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Objectives To propose a novel method for mapping leak location and frequency to a clock‐face representation of the left atrial appendage (LAA) ostium. Background LAA occlusion with the Watchman device (WD) is an established therapy to reduce thromboembolic events in patients with atrial fibrillation (AF) and intolerance to long‐term oral anticoagulation. Postimplantation leaks are known sequelae, but leak locations and characteristics are poorly described. Methods We retrospectively reviewed 101 consecutive WD implants from April 2015 to February 2018. Leak locations from 6‐week post‐implant transesophageal echocardiograms were mapped to a clock‐face representation of the LAA ostium: 12:00 as cranial near the limbus, 3:00 as anterior toward the pulmonary artery, 6:00 as caudal near the mitral annulus, and 9:00 as posterior. Patient demographics, LAA dimensions, and procedural characteristics were also collected. Results Thirty‐four patients had ≥1 leak totaling 45 leaks at 6‐week follow‐up. Baseline patient demographics showed a mean age 77, CHA2DS2VASc 4.69, and 64% of patients with permanent AF. No patient had a detectable leak at the time of implant. At 6 weeks, mean leak size was 2.67 ± 0.89 mm with no leak over 5 mm (largest 4.60 mm). Most leaks occurred along the posterior 6:00–12:00 segment (39/45) and the 6:00–9:00 quadrant (16/45). Conclusion Six‐week post‐WD implant leaks localize to the posterior LAA ostium. This could result from the elliptical LAA orifice, differential LAA tissue composition, or implantation technique. This study provides a novel method for describing the location of post‐implant leaks and serves as the basis for further investigations.

Chronic lymphocytic leukemia (CLL) is a chronic, progressive lymphoproliferative disorder characterized by a monoclonal population of functionally incompetent lymphocytes. Renal involvement is rare and poorly described. A 57-year-old male with no prior medical history was diagnosed with CLL and followed with a watch and wait approach. He was referred to our institution several months later due to concern for Richter’s transformation to diffuse large B-cell lymphoma. A positron emission tomography/computed tomography scan showed no evidence of diffuse large B-cell lymphoma; however, the patient was noted to have hypoalbuminemia, nephrotic range proteinuria, an acute left renal vein thrombus, and a right pulmonary embolus. A nephrotic syndrome workup including autoimmunity and infection was unremarkable, and a kidney biopsy was deferred due to concern for renal compromise in the setting of a renal vein thrombus. The patient was treated with 6 cycles of reduced-dose fludarabine, cyclophosphamide, and rituximab for a presumed CLL-associated nephrotic syndrome and anticoagulation for his venous thromboemboli. At 6-month follow-up, the patient achieved complete remission of his CLL with normalization of all cell lines and resolution of his nephrotic range proteinuria. Repeat computed tomography scans showed no evidence of recurrent venous thromboemboli. This case demonstrates a potential role of empiric chemotherapy in cases of CLL-associated nephrotic syndrome given its potentially life-threatening sequelae and response to treatment.

Objectives This study investigates the correlation of occlusive wedge pressure (WP) with direct left atrial (LA) pressure in patients with severe mitral regurgitation (MR) undergoing transcatheter mitral valve repair (TMVr) with MitraClip. Background There is interest in acquiring objective hemodynamic parameters for intraprocedural guidance in patients undergoing MitraClip. Methods The study included 94 patients with severe MR at prohibitive surgical risk who underwent MitraClip at the University of California Davis Medical Center between 2014 and 2016. Results An average of 1.8 ± 0.7 clips were used to achieve MR grade of 2+ or less in 99% of patients. Correlation analysis of all (n = 236) pre‐clip, inter‐clip, and final‐clip WP and LA pressures yielded a Pearson's R (r) of 0.85 and 0.79 for mean WP vs mean LA and WP V vs LA V, respectively. Median LA V to mean LA ratio (LAV:mLA) was 1.75 (IQR 1.5–1.9). 79% (n = 74) of patients had LAV:mLA ratio ≥ 1.5 with associated WP V vs LA V correlation (r) of 0.83. In patients with LAV:mLA ratio < 1.5, the correlation (r) was 0.69. Baseline characteristics were not significantly different between patients with LAV:mLA ratio ≥ 1.5 and patients with LAV:mLA ratio < 1.5. Post‐procedure, median LA V: mean LA ratio decreased from 1.75 to 1.4, P = 0.0001. Conclusions Correlation between WP and direct LA pressure in patients with severe MR undergoing Mitraclip is modest. Caution is advised when using WP to approximate LA pressure intraprocedurally, especially in patients with baseline low LAV:mLA ratios.

Westcott et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CC-BY 4.0., which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.