Management of peri‐device leak following left atrial appendage closure: A systematic review

Abstract

Objective This study aimed to examine the cumulative experience of peri‐device leak (PDL) closure following left atrial appendage (LAA) closure. Background The management of PDL following LAA closure remains controversial. While PDL closure has been proposed, procedural features and clinical outcomes have not been well established. Methods A systematic review of all published cases of PDL closure with available anatomical, procedural, and clinical outcomes was performed. Results We identified 18 indexed publications and 110 cases between April 2013 and March 2020. 71 patients (mean age 72 ± 8 yrs), met study criteria and were included. PDL closure was most common in males, bilobar LAA morphology, and after Watchman procedures. The mean PDL size was 7.6 ± 5.8 mm (range 2–26 mm). Leaks were classified according to size: small (<5 mm; 45%), moderate (≥5–9 mm; 25%), and large (≥10 mm; 30%). Endovascular coils and endovascular plugs were used to close both small and moderate sized leaks, and second LAA closure devices were exclusively used for large PDLs. Successful PDL closure occurred in 90%, and was similar between PDL sizes and types of occluder used. Procedural complication rates were uncommon (2.8%). No strokes were reported following PDL closure at 6 months. Conclusions In patients with PDL for whom discontinuation of OAC may be considered unsafe, percutaneous closure using a tailored approach with either endovascular coils, plugs, or second occluder represents a safe, and feasible alternative associated with favorable clinical outcomes.

Cardioform Septal Occluder for the Closure of a Peri-Device Leak After Initial Watchman Implantation

“…In a previous systematic review of PDL closure following incomplete LAAO by Sleiman et al, the safety and feasibility of PDL closure are underscored and associated with high procedural success (90%) and low procedural adverse event rates (2.8%), with no stroke events reported at a mean follow-up of six months [ 5 ]. Importantly, the cumulative experience not only highlights the lack of consensus when it comes to device selection but also the large spectrum of PDL size and shapes and the value of ensuring access and the technical dexterity to a myriad of endovascular occluders or plugs that may be safe when tailored to the anatomical characteristics of the defect [ 5 ].…”

“…For many patients at risk of complications related to long-term OAC, this strategy offers its own limitations. Percutaneous closure of PDL has evolved as an alternate solution for these patients [3][4][5].…”

“…Based on the published data, the management of smaller and moderate-sized defects is usually accomplished by the use of endovascular coils and endovascular plugs, and second LAAO devices are more commonly reserved for larger leaks [6][7][8][9][10]. There are multiple reports of the use of different endovascular plugs; the most commonly employed being the Amplatzer vascular plug (St. Jude Medical, Inc., St. Paul, MN) [5,7,10] and Amplatzer septal occluders (St. Jude Medical) [11]. Recent data showed the use of CSO as a second occluder device for post-surgical and post-Lariat LAAO-related leaks [12].…”

A Novel Echocardiographic-Based Classification for the Prediction of Peri-Device Leakage following Left Atrial Appendage Occluder Implantation

“…The diversity in anatomy and shape of the LAA makes the implantation challenging. Therefore, peri-device leaks (PDL) can occur in a number of patients [4][5][6][7][8]. Moreover, a precise definition, pathophysiologic mechanisms, and optimal management especially for those who cannot tolerate long-term anticoagulation have not been established [4,6].…”

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

“…In this issue of the Catheterization and Cardiovascular Interventions , Cubeddu, Sleiman et al 4 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.…”