Catheterization and Cardiovascular Interventions 85:E54–E57 (2015)

VALVULAR AND STRUCTURAL HEART DISEASES Case Reports Left Atrial Thrombus After Complete Left Atrial Appendage Exclusion With LARIAT Device Ketan P. Koranne,* MD, Rajeev R. Fernando, MD, and Susan T. Laing, MD, FACC A 74-year-old woman with paroxysmal atrial fibrillation underwent left atrial appendage (LAA) exclusion with a LARIAT snare device. Transesophageal echocardiogram one month later demonstrated a left atrial thrombus at orifice of the completely occluded LAA that subsequently resolved with two months of anticoagulation. This case highlights that LAA ligation with LARIAT device continues to pose a risk for left atrial thrombosis in the immediate post-operative period. It also emphasizes the need for further evidence regarding antiplatelet and anticoagulation therapy in these patients. C 2014 Wiley Periodicals, Inc. V

Key words: LARIAT; left atrial thrombus; left atrial appendage closure


LARIAT snare device provides a minimally invasive technique for external left atrial appendage (LAA) exclusion. It thereby reduces the risk of thromboembolic episodes in patients with atrial fibrillation that cannot be anti-coagulated. We report a case of left atrial thrombus at LAA orifice after its complete exclusion. Immediate post-operative period after LAA ligation with LARIAT device continues to pose a risk for left atrial thrombus.

left atrium, and normal LAA velocity. No thrombus was visualized within the left atrium (Fig. 1). A right femoral vein percutaneous puncture was done and an 8 Fr sheath was inserted. Epicardial puncture was then performed through the sub-xyphoid approach and an epicardial guidewire was inserted. The position of the guidewire was confirmed with TEE. An 8 Fr sheath was exchanged for 8.5 Fr specialty sheath. Transseptal needle was then advanced across the left atrium and then sheath advanced to the left atrium. Position was confirmed with fluoroscopy. Left atrial angiogram was then performed. SentreHeart


A 74-year-old Caucasian woman with hypertension, type 2 diabetes mellitus, cerebrovascular accident in 2009, and symptomatic paroxysmal atrial fibrillation presented with palpitations. Electrocardiogram demonstrated atrial fibrillation with rapid ventricular response. She was on atenolol for rate control due to failed rhythm control strategy. She was legally blind due to proliferative diabetic retinopathy and had recurrent falls with severe injuries and hence anticoagulation had been discontinued. Given her risk of LAA thrombosis and subsequent thromboembolism, it was decided to perform LAA exclusion with the LARIAT device. A pre-procedural transesophageal echocardiogram (TEE) was performed which demonstrated a moderately dilated left atrium, spontaneous echo contrast in the C 2014 Wiley Periodicals, Inc. V

Division of Cadiovascular Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, Texas Conflict of interest: Nothing to report. *Correspondence to: Ketan P. Koranne, MD, Cardiology Fellow, Division of Cadiovascular Medicine, Department of Internal Medicine, University of Texas Health Science Center at Houston, 6431 Fannin, MSB 1.246 Houston, TX 77030. E-mail: [email protected] Received 26 November 2013; Revision accepted 17 May 2014 DOI: 10.1002/ccd.25549 Published online 21 May 2014 (

in Wiley Online Library

LA Thrombus After LARIAT Placement


Fig. 1. TEE demonstrating dilated left atrium with open LAA and no thrombus.

Fig. 3. TEE demonstrating left atrial thrombus (black arrow) at the orifice of LAA.

Fig. 2. TEE demonstrating LAA post-exclusion with LARIAT.

Fig. 4. TEE demonstrating resolution of left atrial thrombus seen on prior images.

0.025 Finderwire (220 cm) #1 was inserted through the right femoral sheath and advanced to the LAA. Finderwire #2 was inserted through the epicardial canula. Finderwires were magnetically connected. SentreHeart, Inc. LARIAT suture delivery device was inserted over the wire and advanced around LAA. 15  12 Endocath Occlusion Balloon (90 cm) was then inflated in the LAA os. LARIAT suture position was then verified and LARIAT was tightened across the LAA. Occlusion was confirmed with TEE and LAA angiogram. Finderwires were then separated, occlusion balloon was deflated and pulled back and LARIAT was additionally tensed. Post-procedure TEE demonstrated complete occlusion of the LAA (Fig. 2).

Patient was discharged home after the procedure. She was not on anticoagulation. She then presented one month after the LARIAT device placement for an electively planned atrial fibrillation ablation. A preprocedural TEE demonstrated LAA that had been ligated and a severely reduced LAA velocity consistent with complete ligation. A 1 cm  1 cm thrombus was noted just above the ligation, well noted on multiple views (Fig. 3). No other masses were seen in the cardiac chambers. Atrial fibrillation ablation was cancelled and patient was initiated on anticoagulation with intravenous heparin and warfarin and was discharged once she reached

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).


Koranne et al.

TABLE I. Success and Complications in LAA Exclusion With LARIAT Device Number

Number of subjects

Successful closure

1 2

26 Mongrel dogs 89 patients

In all cases 95% had complete closure at 1 month.


21 patients


27 patients

100% complete closure (procedure was not performed in 1 patient due to LAA thrombus). 92.6% acute success rate.

a therapeutic INR. A repeat TEE performed 2 months later showed reduced LAA velocity with no thrombus visualized in the left atrial cavity (Fig. 4). DISCUSSION

More than 6 million people suffer from atrial fibrillation [1]. Thromboembolic phenomena due to left atrial thrombus remain the major complication of atrial fibrillation. Atrial fibrillation has been demonstrated to be an independent risk factor with a fivefold increase in risk for cerebrovascular accident in the Framingham study [2]. A review of 23 separate studies by Blackshear et al. suggested that 91% of left atrial thrombi in non-rheumatic atrial fibrillation originated in the LAA [3]. Significance of isolation of LAA has been proven and multiple procedures and devices exist. Surgeons have long attempted exclusion of LAA. The first LAA exclusion procedure was described in 1940 by Madden [4]. One major limitation of the external LAA closure with suture ligation or surgical staplers has been identification of the anatomic origin of LAA in a beating heart. External surgical occlusion may lead to closure of the LAA at a distal location, leaving behind a part of the appendage that may still act as a site for thrombus formation. Furthermore, this carries a risk of bleeding due to friable left atrial tissue. While endocardial surgical suture ligation may not have the limitation of identifying the LAA origin, it requires the use of cardiopulmonary bypass. It also has an increased risk of injury to the circumflex artery and is associated with 10–36% incidence of incomplete closure [5,6]. Percutaneous techniques for LAA closure have been developed more recently. LAA closure with Watchman device was demonstrated to be non-inferior to warfarin in stroke prevention. However, embolization was noted to be one of the major complications of this device. Percutaneous LAA ligation with LARIAT device was first described by Lee et al. by studying the procedure



No complications. No device related complications. Access related complications—pericarditis (n ¼ 2), pericardial effusion (n ¼ 1), death (n ¼ 2), late stroke (n ¼ 1). RV rupture with percardial tamponade (n ¼ 1).

Lee and coworkers [7]. Bartus et al. [8].

Left atrial appendage rupture (n ¼ 1), pericarditis (n ¼ 3), stroke due to transseptal sheath thrombus (n ¼ 1), non-embolic stroke (n ¼ 1), pleural effusion (n ¼ 1).

Massumi et al. [9].

Stone et al. [10].

performed in 26 healthy mongrel dogs. Safe and reliable ligation of the entire LAA was established in all the animals without any evidence of trauma or bleeding [7]. No randomized controlled trials have so far been published to evaluate the safety and efficacy of LARIAT device. Bartus et al. reported their experience with LARIAT device in 89 patients in a prospective trial. While 95% of the patients had complete closure of LAA in post-operative TEE, there were no complications due to the device. Access-related complications including pericarditis and late pericardial effusion were reported in three patients [8]. Massumi et al. also reported their initial experience with the LARIAT snare device in 21 patients. Complete LAA exclusion was reported in all the patients who underwent the procedure and none of the patients had stroke after 1 year of follow-up [9]. We have tabulated the closure success rates of LARIAT device and complications reported in LARIAT trials that have been published in Medline (Table I). LAA thrombus formation after incomplete closure of LAA was recently reported by Briceno et al. [11]. This was attributed to the thrombogenic focus of the LAA that was not excluded after the procedure. We hereby report formation of a left atrial thrombus after complete exclusion of LAA, at its orifice. While the cause of thrombosis after LARIAT device is unclear, a possible explanation is that inflammation produced at the site of snare device provides a nidus for thrombus formation. Another explanation is the endothelial damage caused by the materials used in the device itself. In our patient, left atrial thrombus resolved after anticoagulation for 2 months. Lee et al. reported in dogs that at 3 months after LAA ligation, atrophic changes with fusion of LAA to the left atrial wall were noted. While endothelialization was noted as early as 7 days after ligation, at 3 months it was complete and the LAA was incorporated into the visceral pericardium.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

LA Thrombus After LARIAT Placement


Thrombosis at LAA orifice site is a potential complication of LAA exclusion with LARIAT device. Further long-term studies are necessary to evaluate the role of antiplatelet and antithrombotic agents as well as their appropriate duration, in preventing post-LARIAT thrombotic risk. More evidence is also necessary to determine the appropriate timing and techniques of monitoring such as TEE. This will help guide the use of LARIAT for prevention of LAA thrombus. REFERENCES





1. Johnson WD, Ganjoo AK, Stone CD, Srivyas RC, Howard M. The left atrial appendage: Our most lethal human attachment. Surgical implications. Eur J Cardiothorac Surg 2000;17:718–722. 2. Wolf PA, Abbott RD, Kannel WB. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke 1991;22:983–988. 3. Blackshear JL, Odell JA. Appendage obliteration to reduce stroke in cardiac surgical patients with atrial fibrillation. Ann Thorac Surg 1996;61:755–759. 4. Madden J. Resection of the left auricular appendix: A prophylaxis for recurrent arterial emboli. J Am Med Assoc 1949;140:769–772. 5. Katz ES, Tsiamtsiouris T, Applebaum RM, Schwartzbard A, Tunick PA, Kronzon I. Surgical left atrial appendage ligation is




frequently incomplete: a transesophageal echocardiographic study. J Am Coll Cardiol 2000;36:468–471. Rosenzweig BP, Katz E, Kort S, Schloss M, Kronzon I. Thromboembolus from a ligated left atrial appendage. J Am Soc Echocardiogr 2001;14:396–398. Lee RJ, Bartus K, Yakubov SJ. Catheter-based left atrial appendage (LAA) ligation for the prevention of embolic events arising from the LAA initial experience in a Canine Model. Circ Cardiovasc Interv 2010;3:224–229. Bartus K, Han FT, Bednarek J, Myc J, Kapelak B, Sadowski J, Lelakowski J, Bartus S, Yakubov SJ, Lee RJ. Percutaneous left atrial appendage suture ligation using the LARIAT device in patients with atrial fibrillation: Initial clinical experience. J Am Coll Cardiol 2013;62:108–118. Massumi A, Chelu MG, Nazeri A, May SA, Afshar-Kharaghan H, Saeed M, Razavi M, Rasekh A. Initial experience with a novel percutaneous left atrial appendage exclusion device in patients with atrial fibrillation, increased stroke risk, and contraindications to anticoagulation. Am J Cardiol 2013;111: 869–873. Stone D, Byrne T, Pershad A. Early results with the LARIAT device for left atrial appendage exclusion in patients with atrial fibrillation at high risk for stroke and anticoagulation. Catheter Cardiovasc Interv 2013; doi: 10.1002/ccd.25065 [Epub ahead of print]. Briceno DF, Fernando RR, Laing ST. Left atrial appendage thrombus post LARIAT closure device. Heart Rhythm 2013;pii: S1547-S5271(13)01284-8.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Left atrial thrombus after complete left atrial appendage exclusion with LARIAT device.

A 74-year-old woman with paroxysmal atrial fibrillation underwent left atrial appendage (LAA) exclusion with a LARIAT snare device. Transesophageal ec...
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