2. Why do some patients undergo left atrial appendage occlusion (LAAO)?
In some patients, taking blood thinners is hazardous because of the bleeding risks. This risk also increases with age. The LAA can be sealed off with a device (much like a plug in a sink which seals off and excludes the LAA from the circulation). This has been shown to reduce the risk of stroke in patients with atrial fibrillation to the same extent as taking blood thinners every day without the associated bleeding risks.
3. What happens during a LAAO procedure?
You will come into our catheterisation lab at Wollongong Private Hospital and an Anaesthetist will administer a general anaesthetic to keep you asleep. Your Cardiologist will administer some local anaesthetic to the vein at the top of your leg and place a catheter which gives them access to the heart. The catheter will be maneuvered inside the heart with the guidance of an x-ray and an ultrasound probe introduced through your oesphagus (transoesophageal echocardiogram). The catheter will cross from the right atrium into the left atrium by means of a fine needle and a larger catheter placed adjacent to the LAA. A self-expanding device made of a springy material (Nitinol) will be deployed to seal / plug off the LAA and the team
will check the device is stable and has completely sealed with LAA such the atrium has a nice smooth wall to it and no blood clots are likely to form. The device can be repositioned if the team are not happy with its position, when they are it is then unhooked from the catheter and everything except the device is removed. You can rest until the following day when most patients will be allowed to go home.
4. What tests are required and how do I get approved for a LAAO?
To be approved for LAAO as a means of stroke prevention, a patient must have:
(a) a history of atrial fibrillation (either in the past, AF that comes and goes or long- standing AF)
(b) a reason to believe ongoing anticoagulation is going to be impractical or dangerous
(c) LAA anatomy that is suitable for a closure device
These factors will be considered by your Cardiologist who will also arrange a CT scan or echocardiogram to look at the anatomy of your LAA.
5. Who will be involved in my LAAO procedure?
There will normally be at least two Cardiologists (one implanting the device from your groin and looking at your heart with the ultrasound probe from the mouth). There will also be a structural heart nurse, an Anaesthetist, Cath lab nurses and a Radiographer.
6. Which LAAO devices do you use for LAAO procedures
There are two commercially available LAAO devices in Australia. The Amulet device https://www.cardiovascular.abbott/us/en/hcp/products/structural-heart/structural-interventions/amplatzer-amulet.html and the Watchman FLX https://www.bostonscientific.com/en-US/products/laac-system/watchman-flx.html.
Our LAAO doctors are accredited to use either device and will inform you of their choice for you if you don’t have any preference.
7. Are there any costs for my LAAO procedure?
Our LAAO doctors do not charge any fees for performing LAAO.
Anaesthetic fees may apply
Patients with a Medicare card without private health cover can also currently access LAAO at Wollongong Private Hospital on a discounted self-funded basis where a hospital bed fee will apply.
8. What are the risks of LAAO?
It is very important that before you go in for an LAAO that you understand that your cardiac team are working extremely hard to keep risks to the absolute minimum but things can sometimes go wrong. Wollongong Private Hospital is very proud that the rates of complications from LAAO are low compared to the expected rates and the doctors & the hospital have a track record of doing more LAAOs than most other hospitals in the country. Dr Danson set up the service in 2018 and is now teaching around the country on how to perform this procedure.
The risks of LAAO include:
(a) Risk of bleeding from the groin – normally not serious and can be managed with application of gentle pressure
(b) Risk of bleeding around the heart – in this situation, a drainage catheter is typically needed to prevent the heart from being compressed by blood. If the bleeding doesn’t stop, then open heart surgery could be required although this would be extremely rare.
(c) Risk of the device dislodging from the left atrial appendage (this is very rare). In this situation, an attempt would be made to retrieve the device with a catheter and to re-implant another one. If this cannot be retrieved with a catheter, open heart surgery could be required although this would be extremely rare.
(d) If any blood clots form inside the heart or are found and dislodged during the procedure, this could be the cause of an acute stroke. Heparin (a blood thinner) is used to prevent blood clots forming during the procedure.
Based on large international registries the risk of any complication occurring during an LAAO procedure is around 3%, although most of these things will be minor and temporary.
9. Do I have to be fasted for a LAAO procedure?
As this procedure involves a general anaesthetic, you should not have anything to eat or drink
six hours before the LAAO procedure.
10. What medications need to be stopped prior to a LAAO?
Your doctor will stop any blood thinners such as Xarelto (Rivaroxaban), Pradaxa (Dabigatran), Eliquis (apixaban) or Warfarin indefinitely at least 72 hours before an LAAO procedure. Many patients have contraindications to these drugs and so have never started these or have stopped them much sooner before the procedure. You can continue taking Aspirin, Clopidogrel or Ticagrelor without stopping these.
If you are taking diabetic medication Dapagliflozin (Forxiga) or Empagliflozin (Jardiance or Jardiamet), you should stop taking these 3 days before the LAAO procedure
11. What new medications might there be after a LAAO?
Most patients will take aspirin 100mg daily and Clopdiogrel 75mg daily for three months following a LAAO procedure. This is to prevent blood cells from sticking to the device implanted until it has gone through a process of endothelialisation (a skin growing on top of it). Some patients cannot tolerate these drugs even for this short period because of bleeding
risks and in this situation your doctor will advise you on the plan.
12. How long with you be in hospital for a LAAO?
You will normally be in hospital for one night after the procedure. We often do our LAAO procedures early in the morning and so you will be asked to come in the night before as well.
Most patients will feel completely normal after the procedure and so there isn’t typically anytime “recovering”.
13. When can I get back to normal activities after an LAAO?
Immediately.
14. When can I drive again after an LAAO?
There are no driving restrictions after an LAAO procedure. However, we advise you to use common sense with regard to whether you feel safe driving, particularly after having a general anaesthetic.
15. Can I have an MRI scan after an LAAO?
Yes, the device is MRI safe.
16. Where should I go to if I have any other questions?
You can contact our structural heart email (checked regularly by either our Structural Heart Nurse Co-ordinator or one of our LAAO doctors) at wollongongstructuralheart@gmail.com
Alternatively, you can contact The Cardiac Centre at reception@thecardiaccentre.com.au and
your question will be passed on to your LAAO doctor.
