Which System Is better?: Watchman or Cardiac Plug or Something Else?
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- Bartholomew Holland
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1 ANGIOPLASTY SUMMIT-TCTAP 2012 Seoul, Korea, April 24-27, 2012 Which System Is better?: Watchman or Cardiac Plug or Something Else? Horst Sievert, Annkathrin Brauth, Isabel Schulmeyer, Patrick Boehm, Jonas Kuropka, Ilona Hofmann, Undine Pittl CardioVascular Center Frankfurt, Frankfurt, Germany
2 LAA Closure Epicardial SentreHeart AEGIS AtriCure Medtronic Endocardial Watchman Cardiac Plug Coherex Sideris Patch Occlutech pfm Medical Lifetech Gore
3 Watchman Device Gen 2 Nitinol frame with PET membrane and fixation barbs CE mark Proven to be non- inferior to anticoagulation Randomized PROTECT AF trial and large registries
4 Watchman Device Frame sits in the LAA Fixation barbs prevent dislodgement PET membrane gets covered by endothelium
5 Amplatzer Cardiac Plug ACP Nitinol wire mesh with distal plug and proximal disk connected by a central waist Polyester patch inside CE mark So far only retrospective registries Results of prospective EU registry are pending Randomized d trial just started
6 Amplatzer Cardiac Plug ACP Plug sits in the LAA Hooks prevent dislodgement Umbrella closes the orrifice
7 Sentre Heart - LARIAT Pericardial access - Wire with magnetic tip pericardial space Transseptal access - Wire with magnetic tip LAA The two wire find each other A loop suture is advanced over the pericardial wire LAA sutured from outside
8 Sentre Heart - LARIAT Transseptal access - Wire with magnetic tip LAA Pericardial access
9 Sentre Heart - LARIAT 2nd magnet wire introduced via the pericardial access The wires find each other Suture snare advanced in the pericardial space
10 Sentre Heart - LARIAT Before ligation After ligation
11 Advantages LAA Ligation - Some of the most serious complications of LAA closure can almost not occur Tamponade Device embolisation Thrombus on the device Disadvantages - Learning curve of pericardial puncture - Not possible after cardiac surgery
12 Is one better than the other? It is rare that a LAA can not be closed - less than 5% with all devices There are no data comparing the different devices head to head You can almost use what you are used to use However, the devices have - some specific exclusion-inclusion i l i criteria i - some advantages and disadvantages in specific anatomical subsets
13 Size of the LAA Watchman: - LAA ostium has to be (-31) mm ACP - LAA ostium has to be 10-28mm Sentre Heart Diameter of the LAA body has to be < - Diameter of the LAA body has to be < 40mm
14 Morphology of the LAA Watchman: - Minimum i "functional" LAA length should be at least equal to device diameter ACP - Minimum i "functional" LAA length 10mm Sentre Heart - Posterior oriented and "chicken wing" LAAs can not be closed
15 Watchman is more forgiving i regarding sheath position
16 ACP Landing Zone
17 ACP Sheath orientation Ideal!!
18 ACP Sheath orientation is more important Ideal!!
19 Difficult!!
20 Difficult!!
21 Sheath orientation not so important with the Watchman
22 Watchman Landing Zone
23 Watchman Sheath orientation optimal
24 Sub-optimal
25 Sub-optimal
26 optimal
27 still ok
28 still ok
29 ACP requires more than the Watchman a well defined landing zone and a perpendicular orientation ti of the sheath in relation to the LAA ostium
30 What's about different LAA shapes?
31 Ideal for everything!!
32 ACP!
33 Watchman!
34 Not as easy as it looks! No good landing zone!
35 Not as easy as it looks! ACP?
36 Not as easy as it looks! ACP?
37 Not as easy as it looks! ACP?
38 Not as easy as it looks! ACP? Here you have to measure precisely! Precisely where you want to place the device
39 Not as easy as it looks! And Watchman?
40 Not as easy as it looks! Watchman? But only if there is enough space! Could be easier
41 What's that?
42 What's that?
43 What's that?
44 Complex morphology
45 Complex morphology Difficult to place an ACP right here!
46 Complex morphology But rather easy here!
47 Complex morpology And Watchman also easy And Watchman also easy despite complex morphology
48 Complex morphology Body diameter may be too Body diameter may be too large for Sentre Heart
49 Other considerations In case of device embolisation it is easier to snare and extract the Watchman than the ACP With Watchman one sheath size fits for all device sizes The sheath can be used for calibration Decision about device size can be made after sheath insertion With ACP no quantitative measurements are needed after device implantation That one LAA closure device is effective in stroke prevention does not mean necessarily that all other devices are effective as well - Data are still much more solid for Watchman To compare the safety profile of different devices a randomized study is needed
50 When to use which device? Very short LAA - ACP may be better than Watchman Very large LAA (>28mm) - Watchman may be better (up to 31mm) Multiple proximal lobes - ACP may be better (short landing zone, umbrella may cover all lobes) But if there is a bad angle between delivery system and LAA - Watchman may be better Patient can not take any blood thinner therapy - Sentre Heart better
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