CE-454611-3 HIGH RISK LEFT ATRIAL APPENDAGE CLOSURE IN PATIENTS WITH A PERSISTENT LEFT ATRIAL APPENDAGE THROMBUS

Abstract

Left atrial appendage closure (LAAC) in patients with a persistent left atrial appendage (LAA) thrombus is controversial. To introduce a novel utilization of a cerebral protection device during high risk LAAC in patients with a persistent LAA thrombus. N/A Case 1: A 50-year-old male with persistent atrial fibrillation (AF) and remote left ventricular thrombus with a thromboembolic stroke presented for an AF ablation. He was found to have a persistent LAA thrombus on multiple pre-operative CT scans despite changing anticoagulation regimen with rivaroxaban and subsequently warfarin with aspirin. The ablation was aborted. He underwent LAAC (Watchman FLXTM, Boston Scientific) with the cerebral protection device (SentinelTM, Boston Scientific) in place. The transesophageal echocardiogram during the procedure confirmed persistent LAA thrombus (Figure A). At the end of the procedure, embolic debris were identified within the SentinelTM (Figure B). The patient was discharged with no neurologic symptoms at the time of discharge and remains neurologically intact 10 months post procedure. Case 2: A 68-year-old female with persistent AF on a therapeutic warfarin dose presented for an AF ablation. She was noted to have a LAA thrombus on the pre-operative CT scan and the procedure was aborted. Her anticoagulation was switched to apixaban. A repeat CT revealed no change in LAA thrombus, and more aggressive anticoagulation was limited by hematuria. Therefore, she underwent LAAC with the SentinelTM for cerebral protection. Of note, the intraoperative TEE revealed filamentous LAA thrombus (Figure C). The patient tolerated the procedure well and was safely discharged the following day. She had no post-operative changes in her neurologic status and the Watchman FLXTM on routine TEE remained in stable position (Figure D). The presence of LAA thrombus is a common concern in patients referred for LAAC. While classically avoided, this case series suggests that a thrombus being present is not a contraindication for LAAC. A cerebral protection device may be used to prevent cardioembolic stroke in selected patients with a persistent LAA thrombus. Further studies are needed to determine the safety and efficacy of this strategy.