JIM Today 2018 - Thursday - page 10

10
JIM today
Issue 1 
Thursday
 22 February 2018
Expanding the reach of LAA occlusion
D
uring today’s Structural Heart
session, Sergio Berti, an in-
terventional cardiologist from
Ospedale del Cuore, Massa, Italy will
present the rationale for transcatheter
left atrial appendage (LAA) occlu-
sion (LAAo), the current indications
and scientific evidence and, crucially,
discuss the results of important recent
trials. “These trials provide a large
amount of data to support the fact
that this treatment is effective in re-
ducing cerebral ischaemic events due
to AF with excellent safety profile,”
he explained to
JIM Today
.
Dr Berti was one of the first inter-
ventional cardiologists in Europe to
learn this procedure, as well as one of
the first LAA proctors in Italy. Indeed,
his work has helped to expand the
technique in his country. “I have
always believed that LAAo can play
an important role in preventing stroke
in patients who do not tolerate oral
anticoagulation – even in the era of
direct oral anticoagulation [DOAC] –
and I am firmly convinced that LAAo
is still underutilised,” he said.
He noted that, despite DOAC
use, a significant number of patients
(around 40%) with AF are not ad-
equately treated: “In particular, about
15% of them have a contraindication
to anticoagulants because of a high
risk of bleeding, or because they have
had a previous severe haemorrhage,”
he said. “The result is that, in the real
world, only 60% of patients with AF
really receive adequate anticoagu-
lant therapy. “In addition, there are
still many patients suffering
stroke or TIA despite optimal
treatment with DOAC. For
these patients, LAAo should
be mandatory.”
Dr Berti added that patients
in haemodialysis are a special
population to consider due
to their extreme fragility. Spe-
cifically, he said that warfarin
does not impart a benefit on
such patients, yet it does bring
with it a consistent array of danger-
ous haemorrhagic side effects. “In
summary, in the real world, a huge
number of patients are at risk of
ischaemic cerebral events due to AF,”
he said, adding: “In this setting, LAAo
is a valid therapeutic option.”
If different areas of medicine col-
laborated more in order to provide
the best treatment for patients af-
fected by AF, and aimed to reduce the
risk of stroke, Dr Berti believes that
this would offer improvement moving
forward. “I am talking about cardiolo-
gists, neurologists, nephrologists,
gastroenterologists, haematologists
etc,” he said.
Suggesting a number of measures
that could be taken, he continued:
“We have a lot of things to do. I
strongly believe that we have to instill
in our patients the awareness of the
risk of stroke due to AF and of how
to prevent it, because it is possible to
do it.”
Dr Berti went on to note that a
further step would be to change the
culture within the medical community.
Specifically, he suggested that more
open sharing of outcomes from key
LAAo studies could be valuable. “We
have to emphasise the benefit for the
patients, i.e. a reduction of stroke risk
of around 70%, elevated procedural
success up to 96-98%, and the high
safety level of the procedure, reached
after years of learning,” he explained.
“Importantly, recent evidence sug-
gests that even operators with a few
LAAo procedures under their belts see
very limited procedural failure or peri-
procedural complications.”
Dr Berti also underlined
that there were “ideal” trials
that should be conducted.
“I would like to see studies
designed to consolidate
the safety and efficacy of
LAA closure in patients with
contraindications to oral an-
ticoagulation therapy, as well
as trials comparing warfarin
and LAAo in AF patients
undergoing haemodialysis,”
he said.
What’s more, Dr Berti hopes that
in the future, young patients with AF
may benefit too. “I have always been
fascinated by the idea of expanding
LAAo to young patients with AF,”
he said. “For these patients, I would
expect that avoiding years of DOAC
due to trans-catheter LAAo would
turn into long-term safety.
“However, for this specific area,
we would need long-term follow-up
…. but it is difficult and, at the mo-
ment, it is just a hope.”
Structural Heart 1 
Club 
Thursday 
12:45
“I have always believed that
LAAo can play an important
role in preventing stroke in
patients who do not tolerate
oral anticoagulation.”
Sergio Berti
“… there are still many patients
suffering stroke or TIA despite
optimal treatment with DOAC.
For these patients, LAAo
should be mandatory.”
Sergio Berti
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