Persistent peri-device leak following left atrial appendage occlusion treated with hybrid coil- and plug-based closure: a case report

Background Left atrial appendage occlusion (LAAO) is an emerging alternative to long-term anticoagulation in patients with atrial fibrillation, but peri-device leaks remain a clinical challenge. Case summary A 63-year-old man with permanent atrial fibrillation, heart failure, a prior ischemic stroke history was referred for LAAO due to recurrent anticoagulation-related bleeding. Pre-procedural computer tomography (CT) showed a markedly enlarged appendage suitable for a 35 mm WATCHMAN FLX®, which was implanted under intracardiac echocardiography guidance, with subsequent transition to aspirin. Three months later, CT revealed a tilted device with a peri-skirt leak; an ischemic stroke had occurred in the interim, and anticoagulation was resumed. An Amplatzer Vascular Plug II was implanted but follow-up CT demonstrated persistent contrast passage and more but incomplete occlusion. Three months later, the patient experienced a second stroke, and CT confirmed ongoing peri-device flow. A hybrid leak-closure procedure was performed with coils in the appendage and within the device, followed by a 12 mm plug at the leak channel, achieving near-complete occlusion. At 7-month follow-up, the patient remained on rivaroxaban therapy, briefly interrupted due to haematuria associated with nephrolithiasis. Discussion Most cases of peri-device leak after LAAO are related to suboptimal device alignment, incomplete endothelialization, or persistent peri-skirt channels. In our case, device tilt with a peri-skirt tract persisted despite initial plug-based closure. This case provides insight into the potential role of hybrid coil- and plug-based strategies in enhancing occlusion but also highlights that anticoagulation remains necessary when full occlusion is not obtained.