Temporal Changes and Clinical Implications of Delayed Peridevice Leak Following Left Atrial Appendage Closure

OBJECTIVES The aim of this study was to assess temporal changes and clinical implications of peridevice leak (PDL) after left atrial appendage closure. BACKGROUND Endocardial left atrial appendage closure devices are alternatives to long-term oral anticoagulation (OAC) for patients with atrial fibrillation. PDL >5 mm may prohibit discontinuation of OAC. METHODS Patients included in the study had: 1) successful Watchman device implantation without immediate PDL; 2) new PDL identified at 45 to 90 days using transesophageal echocardiography; 3) eligibility for OAC; and 4) 1 follow-up transesophageal echocardiographic study for PDL surveillance. Relevant clinical and imaging data were collected by chart review. The combined primary outcome included failure to stop OAC after 45 to 90 days, transient ischemic attack or stroke, device-related thrombi, and need for PDL closure. RESULTS Relevant data were reviewed for 1,039 successful Watchman device implantations. One hundred eight patients (10.5%) met the inclusion criteria. The average PDL at 45 to 90 days was 3.2 +/- 1.6 mm. On the basis of a median PDL of 3 mm, patients were separated into #3 mm (n = 73) and >3 mm (n = 35) groups. In the #3 mm group, PDL regressed significantly (2.2 +/- 0.8 mm vs 1.6 +/- 1.4 mm; P = 0.002) after 275 +/- 125 days. In the >3 mm group, there was no significant change in PDL (4.9 +/- 1.4 mm vs 4.0 +/- 3.0 mm; P = 0.12) after 208 +/- 137 days. The primary outcome occurred more frequently (69% vs 34%; P = 0.002) in the >3 mm group. The incidence of transient ischemic attack or stroke in patients with PDL was significantly higher compared with patients without PDL, irrespective of PDL size. CONCLUSIONS New PDL detected by transesophageal echocardiography at 45 to 90 days occurred in a significant percentage of patients and was associated with worse clinical outcomes. PDL #3 mm tended to regress over time. (J Am Coll Cardiol EP 2022;8:15-25) (c) 2022 by the American College of Cardiology Foundation.