1st order
- Radiofrequency ablation (ablation therapy) – method of permanently eliminating atrial fibrillation using a cardiac catheter. In this procedure, the excitation conduction pathway leading to the arrhythmia is obliterated. According to ESC guidelines (European Society of Cardiology, ESC), catheter ablation is primarily recommended for symptomatic patients in whom at least one previous attempt at drug therapy has been unsuccessful (Class I recommendation, Level of Evidence A for the second-line indication).For more see “Catheter ablation” below.
2nd order
- Left atrial appendage (LAA) occlusion using an atrial appendage occluder (implant; “left atrial appendage”)-occluder), cardiac catheterization-assisted procedure to protect patients with atrial fibrillation from stroke (91% of thrombi in atrial fibrillation originate in the left atrial appendage):
- In the ESC guidelines, atrial appendage occlusion is a IIb indication.
- Indications: previous relevant bleeding/gastric or intestinal bleeding on anticoagulant therapy.
Note: All patients after surgical occlusion or excision of the left atrial appendage should be permanently anticoagulated if a risk constellation is present (IB)
- Patients with AF who have a history of cerebral hemorrhage; the relative risk of clinical events was 81% lower in the occluder group than in the standard care group (primary end point: combination of death, ischemic apoplexy (stroke), and major bleeding events).
- The effect of surgical atrial appendage closure in VHF patients was examined in an analysis of 10,524 patients from more than 1,000 institutions with a mean age of 76 years, 39% female. This showed a
- Significant reduction in all-cause mortality by 15% (7 vs. 10.8%, adjusted HR: 0.85).
- Significant risk reduction of 30% for the combined secondary end point (from all-cause mortality, thromboembolism, or hemorrhagic insult) (8.7 vs. 13.5%, adjusted HR: 0.7)
- No significant difference in hemorrhagic insult (cerebral hemorrhage) (0.2 vs. 0.3%)
- PRAGUE-17 trial: comparison of atrial appendage occlusion (LAA occlusion)versus NOAKs (new oral anticoagulants/anticoagulants) in patients with nonvalvular atrial fibrillation (AF not associated with mitral stenosis) using modified intention-to-treat analysis after nearly 20 months of follow-up:
- Atrial appendage closure was noninferior to NOAK therapy with respect to the primary end point.
- There were also no differences in the respective individual end points for the 2 treatment regimens.
- In 4, 5% of patients, a complication occurred in the course of occluder implantation (occlusion system).
Further notes
- Use of carotid filters in patients with VCF who cannot tolerate anticoagulants: carotid filters are intended to prevent severe strokes by acting as “thrombus catchers.” The procedure is still in the experimental phase.
