Concomitant Mechanical Aspiration and Appendage Closure for Recalcitrant Left Atrial Appendage Thrombi

Importance It is well appreciated that a small yet high-risk subset of patients with atrial fibrillation (AF) develops persistent left atrial appendage (LAA) thrombus despite optimal oral anticoagulation (OAC). In patients with either a heightened risk of bleeding precluding enhanced doses of OAC to dissolve the thrombus, or thromboembolism despite optimal OAC, there are limited nonsurgical options. Objectives To introduce a novel management strategy for resistant LAA thrombus: percutaneous mechanical thrombus aspiration with cerebral protection, followed by LAA closure (LAAC). Design, Setting, and Participants This descriptive, prospective case series of 9 consecutive patients with persistent LAA thrombus was conducted between August 2023 and July 2024 at Mount Sinai Hospital. After placing a cerebral protection device (CPD) when anatomically feasible, balloon atrial septostomy was performed as needed to enhance transeptal access. A 20F mechanical aspiration device with a 15-mm funneled ostium was advanced to the LAA ostium, and manual vacuum aspiration of thrombus was performed. After ultrasonic confirmation of thrombectomy, an LAAC device was implanted. Main Outcomes and Measures Patient demographic, clinical, and intervention data were collected. Results Nine patients (mean [SD] age, 74.7 [13.6] years; median [IQR] CHA 2 DS 2 -VASc [congestive heart failure, hypertension, age 75 years or older, diabetes, stroke, vascular disease, age 65-74 years, and female sex] score, 5 [2-8] points) presented with LAA thrombus in the context of contraindications to OAC. CPD was placed in 8 patients; one had prohibitive aortic arch anatomy. Given the patient’s high thrombotic burden and limited alternatives, the decision was to proceed without CPD, based on a risk-benefit assessment. Balloon atrial septostomy was performed in 8 patients. In 8 patients, complete thrombus removal was achieved, followed by successful LAAC device placement. One patient had a small residual distal thrombus, presumably organized, which was strongly adherent to the LAA myocardium; this was compressed against the wall with the LAAC device. One patient had a small thrombus fragment recovered from the CPD postprocedure. During both the index procedure and during follow-up (range, 4-15 months), there were no complications. Conclusions and Relevance This cases series found that temporary cerebral protection, percutaneous mechanical vacuum thrombectomy, and mechanical LAA closure was feasible in patients with persistent LAA thrombus despite optimal OAC. Larger studies will be needed to fully assess the efficacy and safety of this approach.