Atrial Fibrillation (AF) is the most common abnormal heart rhythm which can cause adverse clinical outcomes such as stroke and heart failure. An estimated 2.7 to 6.1 million people have AF in the United States. As the prevalence of AF increases with increasing age, with an aging population, prevalence of AF is expected to double in the next 2-3 decades. People above the age of 40 years have a 1 in 4 chance of developing AF in their lifetime. Patients with AF are 6-7 times more likely than general population to suffer from a stroke.
Stroke is the most devastating adverse consequence of atrial fibrillation and occurs due to thrombus or clot formation in the heart (usually in the left atrial appendage) which embolizes to the brain (cardio-embolic stroke). Therefore, anticoagulation is one of the mainstays of treatment of AF to prevent thrombus formation.
The elderly, who are more likely to develop AF, are also at a higher risk of bleeding. Anticoagulation medications such as Warfarin or newer agents such as apixaban, rivaroxaban and dabigatran prevent strokes but at the cost of increasing the likelihood of bleeding. Majority of patients tolerate anticoagulation without adverse effect, however, many patients cannot take anticoagulation due to much higher bleeding risk, often due to gastro-intestinal bleeding, recurrent nose bleeds or high frequency of falls due to gait or balance issues.
It is in these patients, that novel devices referred to as left atrial appendage occluder devices, of which the “Watchman” device (which is shaped like an umbrella and made of a nitinol frame), is the only one with FDA approval currently, can improve outcomes by preventing strokes.
This device works because more than 90% percent of thrombus formation occurs the left atrial appendage – an outpouching of the left atrium, which does not perform any known useful function in the heart. Occlusion of the cavity of the left atrial appendage with this device prevents blood from entering it, stagnating in AF and forming clots. Therefore, this device reduces stroke risk without need for long term anticoagulation in patients with AF.
The procedure is performed via venous access from the femoral vein, which allows a catheter to be placed in the left atrium. The delivery catheter is then directed into the left atrial appendage and the device (Watchman) is deployed via the catheter, occluding the left atrial appendage. Patients are typically discharged after overnight observation.
This device has provided similar reductions in ischemic stroke compared to warfarin over a 5-year follow-up and thus serves as a useful tool in reducing strokes in patients with AF who cannot take long term anti-coagulation due to high risk of bleeding. Physicians at HeartSouth Cardiovascular Group now offer this procedure to appropriate patients with Atrial Fibrillation.
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