Percutaneous left atrial appendage closure in the presence of thrombus: A feasibility report

Abstract

Background Patients with a left atrial appendage thrombus (LAAT) despite oral anticoagulation (OAC) are at high risk of thromboembolism (TE) and a relevant proportion of LAAT do not resolve under continued OAC. Left atrial appendage closure (LAAC) in the presence of LAAT was anecdotally described as a therapeutic option to prevent TE in the patients. Objective To describe the feasibility of LAAC despite LAAT in consecutive patients. Methods We searched the LAAC database of our center to identify patients in whom a LAAC was performed despite evidence of a thrombus in the LAA. All procedures were performed under transesophageal echocardiography guidance, no angiographies were performed to avoid LAAT dislocation. An Amulet Occluder device was preferred to allow proximal implantation and sealing of the LAA. Results Nine patients were identified. The mean age was 68.1 ± 10.7 years, four were female, mean CHADSVASC and HASBLED were 3.6 ± 1.7 and 3.0 ± 1.0. Eight of nine patients were on OAC, one patient was under lone aspirin therapy because of bleeding. The mean distance between the LAAT and the estimated landing zone was 18 ± 6 mm, the minimal distance was 11 mm. The mean landing zone was 21 ± 3 mm, devices with a mean size of 25 ± 4 mm were chosen for implantation. All implantation succeeded, only two patients required an intraprocedural replacement. No procedural complication nor short term thromboembolic complication during a follow up of 138 ± 149 days were recorded. Conclusion In the presented series a percutaneous LAAC despite a LAAT resulted to be feasible and safe.

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

“…Tarantini et al [5] showed that over one-third (39.3%) of their patients on discharge received dual antiplatelet therapy, which was followed by oral anticoagulants (28%) and low-molecularweight heparin (18%), while approximately 10% had combinations of antiplatelets and oral anticoagulants prescribed. After 6 months, similarly to the observations of other authors [5,10], approximately half of the patients (45%) in our group were only on aspirin, although many (45%) still remained on oral anticoagulants. There is a general consensus to prescribe aspirin monotherapy for half a year after an LAA closure procedure in typical conditions [6].…”

“…Some of our patients had procedures performed on an infusion of unfractionated heparin in order to maintain a small thrombus size and prevent the possible formation of clots on endovascular tools. Unfortunately, neither the Italian nor German groups [5,10] reported this important periprocedural detail. Experience gathered from catheter ablations of atrial fibrillation showed that instrumentation of the left atrium can be relatively safely performed on uninterrupted anticoagulant therapy [21].…”

“…Tarantini et al [5] presented 28 individuals with nonvalvular atrial fibrillation who had been referred for PLAAC mainly due to major bleeding events on anticoagulants (53%) and so-called "malignant LAA" (29%), which was defined as LAA-persistent thrombus connected to thromboembolic events. On the other hand, Bordignon et al [10] reported a very specific group of patients consisting of a high percentage (67%) of individuals in whom LAA thrombi were discovered after the electrical isolation of LAA (LAAI), which was performed as a part of an invasive treatment of atrial tachyarrhythmias. Our population that was similar to the one described by Tarantini et al [5] included several patients with a history of major bleeding events (47%) and individuals in which an LAAT was found accidentally before arrhythmia catheter ablation.…”

“…The selection of the device was left to the discretion of the physician performing the procedure. All authors advise performing procedures in a gentle manner with as few maneuvers as possible within LAA [7][8][9][10]. There are suggestions that some of the procedure steps be omitted if possible, i.e., LAA angiography, occluder contact with thrombus, or device repositioning [5,10].…”

“…Up to now, all published data, which are mostly case reports, cover fewer than 50 patients with percutaneously closed LAAT. The largest series of patients were reported by Tarantini et al [5], who described 28 patients treated in 8 Italian centers, and by Bordignon et al [10], who, in 2019, summarized a single-center German experience with 9 patients undergoing percutaneous LAAT closure. As this topic remains elusive and needs more evidence [6], we share the experiences of high-volume Polish centers with percutaneous closure of LAA with a thrombus inside.…”