Successful implantation of left atrial appendage occlusion devices in two patients with failed surgical left atrial appendage closure

Atrial fibrillation (AF) is the common heart rhythm abnormality, with about 12.1 million US cases and 1.2 million new cases predicted by 2030[1](#ref-0001). AF doubles mortality and raises stroke risk by 2.4 time[2](#ref-0002). Guidelines recommend oral anticoagulation for non-valvular AF with intermediate or higher thromboembolic risk. If OAC is contraindicated, percutaneous left atrial appendage closure (LAAC) is considered. Surgical occlusion is done if patients are already undergoing cardiac surgery, though outcomes vary.[3](#ref-0003) . We present two high-stroke-risk AF patients who underwent surgical LAAC but had incomplete closure, resulting in cerebral ischemic events. Subsequently, they underwent successful percutaneous LAAC device closure with complete occlusion. Successful implantation of left atrial appendage occlusion devices in two patients with failed surgical left atrial appendage closure Kirtivardhan Vashistha, MD 1 ; Marko Novakovic MD 1 ; Luka Petrovic MD 2 ; Robert Abed MD 2 ; Lyudmila Aurora, MD 2 ; Davendra Mehta MD 2 Affiliations: - Department of Cardiovascular Medicine, Mount Sinai Morningside-West, Manhattan, New York Department of Cardiac Electrophysiology, Mount Sinai Morningside-West, Manhattan, New York Corresponding Author: - Dr Kirtivardhan Vashistha, MD Department of Cardiovascular Medicine Mount Sinai Morningside-west 1111 Amsterdam Ave, New York, NY 10025 Email Address: - [email protected] Financial Disclosures: - There are no relevant disclosures for this work by any of the authors. Total Word Count: - 1486 words (including abstract and excluding references/Figures)

- Atrial Fibrillation Left atrial appendage occluder Surgical left atrial appendage closure Cerebrovascular accident Anticoagulation

- None

Atrial fibrillation (AF) is the common heart rhythm abnormality, with about 12.1 million US cases and 1.2 million new cases predicted by 2030 1 . AF doubles mortality and raises stroke risk by 2.4 time 2 . Guidelines recommend oral anticoagulation for non-valvular AF with intermediate or higher thromboembolic risk. If OAC is contraindicated, percutaneous left atrial appendage closure (LAAC) is considered. Surgical occlusion is done if patients are already undergoing cardiac surgery, though outcomes vary. 3 . We present two high-stroke-risk AF patients who underwent surgical LAAC but had incomplete closure, resulting in cerebral ischemic events. Subsequently, they underwent successful percutaneous LAAC device closure with complete occlusion. CASE 1 An 80-year-old man presented to the hospital for sudden onset painless right eye blindness while watching television. Initial examination was normal except right eye monocular vision loss. Vitals signs were normal. EKG showed sinus bradycardia with left bundle branch block. Blood work including Erythrocyte Sedimentation Rate, lipid panel, hemoglobin A1c and coagulation parameters were within normal limits. International Normalized Ratio (INR) was in therapeutic range 2.9. Patient had history of AF and hypertrophic obstructive cardiomyopathy. Twenty five months prior to this event patient had cardiac surgery including septal myectomy, bioprosthetic mitral valve replacement (MVR), tricuspid valve repair, MAZE procedure, left atrial appendage (LAA) clipping (45 mm Atricure Clip). Patient had been on Warfarin. He had episodes of atrial fibrillation after surgery. Initial imaging work up showed normal Computed Tomography (CT) head, CT-Angiography head and neck and Magnetic Resonance Imaging (MRI) brain. Dilated fundus examination by ophthalmology was concerning for central retinal artery occlusion. Transthoracic echocardiogram (TTE) showed no evidence of thrombus and a well seated bioprosthetic mitral valve. Transesophageal echocardiogram (TEE) showed left atrial clip with patent ostium of cauliflower shaped LAA, residual irregular large pouch that was akinetic with smoke. It had an ostium of 2 cms and depth of 2.7 cms, additionally there was smoke in the left atrium. (Figure 1A) Patient was continued on home warfarin and started on timolol with remarkable symptomatic improvement. As patient had thromboembolic event despite therapeutic anticoagulation in the context of large akinetic pouch of left atrium and failed surgical LAAC, it was presumed that embolic event was related to partial left atrial appendage closure with atrial clip. On review of TEE images lower part of the left atrial appendage was communicating with the appendage lumen. ( Figure 1A and Video 1A) Shape of the appendage suggested that Amulet LAAO device (St Jude) would be appropriate for closure of the communication between appendage and left atrium. Percutaneous femoral approach was undertaken. A 22 mm Amulet device (based on TEE measurements) was deployed the site of appendage communication. TEE and angiogram confirmed complete occlusion of the LAA with no evidence of flow on color Doppler imaging. (Figure 1B and Video 1B) A two month follow up showed device in good position. Warfarin was stopped, he was maintained on aspirin and Plavix. At 6 months follow up he has not had recurrent neurological symptoms. CASE 2 A 71 year old female patient presented to the hospital for persistent nausea, vomiting and dizziness of few days duration. Vital signs were within normal limits. Blood work was largely unremarkable except sub-therapeutic INR (1.4). EKG showed Atrial-paced rhythm. Pertinent history included severe mitral regurgitation, replacement with mechanical mitral valve with LAA suturing 17 years back. There was history of paroxysmal AF, sick sinus syndrome with pacemaker implant and three cerebrovascular accidents (CVA) in the setting of sub-therapeutic INR. Last CVA was 8 months back with near complete recovery of neurological status. Patient had persistent vertigo and due to concerns of a stroke imaging studies were undertaken. A CT head showed subacute left cerebellar hemisphere stroke while CTA head and neck was non-revealing. TTE showed no evidence of intracardiac thrombus. Patient was started on Enoxaparin to warfarin bridge. A TEE showed stiches in place at the LAA ostium, consistent with prior ligation, however ostium remained patent with evidence of flow on color doppler imaging within the LAA (Figure 2A and Video 2A). Due to recurrent strokes, evidence of patent LAA and partial compliance with anticoagulation, percutaneous LAAO device was planned. TEE (Figure) revealed anatomy suitable for a Watchman device. A 24 mm Watchman FLX device was successfully deploy using femoral approach under TEE guidance. Post implantation color doppler imaging and angiogram revealed no flow in LAA and a stable device position (Figure 2B, 2C and video 2B, 2C) . A two-month follow-up TEE showed the device was well-positioned with complete LAA occlusion and no flow in or around the device. Therapeutic INR was maintained for mechanical mitral valve. Patient has been followed for 6 months and has not had any new symptoms to suggest CVA.

It is well known that patients with AF and high risk of stroke most commonly (over 90 % or more) form cardiac thrombi in the LAA 4 . Multiple clinical risk factors are associated with higher risk of stroke and several calculators have been developed for risk stratification most notably CHA2DS2VASc, ATRIA or GARFIELD-AF 5 . First line therapy for stroke prophylaxis in these patients remain long term OAC. LAAO techniques and devices have gained popularity in the last decade and make for an excellent alternative for stroke prophylaxis in patients with non-valvular AF. ACC/AHA guidelines currently have a class IA (you say class II A later) recommendation for surgical LAAO for patients with AF and CHASDVASC >=2 undergoing cardiac surgery 3 . LAAOS III showed a 33 % reduction in risk of stroke and thromboembolism in patients with AF undergoing surgical LAAO with continued anticoagulation 6 which resulted in European guidelines upgrading the class of recommendation from class IIB to IIA 7 . Surgical closure of the LAA is achieved via multiple techniques such as stapling, closure devices, endo and epicardial sutures, or ligation loops. Successful endo and epicardial LAAC depends on the unique anatomic feature of the appendage and associated surrounding structures such as left circumflex artery. For example, if an appendage has a long neck and a small entry point, the epicardial LAAC method is typically the most suitable. On the other hand, a cauliflower-shaped appendage is more commonly associated with embolic events because of its wide neck, short length, thicker muscle layers and variable lobes 8 . Variable success rates have been reported over the years with surgical closure of left atrial appendage. Johnson et al showed left atrial appendectomy in seven patients with chronic AF with 6 out of these 7 patients with no evidence of stroke while off anticoagulation 4 . Appendage ligation had shown a success rate of 33% to 95 % in the literature 9 . LAAO stapling with creation of a stump <1 cm in size had shown to be in successful in 40-72 % of the patients 4,6 . Endocardial closure of the appendage with a suture during mitral valve surgery has been shown to have a high recanalization rate in the long term with a success rate of 23%-89 % in the literature 10 . Recent data for surgical clip device showed that the “Atricure” (nitinol clip covered with polyester mesh) has an overall success rate of >95 % with the cost being the only drawback as compared to other techniques 11 . Despite surgical occlusion of LAA, patients had thromboembolic events related to AF. In both patients there was evidence of incomplete occlusion of LAA. In one patient it was related partial occlusion from Atricure clip and in second related to failure of endocardial ligation of LA appendage at the time of mitral valve replacement. These cases have two major implications. Firstly, failure of surgical LAAO in a proportion of patients. Although post-surgical imaging to check LAAO is not routinely indicated it should be considered in patients with recurrent thrombo-embolic events even if they are minor and patients are adequately anticoagulated. Secondly LAA leaks following surgery can be closed by percutaneous technique. There is a range of implantable occlusion devices that can be used for depending on anatomy of the leak. As indicated by the TEE both patients had a large LAA. In first patient leak had a relatively narrow ostium that made use of Amulet (St Jude) more appropriate. Second patient had a large ostium despite surgical sutures, Watchman FLX (Boston Scientific) appeared to be more suitable. Complete closure was achieved in both patients with persistent good result at follow up TEE. In first patient with a bioprosthetic valve, coumadin was discontinued (due to evidence stroke despite being on therapeutic dose of warfarin after discussion with the referring cardiologist) and patient was maintained on aspirin and Plavix.

In conclusion, above cases highlight the utility of percutaneous LAAO devices in managing patients with AF who experienced failed surgical LAAO procedures. Despite the initial surgical attempts, both cases presented with persistent stroke risk due to incomplete LAAc. The successful deployment of percutaneous LAAO devices in these high-risk patients underscores their effectiveness as a secondary strategy for stroke prevention. This reinforces the importance of considering percutaneous options in cases when surgical interventions fail to provide adequate protection against thromboembolic events.

1. Colilla S, Crow A, Petkun W, Singer DE, Simon T, Liu X. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol . 2013;112:1142–1147.2. Emdin CA, Wong CX, Hsiao AJ, et al. Atrial fibrillation as risk factor for cardiovascular disease and death in women compared with men: systematic review and meta-analysis of cohort studies. BMJ . 2016;532:h7013.3. Joglar JA, Chung MK, Armbruster AL, et al. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation . 2024;149:e1–e156.4. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: our most lethal human attachment! Surgical implications. Eur J Cardiothorac Surg . 2000;17:718–722.5. van den Ham HA, Klungel OH, Singer DE, Leufkens HGM, van Staa TP. Comparative Performance of ATRIA, CHADS2, and CHA2DS2-VASc Risk Scores Predicting Stroke in Patients With Atrial Fibrillation: Results From a National Primary Care Database. J Am Coll Cardiol . 2015;66:1851–1859.6. Whitlock RP, Belley-Cote EP, Paparella D, et al. Left Atrial Appendage Occlusion during Cardiac Surgery to Prevent Stroke. N Engl J Med . 2021;384:2081–2091.7. Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J . 2022;43:561–632.8. Naksuk N, Padmanabhan D, Yogeswaran V, Asirvatham SJ. Left Atrial Appendage: Embryology, Anatomy, Physiology, Arrhythmia and Therapeutic Intervention. JACC Clin Electrophysiol . 2016;2:403–412.9. Zapolanski A, Johnson CK, Dardashti O, et al. Epicardial surgical ligation of the left atrial appendage is safe, reproducible, and effective by transesophageal echocardiographic follow-up. Innovations (Phila) . 2013;8:371–375.10. Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol . 2008;52:924–929.11. Toale C, Fitzmaurice GJ, Eaton D, Lyne J, Redmond KC. Outcomes of left atrial appendage occlusion using the AtriClip device: a systematic review. Interact Cardiovasc Thorac Surg . 2019;29:655–662. FIGURES and VIDEOS: - (with legends) Case 1 Figure 1A: - Transesophageal imaging showing a patent ostium of cauliflower shaped LAA, which was akinetic and with evidence of smoke. Dimension of the LAA as measured on the image are depicted here as well. Figure 1B Transesophageal imaging (X-plane imaging) of the LAA status post a well seated LAAO device (A 22 mm Amulet device; St Jude’s device) implantation. Video 1 A A video clip of a TEE showing patent LAA ostium with evidence of flow on color Doppler imaging Video 2B A video clip of a TEE status post LAAO device (A 22 mm Amulet device; St Jude’s device) implantation with no evidence of flow on color Doppler imaging Case 2 Figure 2A:- Transesophageal imaging showing a patent ostium of LAA with stiches in place at the LAA ostium, consistent with prior ligation Figure 2B:- TEE image showing the dimensions of the patent LAA prior to LAAO device implantation Figure 2C: - An angiogram image (Right Anterior Oblique) of LAA showing opacification with contrast injection consistent with a patent LAA. Video 2A Preimplantation color doppler imaging on TEE with evidence of flow in the LAA Video 2B Post implantation color doppler video of a TEE with no evidence of flow in LAA and a stable device position Video 2C Post implantation cine angiogram with contrast administration showing a well seated device with no evidence of flow in LAA Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License.

Authors Metrics & Citations Metrics Article Usage 245views 127downloads Citations Download citation Kirtivardhan Vashistha, Marko Novakovic, Luka Petrovic, et al. Successful implantation of left atrial appendage occlusion devices in two patients with failed surgical left atrial appendage closure. Authorea. 10 February 2025. DOI: https://doi.org/10.22541/au.173922685.53626823/v1 DOI: https://doi.org/10.22541/au.173922685.53626823/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.