A novel pragmatic paradigm to evaluate device endothelialization: lessons learned from a dual-watchman case

A 78-year-old man with permanent atrial fibrillation (AF) for 30 years (CHA2DS2-VASc score of 5; HAS-BLED score of 3) was admitted with recurrent stroke. Transesophageal echocardiogram and cardiac computed tomography angiography (CCTA) showed a double-lobed left atrial appendage (LAA). A 24 mm Watchman device was used to completely close the superior lobe, and a 27 mm Watchman device was used to close the inferior lobe. The LAA was almost completely occluded with a small (2 mm) residual leak around the inferior device. CCTA was performed at 6-month (Panel A) and 1-year follow-up (Panel F), and the size of the leak was still within an acceptable range (2.2 mm) without device dislocation, thrombosis, or pericardial effusion (Panels D and I). A novel pragmatic paradigm (Crealife, Beijing, China) was used to evaluate the device endothelialization from the same individual. At the 6-month follow-up (Panels B–E), the endothelialization proceeded more rapidly in the device without leakage than the device with leakage (98.7 vs. 85.2%). Moreover, the endothelialization improved over time [99.1 vs. 98.7% for the superior device (Panels B, C, G, and H) and 94.9 vs. 85.2% for the inferior device (Panels E and J)]. These results implied that the endothelialization proceeds more rapidly without leakage, and the endothelialization was improved over time.