Direct current cardioversion practices following percutaneous left atrial appendage closure

Area of Science:

• Cardiology
• Interventional Cardiology
• Electrophysiology

Background:

• Percutaneous left atrial appendage closure (LAAC) is an alternative to oral anticoagulation for stroke risk reduction in non-valvular atrial fibrillation (AF).
• Direct current cardioversion (DCCV) is sometimes performed after LAAC to restore sinus rhythm.
• Optimal protocols for imaging and anticoagulation before and after DCCV in LAAC patients are not well-defined.

Purpose of the Study:

• To evaluate real-world utilization of transesophageal echocardiography (TEE) or cardiac computed tomography angiography (CCTA) prior to DCCV.
• To assess the patterns of oral anticoagulation (OAC) use before and after DCCV in patients with AF post-LAAC.
• To determine the incidence of left atrial thrombus (LAT), device-related thrombus (DRT), and peri-device leak (PDL) in this patient cohort.

Main Methods:

• Retrospective single-center study of patients undergoing DCCV after percutaneous LAAC (2016-2022).
• Key data collected included pre-DCCV imaging (TEE/CCTA), pre- and post-DCCV OAC use, and incidence of adverse events.
• Adverse events included LAT/DRT, PDL, stroke, systemic embolism, device embolization, major bleeding, or death within 30 days.

Main Results:

• 122 DCCV procedures were performed in 76 patients post-LAAC. Watchman devices were most common.
• 25% of DCCV cases were considered non-guideline based due to inadequate OAC duration or lack of pre-DCCV imaging.
• Of 70 cases with pre-DCCV imaging, 23% showed PDL and 6% had LAT/DRT, leading to procedure cancellation in some instances. No DCCV-related complications occurred within 30 days.

Conclusions:

• Significant variability exists in the application of TEE/CCTA and OAC around DCCV post-LAAC.
• Pre-DCCV LAA imaging is crucial, particularly within the first year after LAAC, to evaluate device placement, PDL, and detect LAT/DRT.
• Standardized protocols may improve the safety and efficacy of DCCV in patients with prior LAAC.