title: The role of multimodality imaging in percutaneous left atrial appendage suture ligation with the LARIAT device.
abstract: Atrial fibrillation (AF), the most common cardiac arrhythmia, is a significant cause of embolic stroke. Although systemic anticoagulation is the primary strategy for preventing the thromboembolic complications of AF, anticoagulants carry major bleeding risks, and many patients have contraindications to their use. Because thromboembolism typically arises from a clot in the left atrial appendage (LAA), local therapeutic alternatives to systemic anticoagulation involving surgical or percutaneous exclusion of the LAA have been developed. Surgical exclusion of the LAA is typically performed only as an adjunct to other cardiac surgeries, thus limiting the number of eligible patients. Furthermore, surgical exclusion of the LAA is frequently incomplete, and thromboembolism may still occur. Percutaneous LAA exclusion includes two approaches: transseptal delivery of an occlusion device to the LAA and epicardial suture ligation of the LAA, the LARIAT procedure. In the LARIAT procedure, a pretied snare is placed around the epicardial surface of the LAA orifice via pericardial access. Proper snare placement is achieved with epicardial and endocardial magnet-tipped guidewires. The endocardial wire is advanced transvenously to the LAA apex after transseptal puncture. The epicardial wire, introduced into the pericardial space, achieves end-to-end union with the endocardial wire at the LAA apex. The snare is then placed over the LAA, tightened, and sutured. On the basis of early clinical experience, the LARIAT procedure has a high success rate of LAA exclusion with low risk for complications. The authors describe the indispensable role of real-time transesophageal echocardiography in the guidance of LAA epicardial suture ligation with the LARIAT device.
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Diana M
authors.initials: DM
authors.lastname: Laura
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Larry A
authors.initials: LA
authors.lastname: Chinitz
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Anthony
authors.initials: A
authors.lastname: Aizer
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Douglas S
authors.initials: DS
authors.lastname: Holmes
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Benenstein
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Robin S
authors.initials: RS
authors.lastname: Freedberg
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York.
authors.forename: Eugene E
authors.initials: EE
authors.lastname: Kim
authors.affiliation: Leon H. Charney Division of Cardiology, New York University Langone Medical Center, New York, New York. Electronic address: muhamed.saric@nyumc.org.
authors.forename: Muhamed
authors.initials: M
authors.lastname: Saric
mesh_terms: D020517:Atrial Appendage / Q000000981:diagnostic imaging / Q000601:surgery*; D001281:Atrial Fibrillation / Q000000981:diagnostic imaging / Q000601:surgery*; D006348:Cardiac Surgical Procedures / Q000295:instrumentation*; D017548:Echocardiography, Transesophageal / Q000379:methods*; D006801:Humans; D008026:Ligation / Q000295:instrumentation; D013537:Sutures; D013923:Thromboembolism / Q000517:prevention & control
keywords: 3D; Atrial fibrillation; LARIAT device; Left atrial appendage exclusion; Transesophageal echocardiography