Direct versus deferred left atrial appendage closure in patients with left atrial appendage thrombus via the guidance of intracardiac echocardiography

Abstract Background Atrial fibrillation (AF) is associated with a markedly increased risk of stroke. Most thrombus originate in the left atrial appendage (LAA). The risk of stroke has been reported relatively high in patients with LAA thrombus (LAAT) during oral anticoagulation (OAC) therapy. LAA closure (LAAC) may be safe and feasible in patient with LAAT. The optional timing of LAAC in patients with LAAT is controversial. Purpose This study aimed to compare the clinical outcomes between direct and deferred LAAC in patients with LAAT guided by intracardiac echocardiography (ICE). Methods Patients with AF and LAAT who underwent LAAC between May 2022 and December 2024 were consecutively included. The study population was divided into direct LAAC group and deferred LAAC group. LAAC was performed by experienced operators via the guidance of ICE. Patient characteristics and clinical outcomes were compared between the two groups. Results A total of 34 patients (aged 67.2±9.6 years, 82.4% males) with AF and LAAT were included. Direct LAAC was performed in 21 patients (2 with contraindications to OAC, 11 with high bleeding risk, 5 with LAAT and prevalent stroke during prior intensive OAC, 3 for patient’s preference). Deferred LAAC was arranged in the rest 13 patients with persistent LAAT after OAC therapy with a median period of 125 days (interquartile range 51-349 days). Three patients (3/13, 23.1%) experienced stroke and 2 (2/13, 15.4%) had bleeding events during OAC therapy in the deferred LAAC group. Thrombus at the proximal and distal LAA was detected in 15 (direct LAAC group 9, deferred LAAC group 6) and 19 patients (direct LAAC group 12, deferred LAAC group 7), respectively (Figure 1). Lobe and disc devices (33 LAmbre device, 1 SeaLA device) were used and successfully implanted in all patients. Only 1 patient experienced pseudoaneurysm periprocedurally and recovered after surgery. No peridevice leak 5 mm was detected during transesophageal echocardiography or cardiac CT follow-up. Device-related thrombus occurred in 1 patient in the deferred LAAC group. After a median follow-up period of 383 days (interquartile range 150-645 days), none of the patients experienced death, stroke/transient ischemic attack, or systemic embolism. Two patients in the deferred LAAC group suffered gastrointestinal bleeding during follow-up. None of the clinical outcomes was statistical significance between the two groups (Table 1). Conclusions Direct LAAC via the guidance of ICE may be safe and feasible in patients with LAAT by experienced operators with high procedural success and absence of periprocedural thromboembolic complications. Further randomized controlled trial with large study population is needed to confirm this finding.