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.