US cardiovascular societies publish joint expert consensus on left atrial appendage occlusion requirements


The Society for Cardiovascular Angiography and Interventions (SCAI), the American College of Cardiology (ACC) and the Heart Rhythm Society (HRS) have published a joint document providing recommendations—for institutions and interested physicians—for the establishment and maintenance of left atrial appendage occlusion programmes performing left atrial appendage closure.

The document—published in Catheterization and Cardiovascular Interventions,  the Journal of the American College of Cardiology, and HeartRhythm Journal—was developed by a committee of interventional cardiologists and electrophysiologists to help physicians and hospitals offer consistent and appropriate care to patients with atrial fibrillation treated with left atrial appendage closure to reduce their stroke risk. It recommends physicians performing such procedures have significant knowledge of atrial fibrillation, including medical management, rate and rhythm control, tools for assessing stroke risk, management of oral anticoagulant therapy, knowledge of available medications, an understanding of bleeding risks, and knowledge of risks associated with left atrial appendage closure. The document also recommends physicians have a detailed understanding of the left atrium and left atrial appendage, and experience with procedures requiring access to the left side of the heart.

Furthermore, according to the new document, institutions performing left atrial appendage closure procedures should perform at least 50 structural heart disease or left-sided catheter ablations, with at least 25 involving transseptal puncture through an intact septum, in the year prior to starting a left atrial appendage closure programme. Procedures should be performed in a cardiac catheterisation laboratory, electrophysiology suite or hybrid suite, with quality imaging available.

The document also stresses the importance of continuing to collect data on these procedures as the number of devices and approaches to minimally invasive left atrial appendage closure expands in the coming years. Participation in a national registry should be mandatory and individual institutions should establish processes to regularly review aggregate and physician-specific results, including number of implants, complications and outcomes.

Lead author of the document, Clifford J Kavinsky (director of the Center for Adult Structural Heart Disease at Rush University Medical Center, Chicago, USA), says: “Through our collaboration, SCAI, the ACC and HRS have brought together combined experience in left atrial appendage closure to produce a document that will set the standard for safe and effective implementation of this technology to fulfil an important unmet need in treating patients with atrial fibrillation who are at risk for stroke. This document will ensure that institutions and operators developing left atrial appendage occlusion programmes will have the necessary experience, training and infrastructure to carry out this procedure in a way that optimises patient outcomes.”

After the publication of the document, SCAI/ACC/HRS sent a joint letter to the Centers for Medicare & Medicaid Services (CMS) about its recent draft National Coverage Determination for left atrial appendage closure. The societies say that they support the CMS’s proposal to cover left atrial appendage closure for non-valvular atrial fibrillation patients with elevated risk of stroke performed by experienced operators at high quality facilities with data reported to a registry after a shared decision-making discussion. However, in the letter, the societies outline several suggested revisions. For example, they state that they “question the scientific basis of the proposed requirement for data collection on contemporaneous patients managed with oral anticoagulant therapy to serve as non-interventional controls and recommend it be removed.”