Dr. Szto is the only cardiologist qualified to perform this procedure in the Mornington Peninsula area.
Patients who experience an irregular heart rhythm called atrial fibrillation run a higher risk of developing a stroke. During atrial fibrillation, the top chambers of the heart (called atrium, or atria for the two chambers) do not pump in synchrony with the bottom chambers (called the ventricles). As a result, blood may pool in the atria, particularly in an appendage called the left atrial appendage. If this clot dislodges and travels elsewhere, especially the brain, this clot will prevent circulation to that area of the brain, resulting in a stroke. Alternatively the clot may travel down to the leg, resulting in acute (painful) ischaemia (lack of blood supply), sometimes resulting in gangrene if not attended to immediately. Rarely the clot may even go to the blood vessels supplying the bowels, resulting in death of tissue and significant morbidity.
Patients are at higher risk of developing a clot if they have one or more of the following features: Age over 65 (for women) or 75 (men), Female gender, diabetes, high blood pressure, prior transient ischaemic attack (TIA), congestive heart failure, and vascular disease.
In patients who are at risk of stroke, anticoagulation with blood thinners are recommended. Before late 2013, there was only one choice – warfarin. Since late 2013, three other blood thinners have been approved for use and reimbursed by the government. These are dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis). Anticoagulants are effective in reducing the risk of stroke in patients with atrial fibrillation.
Blood thinners can also increase the risk of bleeding, and in these patients, taking the medication may cause significant harm – such as cerebral haemorrhage, bowel or bladder bleeding. Frail elderly patients may be at risk of falls, hence may not be prescribed these blood thinners.
An alternative to blood thinners is to ligate/close the left atrial appendage, since this appendage is responsible for 90% of clots forming in the heart. Ligation can be achieved either through surgery (during open heart surgery for bypass or valve replacement) or percutaneously (keyhole). This latter method involves the advancement of an umbrella-like device from the groin vein to the mouth or opening of the left atrial appendage, therefore sealing it and preventing the formation of blood clots that could travel (embolise). The procedure is performed under general anaesthetic and typically takes about 1 hour. Before the procedure, the patient is evaluated for suitability of the procedure using transoesophageal echo (TOE) and/or cardiac CT scan. The patient may also need to have a follow-up TOE 6 weeks later to check that placement of the device is satisfactory.
The link to the procedure to implant a left atrial appendage is found here. The procedure is performed in the catheter laboratory at Peninsula Private Hospital by Dr. Szto, with an anaesthetist and a transoesophageal echocardiographer specialist doctor. The procedure lasts about 1 hour and an overnight stay is typical.
A youtube video of the procedure is found below: