The use of percutaneous left atrial appendage occluder device in a patient with prior surgical ligation with incomplete exclusion: a case report

Abstract

Background

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and the most common cause of cardioembolic stroke. The left atrial appendage (LAA) is the main source of thrombus formation in patients with AF. Therapies include use of percutaneous LAA closure devices, or surgical LAA occlusion (LAAO). Despite these options, complete closure of the LAA is not always achieved, and residual communication between the LAA and atrium may result in increased thrombus formation. Although studies have analysed the use of percutaneous measures such as coils, plugs, or second occluder device deployment in LAA with peri-device leak (PDL), use of percutaneous occlude devices in surgically occluded LAA is far less studied.

Case summary

We present a case of a 79-year-old female patient who underwent LAAO device deployment within a surgically occluded LAA with PDL. She underwent 27 mm LAAO device (WATCHMANTM) deployment and all the P.A.S.S. (Position, Anchor, Size, and Seal) criteria were satisfied. Only 1.4 mm PDL was present. She was continued on apixaban and aspirin post-operatively. Post-operative transoesophageal echocardiogram at 6 weeks demonstrated trivial PDL measuring 1.49 mm. Patient was continued on aspirin and clopidogrel, with discontinuation of apixaban.

Discussion

Percutaneous LAAO device deployment in previously surgically ligated LAA with incomplete exclusion is a potential therapeutic option for patients with AF and a high bleeding risk seeking a minimally invasive strategy, in an attempt to de-escalate anticoagulation therapy.

Learning points.

• Surgical ligation of the left atrial appendage may result in incomplete exclusion, resulting in persistent thrombo-embolic risk to patients with atrial fibrillation.

• Percutaneous left atrial appendage occluder devices may provide a therapeutic option to this patient population, offering a non-invasive therapy and also allowing for de-escalation of anticoagulation.

Introduction

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, and the most common cause of cardioembolic stroke.¹ Anticoagulation is the first line therapy for patients with elevated risk of stroke according to the CHA2DS2-VASc score. The left atrial appendage (LAA) is the main source of thrombus formation in patients with AF,² and the primary target of therapy in patients unable to tolerate anticoagulation secondary to coagulopathy. Therapies include use of anticoagulation, percutaneous LAA closure devices, or surgical LAA occlusion (LAAO).^3,4 Despite these options, complete closure of the LAA is not always achieved, and residual communication between the LAA and atrium may result in increased thrombus formation.^5,6 Although studies have analysed the use of percutaneous measures such as coils, plugs, or second occluder device deployment in LAA with peri-device leak (PDL),⁷ use of percutaneous occlude devices in surgically occluded LAA is far less studied.^8,9 We present a case of LAAO device deployment within a surgically occluded LAA with PDL.

Summary figure

Case presentation

A 79-year-old Black female patient was referred for percutaneous LAAO. Past medical history was significant for mitral regurgitation, tricuspid regurgitation, and persistent atrial fibrillation complicated by recurrent significant gastrointestinal haemorrhage on anticoagulation secondary to diverticulosis. Five months prior to referral, she underwent surgical mitral and tricuspid valve repair, as well as LAA ligation with 35 mm AtriClip due to elevated stroke risk (CHA2DS2-VASc score 5) with intolerance to oral anticoagulation. Initial pre-procedural clinical examination revealed a haemodynamically stable, well-appearing female with regular heart rate and irregular rhythm. Pre-operative laboratory assessment revealed normal kidney function (serum creatinine 0.81 mg/dL) and mild anaemia (haemoglobin 10.8 g/dL, reference 12.0–15.0 g/dL). Intra-operative transoesophageal echocardiogram (TEE) demonstrated closure of the LAA. However, 40-day post-operative TEE and cardiac computed tomography (CT) imaging demonstrated a significant persistent communication between the left atrium and LAA with no evidence of LAA thrombus (Figures 1 and 2). After comprehensive review of the TEE and CT scan images, we felt that a LAAO device could be used to achieve adequate occlusion of the residual LAA pouch. For LAAO device implantation, trans-septal atrial imaging was performed using fluoroscopic and TEE guidance, with a mid-septal puncture chosen using intracardiac ultrasound guidance. Intra-procedural TEE was used for sizing of the LAA, and based on these measurements, a 27 mm LAAO device (WATCHMAN™) was selected and deployed, with all the P.A.S.S. (Position, Anchor, Size, and Seal) criteria satisfied (Figure 3). Only 1.4 mm PDL was present. She continued on apixaban 5 mg twice daily and aspirin 81 mg daily post-operatively. Follow-up TEE at 6 weeks demonstrated a trivial PDL measuring 1.9 mm along posterior aspect, with no thrombus seen. At that point, the decision was made to continue aspirin 81 mg daily and clopidogrel 75 mg daily, with discontinuation of apixaban. The patient has not experienced any further episodes of major bleeding, and we are tentatively planning to stop clopidogrel at 6 months post-operatively, with continuation of aspirin 81 mg daily indefinitely thereafter.

Figure 1.

TEE pre-LAAO device deployment demonstrating persistent communication between LAA and left atrium.

Figure 2.

CT reconstruction of the LAA status post-surgical ligation (AtriClip), highlighting presence of the AtriClip with the residual pouch (B) the LAA ostium (A and C) with measurement of the residual communication (D).

Figure 3.

TEE post-LAAO device deployment (WATCHMAN™).

Discussion

Here we describe a case of LAAO device utilization in a previous surgically ligated LAA. The patient required exclusion of the LAA due to demonstrated intolerance of oral anticoagulation with recurrent significant gastrointestinal haemorrhage, and a high risk of stroke (CHA2DS2-VASc score 5), however a persistent communication between the LAA and atrium was still present post-surgical ligation with AtriClip. Based on the size of the residual LAA pouch, we felt that occlusion with the LAAO WATCHMAN™ device was most feasible and offered the best chance of LAA exclusion. The decision to continue aspirin and clopidogrel combination therapy for 6 months post-operatively was made in accordance with guidelines.¹⁰ Had the patient experienced recurrent bleeding while on dual anti-platelet therapy, our plan was to stop clopidogrel.

There is a paucity of clinical experience data utilizing LAAO in patients with prior surgically ligated/occluded LAA. One case series highlighted the successful management of three patients with percutaneous LAAO with the WATCHMAN™ device, after previously undergoing incomplete surgical exclusion of the LAA.⁷ Prior studies have suggested 20–40% rate of incomplete surgical LAA ligation.^3,8 In such cases, patients with high bleeding risk should have percutaneous options available to them, which offer a lower risk therapy for minimizing risk of LAA thrombus. Despite their therapeutic indications, LAAO devices carry a risk of complication, primarily including device thrombosis, bleeding from post-procedural anticoagulation use, post-operative pericardial effusions, and post-procedural stroke.¹¹ Our case study adds a small but growing body of evidence suggesting the safe and efficacious use of percutaneous LAAO device deployment in patients who have undergoing prior surgical ligation with incomplete exclusion of the LAA.

Lead author biography

Dr Waddah Maskoun is a board certified Cardiac Electrophysiologist and Clinical Faculty with Henry Ford Health System in Southeast Michigan. He graduated from Aleppo University School of Medicine, and received post-graduate training in Cardiovascular Medicine from Medical College of Wisconsin, followed by Clinical Electrophysiology from Indiana University Medical Center. He has been involved in a multitude of clinical research publications to-date, focusing on dysrhythmias and complex electrophysiologic therapies.

 

Consent: The patient provided consent for use of de-identified information for publication and educational purposes, in compliance with COPE guidelines

Funding: No funding was provided for this research.

Data availability

No new data were generated or analysed in support of this research.