Abstract
Background: Percutaneous left atrial appendage (LAA) closure is contraindicated in patients with LAA thrombus. It can be challenging to distinguish slow flow (sludge) from organized thrombus on echocardiography. Recent case reports have shown that isoproterenol infusion can distinguish LAA sludge from thrombus, however, no mid/long-term outcome data exists. Methods: A retrospective study was conducted on 32 patients who underwent Watchman™ implantation at Piedmont Atlanta Hospital during 2021. Patients were divided into two groups, 1) clear LAA [Standard] and 2) suspected LAA thrombus versus sludge [Sludge]. The Sludge group underwent isoproterenol infusion prior to implantation of Watchman™ device. Data gathered included demographics, medical history, procedural data, and 6-months outcomes defined as TIA, CVA, or device related thrombus. Chi-square and T-test was used for statistical analysis. Results: The cohort had 8 patients (25%) in Sludge group with remaining 24 patients (75%) in Standard group. The Sludge group was younger at 73.5 years compared to 77.0 years for Standard group [p=0.02]. Other baseline characteristics including sex, comorbidities, and history of prior TIA/CVA were similar among both groups. Median CHA 2 DS 2 VASc Score was 5.0 for Standard and 4.5 for Sludge group [p= 0.21]. All patients in Sludge group had successful clearance with isoproterenol; median dose required was 6 mcg. LAA dimensions were similar with the median device size being 27 mm for both groups [p= 0.343]. At 45-day follow-up, one patient in Standard group had device related thrombus; it resolved on subsequent scan. At 6-months, one patient in Sludge group had experienced TIA; no patients underwent CVA. Conclusions: LAA thrombus is an absolute contraindication for percutaneous LAA device implantation, however, it can be difficult to differentiate between sludge and organized thrombus. This study demonstrates that intraprocedural isoproterenol infusion can be used to clear LAA sludge by improving LV contractility. No significant difference in mid-term outcomes was observed in our study groups, suggesting that isoproterenol assisted differentiation of LAA sludge from thrombus may allow successful LAA closure in cases that are deemed to have LAA sludge.
Published Version
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