Cardiovascular Journal of Africa: Vol 32 No 1 (JANUARY/FEBRUARY 2021)

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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 32, No 1, January/February 2021 AFRICA 33
Nine-year, single-centre experience of left atrial
appendage occlusion: patient characteristics, procedural
outcomes and long-term follow up
Mark Abelson, Andre Phillips, Shirley Middlemost
Abstract
This is a review of 114 patients with atrial fibrillation who
had left atrial appendage occlusion with an Amplatzer cardiac
plug over a nine-year period done by a single operator. This
shows that the procedure can be safely performed with a very
low rate of major complications (< 1%) and a zero procedural
mortality rate. Long-term follow up over an average of 38.5
months showed a 65% reduction in actual versus predicted
stroke rate. This is similar to that seen with oral anti-coag-
ulants and other published trials and registries involving left
atrial appendage occlusion.
Keywords: atrial fibrillation, left atrial appendage occlusion,
Amplatzer cardiac plug, Amulet
Submitted 28/7/20, accepted 6/10/20
Published online 11/11/20
Cardiovasc J Afr 2021; 32: 33–36
DOI: 10.5830/CVJA-2020-051
Left atrial appendage occlusion (LAAO) is a treatment option
for stroke prevention in patients with permanent or paroxysmal
atrial fibrillation (AF) who have a CHADS2-VASc score >
2 and have either contra-indications for oral anticoagulant
therapy (OACT) or decline such therapy. Current European
Society of Cardiology (ESC) guidelines have LAAO as a class
2b recommendation.1 This study is a registry of LAAO done at
MediClinic Vergelegen, Somerset West, South Africa, by a single
operator from November 2010 to 31 March 2020.
Methods
All patients were prospectively entered into a database after
informed consent was obtained. Patient follow up to 31 March
2020 was done either at a recent out-patient examination or
telephonically. Those patients who were lost to follow up by 31
March 2020 were excluded.
The first patient was enrolled in mid-November 2010. All
patients, except two who had a Watchman device (Boston
Scientific) implanted, had an Amplatzer (Abbott Vascular)
device implanted. The first 40 patients received the Amplatzer
cardiac plug (ACP I) and thereafter the Amulet device (ACP II).
All procedures were done under general anaesthetic with trans-
oesophageal echocardiogram (TOE) guidance by one of only
two TOE operators. Almost all patients had no pre-procedural
TOE to look for left atrial appendage (LAA) thrombus and
anatomical suitability for device-based occlusion. If patients
were on OACT, this was stopped a few days earlier.
Following trans-septal puncture using TOE guidance, a
heparin bolus was given intravenously (IV) to raise the activated
clotting time to more than 250 seconds. All patients were
loaded with a minimum of a litre of intravenous fluid prior to
device sizing to raise LAA pressure to greater than 15 mmHg.
Device sizing was initially determined by a combination of
TOE and LAA angiogram measurements, and more recently a
pre-procedural cardiac computed tomography (CT) was added to
these measurements to help improve initial choice of device size.
The device was deployed in the usual manner via a 12- or 14-F
angled delivery sheath depending on the device size required.
The right femoral vein access site was closed routinely with a
Perclose 6-F suture device. Some patients required an additional
superficial skin suture due to persistent wound oozing. Heparin
was reversed with IV protamine in order to reduce any bleeding
risks.
As soon as the patients were awake and able to swallow,
aspirin 300 mg and clopidogrel 600 mg oral loading doses were
given. Patients were observed in cardiac high care overnight and
were discharged home the next day following trans-thoracic
echocardiogram (TTE) confirming the LAA device was in
situ and there was no pericardial effusion. All patients were
discharged on aspirin 75–100 mg and clopidogrel 75 mg daily
unless contra-indicated.
All patients were seen at 30 days’ follow up for TTE to
confirm the device was in situ. Clopidogrel was stopped at one
month and aspirin alone was continued indefinitely if there
were no contra-indications. Thereafter, patients were either seen
routinely on a six- or 12-month basis by the operator or referred
back to the referring physician. No patients had a routine post-
procedural TOE at follow up.
Results
Atotal of 131 patientswere admitted to the cardiac catheterisation
theatre for LAAO device implantation and 122 (93%) had a
successful device implantation over the 112 months. In nine
patients, the procedure was abandoned due to the presence of
an LAA thrombus, inability to pass the TOE probe, the LAA
MediClinic Vergelegen, Somerset West; University of Cape
Town, South Africa
Mark Abelson, MB BCh, MRCP (UK), FCP (SA),
MediClinic Vergelegen, Somerset West, South Africa
Andre Phillips, MB ChB, FCA (SA)
MediClinic Hermanus, Hermanus, South Africa
Shirley Middlemost, MB BCh, FCP (SA), FACC, PhD (Wits)