Electrophysiol Clin 2020; 12:67. 44. Darden D, Duong T, Du C, et al. Sex Differences in Procedural Outcomes Among Patients Undergoing Left Atrial Appendage Occlusion: Insights From the NCDR LAAO Registry. JAMA Cardiol 2021; 6:1275. 45. Pasupula DK, Munir MB, Bhat AG, et al. Outcomes and predictors of readmission after implantation of a percutaneous left atrial appendage occlusion device in the United States: A propensity score-matched analysis from The National Readmission Database. J Cardiovasc Electrophysiol 2021; 32:2961. 46. Glikson M, Wolff R, Hindricks G, et al. EHRA/EAPCI expert consensus statement on catheter- based left atrial appendage occlusion - an update. EuroIntervention 2020; 15:1133. 47. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: a report of the American College of Cardiology/American https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 24/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. 48. January CT, Wann LS, Calkins H, et al. 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society in Collaboration With the Society of Thoracic Surgeons. Circulation 2019; 140:e125. Topic 928 Version 61.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 25/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate GRAPHICS Comparison of the CHADS and CHA DS -VASc risk stratification scores for 2 patients with nonvalvular AF 2 2 Definition and scores for CHADS and Stroke risk stratification with the 2 CHA DS -VASc CHADS and CHA DS -VASc scores 2 2 2 2 2 Unadjusted ischemic stroke rate [1] CHADS acronym Score CHADS acronym 2 2 (% per year) Congestive HF 1 0 0.6 Hypertension 1 1 3.0 Age 75 years 1 2 4.2 Diabetes mellitus 1 3 7.1 Stroke/TIA/TE 2 4 11.1 Maximum score 6 5 12.5 6 13.0 Unadjusted ischemic stroke rate CHA DS -VASc 2 2 [2] CHA DS -VASc acronym Score 2 2 acronym (% per year) Congestive HF 1 0 0.2 Hypertension 1 1 0.6 Age 75 years 2 2 2.2 Diabetes mellitus 1 3 3.2 Stroke/TIA/TE 2 4 4.8 Vascular disease (prior MI, PAD, or 1 5 7.2 aortic plaque) Age 65 to 74 years 1 6 9.7 Sex category (ie, female sex) 1 7 11.2 Maximum score 9 8 10.8 9 12.2 AF: atrial fibrillation; CHADS : Congestive heart failure, Hypertension, Age 75 years, Diabetes mellitus, prior Stroke or TIA or thromboembolism (doubled); CHA DS -VASc: Congestive heart failure, Hypertension, Age 75 years (doubled), Diabetes mellitus, prior Stroke or TIA or thromboembolism 2 2 2 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 26/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate (doubled), Vascular disease, Age 65 to 74 years, Sex category; HF: heart failure; TIA: transient ischemic attack; TE: thromboembolism; MI: myocardial infarction; PAD: peripheral artery disease. [3] These unadjusted (not adjusted for possible use of aspirin) stroke rates were published in 2012 . Actual rates of stroke in contemporary cohorts might vary from these estimates. References: 1. Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. 2. Lip GYH, Nieuwlaat R, Pisters R, et al. Re ning clinical risk strati cation for predicting stroke and thromboembolism in atrial brillation using a novel risk factor-based approach: the euro heart survey on atrial brillation. Chest 2010; 137:263. 3. Friberg L, Rosenqvist M, Lip GY. Evaluation of risk strati cation schemes for ischaemic stroke and bleeding in 182 678 patients with atrial brillation: the Swedish Atrial Fibrillation cohort study. Eur Heart J 2012; 33:1500. Original table and unadjusted ischemic stroke rates, as noted above, have been modi ed for this publication. January CT, Wann LS, Alpert JS, et al. 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2014; 64:e1. Table used with the permission of Elsevier Inc. All rights reserved. Graphic 94752 Version 14.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 27/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Endovascular left atrial appendage closure devices Device name Company Design Device sizes (mm) WATCHMAN* Boston Scientific Single-lobe occluder 21, 24, 27, 30, 33 with nitinol frame, PET membrane, 10 fixation anchors. WATCHMAN FLX* Boston Scientific Single-lobe occluder with nitinol frame, PET 20, 24, 27, 31, 35 membrane, 12 fixation anchors. Amplatzer Cardiac Plug (ACP) Abbott Lobe and disc (polyester mesh in 16, 18, 20, 22, 24, 26, 28, 30 both) nitinol mesh construct. Stabilizing wires. Amulet* Abbott Similar design as Amplatzer Cardiac Plug, but wider lobe and disc and more stabilizing wires. 16, 18, 20, 22, 25, 28, 31, 34 WaveCrest Coherex Medical Single-lobe occluder. 22, 27, 32 Nitinol frame, polyurethane foam, ePTFE membrane, retractable anchors. Occlutech LAA Occluder Occlutech Single-lobe occluder. Nitinol wire mesh, 15, 18, 21, 24, 27, 30, 33, 36, 39 stabilizing loops, nanomaterial covering. Lambre Lifetech Lobe and disc nitinol 16 to 36 frame. PET membrane. Distal barbs anchors. PET: polyethylene terephthalate; ePTFE: polytetrafluoroethylene; LAA: left atrial appendage; FDA: United States Food and Drug Administration; CE: conformit Europ enne (French for "European conformity"). FDA approved. CE mark refers to any product that may be freely traded in any part of Europe (ie, European Union) economic area. https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 28/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Graphic 140267 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 29/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate WATCHMAN implant (A) Watchman left atrial appendage (LAA) closure technology. (B) Watchman LAA closure technology in anatomical position. Reproduced from: Jain AK, Gallagher S. Technology and guidelines Percutaneous occlusion of the left atrial appendage in non-valvular atrial brillation for the prevention of thromboembolism: NICE guidance. Heart 2011; 97:762, with permission from BMJ Publishing Group Ltd. Graphic 61636 Version 5.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 30/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Epicardial percutaneous or surgical left atrial appendage closure devices Device name Company Design Device sizes (mm) LARIAT* SentreHeart Endocardial and LAA sizes up to 40 epicardial percutaneous access width, 20 height, 70 length required. Magnetically assisted snaring of LAA. AtriClip* AtriCure Surgical/thoracotomy approach. Parallel clip 35, 40, 45, 50 with polyester mesh. TigerPaw II* Marquet Surgical approach. Compliant soft silicone fastener. LAA: left atrial appendage; CE: conformit Europ enne (French for "European conformity"). CE mark refers to any product that may be freely traded in any part of Europe (ie, European Union) economic area. Approved for tissue apposition, not specifically for LAA occlusion. United States Food and Drug Administration approved. Current class 1 recall, not commercially available. Graphic 140269 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 31/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate CHADS score, thromboembolic risk, and effect of warfarin anticoagulation 2 Clinical parameter Points Congestive heart failure (any history) 1 Hypertension (prior history) 1 Age 75 years 1 Diabetes mellitus 1 Secondary prevention in patients with a prior ischemic stroke or a transient 2 ischemic attack; most experts also include patients with a systemic embolic event Events per 100 person-years* CHADS score 2 NNT Warfarin No warfarin 0 0.25 0.49 417 1 0.72 1.52 125 2 1.27 2.50 81 3 2.20 5.27 33 4 2.35 6.02 27 5 or 6 4.60 6.88 44 NNT: number needed to treat to prevent 1 stroke per year with warfarin. The CHADS score estimates the risk of stroke, which is defined as focal neurologic signs or symptoms that persist for more than 24 hours and that cannot be explained by hemorrhage, trauma, or other factors, or peripheral embolization, which is much less common. Transient ischemic attacks are not included. All differences between warfarin and no warfarin groups are statistically significant, 2 except for a trend with a CHADS score of 0. Patients are considered to be at low risk with a score of 0, at intermediate risk with a score of 1 or 2, and at high risk with a score 3. One exception is that most experts would consider patients with a prior ischemic stroke, transient ischemic attack, or systemic embolic event to be at high risk, even if they had no other risk factors and, therefore, a 2 score of 2. However, the great majority of these patients have some other risk factor and a score of at least 3. Data from: Go AS, Hylek EM, Chang Y, et al. Anticoagulation therapy for stroke prevention in atrial brillation: how well do randomized trials translate into clinical practice? JAMA 2003; 290:2685; and CHADS2 score from Gage BF, Waterman AD, Shannon W, et al. Validation of clinical classi cation schemes for predicting stroke: results from the National Registry of Atrial Fibrillation. JAMA 2001; 285:2864. Graphic 61615 Version 8.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 32/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Amplatzer plug (A) Amplatzer cardiac plug. (B) Amplatzer cardiac plug in anatomical position. Reproduced from: Jain AK, Gallagher S. Percutaneous occlusion of the left atrial appendage in non-valvular atrial brillation for the prevention of thromboembolism: NICE guidance. Heart 2011; 97:762, with permission from BMJ Publishing Group Ltd. Graphic 82936 Version 4.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 33/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate WaveCrest system Reproduced with permission. Copyright 2015 Coherex Medical, Inc. All rights reserved. Graphic 98061 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 34/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Lariat device for tissue approximation Reproduced with permission. Copyright 2014 SentreHEART, Inc. All rights reserved. Graphic 87967 Version 1.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 35/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Epicardial percutaneous or surgical left atrial appendage closure devices Device sizes Approval Device name Company Design (mm) status LARIAT SentreHeart Endocardial and LAA sizes up to FDA approval epicardial percutaneous access 40 width, 20 height, 70 length CE Mark (for tissue apposition) required. Magnetically-assisted snaring of LAA. AtriClip AtriCure Surgical/thoracotomy approach. Parallel 35, 40, 45, 50 FDA approval CE Mark clip with polyester mesh. TigerPaw II Marquet Surgical approach. Compliant soft silicone fastener. Current class 1 recall, not commercially available FDA approval CE Mark AEGIS AEGIS Medical Innovations Epicardial subxiphoid percutneous approach. Electrode- guided navigation for Not yet LAA tissue capture. Cardioblate Closure System Medtronic Epicardial approach. Silicone band covered by polyester fabric. Not yet LAA: left atrial appendage. Graphic 105505 Version 2.0 https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 36/37 7/5/23, 9:05 AM Atrial fibrillation: Left atrial appendage occlusion - UpToDate Contributor Disclosures Ziyad M Hijazi, MD, MPH, FAAP, FACC, MSCAI, FAHA, FPICS Consultant/Advisory Boards: NuMED Inc [Coarctation of the aorta]. All of the relevant financial relationships listed have been mitigated. Jacqueline Saw, MD, FRCPC, FACC Grant/Research/Clinical Trial Support: Abbott Vascular [SCAD-spontaneous coronary artery dissection]; AstraZeneca [SCAD-spontaneous coronary artery dissection]; Boston Scientific [SCAD-spontaneous coronary artery dissection]; CIHR, Foundation of Canada [SCAD-spontaneous coronary artery dissection]; Michael Smith Foundation [SCAD-spontaneous coronary artery dissection]; National Institutes of Health [SCAD-spontaneous coronary artery dissection]; Servier [SCAD-spontaneous coronary artery dissection]; St Jude Medical [SCAD-spontaneous coronary artery dissection]; UBC Division of Cardiology [SCAD-spontaneous coronary artery dissection]. Consultant/Advisory Boards: Abbott Vascular [LAA closure]; AstraZeneca [LAA closure]; Bayer [Antiplatelet Therapy, LAA Closure]; Boston Scientific [LAA closure]; FEops [LAA closure]; Gore [LAA closure]; St Jude Medical [LAA closure]. Speaker's Bureau: AstraZeneca [LAA closure]; Bayer [SCAD (Watchman, ACP)]; Boston Scientific [LAA closure]; St Jude Medical [LAA closure]; Sunovion [LAA Closure]. All of the relevant financial relationships listed have been mitigated. Bradley P Knight, MD, FACC Grant/Research/Clinical Trial Support: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; MDT [Electrophysiology]; Philips [Electrophysiology]. Consultant/Advisory Boards: Abbott [Electrophysiology]; Atricure [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Electrophysiology]; BSCI [Electrophysiology]; CVRx [Heart failure]; MDT [Electrophysiology]; Philips [Electrophysiology]; Sanofi [Arrhythmias]. Speaker's Bureau: Abbott [Electrophysiology]; Biosense Webster [Electrophysiology]; Biotronik [Electrophysiology]; Boston Scientific [Transeptal catheterization]; BSCI [Electrophysiology]; MDT [Electrophysiology]. All of the relevant financial relationships listed have been mitigated. Nisha Parikh, MD, MPH No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/atrial-fibrillation-left-atrial-appendage-occlusion/print 37/37