The role of peri‐device leak closure after left atrial appendage occlusion: A safe and feasible approach

Abstract

Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults and is associated with high incidence of ischemic stroke. Although oral anticoagulation (OAC) is the cornerstone therapy in stroke prevention, a remarkable number of patients, with high bleeding risk, cannot tolerate long-term OAC. In these cases left atrial appendage occlusion (LAAO) is a valid alternative, as the majority of thrombus formation occurs in the left atrial appendage (LAA). LAAO may be obtained surgically or by a catheter-based procedure with a multitude of endovascular devices. Nevertheless, persistent LAA patency is a fairly common finding, with one-year rate of 12.5%–32%, potentially undermining the effectiveness of these approaches for thromboembolic prevention. The reason is likely multifactorial: first of all, result of mismatch between a circular plug, trying to occlude an elliptical orifice of the LAA. Lobe and disk devices (e.g., Amplatzer Cardiac PlugTM, AmuletTM, Abbott Laboratories, Chicago, IL) appear to be less prone to leak formation compared with those with a single-lobe design (e.g., WatchmamTM Boston Scientific, Malborough, MA), due to double-level expansive seal. In addition some patient-related factors such as left atrial dilatation, non-chickenwing LAA shape and large landing zone diameter are associated with a higher likelihood of leak formation. Therefore, routine surveillance with 2D-, 3Dtrans-esophageal echocardiography or even better with computed tomography with venous phase acquisition is strongly recommended in order to identify patients with LAA patency. Whether these residual leaks following LAAO are associated with an increased risk for thromboembolic events is still a matter of debate. It is also unclear which leak size should be considered “significant” and warrant indefinite OAC continuation. Lacking of evidence-based management recommendations, it is common practice to continue OAC with leaks >5 mm or even >3 mm. As the decision to continue OAC in patients with high bleeding risk can have major clinical implications, some authors have proposed the role of peri-device leak (PDL) closure as an effective alternative. In this issue of the Catheterization and Cardiovascular Interventions, Cubeddu, Sleiman et al. performed a systematic review of the available literature regarding PDL closure following LAAO to further understand the safety and feasibility of this approach. About 18 indexed publication and 110 cases of PDL closure were reviewed. Most of the patients were male (77%), with bilobar LAA (63%), while the most frequently used closure device was Wacthman Occluder (63%). PDL were stratified according to the size in small (<5 mm, 45%), moderate (5–9 mm, 25%), or large (≥10 mm, 30%). Either coil (fiber – or hydrogel coated, 42%), plug (e.g. Amplatzer Vascular PlugTM II, IV, or Amplatzer Septal OccluderTM, 30%), or a second LAA occluder (WatchmanTM in half cases, 28%) were employed for PDL closure, with the former used mainly for small or moderate defects, while the latter for large PDL. Patients were maintained on anticoagulation therapy until the procedure. Technical success, defined as the absence of a residual leak ≥3 mm following PDL closure, was achieved in 90% of the patients (83% for endovascular coil, 94% for endovascular plug, 95% for second LAA occluders), thus leading to discontinuation of OAC therapy in 81% of the patients. Procedural-related complications were uncommon (2.8%) with two patients affected by pericardial effusion following the use of endovascular coils. Among those in whom PDL closure was successful, there were no reported cases of ischemic stroke during a median follow-up of 6 months, which defined clinical success of the procedure. We commend the authors for the purpose to investigate the impact of these novel approaches, putting the light on PDL as a not uncommon, but markedly under diagnosed complication after LAA occlusion, which would become more and more frequent, with aging of an increasingly pluri-pathological population. Received: 14 June 2021 Accepted: 18 June 2021