Advertisement

Transcatheter embolic coils to treat peridevice leaks after left atrial appendage closure

  • Daniel R. Musikantow
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Poojita Shivamurthy
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Lori B. Croft
    Affiliations
    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Iwanari Kawamura
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Mohit K. Turagam
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • William Whang
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Srinivas R. Dukkipati
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Martin E. Goldman
    Affiliations
    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
  • Vivek Y. Reddy
    Correspondence
    Address reprint requests and correspondence: Dr Vivek Y. Reddy, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029.
    Affiliations
    Department of Cardiovascular Medicine, Helmsley Electrophysiology Center, Icahn School of Medicine at Mount Sinai, New York, New York

    Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
    Search for articles by this author
Published:February 04, 2021DOI:https://doi.org/10.1016/j.hrthm.2021.01.030

      Background

      Left atrial appendage closure (LAAC) has proven to be an effective alternative to long-term oral anticoagulation in the prevention of thromboembolic events in patients with atrial fibrillation. In a minority of patients, inadequate seal may result in persistent peridevice flow and inability of the appendage to fully thrombose, thereby representing a potential source for thromboembolism.

      Objective

      The purpose of this study was to study the use of endovascular coiling of the appendage to address persistent peridevice leak in patients undergoing LAAC with the Watchman device.

      Methods

      This is a retrospective single-center analysis involving patients who underwent placement of a LAAC device and returned for endovascular coiling to address persistent device leak between 2018 and 2020. Baseline characteristics, procedural outcomes, and follow-up echocardiograms were analyzed to demonstrate the feasibility and safety of this technique.

      Results

      Patients (N = 20) were identified with a mean leak size of 3.8 ± 1.3 mm (range 2.5–7 mm), all of whom had a non-thrombosed appendage. Acute procedural success was achieved in 95% of patients. Complete or significant reduction in flow beyond the LAAC device was achieved in 61% and 33% of patients, respectively. The 1 procedure-related adverse event was a pericardial effusion before coil deployment, requiring percutaneous drainage.

      Conclusion

      The clinical impact of residual peridevice leak post-Watchman implantation is a matter of continuing investigation. However, appendage coiling represents a new therapeutic tool to address this potential source for thromboembolism. Further studies should address the clinical impact of this technique, including the safety of discontinuing anticoagulation after successful coiling.

      Graphical abstract

      Keywords

      To read this article in full you will need to make a payment

      Subscribe:

      Subscribe to Heart Rhythm
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. Schwartz RS, Holmes DR, Van Tassel RA, et al. Left atrial appendage obliteration: mechanisms of healing and intracardiac integration. JACC Cardiovasc Interv 2010;3:870–877.

        • Fountain R.B.
        • Holmes D.R.
        • Chandrasekaran K.
        • et al.
        The PROTECT AF (WATCHMAN Left Atrial Appendage System for Embolic PROTECTion in Patients with Atrial Fibrillation) trial.
        Am Heart J. 2006; 151: 956-961
        • Holmes Jr., D.R.
        • Kar S.
        • Price M.J.
        • et al.
        Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial.
        J Am Coll Cardiol. 2014; 64: 1-12
        • Osmancik P.
        • Herman D.
        • Neuzil P.
        • et al.
        Left atrial appendage closure versus direct oral anticoagulants in high-risk patients with atrial fibrillation.
        J Am Coll Cardiol. 2020; 75: 3122-3135
        • Sivasambu B.
        • Arbab-Zadeh A.
        • Hays A.
        • Calkins H.
        • Berger R.D.
        Delayed endothelialization of Watchman device identified with cardiac CT.
        J Cardiovasc Electrophysiol. 2019; 30: 1319-1324
        • Glassy M.S.
        • Wung W.
        • Westcott S.
        • et al.
        Watchman occlusion in long-standing persistent atrial fibrillation: larger left atrial appendages with greater residual leak.
        JACC Cardiovasc Interv. 2019; 12: 1018-1026
        • Viles-Gonzalez J.F.
        • Kar S.
        • Douglas P.
        • et al.
        The clinical impact of incomplete left atrial appendage closure with the Watchman device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy.
        J Am Coll Cardiol. 2012; 59: 923-929
        • Alkhouli M.
        • Alqahtani F.
        • Kazienko B.
        • Olgers K.
        • Sengupta P.P.
        Percutaneous closure of peridevice leak after left atrial appendage occlusion.
        JACC Cardiovasc Interv. 2018; 11: e83-e85
        • Guray U.
        • Korkmaz A.
        • Gursoy H.T.
        • Elalmis O.U.
        Percutaneous left atrial appendage closure in a patient with haemophilia and atrial fibrillation: a case report.
        Eur Heart J Case Rep. 2019; 3: ytz124
        • Della Rocca D.G.
        • Horton R.P.
        • Di Biase L.
        • et al.
        First experience of transcatheter leak occlusion with detachable coils following left atrial appendage closure.
        JACC Cardiovasc Interv. 2020; 13: 306-319
        • Grygier M.
        • Olasinska-Wisniewska A.
        • Araszkiewicz A.
        • Trojnarska O.
        • Babicz-Sadowska A.
        • Lesiak M.
        The Watchman FLX—a new device for left atrial appendage occlusion—design, potential benefits and first clinical experience.
        Postepy Kardiol Interwencyjnej. 2017; 13: 62-66
        • Freeman J.V.
        • Varosy P.
        • Price M.J.
        • et al.
        The NCDR Left Atrial Appendage Occlusion Registry.
        J Am Coll Cardiol. 2020; 75: 1503-1518
        • Aryana A.
        • Singh S.K.
        • Singh S.M.
        • et al.
        Association between incomplete surgical ligation of left atrial appendage and stroke and systemic embolization.
        Heart Rhythm. 2015; 12: 1431-1437
        • Pillarisetti J.
        • Reddy Y.M.
        • Gunda S.
        • et al.
        Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications.
        Heart Rhythm. 2015; 12: 1501-1507
        • Singh S.
        • Gordon N.T.
        • Doshi S.K.
        • Sanchez J.M.
        • Natale A.
        • Reddy V.Y.
        The association between Watchman leak severity and ischemic stroke. Paper presented at: Heart Rhythm Society’s 39th Annual Scientific Sessions.
        2018 (May 9–12, Boston, MA)
        • Perkins J.
        • Bhagat R.
        • Nichols M.
        • Shah J.
        Reoccurrence of stroke in a patient with peri-device leak of WATCHMAN device.
        J Investig Med High Impact Case Rep. 2020; 8 (2324709620947622)
        • Bai R.
        • Horton R.P.
        • Biase L.D.I.
        • et al.
        Intraprocedural and long-term incomplete occlusion of the left atrial appendage following placement of the WATCHMAN device: a single center experience.
        J Cardiovasc Electrophysiol. 2012; 23: 455-461
        • Girdhar G.
        • Read M.
        • Sohn J.
        • Shah C.
        • Shrivastava S.
        In-vitro thrombogenicity assessment of polymer filament modified and native platinum embolic coils.
        J Neurol Sci. 2014; 339: 97-101
        • Sacco S.E.
        • Whisnant J.P.
        • Broderick J.P.
        • Phillips S.J.
        • O’Fallon W.M.
        Epidemiological characteristics of lacunar infarcts in a population.
        Stroke. 1991; 22: 1236-1241