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Helal B, Khan J, AlJayar D, Khan MS, Alabdaljabar MS, Asad ZUA, DeSimone CV, Deshmukh A. Risk factors, clinical implications, and management of peridevice leak following left atrial appendage closure: A systematic review. J Interv Card Electrophysiol 2024; 67:865-885. [PMID: 38182966 DOI: 10.1007/s10840-023-01729-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/26/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Left atrial appendage closure (LAAC) is a treatment modality for stroke prevention in patients with atrial fibrillation (AF). One of the potential complications of LAAC is a peri-device leak (PDL), which could potentially increase the risk of thromboembolism formation. METHODS This systematic review was done according to PRISMA guidelines. Using four databases, all primary studies through April 2022 that met selection criteria were included. Outcomes of interest were studies reporting on PDL characteristics, risk factors and management. RESULTS A total of 116 studies met selection criteria (97 original studies and 19 case reports/series). In the original studies (n = 30,133 patients), the weighted mean age was 72.0 ± 7.4 years (57% females) with a HAS-BLED and CHA2DS2-VASc weighted means of 2.8 ± 1.1 and 3.8 ± 1.3, respectively. The most common definition of PDL was based on size; 5 mm: major, 3-5 mm: moderate, < 1 mm minor, or trivial. Follow up time for PDL detection was 7.15 ± 9.0 months. 33% had PDL, irrespective of PDL severity/size, and only 0.9% had PDL of greater than 5 mm. The main risk factors for PDL development included lower degree of over-sizing, lower left ventricular ejection fraction, device/LAA shape mismatch, previous radiofrequency ablation, and male sex. The most common methods to screen for PDL included transesophageal echocardiogram and cardiac CT. PDL Management approaches include Amplatzer Patent Foramen Ovale occluder, Hookless ACP, Amplatzer vascular plug II, embolic coils, and detachable vascular coils; removal or replacement of the device; and left atriotomy. CONCLUSION Following LAAC, the emergence of a PDL is a significant complication to be aware of. Current evidence suggests possible risk factors that are worth assessing in-depth. Additional research is required to assess suitable candidates, timing, and strategies to managing patients with PDL.
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Affiliation(s)
- Baraa Helal
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Jibran Khan
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Dalia AlJayar
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | | | - Zain Ul Abideen Asad
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | - Abhishek Deshmukh
- Department of Cardiovascular Medicine, 200 1St Street SW, Rochester, MN, 55905, USA.
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Ramdat Misier NL, Kharbanda RK, van Schaagen FRN, de Groot NMS. Case report: peri-device leakage after percutaneous left atrial appendage occlusion: plug, clip, or amputate? Eur Heart J Case Rep 2023; 7:ytac494. [PMID: 36694875 PMCID: PMC9856255 DOI: 10.1093/ehjcr/ytac494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/11/2022] [Accepted: 12/30/2022] [Indexed: 01/04/2023]
Abstract
Background Although peri-device leakage is frequently observed after left atrial appendage occlusion (LAAO), there is no consensus on the optimal management strategy. It is unknown whether additional plugging should be preferred over surgical exclusion of the LAA, as experience with additional plugging is limited. Case summary In this case report, we demonstrate the clinical implications of additional plugging and surgical exclusion in a 65-year-old male patient with peri-device leakage and recurrent thromboembolic events. After the recurrence of paroxysmal atrial fibrillation (AF) and a transient ischaemic attack despite adequate anticoagulation, the patient was opted for re-do pulmonary vein isolation and LAAO with a Watchman device. Due to multiple ischaemic strokes and recurrent AF in combination with significant peri-device leakage, additional plugging with a second device was performed. Post-procedurally, the patient had another ischaemic stroke and persisting peri-device leakage was observed during follow-up. Due to progressive symptoms of AF and patient's preference to discontinue DOAC, he underwent a Cox MAZE IV procedure, including amputation of the LAA with both devices. Within six months after surgery, the patient experienced two more ischaemic events. In the following two years, the patient remained free of any cerebrovascular accidents or recurrence of AF. Discussion Additional plugging of peri-device leakage is not always successful in stroke prevention. In combination with recurrent AF, progressive symptoms, contraindication for oral anticoagulation, and patient's preference, surgical LAA exclusion could be preferred over additional plugging.
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Affiliation(s)
- Nawin L Ramdat Misier
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Rohit K Kharbanda
- Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands,Department of Cardiothoracic Surgery, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Frank R N van Schaagen
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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Afzal MR, Gabriels JK, Jackson GG, Chen L, Buck B, Campbell S, Sabin DF, Goldner B, Ismail H, Liu CF, Patel A, Beldner S, Daoud EG, Hummel JD, Ellis CR. Temporal Changes and Clinical Implications of Delayed Peridevice Leak Following Left Atrial Appendage Closure. JACC Clin Electrophysiol 2021; 8:15-25. [PMID: 34454881 DOI: 10.1016/j.jacep.2021.06.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 06/21/2021] [Accepted: 06/21/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of this study was to assess temporal changes and clinical implications of peridevice leak (PDL) after left atrial appendage closure. BACKGROUND Endocardial left atrial appendage closure devices are alternatives to long-term oral anticoagulation (OAC) for patients with atrial fibrillation. PDL > 5 mm may prohibit discontinuation of OAC. METHODS Patients included in the study had: 1) successful Watchman device implantation without immediate PDL; 2) new PDL identified at 45 to 90 days using transesophageal echocardiography; 3) eligibility for OAC; and 4) 1 follow-up transesophageal echocardiographic study for PDL surveillance. Relevant clinical and imaging data were collected by chart review. The combined primary outcome included failure to stop OAC after 45 to 90 days, transient ischemic attack or stroke, device-related thrombi, and need for PDL closure. RESULTS Relevant data were reviewed for 1,039 successful Watchman device implantations. One hundred eight patients (10.5%) met the inclusion criteria. The average PDL at 45 to 90 days was 3.2 ± 1.6 mm. On the basis of a median PDL of 3 mm, patients were separated into ≤3 mm (n = 73) and >3 mm (n = 35) groups. In the ≤3 mm group, PDL regressed significantly (2.2 ± 0.8 mm vs 1.6 ± 1.4 mm; P = 0.002) after 275 ± 125 days. In the >3 mm group, there was no significant change in PDL (4.9 ± 1.4 mm vs 4.0 ± 3.0 mm; P = 0.12) after 208 ± 137 days. The primary outcome occurred more frequently (69% vs 34%; P = 0.002) in the >3 mm group. The incidence of transient ischemic attack or stroke in patients with PDL was significantly higher compared with patients without PDL, irrespective of PDL size. CONCLUSIONS New PDL detected by transesophageal echocardiography at 45 to 90 days occurred in a significant percentage of patients and was associated with worse clinical outcomes. PDL ≤ 3 mm tended to regress over time.
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Affiliation(s)
- Muhammad R Afzal
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - James K Gabriels
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | | | - Lu Chen
- Northwell Health, Long Island Jewish Hospital, Division of Electrophysiology, Manhasset, New York, USA
| | - Benjamin Buck
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Sandra Campbell
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Dawn F Sabin
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bruce Goldner
- Northwell Health, Long Island Jewish Hospital, Division of Electrophysiology, Manhasset, New York, USA
| | - Haisam Ismail
- Northwell Health, Long Island Jewish Hospital, Division of Electrophysiology, Manhasset, New York, USA
| | - Christopher F Liu
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, New York, New York, USA
| | - Apoor Patel
- Division of Electrophysiology, Northwell Health, North Shore University Hospital, Manhasset, New York, USA
| | - Stuart Beldner
- Division of Electrophysiology, Northwell Health, North Shore University Hospital, Manhasset, New York, USA
| | - Emile G Daoud
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - John D Hummel
- The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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