Management of complications associated with percutaneous left atrial appendage closure with or without ablation: experience from 512 cases over a 4-year period

Abstract

Background: Percutaneous left atrial appendage closure (LAAC) serves as an alternative prophylactic strategy for patients with non-valvular atrial fibrillation (AF) who cannot undergo anti-coagulation therapy. Proper management of associated complications is crucial to enhancing the procedure's success rate and mitigating perioperative risks and adverse events during follow-up.

Aims: This study aims to summarize our center's experience and strategies in managing procedural-related complications encountered in 512 cases of LAAC with or without ablation for AF conducted from January 2020 to December 2023.

Results: We identified 11 significant intervention-requiring complications associated with LAAC with or without Ablation procedure. These included three cases of intraoperative thrombosis, three instances of pericardial effusion or tamponade, one case of device-related thrombosis, one peri-device leak, one systemic embolism, one bleeding episode, and one additional device-related complication. The categorization of intraoperative thrombosis was as follows: one patient exhibited heparin resistance; one experienced thrombosis due to prolonged device implantation during the LAAC with ablation procedure; and one had unexplained intraoperative thrombosis. The pericardial effusion or tamponade likely resulted from damage to the atrial appendage during LAAC device insertion. Two patients encountered device-related thrombosis and systemic embolism events possibly caused by non-standard postoperative antithrombotic medication use; one patient's peri-device leak may have resulted from incomplete endothelialization of the occluder post-surgery; one patient experienced postoperative bladder bleeding; and one patient's device-related complications occurred due to a dislodged strut frame that damaged the left atrial appendage, leading to pericardial effusion. Our proactive interventions enabled all patients with these surgical-related complications to be safely discharged, with subsequent follow-ups showing no adverse events.

Conclusion: Implementing targeted interventions for immediate procedural-related complications during the LAAC with or without ablation procedures enhances procedural success rates, diminishes postoperative mortality and patient disability, and bolsters stroke prevention efforts. This approach underscores the importance of a strategic response to complications, affirming the procedure's viability and safety in managing non-valvular AF in patients contraindicated for anticoagulation.

Keywords: atrial fibrillation; device-related thrombus; left atrial appendage closure; management strategy; procedural-related complications.

Figure 1

Intraoperative thrombosis during left atrial appendage closure. (A) A 2D TEE image reveals an accumulating flocculent substance at the catheter's tip, identified as a thrombus (15 mm × 5 mm). (A) 3D TEE visualization highlights the thrombus formation (red arrows) at the catheter's head, with the catheter itself marked by green arrows. (B) Post-deployment of a WATCHMAN device, a thrombus (20 mm × 5 mm) is noted at the catheter's tip during its extraction phase. (B) 3D TEE imagery captures the thrombus (red arrows) and the catheter (green arrows). (C) Following the LACbes device deployment, a distinct linear thrombus (25 mm × 2 mm) is observed along the device's central rivet. (C) Enhanced 3D TEE imaging showcases the thrombus detailed in (C), with red arrows pointing to its formation.

Figure 2

DRT events during follow-up. Red arrows indicate thrombus on the surface of the occluder.

Figure 3

The LAAC procedure utilizing an atrial septal defect occluder on a “chicken-wing” shaped LAA. (A) DSA illustrates a superficial “chicken-wing” configuration of the left auricle. (B) Post-puncture of the LAA, instead of immediate catheter retraction following contrast medium diffusion, the catheter was advanced further into the pericardial space through the breach. (C) Utilizing this strategically retained catheter, an atrial septal defect occluder was deployed atop the LAA opening. Subsequent DSA confirmed the halt of bleeding and effective LAA closure by the occluder. The red arrow highlights the 10-mm atrial septal defect occluder positioned within the LAA. (D) On review at 1 month postoperatively, CCTA suggested good position of the occluder, and no adverse events such as residual leakage were detected.

Figure 4

The cessation of bleeding following a temporary deployment of the LACbes device after inadvertent scratching of the LAA during the LAAC procedure. (A) The LAA undergoes angiographic assessment post-septal puncture, guiding the selection of a suitable occluder. (B) Intraoperative disturbance of the LAA surface resulted in discernible contrast spread into the pericardial space, indicating bleeding. (C) Following the provisional placement of the LACbes device, subsequent angiography revealed the absence of contrast seepage, confirming the halting of hemorrhage.

Figure 5

The effective application of a WATCHMAN device to seal a bleeding LAA breach. (A) Initial angiographic scrutiny is performed on the LAA following septal puncture, aiding in the appropriate choice of occluder. (B) A tear within the LAA is visualized with angiographic contrast dispersing into the pericardium, signaling internal bleeding. (C) Post-deployment of a WATCHMAN device to seal the LAA rupture, no further contrast leakage is observed within the pericardial area, signifying successful occlusion. The red arrow points to the WATCHMAN device, strategically positioned as a temporary measure.

Figure 6

Lower extremity vascular ultrasound suggests lower extremity arterial thrombosis leading to arterial lumen occlusion.

Figure 7

(A) DSA revealed that a strut frame of the implanted occluder had dislodged. (B) CCTA revealed a large pericardial effusion in the pericardial cavity. Red arrow indicates dislodged occluder strut frame.