Residual Surgical Left Atrial Appendage Leaks: Thromboembolic Risk and Anatomy‐Tailored Percutaneous Closure Strategies

BACKGROUND: Atrial fibrillation is a leading cause of cardioembolic stroke, and the left atrial appendage (LAA) is the principal source of thrombus formation in non-valvular disease. Surgical LAA exclusion is commonly performed during cardiac surgery, but incomplete closure resulting in a residual communication is not uncommon and may carry ongoing thromboembolic risk. Unlike peri-device leaks after transcatheter closure, residual surgical leaks are anatomically and mechanistically distinct, typically arising through a central, fibrotic ostium with a variable residual pouch, and no validated management pathway currently exists. METHODS: We conducted a structured literature search of PubMed/MEDLINE, Embase, the Cochrane Library, and Google Scholar for reported cases and surgical subgroups in which residual leaks after surgical LAA ligation or amputation were managed percutaneously. Because the evidence was predominantly observational and case-based, findings were synthesized narratively rather than as a formal meta-analysis. RESULTS: Across 37 reported percutaneous procedures identified from case reports, small series, and registry surgical subgroups, closure strategies comprised vascular plugs and septal occluders, dedicated LAA occlusion devices, non-barbed disc-based occluders in anatomically high-risk cases, and endocardial radiofrequency ablation for uncrossable fibrotic leaks. Acute success was high, although outcome reporting was heterogeneous and long-term data were limited. CONCLUSIONS: Residual surgical LAA leaks are an underrecognized, anatomically distinct entity. We propose an anatomy-tailored management framework integrating leak traversability, adjacent vascular anatomy, ostial morphology, and residual pouch depth; given the limited evidence, this should be regarded as hypothesis-generating, and prospective multicenter data are needed.