Systematic Review of Contiguous Vessel and Valve Injury Associated with Endocardial Left Atrial Appendage Occlusion Devices

Sharan Prakash Sharma1, Ghulam Murtaza2, Bader Madoukh2, Donita Atkins2, Cherie Nydegger2, Courtney Jeffery2, Sudha Bommana2, Edward Wang3, Rakesh Gopinathannair2, Jacqueline Saw4, Andrea Natale5, Dhanunjaya Lakkireddy2

1Garden City Hospital, Department of Cardiology, Garden City, Michigan, USA.2The Kansas City Heart Rhythm Institute, 5701 W 119th Street, Suite 430, Overland Park, KS 66209, USA.3Department of Cardiothoracic Surgery and Transplantation, Fiona Stanley Hospital, Murdoch, Western Australia, Australia.4Vancouver General Hospital, 2775 Laurel St, 9th Floor, Vancouver, British Columbia V5Z 1M9, Canada.5Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, TX, USA.

Abstract

Endocardial LAAO has been increasingly utilized in atrial fibrillation (AF) patients who are not suitable for long term oral anticoagulation. While overall procedural complications have decreased, rare complications like contiguous vessel and valve injury may be more frequently seen in the future with increase in the procedure volume. We performed a systematic search using predefined terms which reviewed all cases published in literature of contiguous vessel (pulmonary artery, pulmonary vein and left circumflex artery) and mitral valve injury caused by LAAO devices. Our results showed that Amplatzer Cardiac Plug (ACP) and Amplatzer Amulet devices were the most commonly used devices. Pulmonary artery perforation was the most commonly seen collateral vessel injury associated with LAAO. Close proximity of left atrial appendage to pulmonary artery was noted in all cases of pulmonary artery injury. Pulmonary artery injury commonly manifests as pericardial tamponade with hemodynamic collapse and is often fatal. Most common denominator of all the reviewed cases was the presence of an oversized LAAO device. In conclusion, collateral vessels and valve injury can be seen after LAAO mostly with double lobe devices such as ACP or Amulet. Increased awareness by the operators along with proper imaging and investigations could potentially mitigate such rare complications associated with LAAO.

Key Words : Left atrial appendage occlusion, Amplatzer Cardiac Plug, Amplatzer Amulet, Collateral injury, Complications.

Correspondence to: Dhanunjaya Lakkireddy, MD, FACC, FHRS Executive Medical Director The Kansas City Heart Rhythm Institute (KCHRI) @ HCA MidWest Professor of Medicine, University of Missouri, Columbia, MO 12200, W 106th street, Oveccrland Park Regional Medical Center Overland Park, KS 66215

Introduction

Left atrial appendage occlusion (LAAO) has emerged as an appealing alternative to stroke prophylaxis in patients with non-valvular atrial fibrillation (AF) who are poor candidates for anticoagulation [1]. While there are several available devices for LAAO, the Watchman (Boston Scientific Corp, Minneapolis, MN) and the Amulet (Abbott Medical, Chicago, IL) are the most commonly implanted devices for catheter-based endocardial LAAO, with a greater percentage of the Amulet device being used within Europe compared to non-European geographies [2]. With the prevalence of non-valvular AF estimated to increase across the globe [3], utilization of LAAO is likely to increase in the future. Since the sharp rise in post market release complications of Watchman, there has been a steady decline in reported rate of common procedure-related complications [4]. A few rare complications of LAAO are linked to the close anatomical proximity of the left atrial appendage (LAA) to adjacent vessels and valve in the heart. LAA lies close to the pulmonary artery anterosuperiorly and left superior pulmonary vein posteriorly, mitral valve inferiorly and the LAA covers an area over the left atrioventricular groove which contains the left circumflex artery [5]. Although rare, contiguous vessel or valve injury with LAAO devices is more likely to be seen in the future with an increase in the utilization of these procedures. In this paper, we aim to review all contiguous vessel and valve injuries associated with LAAO that have been published to date and also aim to understand the pathophysiology of these complications.

Methods

We searched PubMed, EMBASE, CINAHL and Google Scholar from January 1, 2000 till March 15, 2019 using the following key words: “left atrial appendage closure,” “Watchman,” “Amplatzer Cardiac plug,” “Amulet,” “pulmonary vein,” “pulmonary artery,” “left circumflex artery” and “mitral valve”. The goal of this systematic review was to collect all the cases of collateral vessel and valve injuries that occur as complications from LAAO devices. The flow chart of study selection is elucidated in [Figure 1].

Figure 1. Flow chart of study selection



Results

Comprehensive search revealed 12 publications from Asia, Europe, and Australia with description of 13 cases of contiguous vessels and mitral valve injury after LAAO [6-17]. The average age of the patients was 71.4 ± 8.2 years; 92% were Caucasians. Majority had persistent AF (62%). The most common type of injury after LAAO procedure was pulmonary artery injury. Most cases of pulmonary artery (PA) perforation occurred within 24 hours (62%) and were caused by Amplatzer Cardiac Plug and Amplatzer Amulet devices (92%). A case of delayed presentation after 6 months was also described where chronic pressure from the Amulet was found to kink the PA leading to occlusion of vasa vasorum and ischemic necrosis and perforation [13]. Stabilizing hooks of ACP/Amulet or metallic struts of Watchman were seen to cause the perforation of LAA and PA. In all cases, close proximity of LAA with PA was noted. PA perforation had a high mortality rate of 40%. The common presentation was sudden hemodynamic collapse with evidence of pericardial tamponade [Figure 2]. Less common contiguous vessel injuries included left inferior pulmonary vein compression due to atrial disc portion of ACP (10%) [6] as well as left circumflex coronary artery (LCX) compression by the lobe portion of the oversized ACP (10%) causing ST-segment elevation [9]. Pulmonary vein compression by ACP was diagnosed during a follow-up radiofrequency pulmonary vein isolation by low impedance in the ridge between left inferior pulmonary vein and LAA suggesting catheter contact with metal device. In the case of LCX compression, retrieval and repositioning of the device resulted in disappearance of ST elevation. There were three cases of mitral valve impingement and all were due to impingement of mitral leaflet by the outer disc of LAAO devices [15-17]. While two cases manifested as asymptomatic mitral regurgitation detected by imaging [15,17], one patient had recurrent syncope from possible dynamic obstruction of the valve by ACP [16]. The case of recurrent syncope required surgical removal of the device and LAA resection on the 4th post-operative day. Removal and reimplantation of a downsized device was required in the other case [17] while no information on the management was reported regarding the last case [15]. Detailed description of these cases is present in [Table 1].

Figure 2. CT scan demonstrating contrast extravasation from main pulmonary artery with pericardial tamponade



Table 1. Study and patient characteristics
Study Country Age (yr)* Sex AF type LAAO type LAAO size (mm) CHA2DS2VASC Reason for LAAO Implantation Diagnosed Presenting Symptoms/Signs LAA characteristics Injury LAA and vessel relation Management Outcome
Pulmonary artery Injury
Scislo et al 2018 (1st case) Poland 67 F Parox Amulet 25 9 GI and intracranial bleeding No issue 17 hrs post procedure Chest pain, dyspnea, hemodynamic collapse Winsock type, LZ-20mm 3mm posterolateral tear to MPA by anchoring hook 2mm groove between MPA and LAA Thoracotomy and repair Discharged alive
Scislo et al 2018 (2nd case) Poland 62 M Parox Amulet 28 3 GI bleeding No issue 3hrs post-procedure Cardiac tamponade Winsock type, LZ 23mm 3mm posterolateral tear of MPA by anchoring hook No groove between MPA and LAA Thoracotomy and repair Discharged alive
Wang et al 2018 Australia 87 M Persis Amulet 31 6 Hemorrhagic stroke No issue 6months post-procedure Cardiac tamponade and collapse LZ 25mm 2mm posterolateral tear from chronic pressure ofanchoring hook without erosion of LAA - Thoracotomy and repair Discharged alive
Suwalski et al 2016 Poland 66 M Persis ACP 22 - Intracranial hemorrhage No issue 17 days post-procedure Cardiac Tamponade LAA origin 18mm, depth 24mm 2mm lateral surface tear by anchoring hook - Thoracotomy and repair Discharged alive
Bianchi et al 2013 Italy 76 M Persis ACP 22 3 Intracranial hemorrhage No Issue 3hrs post procedure Cardiac tamponade and collapse - 2mm tear by anchoring hook - Thoracotomy and repair Discharged alive
Sepahpour et al 2013 Australia 72 F Parox Watchman 24 6 Complicated PCI and need for lifelong dual antiplatelet Transient inf STEMI, no apparent reason and resolved by reimplantation with 2nddevice 16 days post procedure Shock, PEA, could not be resuscitated LAA orifice diameter 17mm, depth 35mm 10mm tear on superior and left aspect of MPA by a metallic strut of Watchman - Died Died
Zwirner et al 2016 Germany 71 F Persis Amulet - - Traumatic subdural hemorrhage No issue 8hrs post-procedure Patient was found pulseless, failed resuscitation - 2mm tear on the pulmonary artery by a hook of amulet with punctiform tear of LAA - Died Died
Hanazawa et al 2014 Germany 75 F Parox ACP 24 5 Subdural hematoma No issue 24hrs post-procedure Hypotensive, cardiac tamponade LAA orifice diameter 18mm, depth 27mm Perforation of LAA and leading to erosion of the bottom of the pulmonary artery 3D reconstruction of cardiac CT showed one lobe of LAA touched the inferior pulmonary artery Died Died
Pulmonary Vein Compression
Ayati et al 2014 Germany 76 F Persis ACP - - Risk of bleeding No issue 3 months post-procedure Worsening exertional dyspnea - LIPV compression diagnosed on CT and during PVI, mapping at the ridge between LIPV and LAA showed decreased impedance suggesting catheter contact with metal device LIPV was compressed with atrial part of ACP Successful PVI, ACP was left in place Discharged alive
Left Circumflex artery Compression
Katona et al 2015 Hungary 59 M Persis ACP 23 - Recurrent head contusions ST elevation in inferior leads During procedure ST elevation LAA with huge ostium After positioning of ACP inferior lead showing ST elevation Coronary angiogram showing compression of proximal circumflex and device was seen sitting superficially. After removal and repositioning of device STE disappeared. Discharged
Mitral valve impingement
Berrebi et al 2017 France 84 F Pesis Amulet 28 5 Hemorrhagic shock due to GI bleeding No issue. Amulet was in contact with ant. Mitral leaflet but mitral valve kinetics was normal 6 weeks after procedure Denovo mild mitral regurgitation on routine TEE at 6 weeks LAA ostium 31 mm and neck 26mm tear of A1 portion of anterior mitral leaflet Progressive leaflet erosion by amulet outer disc Not available Not available
Cruz-Gonzalez et al 2014 Spain 72 F Parox ACP 24 5 GI bleeding Pericardial tamponade needing tube drainage after transseptal puncture. Following ACP deployment, inferior part of the external disc appeared over posterior leaflet without any mitral valve dysfunction Few days after LAAO Recurrent syncope LAA neck by angiography 22mm, -by TEE 19mm Possible dynamic obstruction of valve by device causing syncope Compression of posterior mitral leaflet by ACP Surgical removal of device and left atrial appendage with resolution of syncope Discharged alive
Walia et al 2016 Taiwan 61 M Persis ACP 26 5 Recurrent strokes and bleeding Immediately post-implantation rhythmic movement of ACP disc edge and mild MR were noted During the procedure Rhythmic movement of disc edge and MR Cauliflower morphology Base 21.8mm Depth 18.5mm Disc impingement and MR Outer disc of ACP causing mitral leaflet impingement Removal of device and reimplantation of downsized ACP (24mm) Discharged alive

*all were Caucasian, yr=year,parox=paroxysmal,persis=persistent,LAA=left atrial appendage LAAO=left atrial appendage occlusion, ACP=Amplatzer cardiac plug,mm=millimeter,GI=gastrointestinal, PCI=percutaneous coronary intervention, MI=myocardial infarction, PEA=pulseless electrical activity, STEMI=ST elevation myocardial infarction, LZ=landing zone,MPA=main pulmonary artery,LIPV=left inferior pulmonary vein, PVI=pulmonary vein isolation, MR=mitral regurgitation, STE=ST elevation

Discussion

Our review of LAAO related contiguous vessel and valve injury provides comprehensive evaluation of a rare complications associated with the procedure. Contiguous vessel and valve injury from LAAO are rare but can add significant morbidity and mortality. With increasing utilization of LAAO for stroke prophylaxis, such complications are likely to be encountered more frequently in the future. Therefore, operators performing LAAO procedures should be cognizant of this complication.

The topographic relationship of LAA with neighboring structures is well known. However, the effect of LAAO devices on potentially causing injury to neighboring vessels and mitral valve is based on sporadic case reports. Furthermore, due to interindividual variation in LAA morphologies and diverse types and sizes of LAAO devices used, ‘one size fits all’ recommendation cannot be made for preventing such adverse outcomes. Therefore, prevention and management of collateral injury related to LAAO should be individually addressed on a case by case basis. However, there may be certain anatomical and imaging characteristics that could enable providers to increase vigilance about the possibility of such complications. Anatomical proximity between LAA and vessels is a prerequisite for such complications. In fact, LAA may get in direct contact with main pulmonary artery in a significant number of patients undergoing LAAO [Figure 3]. In a review of 100 AF patients by cardiac-gated computed tomography angiogram of LAA, Halkin et al found 28% of patients had contact between LAA and PA in the proximal LAA (proximal 15mm extending into LAA from ostium or LAA before 1st major bend that is <15mm from ostium) and 65% had contact involving the distal LAA [18]. Proximal LAA contact poses increased vulnerability to injury where the anchoring hook of LAAO devices are usually situated after deployment. In a vast majority of cases, the landing zone of the lobe or disc-lobe devices is immediately distal to the LCX area and is away from the pulmonary artery or the main LCX trunk. This perhaps explains the rare incidence of these complications even though the ostial and distal portions of the LAA seem to be in closer proximity to the PA. This is again primarily determined by the shape of the LAA. Similarly, a recently published cardiac computed tomography (CT) evaluation in 48 patients with LAAO devices after 6 months of implantation revealed that the distance between occluder device and left upper pulmonary vein was affected by LAA morphology with cauliflower type having the closest proximity [19].

Figure 3. CT scan showing posteriorly directed LAA tucked underneath the pulmonary artery



In the post-FDA approval experience of Watchman, pericardial tamponade occurred in about 1% of patients [4]. Similarly, in a multicenter study of ACP involving 1047 patients, pericardial tamponade was noted in 1.2% (13/1047) with 1 case reported as being caused by pulmonary artery tear (0.09%) [20]. Majority of the bleeding complications after LAAO were able to be treated percutaneously without the need for cardiac surgery. Even though most of these bleeding complications were probably related to micro-perforation of the LAA from the hooks or struts, contiguous vessel injury remains a concern.

Our review has some important clinical implications. First, it underscores the importance of proper preoperative imaging study to define the relationship of LAA with surrounding structures. While transesophageal echocardiography is commonly used as standard modality, additional imaging such as CT scan needs to be considered in select cases. Second, it reinforces the importance of proper device sizing. Based on our cases, from mechanistic perspective, oversized LAA device can erode the vessel after perforating LAA or compress from outside without perforation. Similarly, the outer disc of larger devices can impinge on mitral valve leaflet and the left superior pulmonary vein ostium. Selecting a larger device is associated with risk of LAA perforation and cardiac tamponade in previous studies [21,22]. As a corollary of this, larger devices may be associated with contiguous vessel and valve injury. Sometimes the LAA may be behind the pulmonary artery especially the landing zone of the LAA where an oversized device could potentially exert significant radial forces leading to perforation through the anchors.

Study limitations

Our study has all the potential limitations of a systematic review. The data is retrospectively pooled and many anatomical and intraprocedural details are not readily available. The exact details of the degree of oversizing and degree of the compression of the lobe (ACP/Amulet) and or the main body (Watchman) are largely unknown. Oversizing and compression are almost always thought to be the underlying etiology in most of these cases. Whether it is truly the case or not cannot be accurately verified. But it is logical to hypothesize that significant oversizing can result in over compression with higher radial forces on the walls of the LAA and the contiguous vessels. Oftentimes, operators err on the side of oversizing to accomplish tighter seal of the LAA. This approach has to be reviewed with caution in light of the results of our study. Finally, the true incidence of the contiguous vessel or valve injury in the general population cannot be estimated from our study.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgements

None

Conclusions

Thorough architectural knowledge of pulmonary artery, pulmonary vein, left circumflex artery and mitral valve leaflets in relation to LAA can help guide pre-operative and post-operative management, as well as anticipation of the rare complication of injury to the contiguous vessels and valve during LAAO procedures. Given increasing use of LAAO devices, we anticipate that these rare complications have a potential to increase in frequency in the future. Increased operator awareness along with proper preoperative imaging can potentially mitigate these rare complications.

References

  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]
  • [ PubMed ]