
You will continue taking all of your medication unless instructed otherwise. If able, you will resume the anticoagulant until the confirmation TOE/CT is performed.
If you have any questions or concerns relating to your procedure or pain or discomfort after discharge, contact our office on 03 9789 0088 and speak with one of the critical care nurses.
A copy of your procedural report and TOE or CT scan will be sent to your referring doctor.
Your cardiologist will give you the final reassurance to stop/remain off your anticoagulants at your review appointment in approximately 10 weeks after the procedure.