Left atrial appendage thrombus post LARIAT closure device David F. Briceno, MD,* Rajeev R. Fernando, MD,† Susan T. Laing, MD, FACC† From the *Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas, and †Division of Cardiovascular Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas.

Figure 1

KEYWORDS Left atrial appendage; LARIAT; Thrombus; Complications; Atrial fibrillation ABBREVIATIONS LAA ¼ left atrial appendage; TEE ¼ transesophageal echocardiogram (Heart Rhythm 2014;0:1–2) Address reprint requests and correspondence: David F. Briceno, Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.134, Houston, TX 77030. E-mail address: [email protected]

1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved.

Embolic stroke remains one of the most severe complications of atrial fibrillation, and anticoagulation has been a problematic therapeutic option for several years. Recently, the development of alternative methods for stroke prevention, such as left atrial appendage (LAA) percutaneous closure, has been introduced, but its long-term efficacy and safety remain unknown.

2 A 74-year-old man with permanent atrial fibrillation (CHADS2 ¼ 3) underwent LAA ligation using the LARIAT epicardial closure device (SentreHEART Inc, Redwood City, CA) (Figure 1, A–D). LAA angiography and intraprocedural transesophageal echocardiogram (TEE) demonstrated chicken-wing LAA morphology with a broad-based infundibular area in the orifice of the LAA (Figure 1, B and E). The LARIAT suture was intended to close the orifice of the LAA but when deployed slipped to a lower position, dividing the LAA into two compartments: a proximal portion continuous with the left atrium and a distal portion that was completely excluded with absent color flow. Severe continuous spontaneous echo contrast developed in the proximal compartment; thus, the patient was placed on aspirin and clopidogrel (Figure 1, F). Surveillance TEE 1 month later demonstrated severe continuous spontaneous echo contrast and thrombus in the proximal compartment (10  11 mm) (Figure 1, G and H, arrow). The patient was placed on dabigatran, and 5 months later TEE documented resolution of thrombus (Figure 1, I). Anticoagulation was discontinued, and patient has remained asymptomatic without thrombus recurrence. As previously reported, this case illustrates that LAA anatomic variations pose a challenge for successful percutaneous

Heart Rhythm, Vol 0, No 0, Month 2014 closure.1 Studies have shown that patients with chickenwing LAA morphology are less likely to have an embolic event compared with other morphologies2; however, which morphologies are the most appropriate for successful percutaneous closure is unknown . This morphologic diversity might be a risk for unsuccessful percutaneous closure with subsequent thrombus formation. We hypothesize that if the LAA is closed lower than the orifice, as illustrated in this case, a compartment suitable for blood stasis can occur. This combined with local inflammation related to LARIAT deployment and irregular LAA edges may create a substrate for thrombus formation. Further studies are needed to determine what is the most appropriate LAA anatomy to use the LARIAT device and the best strategy for stroke prevention in atrial fibrillation.

References 1. Bartus K, Han FT, Bednarek J, et al. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation. J Am Coll Cardiol 2013;62:108–118. 2. Di Biase L, Santangeli P, Anselmino M, et al. Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation? J Am Coll Cardiol 2012;60:531–538.

Left atrial appendage thrombus post LARIAT closure device.

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