Our hospital is starting to do more left atrial occlusion devices for people who have afib and aren’t able to tolerate blood thinners. Currently, two types are offered by our cardiologists: Watchman procedure (endocardial) vs Lariat procedure (epicardial).
It look and acts similar to a lariat or lasso. An external guide wire with a magnet at its tip is introduced outside the heart towards the left atrial appendage (LAA). Another wire with a magnet at its tip is introduced from a groin vein and it traverses the interatrial septum to sit at the most distal point inside the LAA. The magnets “connect” and the lariat is introduced along the external guide wire and essentially lassos the LAA.
A large occlusion device is inserted via a groin vein and traverses the interatrial septum into the proximal (base or largest opening) left atrial appendage. The device gets deployed and successfully occludes the LAA.
Is one better than the other?
Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: Understanding the differences in the location and type of leaks and their clinical implications. Pillarisetti J, et al. Heart Rhythm. 2015.
CONCLUSION: The Lariat device is associated with a lower rate of leaks at 1 year as compared with the Watchman device, with no difference in rates of cerebrovascular accident. There was no correlation between the presence of residual leak and the occurrence of cerebrovascular accident.
For these cases, we typically have a good flowing peripheral IV and intubate these patients for general anesthesia. There’s a fair amount of TEE required for placement and verification of correct positioning of the device. Both procedures require transseptal access. Watch for hypotension as there is a risk for pericardial effusion.
Surgically, more and more cases are performed through tiny incisions for minimal scarring. Don’t let that underestimate the size of the procedure. For example, mitral valve surgery is still a common procedure that involves a sternotomy (“cracking the chest”) and stopping the heart — it’s a big procedure. However, surgeons have become adept at making smaller incisions while still undergoing the big procedure.
Chauhan S, Sukesan S. Anesthesia for robotic cardiac surgery: An amalgam of technology and skill. Ann Card Anaesth [serial online] 2010 [cited 2016 Apr 12];13:169-75. Available from: http://www.annals.in/text.asp?2010/13/2/169/62947
Watch this cute and short animation on how anesthesia works. Great for patients and medical students!
Taken from Anesthesiology, April 2016.
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