Po-03-160 trans-fabric approach to achieve peri-device leak closure following incomplete watchman left atrial appendage occlusion

Closure of peri-device leaks (PDL) is commonly performed using embolization coils deployed around or inside the left atrial appendage occlusion (LAAO) device and/or intravascular occluders deployed into the leak itself. In some circumstances, where large, crescent-shaped leaks are present in the setting of an undercompressed Watchman device, both approaches might fail to achieve complete PDL closure despite deployment of multiple leaks/occluders. Herein, we describe our experience of trans-fabric deployment of intravascular occluder devices to achieve complete PDL closure. This is a single center feasibility cohort study of patients undergoing PDL closure using a trans-fabric approach. A trans-fabric approach was attempted and successfully employed in 4 cases of PDL closure, performed after a mean on 318±205 days after the LAAO procedure. In all cases, the originally implanted Watchman (2x31mm, 2x35mm) was undercompressed with a large crescent-shaped leak around the device (Figure). The procedure was performed under general anesthesia and 3D TEE-guidance. A cerebral protection device (Sentinel) was positioned in 3 patients, in which partial clot was observed inside the Watchman. For PDL closure, a 35/25mm Amplatzer PFO Occluder was used in 2 cases, a 25mm Amplatzer Amulet in 1, and a 34mm Amplatzer Amulet in 1. An 8.5Fr deflectable sheath (Agilis) and a 0.035” RF transseptal wire (VersaCross) were used to cross the fabric under 3D TEE and fluoroscopy guidance, aiming to puncture the device on the same size as the PDL (Figure). To accommodate the occluder delivery sheath, the access site was dilated with a dilator (9Fr delivery sheath) or semi-compliant PTA balloon (>12Fr delivery sheaths) advanced over the transseptal wire (Figure). The deflectable sheath was then exchanged with the occluder-specific delivery sheath, which was advanced beyond the fabric: the distal disc/lobe were deployed inside the Watchman while the proximal disc was deployed in front of it. Before release, adequate occluder device positioning and effective PDL closure were confirmed using both fluoroscopy and 3D TEE (Figure). Mean procedural time was 141±15 min, mean fluoroscopy time 40±23 min owing to a mean fluoroscopy dose of 881±464 mGy. There procedure was uneventful in all patients, who were discharged after overnight observation. A trans-fabric approach is a feasible alternative approach to achieve successful PDL closure following incomplete Watchman left atrial appendage occlusion.