Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).
It look and acts similar to a lariat or lasso. An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.
A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.
PPT on Watchman from Boston Scientific
Is one better than the other?
Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications. Pillarisetti J, et al. Heart Rhythm. 2015.
CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.
For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.
Echo Essentials for Endoluminal LAA Closure: April 2014 Cardiac Interventions Today
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation: J Vis Exp. 2012; (60): 3671
Anesthesia and Transesophageal Echocardiography for WATCHMAN Device Implantation: December 2016Volume 30, Issue 6, Pages 1685–1692.
3D Echo inside the Cath Lab – A must in LAA Closure. London, 2016.
ECHONOMY:Tools for Echocardiographic Calculations
YouTube: LEFT ATRIAL APPENDAGE CLOSURE PROCEDURE : Role of Transesophageal Echocardiography
YouTube: TCTAP 2015 SHD Live Case Session: LAA Closure
YouTube: How to image the inter-atrial septum using 3D-TEE “RATLe-90 maneuver”
YouTube: TOE in LA Appendage Assessment by Jason Sharp
WATCHMAN:Baseline TEE:· Full Scripps TEE protocol· Measure the LAA at the following views:o 0°, 45°, 90°, 135°· Report the LAA maximal orifice, as well as the LAA dimensions at each angle using the following Xcelera drop-downs under “Left Atrium”:· Comment on presence or absence of atrial thrombus or “smoke”· Optional: Comment on LAA shape (ie: cauliflower, chicken wing, windsock, cactus)
Intra-Procedural TEE:· Comment on presence or absence of atrial thrombus
· Report the LAA maximal orifice using the following Xcelera drop-down under “Left Atrium”:· Enter LAA device size and implantation date under the “History” section in Xcelera· Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:· If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:· Iatrogenic ASD with direction of shunting· Comment on any post-procedure pericardial effusion (compare to baseline)
Post-Procedure Discharge TTE (pt. in hospital):· LIMITED 2D TTE to rule out pericardial effusion (unless order specifies otherwise)· Spectral Doppler for respirophasic flow changes if an effusion is present
45-Day, 6 Month, 1 year and 2 year F/U TEEs:· Comment on presence or absence of atrial thrombus· Comment on the presence or absence of a residual leak using the following Xcelera drop-down under “Left Atrium”:· If a residual leak is present, comment on the size (mm) of the leak using the following Xcelera drop-down under “Left Atrium”:· Carry over LAA device size and implantation date under the “History” section in Xcelera
· Comment on Iatrogenic ASD with direction of shunting, if still present