Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion

Trevor Simard; Richard G Jung; Kyle Lehenbauer; Kerstin Piayda; Radoslaw Pracoń; Gregory G Jackson; Eduardo Flores-Umanzor; Laurent Faroux; Kasper Korsholm; Julian K R Chun; Shaojie Chen; Moniek Maarse; Kristi Montrella; Zakeih Chaker; Jocelyn N Spoon; Luigi E Pastormerlo; Felix Meincke; Abhishek C Sawant; Carmen M Moldovan; Mohammed Qintar; Mehmet K Aktas; Luca Branca; Andrea Radinovic; Pradhum Ram; Rayan S El-Zein; Thomas Flautt; Wern Yew Ding; Bassel Sayegh; Tomás Benito-González; Oh-Hyun Lee; Solomon O Badejoko; Christina Paitazoglou; Nabeela Karim; Ahmed M Zaghloul; Himanshu Agrawal; Rachel M Kaplan; Oluseun Alli; Aamir Ahmed; Hussam S Suradi; Bradley P Knight; Venkata M Alla; Sidakpal S Panaich; Tom Wong; Martin W Bergmann; Rashaad Chothia; Jung-Sun Kim; Armando Pérez de Prado; Raveen Bazaz; Dhiraj Gupta; Miguel Valderrabano; Carlos E Sanchez; Mikhael F El Chami; Patrizio Mazzone; Marianna Adamo; Fred Ling; Dee Dee Wang; William O'Neill; Wojtek Wojakowski; Ashish Pershad; Sergio Berti; Daniel Spoon; Akram Kawsara; George Jabbour; Lucas V A Boersma; Boris Schmidt; Jens Erik Nielsen-Kudsk; Josep Rodés-Cabau; Xavier Freixa; Christopher R Ellis; Laurent Fauchier; Marcin Demkow; Horst Sievert; Michael L Main; Benjamin Hibbert; David R Holmes Jr; Mohamad Alkhouli

doi:10.1016/j.jacc.2021.04.098

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Predictors of Device-Related Thrombus Following Percutaneous Left Atrial Appendage Occlusion

Authors: Trevor Simard ; Richard G Jung ; Kyle Lehenbauer ; Kerstin Piayda ; Radoslaw Pracoń ; Gregory G Jackson ; Eduardo Flores-Umanzor ; Laurent Faroux ; Kasper Korsholm ; Julian K R Chun ; Shaojie Chen ; Moniek Maarse ; Kristi Montrella ; Zakeih Chaker ; Jocelyn N Spoon ; Luigi E Pastormerlo ; Felix Meincke ; Abhishek C Sawant ; Carmen M Moldovan ; Mohammed Qintar ; Mehmet K Aktas ; Luca Branca ; Andrea Radinovic ; Pradhum Ram ; Rayan S El-Zein ; Thomas Flautt ; Wern Yew Ding ; Bassel Sayegh ; Tomás Benito-González ; Oh-Hyun Lee ; Solomon O Badejoko ; Christina Paitazoglou ; Nabeela Karim ; Ahmed M Zaghloul ; Himanshu Agrawal ; Rachel M Kaplan ; Oluseun Alli ; Aamir Ahmed ; Hussam S Suradi ; Bradley P Knight ; Venkata M Alla ; Sidakpal S Panaich ; Tom Wong ; Martin W Bergmann ; Rashaad Chothia ; Jung-Sun Kim ; Armando Pérez de Prado ; Raveen Bazaz ; Dhiraj Gupta ; Miguel Valderrabano ; Carlos E Sanchez ; Mikhael F El Chami ; Patrizio Mazzone ; Marianna Adamo ; Fred Ling ; Dee Dee Wang ; William O'Neill ; Wojtek Wojakowski ; Ashish Pershad ; Sergio Berti ; Daniel Spoon ; Akram Kawsara ; George Jabbour ; Lucas V A Boersma ; Boris Schmidt ; Jens Erik Nielsen-Kudsk ; Josep Rodés-Cabau ; Xavier Freixa ; Christopher R Ellis ; Laurent Fauchier ; Marcin Demkow ; Horst Sievert ; Michael L Main ; Benjamin Hibbert ; David R Holmes Jr ; Mohamad Alkhouli

Citation: JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, Vol.78(4) : 297-313, 2021-07

Journal Title: JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY

ISSN: 0735-1097

Issue Date: 2021-07

MeSH: Aged ; Atrial Appendage / diagnostic imaging ; Atrial Appendage / surgery* ; Atrial Fibrillation / surgery* ; Cardiac Catheterization / adverse effects* ; Echocardiography, Transesophageal ; Europe / epidemiology ; Female ; Follow-Up Studies ; Heart Diseases / diagnosis ; Heart Diseases / epidemiology ; Heart Diseases / etiology ; Humans ; Incidence ; Male ; Postoperative Complications / diagnosis ; Postoperative Complications / epidemiology ; Postoperative Complications / etiology* ; Registries* ; Risk Factors ; Septal Occluder Device / adverse effects* ; Survival Rate / trends ; Thrombosis / diagnosis ; Thrombosis / epidemiology ; Thrombosis / etiology* ; Time Factors ; Treatment Outcome

Keywords: ACP ; Amplatzer cardiac plug ; Amulet ; DRT ; LAAO ; Watchman ; Watchman FLX ; device-related thrombus ; left atrial appendage occlusion

Abstract: Background: Device-related thrombus (DRT) has been considered an Achilles' heel of left atrial appendage occlusion (LAAO). However, data on DRT prediction remain limited.

Objectives: This study constructed a DRT registry via a multicenter collaboration aimed to assess outcomes and predictors of DRT.

Methods: Thirty-seven international centers contributed LAAO cases with and without DRT (device-matched and temporally related to the DRT cases). This study described the management patterns and mid-term outcomes of DRT and assessed patient and procedural predictors of DRT.

Results: A total of 711 patients (237 with and 474 without DRT) were included. Follow-up duration was similar in the DRT and no-DRT groups, median 1.8 years (interquartile range: 0.9-3.0 years) versus 1.6 years (interquartile range: 1.0-2.9 years), respectively (P = 0.76). DRTs were detected between days 0 to 45, 45 to 180, 180 to 365, and >365 in 24.9%, 38.8%, 16.0%, and 20.3% of patients. DRT presence was associated with a higher risk of the composite endpoint of death, ischemic stroke, or systemic embolization (HR: 2.37; 95% CI, 1.58-3.56; P < 0.001) driven by ischemic stroke (HR: 3.49; 95% CI: 1.35-9.00; P = 0.01). At last known follow-up, 25.3% of patients had DRT. Discharge medications after LAAO did not have an impact on DRT. Multivariable analysis identified 5 DRT risk factors: hypercoagulability disorder (odds ratio [OR]: 17.50; 95% CI: 3.39-90.45), pericardial effusion (OR: 13.45; 95% CI: 1.46-123.52), renal insufficiency (OR: 4.02; 95% CI: 1.22-13.25), implantation depth >10 mm from the pulmonary vein limbus (OR: 2.41; 95% CI: 1.57-3.69), and non-paroxysmal atrial fibrillation (OR: 1.90; 95% CI: 1.22-2.97). Following conversion to risk factor points, patients with ≥2 risk points for DRT had a 2.1-fold increased risk of DRT compared with those without any risk factors.

Conclusions: DRT after LAAO is associated with ischemic events. Patient- and procedure-specific factors are associated with the risk of DRT and may aid in risk stratification of patients referred for LAAO.