**6. Post-procedural management and complications of percutaneous LAAO**

#### **6.1 Acute procedural-related complications**

#### i.Access-related complications

The most common complication for percutaneous LAA closure is the risk of having vascular complications, including bleeding or hematoma in the groin, arteriovenous fistula, pseudoaneurysm, or retroperitoneal bleed. Some of these complications may require further intervention or blood transfusion. These risks are slightly higher than other interventional procedure, especially due to large delivery sheath used, and the procedure is commonly performed under oral anticoagulation [21]. Furthermore, frailty or tortuosity in the vascular anatomy is also very common in elderly patients [22].

#### ii.Transeptal access-related complications

There are few complications that can be related to transeptal access. Large delivery sheath for this procedure increases the risk of air embolism and subsequently increases the risk of stroke or myocardial infarction. In addition, transeptal puncture is also correlated with increased risk of pericardial effusion or tamponade that may require pericardiocentesis, with incidence of 1.39% [22, 23]. The risk of incidental aortic puncture from transeptal was also reported, which was closed by percutaneous approach with Amplatzer Septal Occluder [24].

iii.Device embolization

Due to anatomical variability of LAA, the risk of embolization of LAAO is higher. The incidence of LAA device embolization ranges between 0% and 2%. Recent reports suggest that The Amplatzer family of devices carries a higher risk of

## *Left Atrial Appendage Occlusion: Current and Future DOI: http://dx.doi.org/10.5772/intechopen.105776*

embolization as compared with the Watchman device, with incidence of 0.78% (3,585 patients) vs. 0.26% (7,236 patients)]; p < 0.001) [25]. Device embolization can be located either in the LA, left ventricle (LV), or aorta (Ao). Although the majority cases can be managed in semi-elective manner, some can be life-threatening and need emergency procedure. Limited data of secondary adverse events related to LAA device embolization such as mitral or aortic valve damage, LV outflow tract obstruction, cardiogenic shock, or death have been described [26]. Percutaneous retrieval is preferable as compared with surgical approach. Identification of the location of the embolized device is crucial to determine the retrieval strategy. Successful retrieval using percutaneous snare has been reported [27]. However, several complications such as iatrogenic aortic rupture requiring endovascular repair may occur [28].

## iv.Other complication

Complications related to traumatic damage to surrounding structures (i.e., the circumflex coronary artery, pulmonary arteries, or pulmonary veins) have been previously described [29]. The NCDR registry showed that major complications, including in-hospital adverse events (2.16%), major bleeding (1.25%), were quite prevalent, whereas stroke (0.17%) and death (0.19%) were rare [23].

#### **6.2 Long-term issues related to percutaneous LAAO**

#### i.Iatrogenic atrial septal defects

Following transseptal LA access, iatrogenic atrial septal defects can be notable from either transthoracic or transesophageal echocardiogram. This complication can either disappear within 6 months after the procedure or persist in a small proportion of patients. Nevertheless, no hemodynamic consequences have been reported from this [30].

## ii.Peri-device leakage

The target of LAAO procedure is to get a complete closure of the LAA in order to lower the risk of thromboembolism in AF patients. In the early experience of LAAO, peri-device leakage was quite prevalent. The PROTECT-AF study showed that approximately 32% of patients still have residual leak at 1 year after procedure. However, this did not seem to increase the risk of thromboembolism [31]. Furthermore, the incidence of this outcome has markedly reduced in the more recent registries, which ranging from 0.2 to1% [23, 32].

#### iii.Device-related thrombosis (DRT)

The main reasons of DRT remain unknown. It is postulated that the incidence of DRT is combination of either procedural factors (i.e., technique of implant or type of devices used), patient factors (i.e. patient frailty, LV dysfunction, or AF duration), or post-implant management factors (i.e., duration and type of antithrombotic therapies used) [33]. Few large studies of DRT for Watchman device such as the PROTECT AF, PREVAIL trials, CAP, and CAP2 evaluated procedural outcomes with TOE at 45 days and 12 months and at 6 months in the RCTs. Over 4 years of mean follow-up, it was demonstrated that the rate of DRT was 3.74%. The main characteristics of patients

with DRT observed in this study are higher CHA2DS2VASc scores, permanent AF, and larger LAAs. The presence of DRT was also shown to be associated with a 3.55 fold increase rate of thromboembolic events [34].
