Percutaneous Occlusion of the Left Atrial Appendage with Thrombus Irresponsive to Antithrombotic Therapy

Abstract

We analyzed clinical experience with percutaneous closure of instances of left atrial appendage with thrombus (LAAT) irresponsive to antithrombotic therapy in patients treated in three high-volume cardiology centers. Clinical and procedural data regarding consecutive patients who underwent percutaneous left atrial appendage closure (PLAAC) due to LAAT were retrospectively analyzed. The study population consisted of 17 patients (11 men; 68 ± 14 years; CHA2DS2VASC 4.7 ± 1.9; HASBLED 3 (0–5)) with LAAT confirmed by transesophageal echocardiography, and included 5 patients with mechanical heart valves. Most of the patients (94.1%) received anticoagulation therapy before PLAAC. All LAATs were located in distal portions of the appendage and occupied less than 30% of its volume. Occluding-device implantation was successful in 17 patients; in one, a residual leak was disclosed. Appropriate positioning of occluders required more than 1 attempt in 6 individuals (35.3%); in 3 others (17.6%), the subjects’ devices had contact with thrombi. No procedural complications were noted. Midterm follow-up (median: 10 months) revealed no procedure-related complications or clinically diagnosed thromboembolism. Transesophageal echocardiography (TEE) performed after six months revealed device-related thrombus in one patient. We concluded that LAAT irresponsive to antithrombotic therapy might be effectively treated with PLAAC, even in patients with mechanical-valve prostheses.

Current Status of Left Atrial Appendage Thrombus with Atrial Fibrillation

“…[9,60] Single lobe and lobe-and-disc devices including Watchman and Watchman-FLX (Boston Scientific, Plymouth, Minnesota, USA), Cardia Ultraseal (Cardia, Inc., Eagan, Minnesota, USA), Amplatzer cardiac plug (St Jude Medical, Maple Grove, Minnesota, USA), Amulet (Abbott Inc. St. Paul, Minnesota, USA), and LAmbre (LifeTech, Shengzhen, China) were used for AF patients with LAAT who were undergoing direct LAAC, [21,61,62] but lobe-anddisc devices were more frequently used [Table 3]. [11,21,29,[63][64][65][66][67][68] LAAC can be performed to treat LAAT located in the middle and distal end of the LAA [8] ; there are also reports of successful LAAC with Watchman-FLX implant in the presence of a LAA proximal thrombus. [69] AF patients with LAAT undergoing LAAC treatment require the operator to be skilled, gentle during the LAA angiography, not to touch the thrombus during occlusion, and require the simultaneous application of cerebral embolism protection devices, etc.…”

“…[9,60] Single lobe and lobe-and-disc devices including Watchman and Watchman-FLX (Boston Scientific, Plymouth, Minnesota, USA), Cardia Ultraseal (Cardia, Inc., Eagan, Minnesota, USA), Amplatzer cardiac plug (St Jude Medical, Maple Grove, Minnesota, USA), Amulet (Abbott Inc. St. Paul, Minnesota, USA), and LAmbre (LifeTech, Shengzhen, China) were used for AF patients with LAAT who were undergoing direct LAAC, [21,61,62] but lobe-and-disc devices were more frequently used [Table 3]. [11,21,29,63–68]…”

“…[8][9][10] In addition, LAAC has been performed in AF patients with LAAT even after mechanical valve replacement. [11] This article reviews the progress in diagnosis and treatment of LAAT.…”

TriGuard Embolic Protection Device in percutaneous cardiac interventions with intracavitary cardiac thrombosis: A case series

“…Very recently, among patients candidate to undergo left atrial appendage (LAA) closure, the disappointing results provided by VKA/DOAC attempts to dissolve LAA thrombus have promoted alternative strategies, such as LAA closure with distal debris protection. 1,2 Drug-resistant, recurrent, or incessant ventricular tachycardia (VT) represents a strong indication to prompt intervention; in up to 25% 3 of cases both a left ventricular thrombosis and LAA thrombus may be detected. Without distal protection, in case of clot mobilization, a high risk of intraprocedural stroke or non-cerebral ischemic event has to be considered.…”

“…In these clinical setting, most of the procedures have to be temporarily deferred until the resolution of thrombus. Very recently, among patients candidate to undergo left atrial appendage (LAA) closure, the disappointing results provided by VKA/DOAC attempts to dissolve LAA thrombus have promoted alternative strategies, such as LAA closure with distal debris protection 1,2 . Drug‐resistant, recurrent, or incessant ventricular tachycardia (VT) represents a strong indication to prompt intervention; in up to 25% 3 of cases both a left ventricular thrombosis and LAA thrombus may be detected.…”