ISCHEMIC STROKE IN A PATIENT WITH A WATCHMAN DEVICE: WHAT'S THE LEAK GOT TO DO WITH IT?

Abstract

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: The prevention of stroke is a significant challenge in patients with atrial fibrillation. The advent of the WATCHMAN device has provided a much needed alternative for patients in whom long term anticoagulation is not appropriate. However, the efficacy and safety of this device has not been well studied. CASE PRESENTATION: 82-year-old man presented with visual disturbances and unsteady gait. He underwent MRI of the brain which revealed an acute right occipital infarction which appeared embolic in origin. He had a history of chronic atrial fibrillation requiring anticoagulation and had undergone successful left atrial appendage (LAA) closure via placement of WATCHMAN device 6 months prior. Anticoagulation was discontinued post-implant as per protocol. In the setting of an acute embolic stroke with a WATCHMAN device in place, further workup was advised. To ascertain the source of the embolic stroke, further imaging was undertaken. CT angiogram of the head, neck, and chest did not show any extracardiac source of thromboembolism. Transesophageal echocardiogram (TEE) was negative for intracardiac thrombus, however, a 5 mm residual leak was noted at the edge of the WATCHMAN implant. In the absence of any other source, the patient’s stroke was presumed to be cardioembolic and likely originating in the LAA, given the leak around the implant. Dual antiplatelet therapy was resumed with the intention of initiating anticoagulation once he recovered from his acute stroke. DISCUSSION: Left atrial appendage occlusion (LAAO) is a novel procedure that is becoming more commonplace. It is indicated for patients with atrial fibrillation at high risk for cardioembolic stroke but also have contraindications to anticoagulation. However, LAAO devices are not without complications. Currently, the WATCHMAN implant is the only FDA approved LAAO device on the market. Trial data suggests a higher risk of ischemic strokes in patients who have undergone WATCHMAN implant. However, there is limited awareness and understanding of this complication in clinical practice. Up to 14% of patients can develop device-related thrombi (DRT) and up to 3.7% of patients can have device embolization. Because the incidence of DRT is rare, it is difficult to identify risk factors that may predict individuals at risk of developing them. Current guidelines recommend screening TEE at 45 days, however, most DRT are detected after more than 45 days. This implies that current recommendations may be inadequate for preventing DRT in at-risk patients. CONCLUSIONS: As LAA closure devices become more prevalent, there is a growing need for re-assessing their efficacy and establishing guidelines for assessing device function. Furthermore, identification of sub-groups that are at higher risk for delayed complications will help with patient selection in the future. Reference #1: Moussa Pacha H, Al-Khadra Y, Soud M, Darmoch F, Moussa Pacha A, Alraies MC. Percutaneous devices for left atrial appendage occlusion: A contemporary review. World J Cardiol. 2019;11(2):57-70. Reference #2: Dukkipati S.R., Kar S., Holmes D.R., et al: Device-related thrombus after left atrial appendage closure: incidence, predictors, and outcomes. Circulation 2018; 138: pp. 874-885. Reference #3: Alkhouli M., Busu T., Shah K., Osman M., Alqahtani F., and Raybuck B.: Incidence and clinical impact of device-related thrombus following percutaneous left atrial appendage occlusion: a meta-analysis. J Am Coll Cardiol EP 2018; 4: pp. 1629-1637. DISCLOSURES: No relevant relationships by basma al-bast, source=Web Response No relevant relationships by Mirza Ali, source=Web Response No relevant relationships by Abdisamad Ibrahim, source=Web Response No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response