Device-Related Thrombus After Left Atrial Appendage Closure: Incidence, Predictors, and Outcomes

A 79-year-old woman with atrial fibrillation and new onset of heart failure

As an alternative to oral anticoagulation, percutaneous left atrial appendage (LAA) closure is an increasingly performed procedure to prevent arterial embolism in patients with non‐valvular atrial fibrillation. Besides procedure‐related complications, residual leaks, device‐related thrombus formation, and dislocation of the LAA occluder have been observed during follow‐up. Heart failure as a consequence of interventional LAA closure has not been reported so far. This case report describes a 79‐year‐old lady with permanent non‐valvular atrial fibrillation presenting with New York Heart Association Class IV heart failure. Symptoms had started immediately after attempted LAA closure 11 months before. Transoesophageal echocardiography demonstrated two devices in the LAA, a large peri‐device leak, a mobile LAA thrombus, a right atrial appendage thrombus, and shunting via a patent foramen ovale. Under a maximally tolerated dose of heart failure medication and edoxaban, the patient remains without bleeding or embolism in New York Heart Association Class II. Because of its unique anatomical and endocrine properties, the LAA plays an important role in situations of pressure and volume overload. Interventional LAA closure interacts unfavourably with left atrial compliance and reservoir function. Atrial and brain natriuretic peptide secretion is known to be significantly reduced after LAA closure. Both mechanisms may result in the development of heart failure. Attempted LAA closure—instead of being the solution—may create new serious problems. Development of heart failure should be assessed, and a systematic search for late leaks after LAA closure should be performed in trials investigating safety and efficacy of this intervention.

Real-world survival data of device-related thrombus following left atrial appendage closure: 4-year experience from a single center

This study aimed to estimate the incidence and risk factors of device-related thrombus (DRT) following percutaneous left atrial appendage closure (LAAC) in real-world practices. Between February 2012 and December 2016, 319 consecutive patients with atrial fibrillation underwent percutaneous LAAC using WATCHMAN, WATCHMAN Flx, Amplatzer cardiac plug, and Amulet devices. All patients underwent transesophageal echocardiography (TEE) at a minimum of three time points; periprocedurally, at 45 days, and at 6 months. Other clinical parameters were also evaluated, and a comparison between patients with DRT and those not suffering from DRT was done. The percutaneous LAAC was successfully performed in 97.8% of the patients. DRT was detected in 14 (4.49%) patients; of the 14 patients, DRT was detected in 3 patients at acute phase, 8 patients at subacute phase, 2 patients at late phase and 1 patient at very late phase. Most of the DRT originated from the central screw of device. In 6 out of 14 patients, DRT was successfully resolved by oral anticoagulation. Higher HAS-BLED score (4.1 ± 1.2 vs. 3.5 ± 1.1, p = 0.042) was more frequent in patients with DRT. Multivariable analysis showed that residual peri-device leak may result in a predisposition to DRT (p = 0.023). The incidence of DRT after percutaneous LAAC was acceptable, as a part of the DRT was resolved with oral anticoagulation. Residual peri-device leak was associated with DRT. Optimal implantation without peri-device gap, individual antithrombotic regimens, and careful monitoring with TEE follow-up could be conducive to the prevention of DRT.

Device-Related Thrombus After Left Atrial Appendage Closure

Although left atrial appendage closure (LAAC) has proved non-inferior to oral anticoagulants in patients with AF, there has been recent concern about the occurrence of late complications, especially device-related thrombus (DRT), which was associated with increased risk of stroke. In this article, the incidence, risk factors and time course of DRT after LAAC are discussed, as well as the potential benefits of dedicated strategies in the management of DRT, which remain speculative, especially in patients with a contraindication to oral anticoagulants. In these patients, decision-making should be based on a multidisciplinary evaluation of the ischaemic/bleeding balance on an individual basis.

Atrial Fibrillation in Heart Failure: Left Atrial Appendage Management

Atrial fibrillation is common in patients with congestive heart failure (CHF). Due to reduced left atrial appendage (LAA) emptying velocities and increased sludge formation, a higher rate of stroke and embolism are seen with CHF. Up to 50% of CHF patients are inadequately covered for stroke protection with anticoagulation, and, even while on therapy, CHF patients are at risk for failure to clear LAA or left ventricular (LV) thrombus. Device-based LAA closure (LAAC) alternatives exist. Following intracardiac device closure, an increased rate of device-related thrombus is seen in heart failure patients, which warrants further study to optimize LAAC benefits.

The Year in Electrophysiology: Selected Highlights From 2018

This article is the first in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, the associate editor-in-chief, Dr. Augoustides, and the editorial board for the opportunity to start this series, namely the research highlights of the year that pertain to electrophysiology in relation to cardiothoracic and vascular anesthesia. This first article focuses on esophageal thermal injury during radiofrequency ablation, perioperative management of patients presenting for ablation procedures, left atrial appendage occlusion devices, and, finally, heart failure diagnostic devices.

Current Endocardial Approaches for Left Atrial Appendage Closure

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Incidence and Clinical Impact of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion: A Meta-Analysis

OBJECTIVES

This study sought to assess the incidence and clinical impact of device related thrombus (DRT) following precautions left atrial appendage occlusion (LAAO).

BACKGROUND

Device-related thrombus is a known complication of LAAO. However, data on the incidence of DRT and its impact on outcomes are limited.

METHODS

The authors performed a meta-analysis of randomized and observational studies to calculate the pooled incidence of DRT and the pooled odds ratio (OR) of ischemic events in patients with DRT and those without DRT.

RESULTS

In the 66 included studies; the incidence of DRT was 351/10, 153 (3.8%, range 0% to 17%, I² = 56.8). The diagnosis was made in <90, 90 to 365, and >365 days in 42%, 57%, and 1% of patients, respectively. There was no difference in DRT rates between the AMPLATZER (AMPLATZER, AGA Medical Corporation, Golden Valley, Minnesota) and WATCHMAN (WATCHMAN, Boston Scientific Corporation, Marlborough, Massachusetts) devices (3.6% vs. 3.1%, p = 0.24). In a meta-regression, age, gender, heart failure, diabetes, CHA₂DS₂-VASc score, previous stroke, and post-LAAO antithrombotic regimen did not explain the heterogeneity in the incidence of DRT. The pooled incidence of ischemic events in studies that compared outcomes of patients with and without DRT (32 studies; n = 7,689) was 13.2% (37 of 280) in patients with DRT and 3.8% (285 of 7,399) in those without DRT (OR: 5.27, 95% confidence interval [CI]: 3.66 to 7.59; p < 0.001, I² = 0). In a sensitivity analysis including randomized trials and prospective multicenter registries, the incidence of DRT was 3.7%, and DRT remained associated with higher rates of ischemic events (13.5% vs. 4.4%, OR: 4.15, 95% CI: 2.77 to 6.22; p < 0.001, I² = 0).

CONCLUSIONS

DRT after LAAO is uncommon (3.8%) but is associated with a 4- to 5-fold increase in ischemic events. Further studies are needed to understand the underlying mechanisms and the optimal surveillance and management of DRT.