1. How to Screen Patients for LAAC
Maurice Buchbinder, MDCM, FACC, FSCAI
Medical Director
Foundation for Cardiovascular Medicine
San Diego, California
Professor of Clinical Medicine
Stanford Hospital and Clinics
Stanford, California

2. Disclosures
Within the past 12 months, I or my spouse/partner have had a financial interest/arrangement with the organization(s) listed below.
BSCI
Scientific Advisory Board Member
Speaker Bureau
Equity Ownership

3. Introduction
Left atrial appendage (LAA) exclusion with the Watchman device has emerged as an alternative to oral anti-coagulation for prevention of stroke in patients with non valvular atrial fibrillation
To achieve successful LAA exclusion and avoid complications, understanding optimal patient selection and detailed procedural steps is essential

4. Stroke Prevention: Anticoagulant Effect
Meta-analysis of ischemic stroke or systemic embolism
Favors warfarin
0.3
0.6
0.9
1.2
1.5
Favors other Rx
W vs Placebo
W vs Wlow dose
W vs Aspirin
W vs Aspirin + Clop
W vs Ximelagatran
W vs Dabigatran 110
W vs Rivaroxaban
W vs Dabigatran 150
Category
1.8
2.0
Modified from Camm AJ. EHJ 2009;30:2554-5 12 8 9 4

5. Bleeding Risks with Old and New Drugs
P=.31
P=.003
Bleeding Risk
% per year
Connolly SJ, et.al., N Engl J Med Sep 17;361(12):

6. Thromboembolism versus Haemorrhage
Bleeding risk
? Left Atrial Occlusion Device
3-4% pa
Thromboembolic risk
1-2% pa 6

7. LAA: Pre-Procedure Patient Selection CHA2DS2 (1-5) and HAS-BLED Score
History of Prior Cardiac Intervention
Tolerance to oral anticoagulation, dependence on DAPT
Screening imaging TEE/CT

8. LAA: Pre-Procedure Patient Selection
CHA2DS2-VASc (1-5) and HAS-BLED Score
History of Prior Cardiac Intervention
Tolerance to oral anticoagulation, dependence on DAPT
Screening TEE

9. CHA2DS2 Score and Stroke Rate
Annual Risk of Stroke
Adapted from Gage et al, JAMA 2001;285:2864–2870

10. Camm et al, European Heart Journal doi:10.1093/eurheartj/ehq278
CHA2DS2-VASc
2010 ESC AF Guidelines now call for use of CHA2DS2-VASc score
Recommend oral anticoagulation for score 2 or greater and either anticoagulation or aspirin for score =1
Camm et al, European Heart Journal doi: /eurheartj/ehq278

11. Anticoagulation and Bleeding
“An assessment of bleeding risk should be part of the patient assessment before starting anticoagulation ... It would seem reasonable to use the HAS-BLED score to assess bleeding risk in AF patients, whereby a score of ≥3 indicates ‘high risk’, and some caution and regular review of the patient is needed following the initiation of antithrombotic therapy,whether with VKA or aspirin.”
According to HAS-BLED, 61% of pts currently on warfarin for AF are at “moderate” risk of bleeding and additional 19% are at “high” risk!
Camm et al, European Heart Journal doi: /eurheartj/ehq278
Pisters R, et al Chest 2010; 138:

12. LAA: Pre-Procedure Patient Selection CHADS2 (1-5) and HAS-BLED Score
History of Prior Cardiac Intervention
Tolerance to oral anticoagulation, dependence on DAPT
Screening TEE

13. LAA: Pre-Procedure
Unlike with other devices like the LARIAT™ implantation of the Watchman device is not limited by previous open chest procedures
In patients with previous surgical cardiac interventions, it is important to ensure that attempt at partial or total appendage exclusion was not performed

14. LAA: Pre-Procedure Understanding anatomy of LAA
landmarks PA
LAA
LUPV
LCx
Laura DM et al JASE July 2014

15. LAA: Pre-Procedure Patient Selection CHADS2 (1-5) and HAS-BLED Score
History of Prior Cardiac Intervention
Tolerance to oral anticoagulation, dependence on DAPT
Screening TEE

16. LAA: Pre-Procedure
Particular to the Watchman™, continued oral anticoagulation for 45 days following implantation is recommended
Although small non randomized series have tested the successful use of DUAL ANTI - PLATELET therapy, in lieu of oral anticoagulation, the recommendation remains part of the approved IFU

17. LAA: Pre-Procedure Patient Selection CHADS2 (1-5) and HAS-BLED Score
History of Prior Cardiac Intervention
Tolerance to oral anticoagulation, dependence on DAPT
Screening TEE

18. Understanding anatomy of LAA
LAA morphology: orifice
neck
lobe
450 PA PV

19. LAA: Pre-Procedure Baseline TEE Appendage Size (width-length)
Absence of Thrombus
Single versus multiple lobes
Appendage Tilting
Fossa Ovalis
Anterior-Posterior Appearance
Height Between LAA/Fossa (single vs. Double Curve guide)
Relation between appendage and Left pulmonary vein

20. Baseline Echo Assessment Understand LAA Anatomy
The Wind Sock Type LAA is an anatomy in which one dominant lobe of sufficient length is the primary structure.
The Chicken Wing Type LAA is an anatomy whose main feature is a sharp bend in the dominant lobe of the LAA anatomy at some distance from the perceived LAA ostium.
The Broccoli Type LAA is an anatomy whose main feature is an LAA that has limited overall length with more complex internal characteristics.

21. Baseline TEE Images
Agitated Saline

22. Baseline TEE Images
TEE of LAA at 45 Degrees

23. Baseline TEE Measurements
0 Degrees
45 Degrees
90 Degrees
135 Degrees

24. Understanding anatomy of LAA
landmarks
Circumflex Artery Warfarin Ridge LAA orifice
Atrial Septum
L. Circumflex artery R
LAA N L
IAS
inferoposterior
Surgical view MV
Warfarin ridge

25. Understanding anatomy of LAA
cactus
windsock
450
1350 PA
chicken wing PV
cauliflower

26. Device sizing Orifice Landing zone Lobe height
Landing zone 22x20mm Lobe Height/depth 23mm
Measure widest diameter in cardiac cycle
LAA in sinus rhythm → (usually end systole)
Fluid status, volume loading

27. WATCHMAN Device Selection
Maximum LAA Ostium (mm)
Device Size (mm)
(uncompressed diameter)
17-19 21
20-22 24
23-25 27
26-28 30
29-31 33
Device sizing is based on maximum LAA diameter
Maximum LAA ostium range: 17 to 31mm
Max LAA length should be equal to or greater than the ostium
Select Size
Maximum Measured LAA Ostium (mm) Minimum Measured LAA length mm Implant Diameter.
Note: Use TEE and fluoro to confirm baseline measurements and select device size.

28. Thank you!