Ramdat Misier Nawin L, Kharbanda Rohit K, van Schaagen Frank R N, de Groot Natasja M S
Department of Cardiology, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
Department of Cardiothoracic Surgery, Erasmus Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, the Netherlands.
Eur Heart J Case Rep. 2023 Jan 3;7(1):ytac494. doi: 10.1093/ehjcr/ytac494. eCollection 2023 Jan.
Although peri-device leakage is frequently observed after left atrial appendage occlusion (LAAO), there is no consensus on the optimal management strategy. It is unknown whether additional plugging should be preferred over surgical exclusion of the LAA, as experience with additional plugging is limited.
In this case report, we demonstrate the clinical implications of additional plugging and surgical exclusion in a 65-year-old male patient with peri-device leakage and recurrent thromboembolic events. After the recurrence of paroxysmal atrial fibrillation (AF) and a transient ischaemic attack despite adequate anticoagulation, the patient was opted for re-do pulmonary vein isolation and LAAO with a Watchman device. Due to multiple ischaemic strokes and recurrent AF in combination with significant peri-device leakage, additional plugging with a second device was performed. Post-procedurally, the patient had another ischaemic stroke and persisting peri-device leakage was observed during follow-up. Due to progressive symptoms of AF and patient's preference to discontinue DOAC, he underwent a Cox MAZE IV procedure, including amputation of the LAA with both devices. Within six months after surgery, the patient experienced two more ischaemic events. In the following two years, the patient remained free of any cerebrovascular accidents or recurrence of AF.
Additional plugging of peri-device leakage is not always successful in stroke prevention. In combination with recurrent AF, progressive symptoms, contraindication for oral anticoagulation, and patient's preference, surgical LAA exclusion could be preferred over additional plugging.
尽管在左心耳封堵术（LAAO）后经常观察到装置周围渗漏，但对于最佳管理策略尚无共识。由于额外封堵的经验有限，额外封堵是否应优于手术切除左心耳尚不清楚。
在本病例报告中，我们展示了在一名65岁男性患者中，额外封堵和手术切除对装置周围渗漏和复发性血栓栓塞事件的临床意义。尽管进行了充分的抗凝治疗，但患者仍出现阵发性心房颤动（AF）复发和短暂性脑缺血发作，因此选择再次进行肺静脉隔离术和使用Watchman装置进行LAAO。由于多次缺血性中风、复发性AF以及严重的装置周围渗漏相结合，遂使用第二个装置进行额外封堵。术后，患者又发生了一次缺血性中风，随访期间观察到装置周围渗漏持续存在。由于AF症状逐渐加重且患者倾向于停用直接口服抗凝剂（DOAC），他接受了Cox迷宫IV手术，包括切除带有两个装置的左心耳。术后六个月内，患者又经历了两次缺血性事件。在接下来的两年里，患者未再发生任何脑血管意外或AF复发。
额外封堵装置周围渗漏在预防中风方面并不总是成功的。结合复发性AF、症状逐渐加重、口服抗凝的禁忌症以及患者的偏好，手术切除左心耳可能优于额外封堵。
