Watchman Occlusion in Long-Standing Persistent Atrial Fibrillation: Larger Left Atrial Appendages With Greater Residual Leak.

Abstract

OBJECTIVES\nThis study sought to compare patients with and without long-standing persistent atrial fibrillation (LSPAF) undergoing Watchman left atrial appendage (LAA) occlusion.\n\n\nBACKGROUND\nAn increased burden of atrial fibrillation is associated with progressive left atrial remodeling and enlargement.\n\n\nMETHODS\nTransesophageal echocardiography (TEE) measures of LAA ostial diameter and depth, device compression, and residual leak were evaluated in 101 consecutive Watchman cases. The patients were categorized into LSPAF (n\xa0= 48) or non-LSPAF (n\xa0= 53) groups and compared.\n\n\nRESULTS\nThe average LAA ostial diameter for LSPAF versus non-LSPAF by TEE omniplane at 0° was 21.1 ± 4.1\xa0mm versus 18.2 ± 3.6\xa0mm (p\xa0= 0.0002); at 45° was 18.7 ± 3.4\xa0mm versus 16.3 ± 3.1\xa0mm (p\xa0= 0.0004); at 90° was 19.6 ± 3.8\xa0mm versus 16.2 ± 3.4\xa0mm (p\xa0= 0.00001); and at 135° was 21.0 ± 4.1\xa0mm versus 18.0 ± 4.1\xa0mm (p\xa0= 0.0005). The average LAA depth for LSPAF versus non-LSPAF by TEE at 0° was 28.1 ± 6.4\xa0mm versus 25.2 ± 4.9\xa0mm (p\xa0= 0.02); at 45° was 27.9 ± 5.8\xa0mm versus 25.1 ± 4.3\xa0mm (p\xa0= 0.007); at 90° was 27.2 ± 5.2\xa0mm versus 22.8 ± 3.7\xa0mm (p\xa0= 0.0001); and at 135° was 25.6 ± 5.4\xa0mm versus 21.5 ± 3.8\xa0mm (p\xa0= 0.0001). In successfully treated patients, 77% of the LSPAF group received larger device (27, 30, or 33 mm) implants versus only 46% in the non-LSPAF group (p = 0.003). While both groups had similar rates of moderate (3 to 5 mm) leaks at implant (2% vs. 0%; p = 0.14), 27% of the LSPAF vs. 4% of the non-LSPAF group had moderate leaks (p = 0.04) on 6-week follow-up TEE.\n\n\nCONCLUSIONS\nPatients with LSPAF have significantly larger LAA sizes, require larger devices, and have more residual\xa0leak on follow-up TEE. LSPAF may represent a higher risk group that warrants more stringent long-term follow-up.