Han Xinqiang, Benditt David G
Cardiology Division of Reid Health, Indiana University School of Medicine, Richmond, IN 47374, USA.
Cardiac Arrhythmia Center, Cardiovascular Division, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, USA.
Rev Cardiovasc Med. 2023 Jul 19;24(7):211. doi: 10.31083/j.rcm2407211. eCollection 2023 Jul.
Atrial fibrillation (AF) is the most common cardiac arrhythmia and if untreated, significantly increases both the risk of intracardiac thrombus formation and ischemic stroke. In patients with nonvalvular AF (NVAF), the left atrial appendage (LAA) has been estimated to be the source of thrombus development in 91% to 99% of cases. Consequently, oral anticoagulation (OAC) to provide stroke prevention has become the standard of care for most AF patients; however, OACs are associated with a risk of bleeding and their efficacy depends on optimal patient compliance. In terms of alternative approaches to preventing embolic events, surgical LAA excision was attempted as early as in the late 1940s in patients with valvular AF; LAA excision remains a recommendation in surgical guidelines for NVAF patients who need open-heart coronary bypass or valvular replacement/repair surgeries. However, due to its invasive nature surgical LAA intervention has limited clinical application in present cardiology practice. Percutaneous LAA occlusion (LAAO) is increasingly being performed as an alternative to OAC for stroke prevention; this is particularly the case in patients at increased bleeding risk. Substantial progress has been made in percutaneous LAAO therapy since its inception some twenty years ago. Herein we systematically review both the critical literature that led to the development of LAAO, and the increasing clinical evidence supporting the application of this treatment strategy in NVAF. To this end we focus on recently published critical evaluations of United States Food and Drug Administration (US FDA) and Conformité Européenne (Commercial Sale of Licensed Product in the EU) (CE-Mark) approved LAAO devices, summarize the current status of LAAO therapy, and discuss the future perspectives regarding the knowledge and technology gaps in this area by recognizing the potential contributions of many ongoing but likely transformative clinical trials.
心房颤动（AF）是最常见的心律失常，若不治疗，会显著增加心内血栓形成和缺血性中风的风险。在非瓣膜性房颤（NVAF）患者中，据估计91%至99%的病例血栓形成源于左心耳（LAA）。因此，口服抗凝药（OAC）预防中风已成为大多数房颤患者的标准治疗方法；然而，OAC有出血风险，其疗效取决于患者的最佳依从性。在预防栓塞事件的替代方法方面，早在20世纪40年代末就尝试对瓣膜性房颤患者进行外科LAA切除；对于需要进行心脏直视冠状动脉搭桥或瓣膜置换/修复手术的NVAF患者，LAA切除仍是外科指南中的一项推荐。然而，由于其侵入性，外科LAA干预在目前的心脏病学实践中临床应用有限。经皮LAA封堵术（LAAO）作为预防中风的OAC替代方法越来越多地被采用；在出血风险增加的患者中尤其如此。自大约二十年前经皮LAAO疗法问世以来，已取得了实质性进展。在此，我们系统回顾了导致LAAO发展的关键文献，以及支持该治疗策略在NVAF中应用的越来越多的临床证据。为此，我们重点关注最近发表的对美国食品药品监督管理局（US FDA）和欧洲合格评定（欧盟许可产品商业销售）（CE标志）批准的LAAO装置的关键评估，总结LAAO疗法的现状，并通过认识到许多正在进行但可能具有变革性的临床试验的潜在贡献，讨论该领域知识和技术差距的未来前景。
