From the Guidelines
It is standard of care to check for complete left atrial appendage (LAA) closure prior to discontinuing anticoagulation in patients who have undergone LAA closure with a clip device, as recommended by the 2024 ESC guidelines for the management of atrial fibrillation 1.
Key Considerations
- The LAAOS III trial demonstrated that surgical occlusion or exclusion of the LAA can contribute to stroke prevention in patients with AF undergoing cardiac surgery, with a significant reduction in ischemic stroke or systemic embolism 1.
- However, the trial also highlighted the importance of complete closure, as incomplete closure can leave patients at continued risk for thrombus formation and subsequent stroke.
- The 2024 ESC guidelines suggest that surgical LAA closure should be considered as an adjunct therapy to prevent thromboembolism in addition to anticoagulation in patients with AF 1.
Recommendations
- Typically, a transesophageal echocardiogram (TEE) should be performed at approximately 45-90 days post-procedure to confirm complete closure of the LAA.
- If the TEE demonstrates complete closure with no residual leak greater than 5mm, anticoagulation can generally be discontinued.
- If incomplete closure is found, anticoagulation should be continued indefinitely.
- During the waiting period between clip placement and the confirmation TEE, patients should remain on their prescribed anticoagulation regimen.
Rationale
- Incomplete closure of the LAA can lead to thrombus formation and subsequent stroke, defeating the purpose of the procedure.
- The LAA is the source of approximately 90% of thrombi in patients with non-valvular atrial fibrillation, making confirmation of complete closure essential before removing stroke prophylaxis.
- The 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation also highlights the importance of complete closure, with studies showing that incomplete closure can lead to thromboembolic events 2.
From the Research
Checking Post Left Atrial Clip Prior to Stopping Anticoagulation
- The standard of care for checking post left atrial clip prior to stopping anticoagulation is not explicitly stated in the provided studies, but it can be inferred that transesophageal echocardiography (TEE) plays a crucial role in evaluating the success of left atrial appendage (LAA) occlusion and guiding post-procedure care 3, 4, 5, 6.
- TEE is used to assess the presence of residual pouch, flow into the LAA, or device-related thrombus (DRT) after LAA occlusion, which are considered failures of the procedure 3.
- The use of TEE for excluding LAA thrombi in patients with atrial fibrillation before cardioversion is well established, and it can also be used to guide the decision to stop anticoagulation after LAA occlusion 7, 6.
- Timely follow-up with TEE after LAA occlusion is critical in reducing the risk of device-related complications, such as DRT, and may help avoid delayed detection of these complications 5.
- Serial TEE evaluations can provide valuable information on device-related complications and guide post-LAA occlusion care, including the decision to stop anticoagulation 5.