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Device-Related Thrombus After LAA Occlusion
Study Questions:
What are the incidence, characteristics, and clinical impact of device-related thrombus (DRT) following left atrial appendage occlusion (LAAO) with the AMPLATZER Amulet device?
Methods:
The investigators analyzed 1,088 patients enrolled in a multicenter prospective study and followed for 1 year. All events were adjudicated by an independent committee, including the presence of DRT. Patients with DRT were reviewed for suboptimal device implantation and characterization of DRT formation. Multiple Cox regression was performed to identify predictors of DRT formation.
Results:
Device implantation was successful in 1,078 patients (99%), with 1-year follow-up completed in 96.3% of patients. A total of 18 DRTs occurred in 17 patients (1.7%/year), as a second DRT developed following complete resolution of an initial DRT in one patient. The left upper pulmonary vein (PV) ridge was not covered by the Amulet disc in 82% of DRT patients, indicating suboptimal implantation, with most thrombus developing in the untrabeculated area of the LAA ostium between the PV ridge and the upper edge of the disc. Three (18%) DRT patients had an ischemic stroke, all within 3 months of DRT diagnosis. Patients with a DRT were at a greater risk for ischemic stroke or transient ischemic attack (TIA) compared to non-DRT patients (hazard ratio [HR], 5.27; 95% confidence interval [CI], 1.58-17.55; p = 0.007). Larger LAA orifice width was a predictor of DRT formation (HR, 1.09; 95% CI, 1.00-1.19; p = 0.04).
Conclusions:
The authors concluded that following LAAO with the AMPLATZER Amulet device, DRT was observed infrequently.
Perspective:
This observational study reports that while overall DRT was infrequent, the presence of a DRT increases the risk of clinical events as compared to patients without DRT with an increased rate of ischemic stroke and cardiovascular mortality. Furthermore, most DRTs developed near the superior edge of the Amulet disc close to the PV ridge, with an uncovered PV ridge as a potential contributing factor. Of note, not all patients received a transesophageal echocardiogram to evaluate for presence of DRT at the time of ischemic stroke or TIA, which may have led to under-reporting of the DRT rate. Additional studies are needed to define strategies to prevent DRT including use of antiplatelet/antithrombotic therapies post-procedure and optimized device implantation.
Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Echocardiography/Ultrasound
Keywords: Arrhythmias, Cardiac, Atrial Appendage, Brain Ischemia, Coronary Occlusion, Echocardiography, Transesophageal, Incidence, Ischemic Attack, Transient, Pulmonary Veins, Secondary Prevention, Stroke, Thrombosis, Vascular Diseases
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