BlueCross and BlueShield of Montana Medical Policy/Codes
Occlusion, Ablation or Surgical Removal of the Left Atrial Appendage
Chapter: Surgery: Procedures
Current Effective Date: September 24, 2013
Original Effective Date: September 24, 2013
Publish Date: June 24, 2013
Description

The left atrial appendage (LAA) is found in the left wall of the primary atrium, and is formed during the fourth week of embryonic development. It has developmental, structural, and physiological characteristics distinct from the left atrium proper. The LAA lies within the confines of the pericardium in close relation to the free wall of the left ventricle and thus its emptying and filling may be significantly affected by left ventricle function. The physiological properties and anatomical structure of the LAA render it ideally suited to function as a decompression chamber during left ventricular systole and during other periods when left atrial pressure is high. These properties include the position of the LAA high in the body of the left atrium; the increased elasticity of the LAA compared to the left atrium proper; the high concentrations of atrial natriuretic factor (ANF) granules contained within the LAA; and the neuronal configuration of the LAA.

The LAA is the site most commonly associated with thrombus formation, particularly in patients with non-valvar atrial fibrillation. The pathogenesis of LAA thrombus is not fully understood, but the tendency of thrombus formation in the LAA is likely to result from stagnation within the long, blind-ended tissue banded-pouch. LAA dysfunction is also likely to be related in part to a myopathic process that results in atrial fibrillation or that occurs as a result of the atrial fibrillation itself (an atrial fibrillation-induced myopathy). LAA function in patients with atrial flutter is reported to be associated with a regular pattern of LAA emptying and significantly higher peak emptying velocities than in patients with atrial fibrillation, in keeping with the lower incidence of thromboembolism in atrial flutter.

Atrial fibrillation is the most common sustained arrhythmia, increases with age, and presents with a wide spectrum of symptoms and severity. Paroxysmal, persistent, and permanent forms require very individualized approaches to management. New information about electrical and anatomic remodeling emphasizes the importance of time-related thrombogenicity and progressive interference with mechanical function of the atria and ventricles. The most important aspect of diagnosis is risk stratification with respect to risk of thromboembolism.

The occlusion, ablation or surgical removal of the LAA may help to reduce the risk of thromboembolism but this may result in undesirable physiological aftereffects such as increased risk of reduced atrial compliance and a reduced capacity for ANF secretion in response to pressure and volume overload.

Stroke prevention in atrial fibrillation is an important consideration. Treatment with anticoagulant medications is the most common approach to stroke prevention. The majority of embolic strokes originate from the left atrial appendage; therefore, left atrial appendage occlusion devices offer a non-pharmacologic alternative to anticoagulant medications.

Stroke is the most serious complication of atrial fibrillation. The estimated incidence of stroke in non-treated patients with atrial fibrillation is 5% per year. Stroke associated with atrial fibrillation is primarily embolic in nature, tends to be more severe than the typical ischemic stroke, and causes higher rates of mortality and disability. As a result, stroke prevention is one of the main goals of atrial fibrillation treatment.

Stroke occurs primarily as a result of thromboembolism from the left atrium. The lack of atrial contractions in atrial fibrillation leads to blood stasis in the left atrium, and this low flow state increases the risk for thrombosis. The area of the left atrium with the lowest blood flow in atrial fibrillation, and, therefore, the highest risk of thrombosis, is the left-atrial appendage (LAA). It has been estimated that 90% of left-atrial thrombi occur in the LAA.

The main treatment for stroke prevention in atrial fibrillation is anticoagulation, which has proven efficacy. Warfarin is the predominant agent in clinical use. A number of newer anticoagulant medications have recently received U.S. Food and Drug Administration (FDA) approval for this indication and have demonstrated noninferiority to warfarin in clinical trials. While anticoagulation is effective for stroke prevention, there is an increased risk of bleeding. Also, warfarin requires frequent monitoring and adjustments, as well as lifestyle changes. Dabigatran does not require monitoring. However, unlike warfarin, the antithrombotic effects of dabigatran are not reversible with any currently available hemostatic drugs.

Surgical removal, or exclusion, of the LAA is often performed in patients with atrial fibrillation who are undergoing open heart surgery for other reasons. Percutaneous LAA closure devices have been developed as a nonpharmacologic alternative to anticoagulation for stroke prevention in atrial fibrillation. The devices may prevent stroke by occluding the LAA, thus preventing thrombus formation.

Several versions of LAA occlusion devices have been developed. The WATCHMAN® left atrial appendage system (Boston Scientific, Maple Grove, MN) is a self-expanding nickel titanium device. It has a polyester covering and fixation barbs for attachment to the endocardium. Implantation is performed percutaneously through a catheter delivery system, utilizing venous access and transseptal puncture to enter the left atrium. Following implantation, patients are anticoagulated with warfarin or alternate agents for approximately 1-2 months. After this period, patients are maintained on antiplatelet agents (i.e., aspirin and/or clopidogrel) indefinitely. The Lariat® Loop Applicator is a suture delivery device that is intended to close a variety of surgical wounds in addition to left atrial appendage closure. The Cardioblate® closure device developed by Medtronic Corp. is currently being tested in clinical studies. The Amplatzer® cardiac plug (St. Jude Medical, Minneapolis, MN), is FDA-approved for closure of atrial septal defects but has not received FDA approval for LAA closure device. The Percutaneous LAA Transcatheter Occlusion (PLAATO) device (eV3, Plymouth, MN) has also been evaluated in research studies but has not received FDA approval.

Regulatory Status

There are currently no percutaneous LAA closure devices with FDA approval. The WATCHMAN® device was considered for FDA approval in 2009 based on the results of the Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients with Atrial Fibrillation (PROTECT-AF) randomized controlled trial. While the FDA advisory panel for this topic voted in favor of approval, the FDA did not grant final approval after concluding that further studies of efficacy and safety were necessary.

At least two other devices, referred to earlier, have been studied for left atrial appendage occlusion, but are not approved in the U.S. for percutaneous closure of the left atrial appendage. The Lariat® Loop Applicator device (SentreHEART, Inc, Redwood City, CA) is a suture delivery system that received 510(k) marketing clearance from the FDA in 2006. The intended use is to facilitate suture placement and knot tying in surgical applications where soft tissues are being approximated or ligated with a pre-tied polyester suture. The Amplatzer Amulet® device (St. Jude Medical, Plymouth, MN) has a CE approval in Europe for left atrial appendage closure, but is not currently approved in the U.S. for any indication.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Coverage

Prophylactic occlusion, ablation or surgical removal of the left atrial appendage (LAA) is considered not medically necessary during open heart surgery to reduce future stroke risk except when performed in conjunction with a Maze procedure for atrial fibrillation (AF).     

The use of percutaneous left-atrial appendage closure devices for the prevention of stroke in atrial fibrillation is considered experimental, investigational and unproven.

Rationale

Amputation of the LAA remains controversial, although excision or ligation of the right atrial appendage is frequently performed during insertion or withdrawal of cannulae during coronary artery bypass grafting. A recent review suggested that surgeons use the technique of LAA obliteration sporadically. Some obliterate the appendage during mitral valve replacement and repair, while others use it only as part of the maze procedure or corridor procedures for the surgical treatment of atrial fibrillation. Various techniques for the intraoperative amputation of the LAA have been described, including use of an automatic surgical stapler.

LAA has unique developmental, anatomical, and physiological properties. These properties render it ideal to act as a reservoir in conditions of volume overload, and to affect the adaptive responses necessary for the reduction of circulating blood volume. The LAA is the major site of thrombus formation in non-valvar atrial fibrillation and to a lesser extent in mitral valve disease. Although the exact pathogenesis of this complication has not been fully elucidated, it is likely that stasis of blood flow within the LAA plays a major role, but much is unknown. In particular, the roles of the endothelium of the LAA and the hematological mechanisms of LAA thrombus formation have not been adequately studied.

The most effective current prophylaxis of stroke in atrial fibrillation is warfarin. Warfarin is contraindicated in many patients, particularly in the elderly in whom the risk of stroke is highest. Alternative treatments are needed, and obliteration of the LAA is one such option. However, this is technically challenging and may result in unfavorable hemodynamic and hormonal effects, which could be particularly important in patients with left ventricular failure and valvar heart disease. Direct or thoracoscopic obliteration is possible, but technical aspects of the thoracoscopic procedure must be developed before it can be offered as an alternative. The technique will not prevent all episodes of thromboembolism, particularly in patients with mitral valve disease, in whom the appendage is the sole location of thrombus in only 60% of patients.

The “elimination” of the left atrial appendage seems to be an attractive alternative to oral anticoagulation in the treatment of atrial fibrillation, especially in patients with contraindications to oral anticoagulation therapy. However, the LAA plays an important role in the maintenance and regulation of the cardiac function, in atrial hypertension, atrial fibrillation, coronary heart disease, and heart failure. Data, mainly from animal studies, indicate that elimination of the LAA may impede thirst in patients with hypovolemia, may impair hemodynamic response to volume or pressure overload, may decrease cardiac output, and may promote heart failure. It may have adverse effects in humans as well.  Further studies on the hemodynamic and neuro- humoral consequences of left atrial appendage elimination are required to advance our understanding of LAA physiology and pathophysiology.   

Komohara and colleagues investigated the short-term and mid-term effects of left atrial appendage exclusion on left atrial function in nineteen dogs and concluded that left atrial appendage exclusion may affect left atrial reservoir function in the short-term and mid-term periods. Further long-term studies with more clinically relevant models are needed.

Johnson and colleagues studied the surgical feasibility of removing the left atrial appendage to prevent future deaths in two categories, prophylactic removal during open heart surgery to study its safety and therapeutic removal in chronic atrial fibrillation. They reached the conclusion that the left atrial appendage is a lethal source of emboli in atrial fibrillation patients. As patients age and often develop atrial fibrillation, prophylactic appendage removal whenever the chest is open is suggested as a method to prevent future strokes. In chronic atrial fibrillation patients, left atrial appendectomy can be done with a mini-thoracoscopic approach. Further studies are planned to demonstrate the effectiveness of left atrial appendectomy in preventing strokes in the chronic fibrillating patient. 

Closure of the LAA is feasible in humans and may be appropriate for patients with AF who are not suitable candidates for anticoagulation therapy. However, performing LAA in patients with AF has raised several concerns:

  • It has not been shown that LAA thrombi are responsible for an increased number of thromboembolic events in patients with AF; AND,
  • It has not been shown whether LAA occlusion impairs release of natriuretic peptides; AND
  • It may result in adverse hemodynamic and physiological effects.

2009 Update

A search of peer reviewed literature through April 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.

2013 Update

A search of peer reviewed literature was conducted through August 2013.  This medical policy has been updated with searches of the MEDLINE database. Following is a summary of the key literature to date.

The evidence on the efficacy of left-atrial appendage (LAA) closure devices consists of numerous case series of various occlusion devices, and one randomized controlled trial (RCT) of the WATCHMAN device that compared LAA closure to warfarin anticoagulation. Evidence on each different device will be reviewed separately, since the devices are not similar in design and each may have its own unique considerations.

WATCHMAN device

The single RCT published is the PROTECT-AF study, (1) which was a randomized, unblinded trial that evaluated the noninferiority of an LAA closure device compared to warfarin for stroke prevention in atrial fibrillation. The trial randomized 707 patients from 59 centers in the U.S. and Europe to the WATCHMAN® device or warfarin treatment in a 2:1 ratio. Mean follow-up was 18 +/- 10 months. The primary efficacy outcome was a composite endpoint of stroke (ischemic or hemorrhagic), cardiovascular or unexplained death, or systemic embolism. There was also a primary safety outcome, which was a composite endpoint of excessive bleeding (intracranial or gastrointestinal [GI] bleeding) and procedure-related complications (pericardial effusion, device embolization, or procedure-related stroke).

The primary efficacy outcome occurred at a rate of 3.0 per 100 patient-years in the LAA closure group compared to 4.9 per 100 patient-years in the warfarin group (rate ratio [RR]: 0.62; 95% credible interval [CrI]: 0.35-1.25). Based on these outcomes, the probability of noninferiority was greater than 99.9%. For the individual components of the primary outcome, cardiovascular/unexplained death and hemorrhagic stroke were higher in the warfarin group. In contrast, ischemic stroke was higher in the LAA closure group at 2.2 per 100 patient-years compared to 1.6 per 100 patient-years in the warfarin group (RR: 1.34; 95% CrI: 0.60-4.29).

The primary safety outcome occurred more commonly in the LAA closure group, at a rate of 7.4 per 100 patient-years compared to 4.4 per 100 patient-years in the warfarin group (RR: 1.69; 95% CrI: 1.01-3.19). The excess in adverse event rates for the LAA closure group were primarily the result of early adverse events associated with placement of the device. The most frequent type of complication related to LAA closure device placement was pericardial effusion requiring intervention, which occurred in 4.8% of patients (22/463).

Longer term follow-up from the PROTECT AF study was reported by Reddy et al. in 2012. (2) At a mean follow-up of 2.3 years, the results were similar to the initial report. The relative risk for the composite primary outcome in the Watchman group compared to anticoagulation was 0.71, and this met non-inferiority criteria with a confidence of >99%. Complications were more common in the Watchman group, with an estimated rate of 5.6%/year in the Watchman group compared to 3.6%/year in the warfarin group.

In addition to this RCT, a number of case series have reported on outcomes on the WATCHMAN device. The published case series are primarily small and intended to establish safety and feasibility of the device. (3-8) A larger case series of 143 patients from Europe was published in 2011. (6) This series reported that successful implantation was achieved in 96% (137/143) of patients and that serious complications occurred in 7.0% (10/143). Complications included stroke (n=3), device embolization (n=2), and pericardial effusion (n=5). Another larger series was reported by Reddy et al., (7) primarily focusing on the adverse event rate from a registry of 460 patients who received the WATCHMAN® device. Serious pericardial effusion occurred in 2.2% of patients, and there were no deaths or periprocedural strokes reported. Bayard et al. (3) reported on 180 patients with nonrheumatic atrial fibrillation and a contraindication to warfarin and who were treated with the Percutaneous Left Atrial Appendage Transcatheter Occlusion (PLAATO) device. Placement was successful in 90% of patients. Two patients died within 24 hours of the procedure (1.1%), and 6 patients had cardiac tamponade (3.3%), with 2 requiring surgical drainage. During a follow-up of 129 patient-years, there were 3 strokes, for a rate of 2.3% per year. Other case reports and small case series report complications, including multiple reports of thrombus formation at the site of device placement. (9-11)

Lariat® device

The available evidence on the efficacy of the Lariat device consists of a number of small case series. The largest case series was reported by Bartus et al. in 2012. (12) This study enrolled 89 patients with atrial fibrillation and either a contraindication to warfarin or previous warfarin failure. A total of 85/89 (96%) had successful left atrial ligation, and 81/89 (91%) had complete closure immediately. There were 3 access-related complications, 2 cases of severe pericarditis postoperatively, 1 late pericardial effusion, and 2 cases of unexplained sudden death. There were 2 late strokes, which the authors did not attribute to an embolic source. At one year of follow-up, complete closure was documented by echocardiography in 98% of available patients (n=65). In a smaller, earlier series from the same research group, (13) 13 patients were treated with the Lariat device, 11 of whom were treated as part of percutaneous radiofrequency ablation for atrial fibrillation. One of the 11 procedures was terminated due to unsuccessful placement, and the other 10 procedures were successful, with complete closure verified on echocardiography. There was one procedural complication in which the snare was unable to be removed and needed to be retrieved by thoracoscopy.

Massumi et al. (14) reported on 21 patients with atrial fibrillation and contraindications to anticoagulation. A total of 20/21 patients had successful atrial closure, which was documented by echocardiography to be intact at a mean follow-up of 96 days. No patients had a stroke during a mean follow-up of approximately one year. There were complications reported in 5/21 patients. One patient had right ventricular perforation and tamponade requiring surgical intervention. One patient developed pleuro-peridicarditis that required multiple drainage procedures. Three additional patients developed pericarditis within 30 days of the procedure.

Amplatzer® Cardiac Plug device

The available evidence on use of the Amplatzer device for left atrial occlusion consists of a number of case series. The largest series identified was by Nietlispach et al., (15) which included 152 patients from a single institution in Europe. Short-term complications occurred in 9.8% (15/152). Longer-term adverse outcomes occurred in 7% of patients, including 2 strokes, 1 peripheral embolization, and 4 episodes of major bleeding. Device embolization occurred in 4.6% (7/152) of patients.

Other smaller series of patients treated with the Amplatzer device include a series of 86 patients from Portugal, (16) 37 patients from Italy, (17) 35 patients from Spain, (18) 21 patients from Poland, (19) and 20 patients from China. (20) All of these series reported high procedural success, but also reported various complications such as vascular complications, air embolism, esophageal injury, cardiac tamponade, and device embolization.

Ongoing clinical trials

There are currently a number of additional ongoing clinical trials of LAA closure devices. (21) Of studies listed online at ClinicalTrials.gov, there are at least 4 randomized, controlled trials listed:

  • NCT01182441. (Evaluation of the Watchman® LAA Closure Device in Patients with Atrial Fibrillation Versus Long-term Warfarin Therapy [PREVAIL trial]). This is a study of LAA closure versus warfarin using the WATCHMAN® device. Eligibility for PREVAIL includes a CHADS score (a clinical risk prediction score of atrial–fibrillation-related stroke) of 2 or greater, or a CHADS score of 1 with other indicators of high risk, indicating a patient population with a higher risk of stroke compared to the PROTECT-AF trial. This trial plans to enroll 475 patients with an estimated completion date of November 2015. Other nonrandomized, single-group studies are in progress evaluating the safety and efficacy of various LAA closure devices.
  • NCT01628068. ELIGIBLE (Efficacy of Left atrIal Appendage Closure After GastroIntestinal Bleeding) study. This is a study of 120 patients with a history of GI bleed randomized to left atrial occlusion or usual care with anticoagulation. Expected completion date is July 2014.
  • NCT01363895. Interventional Strategies in Treatment of Atrial Fibrillation: Percutaneous Closure of the Left Atrial Appendage Versus Catheter Ablation. This is a study that randomizes 120 patients with atrial fibrillation to left atrial closure with the Watchman device or catheter ablation. Estimated completion date is November 2013.
  • NCT01118299. AMPLATZER Cardiac Plug Clinical Trial. This trial randomizes 3,000 patients with atrial fibrillation to left atrial occlusion with the Amplatzer® cardiac plug versus optimal medical care. Estimated completion date is June 2017.

Summary

LAA occlusion devices are nonpharmacologic alternatives to anticoagulation for patients with atrial fibrillation. Currently, there are no devices that have FDA-approval for this indication in the U.S., but at least 3 different devices (WATCHMAN®, Lariat®, and Amplatzer®) have been evaluated for this purpose. Case series have demonstrated that these devices can be successfully implanted percutaneously in most patients. Complications such as pericardial effusion and tamponade are reported in available studies at a rate of 2-5%. Periprocedural stroke has been reported uncommonly. One randomized, controlled trial compared the WATCHMAN® device to warfarin and reported noninferiority on a composite outcome of stroke, cardiovascular/ unexplained death, or systemic embolism after 2 years of follow-up. There were a higher number of complications in the LAA closure group, primarily due to early complications associated with the device placement. Longer term outcomes past 2 years have not been reported. For the Lariat and Amplatzer devices, there were no controlled trials identified. Case series of these devices report high procedural success but also numerous complications.

Given the lack of FDA approval, the limited data regarding impact on net health outcome from controlled trials, and the potential for complications, left atrial appendage closure devices are considered experimental, investigational and unproven.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes
None
ICD-10 Codes
None
Procedural Codes: 33999, 93799, 0281T
References
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  2. Reddy VY, Doshi SK, Sievert H et al. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-year follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients With Atrial Fibrillation) trial. Circulation 2013; 127(6):720-9.
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  47. Hanna, IR., Kolm, P., et al. Left atrial structure and function after percutaneous left atrial appendage transcatheter occlusion (PLAATO®):  six-month echocardiographic follow-up. Journal of the American College of Cardiology (2004 May 19) 43(10):1868-72.
  48. Corradi, D., Callegari, S., et al. Regional left atrial interstitial remodeling in patients with chronic atrial fibrillation undergoing mitral-valve surgery. Virchows Archives (2004 November) 445(5):498-505.
  49. Benussi, S. Treatment of atrial fibrillation. European Journal of Cardio-Thoracic Surgery (2004 December) 26 Supplement 1:S39-41; discussion S41.
  50. Schneider, B., Stollberger, C., et al. Surgical closure of the left atrial appendage – a beneficial procedure? Cardiology (2005) 104(3):127-32.
  51. Schneider, B., Finsterer J., et al. Effects of percutaneous left atrial appendage transcatheter occlusion (PLAATO®) on left atrial structure and function. Journal of the American College of Cardiology (2005 February 15) 45(4):634-5; author reply 635.
  52. Hanna, I.R., and P.C. Block. Effects of percutaneous left atrial appendage transcatheter occlusion (PLAATO®) on left atrial structure and function: Reply. Journal of the American College of Cardiology (2005 February 15) 45(4):635.
  53. Schneider, B., Stollberger, C., et al. Surgical closure of the left atrial appendage – a beneficial procedure? Cardiology (2005) 104(3):127-32.
  54. Di Chiara, A., and G. Bernardi. Percutaneous left atrial appendage transcatheter occlusion as an alternative to oral anticoagulation in patients with atrial fibrillation. Is it the time? Italian Heart Journal (2005 May) 6(5):418-9. 
  55. Onalan, O., Lashevsky, I., et al. Nonpharmacologic stroke prevention in atrial fibrillation. Expert Review of Cardiovascular Therapy (2001 February) 19(2):231-4.
  56. Ostermayer, S.H., Reisman, M., et al. Percutaneous left atrial appendage transcatheter occlusion (PLAATO® system) to prevent stroke in high-risk patients with non-rheumatic atrial fibrillation: results from the international multi-center feasibility trials. Journal of the American College of Cardiology (2005 July 5) 46(1):9-14.
  57. Onalan, O., Lashevsky, I., et al. Prophylaxis and management of postoperative atrial fibrillation. Current Cardiology Report (2005 September) 7(5):382-90.
  58. Mohra, O.K., Schraeder, R., et al. Percutaneous left atrial appendage transcatheter occlusion (PLAATO®): planning and follow-up using contrast-enhanced MRI. American Journal of Roentgenology (2006 February) 186(2):361-4.
  59. Stollberger, C., Finsterer, J., et al. Does percutaneous closure of the left atrial appendage prevent stroke in atrial fibrillation? Journal of the American College of Cardiology (2006 April 4) 47(7):1500-1.
  60. Stollberger, C., Schneider, B., et al. Benefits of left atrial appendage occlusion for stroke prevention. American Heart Journal (2006 June) 151(6):el; author reply e3.
  61. Ussia, G.P., Mangiafico, S., et al. Percutaneous left atrial appendage transcatheter occlusion in patients with chronic nonvalvular atrial fibrillation:  early institutional experience. Journal of Cardiovascular Medicine (Hagerstown) (2006 August) 7(8):569-72.
  62. Komohara, K., Popovic, Z.B., et al. Impact of left atrial appendage exclusion on left atrial function. Journal of Thoracic and Cardiovascular Surgery (2007 January) 133(1):174-81.
  63. Onalan, O., and E. Crystal. Left atrial appendage exclusion for stroke prevention in patients with nonrheumatic atrial fibrillation. Stroke (2007 February) 38(2):624-30.
  64. Percutaneous Left-Atrial Appendage Closure Devices for Stroke Prevention in Atrial Fibrillation. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (March 2013) Medicine 2.02.26.
History
June 2013 New 2013 BCBSMT medical policy.  Prophylactic occlusion, ablation or surgical removal of the left atrial appendage (LAA) is considered not medically necessary during open heart surgery to reduce future stroke risk except when performed in conjunction with a Maze procedure for atrial fibrillation (AF).
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Occlusion, Ablation or Surgical Removal of the Left Atrial Appendage