ABC | Volume 113, Nº4, October 2019

Short Editorial Pisani & Scanavacca Percutaneous occlusion of left atrial appendage Arq Bras Cardiol. 2019; 113(4):722-724 1. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg. 1996;61(2):755-9. 2. Johnson WD, Ganjoo AK, Stone CD Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg. 2000;17(6):718-22. 3. Stoddard MF, Dawkins PR, Prince CR Ammash NM. Left atrial appendage thrombus is not uncommon in patients with acute atrial fibrillation and a recent embolic event: a transesophageal echocardiographic study. J AmColl Cardiol. 1995;25(2):452-9. 4. Sievert H, Lesh MD, Trepels T Omran H, Bartorelli A, Della Bella P, et al. Percutaneous left atrial appendage transcatheter occlusion to prevent stroke in high-risk patients with atrial fibrillation: early clinical experience. Circulation. 2002;105(16):1887-9. 5. Omran H, Tzikas A, Sievert H Stock F. A history of percutaneous left atrial appendage occlusion with the PLAATO device. Interv Cardiol Clin. 2018;7(2):137-42. 6. Holmes DR, Reddy VY, Turi ZG Doshi SK, Sievert H, Buchbinder M, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374(9689):534-42. 7. Holmes DR Jr, Kar S, Price MJ Whisenant B, Sievert H, Doshi SK, et al. Prospective randomized evaluation of theWatchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64(1):1-12. 8. JanuaryCT,WannLS,CalkinsHChenLY,Cigarroa JE,Cleveland JC Jr,etal.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the managementofpatientswithatrialfibrillation:areportoftheAmericanCollegeof Cardiology/AmericanHeartAssociationTaskForceonClinicalPracticeGuidelines andtheHeartRhythmSociety.JAmCollCardiol.2019;74(1):104-32. 9. Kirchhof P, Benussi S, Kotecha D Kotecha D, Ahlsson A, Atar D, et al. 2016 ESC guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg. 2016;50(5):e1-e88. References a cardiac tamponade rate of 1.02%, most of them adequately treated with pericardiocentesis; however, the tamponade resulted in death in three cases. These rates were lower than those observed in clinical studies, although most devices were implanted by less experienced operators. Another European registry (EWOLUTION) 11 also demonstrated a low complication rate, showing 34 (3.3%) adverse events among 1021 patients included in the study. Two Brazilian registries have been recently published and suggested the safety of appendage occlusion device implantation. Guerios et al., 12 performed a multicenter registry and evaluated the results of 91 patients with nonvalvular AF (62% ineligible for anticoagulation) and high risk of stroke (CHA2DS2VASc 4.5 ± 1.5), submitted to the implantation of 96 prostheses, with the ACP (Amplatzer Cardiac Plug) being implanted in 94.6%. The implant success rate was 97.8%, with 7.2% of complications, with five pericardial effusions requiring pericardiocentesis, one non-dedicated device embolization and one gas embolism without sequelae. In this series, during a median follow-up of 346 days (128.6 patient-years), three non-procedure-related deaths were observed, as well as five cases of peri-prosthesis leakage, with thrombus formation next to the prosthesis in two, resolved with the return of anticoagulation and only two patients had stroke at the follow-up. In the second registry, Marcio Costa et al., 13 evaluated 15 patients with nonvalvular AF and high risk of bleeding, submitted to implantation of the ACP prosthesis. In this small series, the procedure was successfully performed in all cases with no reports of hemopericardiumor prosthesis displacement. In this issue of the Brazilian Archives of Cardiology, Şahiner et al. 14 disclose retrospective data from a center in Turkey, which included 60 patients submitted to implantation of the Amplatzer Amulet device. The main indication for the procedure was the occurrence of bleeding (usually gastrointestinal) in the presence of oral anticoagulation. The authors demonstrated that the implantation procedure was successful and safe in most patients. One patient had pulmonary artery rupture due to a probable direct injury by the prosthesis struts. In most patients, antiplatelet therapy consisted of ASA (100 mg) and clopidogrel (75 mg) for 6 months after the procedure, being maintained on single therapy after transesophageal echocardiography demonstrated the absence of periprosthetic leaks or thrombi. During a mean follow-up of 21 ± 15 months, none of the patients had a stroke but two patients had clinical symptoms of transient ischemic attack. Thus, due to the lack of robust evidence, the most recent guideline on atrial fibrillation recommends the implantation of appendage occlusion devices as a IIb indication, level of evidence B-NR, in patients with non-valvular AF at high risk for stroke and with contraindications for long-term oral anticoagulation use. 8 An ongoing randomized trial (ASAP-TOO) 15 is seeking to demonstrate the effectiveness of the Watchman prosthesis in this clinical condition, but the study is estimated to be completed in 2023. Apparently, we are reaching a stage of clinical knowledge and experience in optimizing the use of warfarin and direct- acting anticoagulants in patients with non-valvular AF at high risk of stroke and systemic embolization, recognizing and establishing the safe limits for their use. This opens up a new phase for the consideration of LAA occlusion devices. Therefore, additional prospective, multicenter, controlled clinical trials are needed to clarify the effectiveness and safety of the implantation of the devices in these new clinical situations, such as patients with absolute contraindication to OACs and antiplatelet use, even for a short period of time; patients that had a stroke while receiving apparently effective oral anticoagulation; LAA occlusion as an alternative to chronic use of NOACs; occlusion device implantation simultaneously with AF ablation; in addition to establishing the need and safe handling of short-term anticoagulant therapy and minimal antiplatelet therapy, which should be maintained after the implantation of different prostheses. 723