LARIAT Technique for Atrial Fibrillation Reduces Stroke Risk

Minimally invasive surgical technique for patients with atrial fibrillation who cannot tolerate standard anticoagulant therapy uses sutures to tie off the left atrial appendage and offers increased stroke protection.

The minimally invasive surgery for patients with atrial fibrillation who cannot tolerate standard anticoagulant therapy uses sutures to tie off the left atrial appendage and offer increased stroke protection.

The Lariat Suture Delivery System features a loop of suture that slips over the left atrial appendage (LAA) and tightens until it seals stroke-causing clots away from the rest of the heart and body.

Atrial fibrillation, which afflicts roughly 3 million Americans, increases clot formation by throwing the upper and lower chambers of the heart out of synch. More clots, in turn, increase the risk of stroke fivefold.

Doctors combat this risk in most atrial fibrillation patients with anticoagulant medications such as warfarin, rivaroxaban, apixaban or dabigatran. But serious complications such as gastrointestinal bleeding prevent about a fifth of patients from taking such medications.

For such patients, surgery has long been an option.

“The left atrial appendage is much like the appendix in that we can live without it, but it can also be problematic, in this case as a source of stroke,” explains electrophysiologist Vincent See, MD, an assistant professor of medicine at the University of Maryland School of Medicine.

“Research indicates that 80 to 90 percent of blood clots that create an issue like stroke for A-fib patients may originate there.”

For decades, the LAA was sealed via open-heart surgery, but 5 years ago, the FDA approved the Lariat as a minimally invasive alternative.

During a Lariat procedure, surgeons access the LAA by inserting a catheter under the rib cage into the sac that surrounds the heart. Another catheter is then advanced through the femoral vein into the heart and positioned inside the LAA to help guide the suture that closes off the LAA.

Trials have found the Lariat to be an effective tool for safely shutting off the LAA.

Indeed, a 2013 paper in the Journal of the American College of Cardiology reported that 85 of 89 (96%) patients were successfully treated with the procedure and that 81 of the 85 patients had complete closure immediately. The other 4 of 85 patients had a ≤3-mm residual LAA leak by TEE color Doppler evaluation. There were no complications due to the device (though 3 minor access-related complications). Of the patients undergoing one-year TEE (n = 65), there was 98% complete LAA closure, including the patients with previous leaks.

Trials designed to show how much stroke risk is reduced by the Lariat procedure‑‑and other procedures for sealing off the LAA‑‑are underway, but they have yet to publish any data.

Still, medical centers across the country are beginning to embrace the Lariat.

In just the past year, doctors have begun to offer it at venues as diverse as The University of Maryland Medical Center in Baltimore, St. John Hospital in Detroit, St. Francis Hospital in Wichita, and the Jersey Shore University Medical Center in Neptune.

“The Lariat is truly a breakthrough for patients who can’t take blood thinners,” said Ashish Patel, MD, electrophysiologist at Jersey Shore, who touted the reduced discomfort and shorter recovery time compared to open-heart surgery.