Atrial fibrillation ( AF) is the most common arrhythmia in our region. Its incidence is closely related to age, with a prevalence of approximately 25% in patients over 80 years old. Among the problems arising from this condition, the need for oral anticoagulant therapy to prevent stroke is noteworthy, as stroke is the most serious complication of AF due to its high rate of disability and mortality. This need is even more pronounced in advanced age, as the risk of experiencing a stroke is even greater; the risk of complications associated with anticoagulant therapy, and especially the risk of bleeding, is also higher. Therefore, percutaneous left atrial appendage closure is currently an alternative for patients with AF who have contraindications to anticoagulant therapy.
Let's explain what it consists of.
The left appendage is an embryological remnant in the form of an atrial appendage with contractile activity, emptying all its contents with each heartbeat when the patient is in sinus rhythm (normal heart rhythm). In AF, the appendage loses this contractile capacity and dilates, which causes a slowing of blood at that level, with a consequent increase in the risk of thrombosis. It is known that around 80-90% of the thrombi that form in the heart of patients with AF do so within the left appendage; hence its percutaneous closure can be used as a strategy to prevent cardioembolic events. The closure is carried out thanks to a device that is placed at the entrance to the appendage, thus excluding it from circulation. This device reaches the heart through a catheter from the patient's groin and is released under radiographic and echocardiographic control. It is an effective and safe procedure that requires a team with experience in structural cardiac intervention; In experienced hands it is successful in more than 95% of cases with a low rate of complications (the most serious: 1,9% of pericardial tamponades, 0,4% of device embolizations and 0,6% of deaths associated with the procedure). ).
Let's describe which patient would benefit the most from this therapy.
Percutaneous closure of the left appendage is still in its initial phase. Although in the future it could constitute a real alternative to oral anticoagulants for all patients with AF, currently its use should be reserved for patients with contraindications for anticoagulation as stated in the European guidelines. In fact, most procedures are performed in anticoagulated patients referred from the neurology service after an episode of intracranial hemorrhage or from the gastroenterology service after recurrent digestive bleeding without a treatable cause is observed. The absence of valid alternatives to oral anticoagulants to prevent cardioembolic risk, which is generally high due to elderly and multi-pathological patients, makes closure of the left atrial appendage a very attractive option for these patients.
By Dr. Ana Casado
Specialist in Cardiology at UICAR