BACKGROUND: Transcatheter left atrial appendage (LAA) closure device is an alternative to oral anticoagulation to reduce the risk of stroke in patients with atrial fibrillation that are considered at high risk for bleeding complications. Device malposition and/or incomplete LAA seal are known inherent modes of device failure. These events may be underreported, because most of these nonfatal complications can be managed by continued anticoagulation. There are a few surgical repair reports, but most of them were performed through median sternotomy. We experienced a rare device failure and performed robotic-assisted surgical repair through right thoracotomy.
METHODS: A 70-year-old female with a history of paroxysmal atrial fibrillation/flutter underwent transcatheter LAA closure device placement in November 2019. The implant was compromised by recurrent device-related thrombus (DRT), which was on the central pin of the device. The patient went on multiple aggressive anticoagulation including subcutaneous heparin and direct oral anticoagulant therapy with antiplatelet therapy to get rid of the DRT. Ultimately, transesophageal echocardiogram (TEE) showed a complete resolution of the DRT in March 2023. However, there appeared to be evidence of loose fabric on one side of the device with communication between the LAA and LA cavity. There was a risk of coming off fabric from the device, and the patient needed to continue anticoagulation. We discussed whether the fabric can be reattached or, pericardial patch can be placed over the device, or whether the device can be removed.
RESULTS: Robotic-assisted surgical repair through right thoracotomy was selected. Cardiopulmonary bypass was established with femoral artery perfusion and femoral vein drainage. From 3 to 5 o'clock of the surgeon's view, there was fabric separation (Fig. Left). The device severely adhered to the LAA wall. The bovine pericardium patch was anastomosed around the device with a running suture of Goretex to cover it completely (Fig. Right). Postoperative TEE showed no communication between LAA and LA cavity. The patient is free from anticoagulation therapy.
CONCLUSIONS: Robotic-assisted surgical repair is a favorable option to treat a failed transcatheter LAA closure device.
