Cerebral Protection Devices in Case of Left Sided Intracardiac Thrombus: A Multicentre Experience From the Cath Lab and EP Lab

BACKGROUND: Performing a left atrial appendage occlusion (LAAO) or catheter ablation with left-sided intracardiac thrombus is considered very-high risk for periinterventional stroke. Cerebral embolic protection (CEP) devices are designed to prevent cardioembolic stroke and have been widely studied in TAVR procedures. However, their role in LAAO and catheter ablation of ventricular tachycardia (VT) or in pulmonary vein isolation (PVI) with cardiac thrombus present remains unknown. PURPOSE: to study utility and safety of CEP devices during LAAO and catheter ablation in patients with left sided intracardiac thrombus in a multicenter setting. METHODS: Two different CEP devices were used according to the physician's discretion: (1) a capture device consisting of two filters for the brachiocephalic and left common carotid arteries placed from a radial artery; or (2) a deflection device covering all three supra-aortic vessels placed over a femoral artery. Periprocedural and safety data from 2019 to 2023 were retrospectively obtained from procedural reports and discharge letters for all patients with left-sided intracardiac thrombus undergoing LAAO, VT ablation, or PVI under protection with a CEP device. Long-term safety data were obtained by clinical follow-up in the respective institutions and telephone consultations. RESULTS: Sixty-five patients were enrolled in five centers in Italy. Fifty-two patients underwent LAA closure, 12 patients underwent VT ablation and one patient underwent PVI. Mean age was 73 ± 10 years and 43 (66%) were male, mean LVEF was 46 ± 13%. The location of the cardiac thrombus was the LAA in all 52 patients (100%) undergoing LAA closure whereas in patients undergoing VT ablation, thrombus was present in the LAA in five cases (42%), left ventricle (n = 6; 50%) and aortic arch (n = 1;8%). One patient developed left atrial thrombus during PVI. The capture device was used in 39 out of 65 (60%) and the deflection device in 26 out of 65 cases (40%). There were no periprocedural strokes or transitory ischemic attacks (TIA). CEP-related complications at the arterial access site were noted in 4 cases (6%) and were minor, not requiring surgery. Other periprocedural events were one transient ST-elevation caused by coronary spasm in a patient undergoing LAA closure, not related to the CEP device. There was one in-hospital death after VT ablation due to cardiogenic shock, not related to the CEP device. At long-term follow-up, one TIA and three non-cardiovascular deaths occurred with a mean follow-up time of 455 days. CONCLUSIONS: This is the first multicentre experience showing that LAA closure or catheter ablation with cerebral protection in patients with cardiac thrombus is feasible without thromboembolic complications. The possibility of safely performing an intervention in this high-risk setting is promising and should be tested in a prospective randomized trial.