Delayed Common Postoperative complications occurred after LAAO Dr

Delayed Common Post-operative complications occurred after LAAO Dr. Iat-Lon , Leong Department of Medicine, Division of Cardiology Macau Kiang Wu Hospital

Atrial Fibrillation Stroke prevention is an important Consideration. (1/3 Afib patients will suffer a stoke) Treatment with anticoagulant medications. The majority of embolic strokes originate from the left atrial appendage ( 90% of the clots form in the LAA) Left atrial appendage occlusion devices offer a nonpharmacologic alternative to anticoagulant medications.

Case Information Asian Gentleman 67 y. o PH: HBP & T 2 DM Holter : Paroxysmal atrial fibrillation and atrial flutter (2010) CHA 2 DS 2 -VASC Score : 3

Case Information Anticoagulant medications Warfarin 3~3. 5 mg Dabigatran 110 mg BID Poor INR control Recurrent Side effect Petechiae 11/2010 Transient Ischemic Attack 2/2012 Hematuria 1/2014 Thalamus hemorrhage 4/2014 Stable after Conservative treatment

Case Information HAS-BLED Score: 4 HAS-BLEDscore: 4. The patient has a HIGH risk of bleeding (HASBLED score >/=3). The risk of major bleeding within 1 year in patients with atrial fibrillation enrolled in the Euro Heart Survey, expressed as bleeds per 100 patient years: 8. 7%. Some caution and regular review of the patient is needed following the initiation of antithrombotic therapy, whether with oral anticoagulation or aspirin.

LAAO 2014/06/21 LAA Orifice diameter 21. 6 mm (TEE) 26 mm Amplatzer Cardiac Plug was selected Smooth Procedure Angiography and TEE were performed Antithrombotic Therapy (Dual platelet inhibition): ASA(100 mg/d)+Clopidogrel(75 mg/d) =4 -6 weeks=> ASA(100 mg/d) Good condition follow up at 7/2014

REFERENCE LAA Orifice

TEE

IMPLATION ANGIOGRAPHY

Nightmare 22/7 was send to AED Complain : SOB , Abdominal pain and sweating for half hour BP: 79/53 mm. Hg , Pulse: 87 bpm, SPO 2: 95% FAST test : Large pericardial effusion ◦ Pericardiocentesis : bloody drainage solution Continue to observation at ICU

Recurrent drainage of pericardial effusion 400~500 ml drainage Solution /1 st day 10~20 ml drainage at follow time CT (23/7) : No Peri-device Leak , Mild pericardial effusion, No significant contrast extravasation

Treatment 1. Stop Antithrombotic Therapy 2. Pericardial drainage 3 Remove the drainage set 7 days later ECHO follow up : No significant pericardial effusion Patient discharged at 15/Aug Good Condition F/U at OPD

Question 1. Why was it happened 1 month after procedure? 2. Why did it occur so urgent in this event ? 3. Did it relate with antithrombotic therapy? 4. How is the follow up of this procedure?

LAA occlusion Complication RATE Pericardial Effusion 5% Stroke (Procedure-Related , No Procedure-Related) 0. 9% Device-associated thrombus 4. 2% Bleeding 0. 8% Vascular Complications 0. 8% Device Embolization 0. 6% V Reddy, et al Circulation, 2011

Amplatzer Left Atrial Appendage Occlusion: Single Center 10 -Year Experience 152 pts in Europe

ACP Post-Market EU observational Study

ACP Post-Market EU Observational Study

Antithrombotic Therapy Time Aspirin 100 mg/d + Clopidogrel 75 mg /d Aspirn 100 mg/d 6 weeks Aspirin 100 mg/d 6 weeks Warfarin/NOAC (prexisting OAC) 6 weeks First 6 weeks TEE ruled out thrombus and Peri-Device flow OAC, Dual Platelet Inhibition ASA 100 mg/d

Conculsion: Cause of Pericardial Effusion is unknow Dual platelet inhibition? ? No Guideline can be follow of the Antithrombotic Therapy (ASA? ASA + Clopidogrel? Warfarin? ) Regular Follow up is necessary (TEE/CT/ECHO) Closely monitor at first month 6 week / 3 month / 6 month /1 yr

In the future More Trial to reduce the Probability of complications Recommendation of Antithrombotic Therapy Type and Duration

Thank you