Discussion
We performed a retrospective analysis of 5 consecutive patients who
presented for closure of a residual communication between the LAA and
the LA after prior closure attempts. Depending on the anatomy and the
size of the residual communication, either Amplatzer closure devices or
WATCHMAN devices were used successfully to achieve LAA occlusion. No
patients experienced a subsequent stroke or systemic embolism after
closure with a median follow up of 888 ± 426 days. One patient had a
recurrent GIB requiring transfusion while on dual antiplatelet therapy
after device placement.
Incomplete closure of the LAA after attempted surgical LAA ligation is
common, and is associated with increased risk of thromboembolism by
causing sluggish flow into the remaining LAA.[3–5] While this has
most commonly been reported after a surgical attempt to close the LAA,
residual LAA connections have also been described after percutaneous
closure attempts with the Lariat and WATCHMAN devices.[8] While
peri-device leaks smaller than 5 mm around WATCHMAN devices are not
associated with increased risk of thromboembolism, larger leaks have
generally required treatment.[7] Because of the varied anatomy of
the LAA, variable sizes of residual connections, and the location of the
residual connection (edge vs. central), several different interventional
approaches have been published to address this problem. Similar to 3 of
our patients, the Amplatzer Septal Occluder was successfully used in 6
of 7 cases in a series of patients with incomplete surgical LAA
ligation, [9] as well as in 5 of 6 patients with persistent LA-LAA
connection after an initial Lariat procedure.[10] Other case series
have demonstrated the use of alternate devices for this purpose,
including the Gore Helex septal occluder,[11] a vascular
plug,[12] the AGA Cardiac plug,[13] and the WATCHMAN
device.[14]
Our study adds to this body of literature and provides a useful method
of entering the LAA through a small neck using an ablation catheter for
support. In addition, we present a case of closing a residual leak after
WATCHMAN placement. Closure of edge leaks is challenging given the
anatomy of the gap, and placement of certain devices would be precluded
by the size and morphology of the residual connection. Our 3D printed
LA/LAA and WATCHMAN models allowed testing of device types and sizes;
this pre-procedural planning led to a successful deployment of the
Amplatzer device to close the gap for this patient.
Antithrombotic management after device placement was individualized.
These were patients who were at both high thromboembolic and bleeding
risk with elevated CHA2DS2-Vasc and
HAS-BLED scores, respectively. Fortunately, no strokes or systemic
emboli were noted in follow up of our patients, but there was one GIB
while on dual antiplatelet therapy. ASD occlusion devices such as the
device used in this study are routinely managed with post-procedural
dual antiplatelet therapy in the absence of atrial fibrillation. It
should be noted, that there has been growing use of DOACs after WATCHMAN
placement despite the fact that they were not studied in the trials
leading to approval of the device, and we used apixaban after placement
of a WATCHMAN device in this case series. Device related thrombosis
(DRT) has been reported in up to 3.7% of patients in the year after
WATCHMAN implant, but only 0.8% of patients at six weeks after device
placement [15]. In our study, these patients only had a TEE
performed at 6 weeks and we observed no DRT.