SCAI, HRS release joint consensus statement on transcatheter LAA closure for AF

Dec 20, 2023

Saw J, et al. J Soc Cardiovasc Angiogr Interv. 2023.doi:10.1016/j.jscai.2022.100577.

Saw J, et al. J Soc Cardiovasc Angiogr Interv. 2023.doi:10.1016/j.jscai.2022.100577.

The Society for Cardiovascular Angiography and Interventions and the Heart Rhythm Society released an updated expert consensus statement on transcatheter left atrial appendage closure for atrial fibrillation.

The statement was also endorsed by American College for Cardiology and the Society of Cardiovascular Computed Tomography.

The consensus statement, published in the Journal of the Society for Cardiovascular Angiograpy and Interventions and Heart Rhythm, contains recommendations regarding patient selection for transcatheter LAA closure; physician and institution requirements; pre- and intraprocedural imaging; treatment of intraprocedural complications; management of late adverse events; and more.

"Previous SCAI consensus documents were published in 2015 and 2016, which addressed operator and institutional requirements for LAA closure," Jacqueline Saw, MD, FSCAI, interventional cardiologist at Vancouver General Hospital and St. Paul's Hospital, program director of the interventional cardiology fellowship program at Vancouver General Hospital, clinical professor of medicine at the University of British Columbia and chair of the expert consensus statement writing group, told Healio. "Since then, there has been substantial new data published, improved operator techniques, matured imaging guidance, new iterations of devices, a new approved device, and several devices in development. This new SCAI consensus statement aims to provide recommendations on contemporary evidence-based best practices for transcatheter LAAC focusing on endovascular devices. This much broader document covers guidance on patient selection, operator/institutional requirements, imaging (baseline, peri-procedural, and longterm surveillance), technical approaches, procedural complications and management, antithrombotic therapy post-LAAC, and combined procedures."

Transcatheter LAA closure is appropriate for patients with nonvalvular AF with high thromboembolic risk not suited for long-term oral anti-coagulation and have a life expectancy of more than 1 year and will likely gain a quality of life to benefit from the procedure, the authors wrote.

The writing group recommended that physicians performing LAA closure should have previously completed 50 or more left-sided ablations or structural procedures and 25 or more transseptal punctures. Physicians should continue to complete 25 transseptal punctures and more than 12 LAA closures over the course of every 2-year period.

New programs and physicians with only early experience in LAA closure should have on-site CV surgery backup, according to the statement.

In addition, interventional imaging physicians should have previously guided 25 or more transseptal punctures before supporting any LAA closure procedures.

Baseline transesophageal echocardiography (TEE) or cardiac CT is recommended before performing LAA closure. TEE or intracardiac echocardiography are recommended for intraprocedural guidance.

The technical aspects of LAA closure should be performed in accordance with the labeling of each specific LAA closure device, according to the statement.

Two-dimensional transthoracic echocardiography should be performed to rule out pericardial effusion and device embolization predischarge.

Same-day discharge may be considered after several hours of observation with no observed complications or pericardial effusion.

The writing group recommended that device-related thrombus be treated with anticoagulation, and repeat imaging at 45- to 90-day intervals can be performed to assess for resolution and cessation of anticoagulation.

Routine closure of iatrogenic atrial septal defects associated with LAA closure should not be performed, according to the statement.

The writing group also recommended that patients be prescribed antithrombotic therapy with warfarin, direct oral anticoagulants or dual antiplatelet therapy after LAA closure according to the studied regimen and device specific instructions for use and tailored to bleeding risk.

All efforts should be made to minimize peridevice leaks at the time of LAA closure, according to the statement. TEE or cardiac CT is recommended at 45 to 90 days after closure to assess for leaks and device-related thrombus.

Combined procedures with LAA closure such as other structural interventions and pulmonary vein isolation are not routinely recommended. Data on combined procedures are pending from ongoing trials.

"Despite substantial evolution in this technological space and expertise in the past 2 decades, gaps in knowledge remain, including randomized trials comparing DOAC vs. LAA closure in oral anticoagulant-eligible patients, optimal antithrombotic therapy and duration post-LAA closure, optimal post-LAA closure imaging surveillance and timing, and management of peri-device leak," Saw told Healio.

Please see the updated expert consensus statement for full details on the societies’ recommendations for transcatheter LAA closure.

Jacqueline Saw, MD, can be reached at [email protected]; Twitter: @docsaw.