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Dr Oliver Segal
Left atrial appendage occlusion
Discuss the best device for you, with an expert.
State-of-the-art devices to help prevent stroke
If you have atrial fibrillation (AF) you’ll have an increased risk of stroke. The state-of-the art Abbott Amulet device is a permanent implant designed to close the left atrial appendage in your heart to help reduce the risk of stroke. Dr Segal is skilled at carrying out this minimally invasive implant procedure as an effective alternative to taking lifelong blood thinners, delivering great clinical outcomes and better heart health.
Left atrial appendage occlusion devices are effective at reducing stroke risk without increasing your risk from bleeding.
The CHADS-VA score is used to quantify stroke risk in people with AF. If you have a score of 1 or more, the prescription of direct anticoagulant drugs (DOACs) will have been discussed with you. While taking one of these drugs will reduce stroke risk, it also increases your risk of serious bleeding.
If you’re unlucky and develop a brain haemorrhage, bleeding from the bowel or other area after starting an anticoagulant, many doctors will understandably advise to you to stop the medication. While that’s good at reducing your risk of a bleed, you’ll be left unprotected from developing a stroke.
At that point, your cardiologist may recommend that you have a left atrial appendage occlusion device implanted, so you can safely stop taking blood thinners.
The Abbott Amulet is a type of left atrial appendage occlusion device which Dr Segal favours due to its adaptability and safety profile. It looks a bit like a top hat/collapsible umbrella, and it’s designed to sit at the entrance to the left atrial appendage in the heart.
The appendage is a tube-like pouch that arises from the left atrium, in a similar way that the appendix rises from the bowel. It’s the principal place for clots to form in the heart in people with AF, which can result in a stroke if they break off and travel to the brain.
The Amulet device works by sealing off the left atrial appendage (LAA), preventing clots from entering the bloodstream and causing a stroke.
Dr Segal will insert the Amulet device in the appendage, and tissue will grow over the device over the next few weeks. That stops clotted blood moving from the appendage to the rest of the heart and circulation, significantly reducing the risk of stroke.
A large trial using the Amulet device (called the Amulet IDE trial) showed that it’s better than another device called the Watchman at preventing fatal or disabling strokes. This allowed more people to discontinue anticoagulants safely, and it also had superior appendage closure rates. Because patients with the device don’t need to take anticoagulants long term, the risk of bleeding is much lower.
One advantage of the Amulet is that it has two components with a lobe and a disc section. The disc section acts like a ‘door’, completely sealing off the entrance to the appendage immediately, at the point of implantation. Another advantage is that, unlike the Watchman, it doesn’t need to be placed deep within the appendage, meaning implantation is safer and easier.
The day after your procedure, Dr Segal will check the position of your new device using a standard echocardiogram, as well as with a chest X-ray.
You’ll need to keep taking a DOAC or a combination of aspirin and clopidogrel for two months following the procedure while your heart tissue grows over the device and it beds in.
A CT scan of the heart is then performed to check the position of the device and ensure that no blood is flowing into the appendage, and that no blood clots have formed on its surface. Once the appendage is closed, you can permanently stop taking a DOAC. You may benefit from taking aspirin longer term.
Left atrial appendage occlusion FAQs
As one might expect, there are risks implanting a device like this into the heart. Complications occurs in 3 to 5 people in every 100 who undergo the procedure and principally include stroke, creating a small hole in the heart (known as cardiac perforation) or the device falling out of the appendage and travelling through the circulation, known as device embolisation.
Cardiac perforation causes blood to leak out of the heart into its surrounding sac and this can put pressure on the heart and impede its pumping action, a condition known as cardiac tamponade. If this occurs, a fine drain needs to be inserted as an emergency under the ribs into the sac, to drain the blood. This will usually be sufficient to control the problem, but if it is not, surgery is required. If the device embolizes, it will travel through the circulation until it becomes lodged somewhere. Common sites where this can happen are in the aortic or mitral valves of the heart, or in one of the bigger arteries in the lower part of the abdomen. If it becomes trapped in a heart valve, it usually requires surgery to remove and surgery to repair the valve may also be necessary. If it gets lodged in an artery, it may be possible to rescue the device using a snare, which can be deployed using ‘key-hole’ techniques from the artery at the top of the leg. If it is not, surgery is required.
For these reasons, the decision to have a left atrial appendage occlusion device needs to be weighed up carefully. In general, it is reserved for people with high risk of stroke who have bled significantly while taking warfarin or have some other reason why they cannot take an anticoagulant. To undergo the procedure, patients must either take warfarin before and afterwards for a short period, or if this is not possible, a combination of aspirin, and a drug called clopidgrel. This is a drug similar to aspirin, which thins the blood by acting on platelets.
The procedure is performed under general anaesthetic. This allows continuous visualization of the heart using trans-oesophageal echocardiography, or TOE. TOE is an ultrasound probe that is passed into the oesophagus, or food pipe/gullet. This enables high quality imaging of the appendage. The appendage is accessed using the transseptal puncture technique described previously in the atrial fibrillation page.
A sheath is then advanced into the appendage, which is imaged in detail by injecting dye into it and by using TOE. Measurements are taken at different sites within the appendage to help determine the correct size of device to be used. Once chosen, the device is advanced through the sheath and pushed out through the end into the appendage. Once out of the sheath the device immediately expands into its per-determined shape so that it locks into the entrance to the appendage. Injecting more dye and performing further TOE imaging then checks this position is satisfactory, before release.
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