Residual Leaks Following Percutaneous LAAO and Outcomes

Dec 18, 2023
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Authors:
Samaras A, Papazoglou AS, Balomenakis C, et al.
Citation:
Residual Leaks Following Percutaneous Left Atrial Appendage Occlusion and Outcomes: A Meta-Analysis. Eur Heart J 2023;Dec 13:[Epub ahead of print].
Summary By:
Geoffrey D. Barnes, MD, MSc, FACC

Quick Takes

  • Peri-device leak after LAAO placement is common and associated with an increased risk of thromboembolism in patients with AF.
  • Even very small leaks (>0 mm to 5 mm) are associated with an increased thromboembolism risk when detected on TEE.
  • Personalized approaches for pre-procedure planning, peri-procedural imaging, and post-procedure antithrombotic therapy are critical after LAAO placement.

Study Questions:

What is the impact of residual leaks after left atrial appendage occlusion (LAAO) in patients with atrial fibrillation (AF)?

Methods:

The authors performed a literature search through February 2023 for observational and randomized studies examining residual leak after LAAO. Residual leak included peri-device leaks seen on transesophageal echocardiogram (TEE) or computed tomography (CT) as well as left atrial appendage (LAA) patency seen on CT. Rates of clinical events were collected and analyzed using a random-effects meta-analytic method.

Results:

This meta-analysis included 48 eligible studies (44 nonrandomized, 4 randomized) including 61,666 patients with AF who underwent LAAO. Peri-device leak seen on TEE was present in 26.1% of patients. CT-based LAA patency and peri-device leak were present in 54.9% and 57.3% of patients, respectively. TEE-based peri-device leak was associated with a higher risk of thromboembolism (odds ratio [OR], 2.04; 95% confidence interval [CI], 1.52-2.74) compared to no peri-device leak. There was a graded association between peri-device leak size and risk of thromboembolism. Neither LAA patency nor peri-device leak by CT was associated with thromboembolism.

Conclusions:

The authors concluded that peri-device leak detected by TEE was associated with thromboembolism risk. However, residual leak detected by CT was more common than TEE-based peri-device leak, but not associated with thromboembolism risk.

Perspective:

Complete occlusion of the LAA is critical for preventing thromboembolism risk in patients with AF. Unfortunately, residual leak is common, occurring in up to one-in-four patients by TEE. These patients experience higher rates of thromboembolism. In fact, the larger the lead, the higher the risk of thromboembolism (OR ranged from 1.82 to 4.44 as leak size increased). Even small leaks (anything >0 mm) are associated with an increased risk of thromboembolism. As such, this meta-analysis calls into question the peri-device leak size threshold for de-escalating antithrombotic therapy. It may be prudent to continue anticoagulation or dual antiplatelet therapy even when peri-device leak <3 mm is present early after LAAO placement if the risk of bleeding is not markedly elevated. It also highlights the importance of meticulous evaluation for any leak after LAAO placement. Of equal importance is the finding that CT scan detection of leak/patency is even more common than detection by TEE but not associated with an increased risk of thromboembolism. Further research is needed to explore what role CT plays in the follow-up of patients after LAAO placement.

Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging

Keywords: Atrial Appendage, Thromboembolism


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