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Maurina et al. Mini-invasive Surg 2021;5:53 https://dx.doi.org/10.20517/2574-1225.2021.88 Page 7 of 13

TEE in detecting LAA thrombosis and can lead to misdiagnosis in the case of a “pseudo-thrombus” due to a
delayed contrast flow into the LAA body. Moreover, it requires intravenous injection of nefrotoxic contrast
medium.

Finally, image fusion is a very innovative technique that has gained popularity over the last years as an
alternative to traditional imaging in guiding LAA occlusion procedures. This technology integrates the
fluoroscopy into 3D CCTA and provides both real-time images regarding trans-septal puncture and device
deployment and spatial information about the surrounding structures, which are difficult to assess with the
3D TEE alone. This technique, when performed by highly experienced operators, has been demonstrated to
be even superior to standard TEE in terms of one-time successful deployment rate . However, due to the
[34]
higher cost compared to standard imaging, we believe that it could enter common clinical practice only in
high-volume centers where LAAO is routinely performed.

PERIPROCEDURAL COMPLICATIONS
The most relevant and frequent periprocedural complications of LAAO are pericardial effusion and device
embolization, while others such as stroke or access-site-related complications are relatively rare.

Pericardial effusion may be completely asymptomatic, or it may present as acute/subacute cardiac
tamponade. It may be related to the transeptal puncture or the manipulation of catheters and the device
against the thin-walled left atrium. Incidence of serious pericardial effusion ranges from 2.2% to 5%, and
pericardiocentesis has shown to be a safe and effective treatment for it . It should be performed
[35]
immediately in the case of hemodynamic instability, while, in the case of subacute or mild effusion, non-
steroidal anti-inflammatory drugs (e.g., aminosalicyclic acid or ibuprofen) are the treatment of choice.

Device embolization may happen early, during the procedure, or later, during follow-up. Embolization
[13]
occurs in < 0.5% of patients . Careful selection of the appropriate device and a correct deployment
technique are the best way to avoid it. Percutaneous retrieval of the embolized device is the treatment of
choice, if technically feasible, otherwise surgical retrieval may be required.

MANAGEMENT OF ANTITHROMBOTIC THERAPY
Periprocedural antithrombotic therapy
LAA closure is a percutaneous procedure, performed via transfemoral venous access. Anticoagulation with
unfractionated heparin (UFH) is recommended during the procedure: it should be started prior to or
immediately after transeptal puncture, at a dose of 70-100 IU/kg, aiming for an activated clotting time of ≥
250 ms. In patients with a contraindication to UFH, bivalirudin may be considered. Ideally, naive patients
should receive a loading dose of acetylsalicylic acid (300-500 mg). Moreover, patients who are candidate to
be discharged without oral anticoagulant therapy should be given an oral loading dose of clopidogrel (300-
600 mg) prior to the procedure .
[12]

Antithrombotic therapy discharge
The only available randomized clinical trials (RCTs) (PREVAIL and PROTECT-AF) did not include
patients with contraindication to OAC. For this reason, the post-procedural management pursued in these
studies consisted in a combination of warfarin (target INR 2-3) and aspirin 100 mg for the first 45 days,
followed by a first six-month DAPT period (aspirin and clopidogrel) and then by SAPT indefinitely.
However, most patients undergoing percutaneous LAA closure have an absolute contraindication to OAC.
In these cases, as endorsed by the recent EHRA/EACPI expert consensus statement , a first six-month
[12]
period of DAPT (aspirin and clopidogrel), followed by SAPT indefinitely is recommended. Although this