Left Atrial Appendage

Occlusion Case Studies

(Including Complications)

Andrew Krumerman MD, FHRSProfessor of Medicine

Albert Einstein College of MedicineMontefiore Medical Center

New York, USA

LAAO Case 1

• 76 year old woman with a history of permanent AF treated with

Rivaroxaban for several years despite recurrent hemorrhoidal

bleeding and diverticulosis.

• Past medical history includes DM, HTN and non obstructive coronary

disease Echocardiogram revealed a preserved LVEF and LA size of

5.1cm. Following a diagnosis of uterine and vaginal cancer, she

required TAH/BSO and chemotherapy / radiation therapy.

• She now presents with rectal bleeding secondary to radiation

proctopathy as well as recurrent hematuria due to inflammatory

cystitis.

• Physical Exam- Frail woman 55 kg, BMI 18kg/m2

LAAO Case 1

• CHASDSVASC= Female,

Age-2, CAD, DM, HTN= 5

• HASBLED= 3

• Frail- Elderly

• CHASDSVASC= Female,

Age-2, CAD, DM, HTN= 5

• HASBLED= 3

• Frailty

• What is the best device for

this patient?

Green P et al. J Am Coll Cardiol Intv 2012;5:974–81

Cruz-Gonzalez I et a. Rev Esp Cardiol. 2020;73(1):21–27

LAAO Case 1

Baseline Imaging

• Neck 18-21mm

• Depth 22-27mm

• Windsock Morphology

TEE 45 days post LAAO

Six Months Post LAAO

Six Months Post LAAO

Causes of DRT

• Device too deep, residual pouch

• Peri-device leak

• Failure of endothelialization

• Non compliance or limited OAC regimen

Dukkipati SR et al. Circulation. 2018;138:874–885.

• 3.7% DRT

• 25% of patients with DRT

developed SSE

• Predictors of DRT

• Permanent AF

• Previous TIA/CVA

• Vascular Disease

• LAA diameter

• Depressed LVEF

Dukkipati SR et al. Circulation. 2018;138:874–885.

Timing of DRT

Dukkipati SR et al. Circulation. 2018;138:874–885.

Timing of DRT

DRT in EWOLUTION

Boersma LV et al.Circ A&E. 2019;12:e006841.

One Year Post Implant

Ellis CR, Piccini JP. Circulation. 2018;138:886–888

DAPT x2 months

ASA/Clopidogrel

Del Rocca, DiBiase, Natale, et al Unpublished abstract

CYP2C19• Loss of function polymorphisms of the cytochrome P450

2C19 (CYP2C19) gene are associated with reduced

hepatic bio-activation of clopidogrel and may lead to

potential consequences

• Investigators studying stent thrombosis have

demonstrated that LOF polymorphisms of CYP2C19 do

not break down clopidogrel into its active form.

Ichikawa M. et al Circ J 2015; 79: 85–90

Human Heart 200 days post

Watchman

Schwartz RS et al J Am Coll Cardiol Intv 2010;3:870–7

Follow Up TEE

LAAO Case 2

Its Better to Be Lucky Than Good…

• 60 year old retired police officer with a history of permanent

AF (>10 years) treated with Rivaroxaban and Metoprolol.

• Referred for LAAO after presenting on two separate

occasions to the hospital with fatigue, weakness and anemia

with a Hemoglobin of 6 g/dl. GI work was unrevealing.

• Past medical history included ischemic heart disease status

post remote PCI with preserved LVEF and LA size 5.6cm.

Remote CVA, Hypertension and Hypothyroidism.

LAAO Case 2

• Physical exam revealed a heart rate of 62, BP 140/80

mmHg, no murmurs rubs or gallops, clear lungs,

abdominal exam benign without bruits, chronic venous

stasis changes of the lower extremities and non focal

neurologic examination. BMI 29kg/m2

• Medications Levothyroxine, Metoprolol, HCTZ, ASA

• How should this be approached?

LAAO Case 2

• CHADSVASC= 4 / HASBLED=4

• Patient was send for pre-operative CT Imaging

• Large partially imaged infrarenal

abdominal aortic aneurysm with

thrombus measuring up to 7.5

cm on available images. Further

characterization with imaging is

required.

Baseline Views of LAA

LARIAT DRT

• This guy was neither lucky nor good.

• First required open AAA repair

• Ultimately received LARIAT ligation and developed large

thrombus.

• Initial post operative course was single APT- ASA

• Eliquis 5mg BID initiated

• n=306 CHADSVASC >3, HASBLED >3

• OAC x4 weeks then ASA

• TEE at 1, 6 and 12 months

• Follow up for at least one year

Mohanty S. et al. Heart Rhythm 2020;17:175–181

LARIAT Leak

• 26.5% (81/306) demonstrated leaks at 4week TEE

• 26% (21/81) of leaks spontaneously closed at 6 months

• 31% Required leak closure procedure

• SSE 11.7% vs. 0.81% for patients with leak vs. no leak

Mohanty S. et al. Heart Rhythm 2020;17:175–181

Gunnysack Effect

Pillarisetti et al. Heart Rhythm 2015;12:1501–1507

Conclusions

• DRT is a serious complication and may develop more than

one year post procedure

• Possible etiologies include failure of adequate

endothelialization, incomplete closure (leak, stump, residual

lobes), inadequate OAC regimen

• Available data suggests that risk factors include permanent

AF, history of CVA, vascular disease and depressed LVEF

• Prospective Randomized Trials are necessary to identify

those at risk and optimal therapies for DRT prevention and

treatment

EHRA Expert Consensus

Glickson et al. Europace (2020) 22, 184

EHRA Expert Consensus

Glickson et al. Europace (2020) 22, 184

Should

Thank You

LARIAT DRT

Sivasambu B. et al. J Cardiovasc Electrophysiol. 2019;30:1319-1324

Alkhouli M et al. J Am Coll Cardiol EP 2018;4:1629–37

DRT

DRT due to Localized

Prothrombotic Factors?

K. Bartus et al. International Journal of Cardiology 301 (2020) 103–107