Cardioembolic Stroke in Patient With Transcatheter Occluded Left Atrial Appendage

J INVASIVE CARDIOL 2018;30(1):E7-E8.

Key words: left atrial appendage, embolism, stroke

A 73-year-old man with history of coronary artery bypass graft and paroxysmal atrial fibrillation (AF), treated with warfarin, was admitted to our hospital for severe microcytic anemia (hemoglobin, 7.5 g/dL). A low mitotic-index gastrointestinal stromal tumor was discovered and treated conservatively. Contemporary indication was given to elective percutaneous occlusion of the left atrial appendage (LAA) performed with implantation of an Amplatzer Amulet 28 mm (AGA, St. Jude Medical) without complications. Due to the high hemorrhagic risk, only single-antiplatelet treatment was prescribed at discharge for 3 months. Six months later, the patient was admitted to the neurology department for a cardioembolic stroke. The cerebral nuclear magnetic resonance described small acute ischemic areas on the territory of the left mid-cerebral artery. Vascular ultrasonography didn’t reveal any certain cardioembolic source, whereas transesophageal echocardiographic (TEE) study showed a leak in the cranial edge of the device for LAA occlusion, confirmed on color and spectral Doppler (Figure 1) and morphologically detailed on three-dimensional examination (Figure 2).

The presence of a leak around the LAA closure device, implanted for stroke prevention in AF patients who are ineligible for antithrombotic treatment, has been reported as a relatively common finding at both early and delayed follow-up.¹ The clinical effect of residual leak is not well defined, but is considered non-significant, particularly if small (peridevice color flow jet width <5 mm by TEE).² Our case shows that the persistence of LAA patency after percutaneous occlusion in an AF patient could be a direct cause of embolic stroke, in the absence of any other definite cardioembolic source. The application of three-dimensional TEE allows a precise definition of the peridevice leakage (Figure 2).

References

1.    Jaguszewski M, Manes C, Puippe G, et al. Cardiac CT and echocardiographic evaluation of peri-device flow after percutaneous left atrial appendage closure using the Amplatzer cardiac plug device. Catheter Cardiovasc Interv. 2015;85:306-312.

2.    Viles-Gonzalez JF, Kar S, Douglas P, et al. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol. 2012;59:923-929.

From the Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted May 24, 2017. 

Address for correspondence: Umberto Cucchini, MD, PhD, University of Padua, Department of Cardiac, Thoracic and Vascular Sciences, Via Giustiniani, 2, 35128 Padova, Italy. Email: ucucchini@yahoo.it