Key result
Deep LAAO implantation increases modeled residual blood ~50% vs ostial positioning, suggesting higher thrombus risk.
Why the study?
Although clinical reports suggest device type and position affect device-related thrombus risk after LAAO, in-depth studies of the mechanistic basis were needed.
Does LAAO device type and implant position impact surrogate markers of device-related thrombus in an in silico model?
Does LAAO device type and implant position impact surrogate markers of device-related thrombus in an in silico model?
In silico modeling demonstrates that deep or off-axis implantation of LAAO devices increases surrogate markers for device-related thrombus, providing a mechanistic basis for clinical observations.
May guide LAAO positioning to reduce thrombus risk; hypothesis-generating pending clinical validation.
BACKGROUND: Device-related thrombus (DRT) after left atrial appendage occlusion (LAAO) is potentially linked to adverse events. Although clinical reports suggest an effect of the device type and position on the DRT risk, in-depth studies of its mechanistic basis are needed. This in silico study aimed to assess the impact of the position of non-pacifier (Watchman) and pacifier (Amulet) LAAO devices on surrogate markers of DRT risk. METHODS: The LAAO devices were modeled with precise geometry and virtually implanted in different positions into a patient-specific left atrium. Using computational fluid dynamics, the following values were quantified: residual blood, wall shear stress (WSS) and endothelial cell activation potential (ECAP). RESULTS: In comparison to an ostium-fitted device position, deep implantation led to more residual blood, lower average WSS and higher ECAP surrounding the device, especially on the device's atrial surface and the surrounding tissue, suggesting increased risk for potential thrombus. For the non-pacifier device, an off-axis device orientation resulted in even more residual blood, higher ECAP and similar average WSS as compared to an ostium-fitted device position. Overall, the pacifier device showed less residual blood, higher average WSS and lower ECAP, compared to the non-pacifier device. CONCLUSIONS: In this in silico study, both LAAO device type and implant position showed an impact on potential markers of DRT in terms of blood stasis, platelet adhesion and endothelial dysfunction. Our results present a mechanistic basis for clinically observed risk factors of DRT and the proposed in silico model may aid in the optimization of device development and procedural aspects.
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Zhong et al. (2023) studied Atrial fibrillation (n=1). Deep implantation of non-pacifier LAAO device (NP-DS) vs. Ostium-fitted device position (NP-OS) was evaluated on Volume fraction of residual blood. In a patient-specific in silico model, deep implantation of a non-pacifier LAAO device increased the volume fraction of residual blood to 12% compared to 8% with an ostium-fitted position, suggesting an increased risk for device-related thrombus.
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