The Role of Epicardial LAA Exclusion in AFib Stroke Prevention

In this video from CRT 2025, JIC speaks with Dr Basel Ramlawi of the Lankenau Heart Institute about the role of epicardial left atrial appendage exclusion in atrial fibrillation stroke prevention.

Transcript:

Hello, good afternoon. We're here at CRT 2025. My name is Dr Basel Ramlawi and I am the Chief of Cardiac Surgery and Co-Director of the Lankenau Heart Institute in Philadelphia, Pennsylvania.

Could you please provide a brief overview of the epicardial LAA exclusion procedure, particularly what distinguishes it from other LAA occlusion options?

As we all know, left atrial appendage exclusion has become a primary interest for patients, physicians, surgeons, and cardiologists who are interested in reducing the risk of stroke for these patients, as the vast majority of atrial fibrillation strokes tend to come from the left atrial appendage. And the main difference between intracardiac or percutaneous devices and the epicardial devices that are being used actively in surgery is that these are done from the outside of the heart. So, there's nothing left inside the cardiac anatomy, there's nothing mixing with the blood, there's no blood foreign body interface. So, there's potentially some benefits there where you can completely exclude the appendage from the outside without necessarily the risk of endocarditis, the risk of thrombus formation, the need for blood thinners, either transiently or long-term because there's really no other foreign body mixing with the clip or the device on the outside of the heart.

What factors should operators be considering when deciding whether a patient should undergo this procedure vs other therapies?

The vast majority of left atrial appendage exclusions done surgically or epicardially are done in conjunction with open-heart surgery, so the patient's usually coming in for bypass operation, an aneurysm repair, or a valve repair or replacement, and then they undergo a left atrial appendage exclusion at the same time in order to reduce the risk of stroke – hopefully a procedure that reduces their risk from from AFib-related stroke for the rest of their life. We do have techniques right now that we've published on, that we can do the same procedure with the left atrial appendage clip, either the AtriCure device or the Medtronic Penditure device, where we can go in and place that clip at the base of the appendage, off-pump, beating heart with no real open-heart surgery, but mainly just an epicardial approach, and that could be done within half an hour, 40 minutes at the most, and the patient goes home the next day. So, it's a much less invasive operation, it's completely effective, and it achieves the efficacy and the safety that we would want based on preliminary data.

How does patient anatomy influence the feasibility and complexity of left atrial appendage exclusion, and are there specific anatomical considerations that make one approach preferable over another?

So, the main difference is that there's really no anatomical concerns of the left atrial appendage when it comes to an epicardial left atrial appendage clip deployment.  Surgical appendage exclusion approaches are not affected by whether the appendage is a chicken wing or a cauliflower or is large or small, it's all going to be fitting inside the appendage. And we have direct TEE echo confirmation that is done usually at the same time where we can completely confirm that the appendage has been excluded. Unlike endocardial devices that depend on the size of the appendage, the morphology of the appendage, if it's too big or too small or inverted, or so on. So, unlike that, the appendage morphology does not really affect the epicardial placement of a clip. Of course, there are concerns if the patient is a redo or there are scar tissues around the appendage that may make the operation a little bit more difficult.

Based on your experience, how do the outcomes of an LAA exclusion compare with other treatments?

This is a major area of investigation currently, to confirm and really offer a relationship between the stroke prevention benefit and the epicardial left atrial appendage epicardial exclusion approach. So, we have a couple of trials. We do have the Left Atrial Appendage Occlusion Study (LAAOS) trial that was published in the New England Journal of Medicine a few years ago, and that showed a significant correlation in patients with atrial fibrillation, with surgical epicardial exclusion, or a stroke reduction of these patients very early on in the follow up period. So, it was a very strongly positive study. At the heels of that, now, we are currently in the final quarter of the Left Atrial Appendage Exclusion for Prophylactic Stroke Reduction (LeAAPS) trial, which is a major trial sponsored by AtriCure, looking at the left atrial appendage clip to be able to exclude the appendage in patients coming in for open surgery without atrial fibrillation. So, we're looking at patients who are at high risk of developing AFib and randomizing them one-to-one for a clip or no clip. And we are very much anticipating the results of that and hopefully it will lead to a stroke indication for the AtriClip device. This will then lead to a lot of patients benefiting from stroke reduction by applying epicardial clip procedures during cardiac surgery.

Do you anticipate increased adoption of left atrial appendage exclusion, or are there still barriers that may limit its widespread use?

Well, at this point, the AtriCure left atrial appendage clip is by far the most commonly used device on the market right now, and it's being used very commonly in all patients coming in for open-heart surgeries in the United States and in other countries. Now, of course, as we anticipate the completion of the LeAAPS trial and hopefully if there's positive relationship between stroke prevention and the AtriClip in patients at high risk of developing AFib, based on our hypothesis, then we would expect that this would become the standard of care for all patients going into cardiac surgery. In addition, there likely will be potentially benefits for standalone therapies through less invasive video-assisted approaches previously discussed.

The transcript has been lightly edited for clarity.