• Left Atrial Appendage Closure Using Ligation and the LARIAT Device


    If you have atrial fibrillation and are unable to take anticoagulant medications, your doctor may recommend a procedure known as left atrial appendage closure (LAAC or LAA closure). This procedure helps reduce the risk of stroke. There are different types of LAA closure techniques. One of these includes use of the LARIAT device.

    The LARIAT device works through a process known as ligation. To “ligate” means to tie or sew closed. The LARIAT is a tool used to tie the left atrial appendage (LAA) closed in order to prevent any blood from entering. The LAA is a small pouch that sits on the top-left part of the heart. In people with atrial fibrillation, blood tends to pool and form clots in the LAA. The clots can then move through the bloodstream to the brain, where they can block blood flow and cause an ischemic stroke. Blocking the LAA so blood cannot flow into it greatly reduces the chance of an ischemic stroke.

    What Is the LARIAT?

    The LARIAT device may be used to tie a knot around the opening of the left atrial appendage and close it off. By sealing off the LAA, the device prevents blood from flowing into the LAA where blood clots could form. Images provided courtesy of SentreHEART, Inc. 

    The LARIAT is a small, Teflon-coated polyester loop shaped like a slipknot. It can be used in either open-heart surgery or during a minimally invasive procedure that uses slender tubes (catheters) to deliver the LARIAT to the opening of the LAA. In both the surgical procedure and the minimally invasive procedure, the LARIAT is tied around the LAA to close it off. This prevents blood from entering the LAA sac, where it could form blood clots that could break loose and travel to the brain.

    A LARIAT device only needs to be placed one time. Once it is in position and working, you will not have to undergo the procedure again, barring any complications.

    How the LARIAT Device Is Used

    As mentioned above, there are two methods for implanting the LARIAT in the heart in order to close off the left atrial appendage. Both techniques require you to be under general anesthesia, which means you would be “asleep” during the whole procedure. Your medical team will recommend the best option for you.

    Pericardial Ligation

    Pericardial ligation is the LARIAT method that does not require open-heart surgery. Instead, your medical team will make one tiny incision in your upper leg and a second incision just under your rib cage.

    A slender tube called a catheter will be inserted into a vein that is accessed through these tiny incisions. The catheters are used to deliver the LARIAT device through the heart and directly to the LAA sac, without having to open up your chest. The catheter in the vein in your leg will be used to perform a transseptal puncture, to push the tip from your heart’s right upper chamber (right atrium) to the left upper chamber (left atrium). A wire with a magnet on its tip will be inserted through the catheter and steered to the tip of the left atrial appendage. A second wire, also tipped with a magnet, will be inserted through the other catheter. The tips of the two wires will be steered toward each other and then held together by magnetic force. Next, a suture-delivering catheter will be advanced over the wire that was inserted from under your rib cage. This catheter will deliver the loop over the left atrial appendage. Once the loop is in place around the opening to the LAA, your doctor will tighten the loop so that it completely closes the LAA. Then the catheters and wires will be backed out of your body and the LARIAT will remain in place, where it will begin doing its job of keeping blood from entering the LAA.

    Throughout the procedure, your doctor will use imaging tools to carefully track the movement and placement of the device in your blood vessels and heart. 

    Complications May Occur During LAA Procedures

    Throughout the procedure, your doctor will use imaging tools to carefully track the movement and placement of the device in your blood vessels and heart. Nevertheless, like all procedures, there are risks associated with left atrial appendage closure. For example, once the transseptal puncture is performed, it is possible for a blood clot to form in a catheter or for air to get into a catheter and be injected into the heart. If a blood clot or air travels to the brain, it could cause a stroke. Physicians are aware that these complications can occur and so they take steps, such as flushing out the catheters, to minimize these risks.  

    Another possible complication is rupture of the left atrial appendage. This complication may occur because the left atrial appendage is a relatively thin-walled structure devices and the device may apply some pressure on the LAA while it is being used. This is a potentially disastrous complication that requires emergency heart surgery.

    To learn more about the risks and benefits associated with LAA procedures, click here.

    Surgical Ligation

    The second LARIAT method, surgical ligation, is performed during open-heart surgery. If you are undergoing surgery for another reason, such as to bypass blocked heart arteries or repair a faulty heart valve, surgical ligation may be a good choice. Because your chest will already be open for surgery, the catheter tubes will not be needed to guide the LARIAT device into place.

    Before & After Your LAAC LARIAT Procedure

    If you are having an LAAC procedure, your medical team will provide detailed information about what you need to do before the procedure to prepare and what you can expect to happen after the procedure is concluded. For general information, visit these articles:

    What to Expect Before LAA Closure Using Ligation and the LARIAT Device

    What Happens After LAA Closure Using Ligation and the LARIAT Device