Feasibility of left atrial appendage device closure following chronically failed surgical ligation

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Incomplete surgical left atrial appendage occlusion (S-LAAO) with a narrow neck has been shown to predict an increased rate of embolic stroke. Patients with a previously attempted S-LAAO were systematically excluded from all clinical trials of LAA closure devices. The purpose of this study was to evaluate the feasibility of Watchman LAA device closure for patients referred with chronically incomplete S-LAAO. A prospective single-arm feasibility cohort evaluated only subjects undergoing Watchman LAA closure following incomplete S-LAAO. Patients referred and implanted were followed in the Vanderbilt LAA Registry. Preprocedure computed tomographic angiography and transesophageal echocardiography (TEE) were performed to evaluate suitability for closure, with 45-day follow-up TEE postimplant. All attempted LAA closures after incomplete S-LAAO were successful (n = 6). Mean age was 76.3 ± 7 years. Mean CHADS2Vasc score was 3.8 ± 0.8, and HAS-BLED score was 3.5 ± 0.5. At 45-day follow up, all subjects had complete device seal with no thrombus on device and had transitioned to clopidogrel plus aspirin. Three subjects had narrow ostial necks with a maximum diameter ≤9mm. In all cases, the 4.7-mm Watchman access sheath was able to cross the ostial stricture. Mean occluder size implanted was 28 ± 4 mm. Mean LAA dimension by TEE in the 45° and 135° views for depth was 31 mm and ostial diameter was 11 × 16 mm, below the minimum Watchman indication for use of 17 mm. No major intraoperative complications occurred. Watchman LAA closure seems to be feasible in patients with chronically incomplete S-LAAO, including subjects with a narrow neck ≤9 mm in width.