Watchman Left Atrial Appendage Closure After Incomplete AtriClip Closure

Abstract

The AtriClip device (AtriCure, Mason, OH) has emerged as a tool to occlude the left atrial appendage (LAA) concomitantly during cardiac surgery or as a stand-alone procedure. This therapy has previously been shown to have a high success rate with regards to safe, complete, and durable LAA occlusion. However, residual stump formation can occur after AtriClip use.1Caliskan E. Eberhard M. Falk V. Alkadhi H. Emmert M.Y. Incidence and characteristics of left atrial appendage stumps after device-enabled epicardial closure.Interact Cardiovasc Thorac Surg. 2019; 29: 663-669Crossref PubMed Scopus (9) Google Scholar A previous study demonstrated feasibility of Watchman device (Boston Scientific, Natick, Massachusetts) use in incomplete surgical ligation but excluded AtriClip patients.2Ellis C.R. Metawee M. Piana R.N. Bennett J.M. Pretorius M. Deegan R.J. Feasibility of left atrial appendage device closure following chronically failed surgical ligation.Heart Rhythm. 2019; 16: 12-17Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar Currently, there are no published reports of Watchman device use for a residual appendage stump after AtriClip. A 75-year-old male with a past medical history of coronary artery bypass graft surgery, aortic stenosis status post aortic valve replacement, and surgical ligation of his LAA with an AtriClip ligation clip 1 year prior was referred to our center for consultation regarding discontinuation of his oral anticoagulation. He had a past medical history of paroxysmal atrial fibrillation on anticoagulation with Xarelto and later warfarin. The patient experienced fluctuating international normalized ratios with associated severe epistaxis on warfarin. His CHADS-VASc score was 6. A transesophageal echocardiogram was performed to evaluate the status of the surgical ligation and assess for complete closure of the appendage. This demonstrated the presence of a residual nonoccluded stump of the appendage with a maximum ostium of 1.1 cm and depth of 1.3 cm (Figure 1a). Atrial appendage angiography confirmed the residual stump (Figure 1b, Supplemental Video 1), and a 21 mm Watchman device was successfully deployed. In summary, surgical AtriClip device use may provide better long-term closure of the LAA than suture ligation or stapled excision, but residual appendage stumps can still occur. Appropriate clinical anticoagulation management in the presence of a residual lobe or stump is unknown. The use of a Watchman device to occlude the residual stump is feasible in selected LAA anatomies. The long-term outcomes of this strategy remain to be assessed. Consent was obtained from the patient for publication of this report and any accompanying images.