Anatomical and electrical remodeling with incomplete left atrial appendage ligation: Results from the LAALA‐AF registry

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Atrial fibrillation (AF) is the most common arrhythmia seen in clinical practice and is also the most common cause of ischemic strokes and accounts for 15–20% of patients.1 Treatment strategies of AF are directed toward prevention of stroke, systemic thromboembolism, and restoration of sinus rhythm to control symptoms. Recent guidelines recommend oral anticoagulation (OAC) with warfarin or non‐vitamin K oral anticoagulants (NOACs) is a first‐line treatment strategy for stroke prevention in AF and CHA2DS2VASC score of ≥2.3 Despite their efficacy, real‐world data have demonstrated that 35% of patients do not receive OAC and up to 25–30% of patients stop OAC on long‐term follow‐up.5 Left atrial appendage (LAA) exclusion by device therapy has recently emerged as a suitable alternative strategy in AF patients at risk of stroke who are intolerant to long‐term OAC.7
Catheter ablation (CA) is recommended as an effective treatment option in controlling symptoms and restoring sinus rhythm in drug‐refractory AF.3 However, several studies have demonstrated suboptimal results, requiring multiple CA procedures, especially in persistent and longstanding persistent AF.9 LAA has been recently demonstrated as an important site of trigger in the maintenance of organized atrial arrhythmias and persistent AF where electrical isolation of the LAA is proven to improve AF‐free survival.13
Endoepicardial LAA exclusion by the Lariat system (SentreHEART, Redwood, CA, USA) has been shown to be feasible and effective with high procedural success in patients with persistent AF and/or intolerant to OAC.16 Lariat can result in both electrical and mechanical isolation of the LAA by ischemic remodeling, thus simultaneously preventing stroke and decreasing AF burden. Even though most LAA ligations are successful and give excellent results, residual stumps and leaks are reported in a substantial number of patients (0–24%) undergoing the Lariat procedure.17 There are limited data regarding anatomical and electrical remodeling of LAA in patients with incomplete LAA ligation and its long‐term impact on clinical outcomes.22 In this study, we describe the characteristics of morphological and electrical remodeling in such patients by serial computed tomographic (CT) scan and electrophysiological study and the effect on long‐term clinical outcomes from the LAALA‐AF registry.
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