PO-03-195 AMULET IMPLANTATION AFTER FAILED WATCHMAN: A RETROSPECTIVE REVIEW WITH COMMENTARY ON IMPLICATIONS OF LAA ANATOMY

Abstract

Watchman and Amulet are both approved and effective left atrial appendage closure (LAAC) devices, each utilizing different design and characteristics to prevent AF-related strokes. Failed LAAC is a complication often seen with complex LAA anatomy particularly with inexperienced implanters. A patient may have LAA measurements that do not screenfail but are still unable to securely or completely occlude the LAA. Watchman received FDA approval in 2015, Amulet in 2021. Thus, Watchman has become the more widely used device in the United States. At a single center with 7 implanters, we have found that Amulet is often successfully implanted after failed Watchman. We present our experience as well as observations on anatomical characteristics amenable to Amulet implantation after failed Watchman. We present our experience in Amulet implantation after failed watchman. At a single center with experienced implanters, 27 patients failed Watchman implant were then sent for LAAC with Amulet. A failed Watchman was defined as a patient who did not screenfail but could not meet deploy with stability, significant leaks, or uncovered trabeculations or lobes. Of the 27 patients who failed Watchman, 26 (96%) were successfully implanted with Amulet. Upon retrospective review of the LAA that failed both Amulet and Watchman should have failed preop screening and not attempted; the short depth to the top of the trabeculations at the deepest point did not provide adequate room for either device to deploy. The reasons for Watchman failure were all anatomical in nature and can be subdivided into four basic categories each with their own mechanism of failure: 1. Shallow / Insufficent depth 2. Appropriate depth with intervening trabeculations 3. Bilobed appendages 4. Wide, with posterior sloping trabeculations above implant plane No perioperative complications or postoperative dislodgment or leak were observed in these cases. These findings indicate that for many, failed Watchman implant does not mean that LAAO is futile. There are at least four general categories of LAA anatomy that are amenable to Amulet implantation when Watchman cannot be succesfully or safely deployed. The design of Amulet tends to allow successful implanted in these four challenging anatomical variations unable to be closed by Watchman, even for providers more experienced with Watchman. These results suggest that preoperative imaging may be helpful to preemptively anticipate which device may be more suitable for closure.