Managing LAAO Complications:

Clots, Bleeds, Bruises

Vivian Ng, MD
Assistant Professor of Medicine
Columbia University Medical Center
 Disclosure Statement of Financial Interest

I, Vivian Ng DO NOT have a financial interest/arrangement

or affiliation with one or more organizations that could be perceived
as a real or apparent conflict of interest in the context of the subject
of this presentation.

Faculty disclosure information can be found on the app

 PROTECT AF

Timing Event Watchman (463)

Event <7 Days Pericardial Effusion 21 4.5%

Ischemic Stroke 5 1.1%

Device Embolization 1 0.2%

Major Bleeding 5 1.1%

Other 2 0.4%

Total 34 7.3%
Improved Outcomes with Experience

Tertiles by Enrollment Date

 PREVAIL

• 407 AF patients who were OAC eligible

 Significant decrease in procedural complications despite higher risk
patients

D Holmes. JACC 2014

 PINNACLE FLX
• Met primary efficacy endpoint
 100% LAA closure
• Met primary safety endpoint
 0.5% event rate
 0% pericardial effusions requiring
open cardiac surgery
 0% device embolization
Amulet IDE
LAA CLOTS
 Patient 1

• 87 y/o woman h/o HTN, HLD, PAD, CAD s/p MI and

CABG and PCI, HFrEF, AF
 Had large subdural hematoma after a fall.
Patient 1
 Patient 1

• Multidisciplinary discussion
• Cleared by neurology for AC
 Will re-evaluate LAA after on therapeutic AC
 Patient 2

• 81 y/o man h/o HTN, HLD, prior hemorrhagic CVA, chronic

AF
 Originally on DOAC
Planning CT
Delayed enhancement
 Patient 2

• 81 y/o man h/o HTN, HLD, prior hemorrhagic CVA, chronic

AF
 Originally on DOAC
 Patient 2

• 81 y/o man h/o HTN, HLD, prior hemorrhagic CVA, chronic

AF
 Originally on DOAC
• Transitioned to coumadin
Procedural TEE

Max diam 25mm

Min diameter 19mm

Patient 2

27mm Watchman
Device Related Thrombus
 Patient 3

• 81 y/o man h/o HTN, AF on DOAC, previously presented with

HA and diplopia and found to have a pontine hemorrhage and
subdural hematoma. Also found to have Acomm aneurysm
s/p clipping
 Long term AC was contraindicated
 Cleared by neurology and neurosurgery for ASA monotherapy
45 DAYS BASELINE
45D Imaging
Location of Thrombus in NVAF

Annals of Thoracic Surgery (1996)

 Patient 4

• 77 y/o man h/o COPD, HLD, DM2, HFpEF, s/p PPM, AF not
on AC 2/2 recurrent GIB
 45 Day Imaging

• Maintained on ASA 81mg daily post procedure

• Was not cleared for AC so was maintained on ASA81mg daily
 6 Month Imaging

• Had GIB requiring discontinuation of ASA

Device Related Thrombus

T Simard. JACC 2021

Device Related Thrombus

T Simard. JACC 2021

Device Related Thrombus Predictors

Saw. JACC Cardio Interv 2019

Pericardial Effusion
Patient 5

Max Diameter 19mm

Depth 16mm
 Patient 5

27mm Watchman
Patient 5
Patient 5
 Patient 5

Post tap – 200cc fluid drained

 Patient 5

• Drain left in place

 No significant drainage and no re-accumulation of fluid. Drain
removed
• Patient slowly loaded with coumadin prior to discharge
Patient 6
Patient 6
Patient 6
Patient 6
 Patient 6

• Despite successful device implantation, patient continued to

have significant output through pericardial drain (600cc)
• Taken to OR
 1 stitch placed at apex of LAA
Pericardial Effusion

Schmidt J Cardiovasc Electrophys 2018

Pericardial Effusions and Outcomes

Price; Circ: Cardiovasc Interventions 2022

Predictors of Pericardial Effusion

Price; Circ: Cardiovasc Interventions 2022

 Conclusion

• With improvements in technique and devices, complications

related to LAAO are now rare
• Device related thrombus and pericardial effusions are
associated with worse outcomes
 Additional studies are needed to determine predictors of procedural
complications