Post on 03-Aug-2020
Left Atrial Appendage
Occlusion Case Studies
(Including Complications)
Andrew Krumerman MD, FHRSProfessor of Medicine
Albert Einstein College of MedicineMontefiore Medical Center
New York, USA
LAAO Case 1
• 76 year old woman with a history of permanent AF treated with
Rivaroxaban for several years despite recurrent hemorrhoidal
bleeding and diverticulosis.
• Past medical history includes DM, HTN and non obstructive coronary
disease Echocardiogram revealed a preserved LVEF and LA size of
5.1cm. Following a diagnosis of uterine and vaginal cancer, she
required TAH/BSO and chemotherapy / radiation therapy.
• She now presents with rectal bleeding secondary to radiation
proctopathy as well as recurrent hematuria due to inflammatory
cystitis.
• Physical Exam- Frail woman 55 kg, BMI 18kg/m2
LAAO Case 1
• CHASDSVASC= Female,
Age-2, CAD, DM, HTN= 5
• HASBLED= 3
• Frail- Elderly
• CHASDSVASC= Female,
Age-2, CAD, DM, HTN= 5
• HASBLED= 3
• Frailty
• What is the best device for
this patient?
Green P et al. J Am Coll Cardiol Intv 2012;5:974–81
Cruz-Gonzalez I et a. Rev Esp Cardiol. 2020;73(1):21–27
LAAO Case 1
Baseline Imaging
• Neck 18-21mm
• Depth 22-27mm
• Windsock Morphology
TEE 45 days post LAAO
Six Months Post LAAO
Six Months Post LAAO
Causes of DRT
• Device too deep, residual pouch
• Peri-device leak
• Failure of endothelialization
• Non compliance or limited OAC regimen
Dukkipati SR et al. Circulation. 2018;138:874–885.
• 3.7% DRT
• 25% of patients with DRT
developed SSE
• Predictors of DRT
• Permanent AF
• Previous TIA/CVA
• Vascular Disease
• LAA diameter
• Depressed LVEF
Dukkipati SR et al. Circulation. 2018;138:874–885.
Timing of DRT
Dukkipati SR et al. Circulation. 2018;138:874–885.
Timing of DRT
DRT in EWOLUTION
Boersma LV et al.Circ A&E. 2019;12:e006841.
One Year Post Implant
Ellis CR, Piccini JP. Circulation. 2018;138:886–888
DAPT x2 months
ASA/Clopidogrel
Del Rocca, DiBiase, Natale, et al Unpublished abstract
CYP2C19• Loss of function polymorphisms of the cytochrome P450
2C19 (CYP2C19) gene are associated with reduced
hepatic bio-activation of clopidogrel and may lead to
potential consequences
• Investigators studying stent thrombosis have
demonstrated that LOF polymorphisms of CYP2C19 do
not break down clopidogrel into its active form.
Ichikawa M. et al Circ J 2015; 79: 85–90
Human Heart 200 days post
Watchman
Schwartz RS et al J Am Coll Cardiol Intv 2010;3:870–7
Follow Up TEE
LAAO Case 2
Its Better to Be Lucky Than Good…
• 60 year old retired police officer with a history of permanent
AF (>10 years) treated with Rivaroxaban and Metoprolol.
• Referred for LAAO after presenting on two separate
occasions to the hospital with fatigue, weakness and anemia
with a Hemoglobin of 6 g/dl. GI work was unrevealing.
• Past medical history included ischemic heart disease status
post remote PCI with preserved LVEF and LA size 5.6cm.
Remote CVA, Hypertension and Hypothyroidism.
LAAO Case 2
• Physical exam revealed a heart rate of 62, BP 140/80
mmHg, no murmurs rubs or gallops, clear lungs,
abdominal exam benign without bruits, chronic venous
stasis changes of the lower extremities and non focal
neurologic examination. BMI 29kg/m2
• Medications Levothyroxine, Metoprolol, HCTZ, ASA
• How should this be approached?
LAAO Case 2
• CHADSVASC= 4 / HASBLED=4
• Patient was send for pre-operative CT Imaging
• Large partially imaged infrarenal
abdominal aortic aneurysm with
thrombus measuring up to 7.5
cm on available images. Further
characterization with imaging is
required.
Baseline Views of LAA
LARIAT DRT
• This guy was neither lucky nor good.
• First required open AAA repair
• Ultimately received LARIAT ligation and developed large
thrombus.
• Initial post operative course was single APT- ASA
• Eliquis 5mg BID initiated
• n=306 CHADSVASC >3, HASBLED >3
• OAC x4 weeks then ASA
• TEE at 1, 6 and 12 months
• Follow up for at least one year
Mohanty S. et al. Heart Rhythm 2020;17:175–181
LARIAT Leak
• 26.5% (81/306) demonstrated leaks at 4week TEE
• 26% (21/81) of leaks spontaneously closed at 6 months
• 31% Required leak closure procedure
• SSE 11.7% vs. 0.81% for patients with leak vs. no leak
Mohanty S. et al. Heart Rhythm 2020;17:175–181
Gunnysack Effect
Pillarisetti et al. Heart Rhythm 2015;12:1501–1507
Conclusions
• DRT is a serious complication and may develop more than
one year post procedure
• Possible etiologies include failure of adequate
endothelialization, incomplete closure (leak, stump, residual
lobes), inadequate OAC regimen
• Available data suggests that risk factors include permanent
AF, history of CVA, vascular disease and depressed LVEF
• Prospective Randomized Trials are necessary to identify
those at risk and optimal therapies for DRT prevention and
treatment
EHRA Expert Consensus
Glickson et al. Europace (2020) 22, 184
EHRA Expert Consensus
Glickson et al. Europace (2020) 22, 184
Should
Thank You
LARIAT DRT
Sivasambu B. et al. J Cardiovasc Electrophysiol. 2019;30:1319-1324
Alkhouli M et al. J Am Coll Cardiol EP 2018;4:1629–37
DRT
DRT due to Localized
Prothrombotic Factors?
K. Bartus et al. International Journal of Cardiology 301 (2020) 103–107