Management of peri-device leaks after left atrial appendage closure using endovascular coils and/or amplatzer plugs and radiofrequency ablation

Background Peri-device leaks (PDLs) after left atrial appendage closure (LAAC) portend a higher residual risk of thromboembolism in patients with Atrial Fibrillation (AF). Therefore, closure of PDLs has evolved as a procedural strategy to mitigate this residual thromboembolic risk. Objective To present our procedural experience and outcome data in patients who underwent PDL-closure after prior LAAC. Methods We performed a retrospective review of patients with follow-up imaging data (either transesophageal echocardiograms or Cardiac CT scans) performed at ∼1 year after LAAC between the time-period 5/2015 – 10/2022 to assess PDLs. Results We included a total of 532 patients with follow-up imaging data. At a mean follow up of 696±359 days post-LAAC, 63 of 532 (11.8%) patients underwent PDL closure. These PDL closure cohort was age 73.1±9.5 years, 41 of 62 (65%) had paroxysmal AF, and the CHA2DS2-Vasc was 3.7±1.5. In 42 of 62 (67.7%) patients, the initial LAAC device was Watchman, and in 21 (33.8%) patients, it was Watchman-FLX. Of the PDL closure cohort, 8 of 62 (12.9%) had a post-LAAC thromboembolic event (transient ischemic attack [TIA], stroke or systemic embolism). The PDL size was 3.8±2.0 mm. PDL closure was performed using endovascular coils alone in 23 (37.1%), plugs (Amplatzer devices, Abbott) alone in 18 (29%), and combinations of both in 13 (19.4%) patients. In 8 (14.5%) patients, radiofrequency ablation was used in concert with both coils and plugs (Figure). There was only 1 complication (pericardial effusion drained percutaneously) during the PDL closure procedure. During follow-up post-PDL closure, no patient sustained a stroke and only 1 patient had a TIA (Table). Conclusions Our data indicate that PDL closure after LAAC is feasible and safe, with a low risk of procedural complications. Such a strategy can be used in a subset of high-risk patients with PDL after LAAC who are at an elevated residual risk of thromboembolism.