Oregon Health Plan Prioritized List

Guideline Note 173

In January 2018, these codes were moved to Guideline Note 173.

CPT 33340 Percutaneous transcatheter closure of the left atrial appendage with
endocardial implant, including fluoroscopy, transseptal puncture, catheter
placement(s), left atrial angiography, left atrial appendage angiography, when
performed, and radiological supervision and interpretation

Last reviewed at VbBS in November 2016. Minutes indicate that the staff
recommendation was accepted without significant discussion.

The following was presented in the meeting materials for the November, 2016 VbBS
meeting:

1) 33340 Percutaneous transcatheter closure of the left atrial appendage with endocardial
implant, including fluoroscopy, transseptal puncture, catheter placement(s), left atrial
angiography, left atrial appendage angiography, when performed, and radiological
supervision and interpretation
a. Current coding: this procedure is coded with the generic CPT 93799 Unlisted
cardiovascular service or procedure
b. Description: placement of a device to reduce the risk of thromboembolism from
the left atrial appendage (LAA) in patients with non-valvular atrial fibrillation in
patients who are candidates for anticoagulation but who have an appropriate
rationale to seek a non-pharmacologic alternative to warfarin. The FDA
approved the Watchman device in 2015 for percutaneous left atrial appendage
occlusion
c. Evidence
i. Noelk 2016, systematic review percutaneous left atrial appendage
occlusion for stroke prevention in atrial fibrillation vs oral
anticoagulation (OAC)
1. N=20 studies
a. 2 RCTs (1,104 patients), 11 observational studies (1,792
patients) of percutaneous LAA occlusion
b. 7 studies of surgical LAA occlusion
2. Trials found low-strength evidence that percutaneous LAA
exclusion confers similar risks of stroke and mortality as
continued OAC, but this evidence was limited to the Watchman
device in patients eligible for long-term OAC. Observational
studies found moderate-strength evidence of serious harms
with a variety of percutaneous LAA procedures. There is low-
strength evidence that surgical LAA exclusion does not add
significant harm during heart surgery for another indication, but
evidence on stroke reduction is insufficient.

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Guideline Note 173

3. Conclusions:
a. There is limited evidence that the Watchman device
may be noninferior to long-term OAC in selected
patients.
b. There is no evidence to recommend percutaneous left
atrial appendage exclusion in patients with atrial
fibrillation who are ineligible for therapeutic
anticoagulation; randomized trials have not been
performed.
c. In the few published case series available, the overall
risk of serious adverse events with percutaneous device
therapy is ≈1 in 15 patients.
d. Surgical left atrial appendage exclusion does not seem
to be associated with increased harm when performed
during cardiac surgery for another indication, but there
is insufficient evidence to compare the efficacy of this
procedure to anticoagulation therapy.
ii. Singh 2013, economic analysis of left atrial appendage occlusion vs oral
anticoagulation
1. Canadian study
2. Warfarin therapy had the lowest discounted quality-adjusted
life years at 4.55, followed by dabigatran at 4.64 and LAA
occlusion at 4.68. The average discounted lifetime cost was $21
429 or a patient taking warfarin, $25 760 for a patient taking
dabigatran, and $27 003 for LAA occlusion. Compared with
warfarin, the incremental cost-effectiveness ratio for LAA
occlusion was $41 565. Dabigatran was extendedly dominated.
3. Conclusions—Percutaneous LAA occlusion represents a novel
therapy for stroke reduction that is cost-effective compared
with warfarin for patients at risk who have nonvalvular atrial
fibrillation.
iii. Munkholm-Larsen 2012, systematic review percutaneous left atrial
appendage occlusion for stroke prevention in atrial fibrillation
1. N=14 studies (2,444 patients)
2. Periprocedural mortality and stroke rates were 1.1% and 0.6%,
respectively. The incidences of pericardial effusion/ cardiac
tamponade and device embolisation were 4% and 0.7%,
respectively. At the time of the latest followup (up to 40
months), the overall incidence of stroke among all studies was
1.4% per annum.
3. Existing evidence suggests that PLAAO is a relatively safe
treatment for patients with AF. However, there is a need for

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Guideline Note 173

further evaluation of its efficacy in the form of large and well-
designed randomised controlled trials.
a. Other policies
i. NICE 2010
1. Update 2014:
a. Consider left atrial appendage occlusion (LAAO) if
anticoagulation is contraindicated or not tolerated and
discuss the benefits and risks of LAAO with the person.
b. Do not offer LAAO (left atrial appendage occlusion) as
an alternative to anticoagulation unless
anticoagulation is contraindicated or not tolerated
2. Current evidence suggests that percutaneous occlusion of the
left atrial appendage (LAA) is efficacious in reducing the risk of
thromboembolic complications associated with non-valvular
atrial fibrillation (AF)
3. Percutaneous occlusion of the LAA is a technically challenging
procedure which should only be carried out by clinicians with
specific training and appropriate experience in the procedure.
4. This procedure should be carried out only in units with on-site
cardiac surgery
ii. American College of Cardiology/American Heart Association 2015;
study not included due to length, can be viewed here:
http://content.onlinejacc.org/article.aspx?articleid=2360689\

a. The current ACC/American Heart Association/HRS Guideline

for the Management of Patients with Atrial Fibrillation does
not include recommendations for the use of LAA occlusion
devices because of the lack of adequate data and the absence
of an FDA-approved LAA closure device labeled for the
indication of stroke prevention at the time of their
development
iii. HERC staff summary: percutaneous left atrial appendage occlusion has
not been shown to be superior or cost-effective compared to
anticoagulation in patients who are eligible for anticoagulation. These
devices have not been studied in patients who are not eligible for
anticoagulation. There is a high rate of complications with these
devices
iv. HERC staff recommendation:
a. Add 33340 Percutaneous transcatheter closure of the left
atrial appendage with endocardial implant to the Services
Recommended for Non-Coverage table
i. Experimental