Related Experiment Video
Updated: Jan 20, 2026
Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
Published on: February 8, 2022
Recurrent device-related thrombosis after left atrial appendage closure with the watchman FLX: A case report and
Yuemiao Jiao1, Yue Yu1, Guangyuan Song1
1Department of Interventional Center of Valvular Heart Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, 100029, China.
Insights
Device-related thrombosis (DRT) can recur late after Watchman FLX left atrial appendage closure (LAAC), even with anticoagulation. Management requires vigilant imaging, tailored anticoagulation, and advanced device designs to prevent future events.
Area of Science:
- Cardiology
- Medical Devices
- Thrombosis Research
Background:
- Left atrial appendage closure (LAAC) is effective for stroke prevention in atrial fibrillation (AF) patients intolerant to anticoagulation.
- Device-related thrombosis (DRT) is an infrequent but serious complication, increasing embolic event risk, even with newer devices like the Watchman FLX occluder.
Purpose of the Study:
- To highlight the challenges in managing device-related thrombosis (DRT) after left atrial appendage closure (LAAC).
- To discuss the multifactorial nature of DRT and propose optimal management strategies.
Main Methods:
- A case report of a 72-year-old female patient with paroxysmal AF who developed recurrent DRT after LAAC with a Watchman FLX device.
- Utilized cardiac CT and transesophageal echocardiography for diagnosis and monitoring.
- Reviewed current evidence on DRT pathogenesis and management.
Main Results:
- The patient developed device-surface thrombus eight weeks post-LAAC, which resolved with warfarin.
- Recurrent, larger DRT was detected at 22 months despite continued anticoagulation.
- Case highlights multifactorial DRT causes including patient-specific hypercoagulability, device size, and antithrombotic regimen.
Conclusions:
- Recurrent, large-burden DRT can occur late after Watchman FLX implantation despite initial treatment.
- Optimal management necessitates vigilant imaging, tailored anticoagulation, thrombophilia assessment, and improved device bioengineering.
- Further research is needed to refine antithrombotic strategies and identify imaging biomarkers for DRT prevention.
Background:
Left atrial appendage closure (LAAC) effectively lowers stroke risk in atrial-fibrillation (AF) patients who cannot tolerate long-term anticoagulation. Device-related thrombosis (DRT), although infrequent, carries a threefold increase in subsequent embolic events and remains a therapeutic challenge, even with the newer Watchman FLX occluder.
Case Summary:
A 72-year-old woman with paroxysmal AF (CHA2DS2-VASc = 5; HAS-BLED = 2) underwent LAAC with a 30 mm Watchman FLX after bleeding-limited warfarin use. She was prescribed dual antiplatelet therapy (DAPT) post-procedure. Eight weeks later, cardiac CT detected a device-surface thrombus; warfarin (INR 2.5-3.0) achieved complete resolution by 7 months. Despite continued anticoagulation, repeat CT at 22 months revealed a larger thrombus. Transesophageal echocardiography confirmed recurrent DRT.
Discussion:
This case underscores multifactorial DRT pathogenesis: patient-specific hypercoagulability (age, persistent AF, PAI-1 variant), anatomic factors (large LAA, 30 mm device), and premature INR reduction. Current evidence indicates that early hypoattenuation thickening on cardiac CT, peri-device leak, and suboptimal antithrombotic regimens are associated with DRT. Emerging data support CT-based surveillance, individualized anticoagulation-potentially favoring direct oral anticoagulants (DOACs)-and next-generation, endothelialization-oriented device designs.
Conclusion:
Recurrent, large-burden DRT can occur late after Watchman FLX implantation despite initial thrombus resolution and guideline-directed therapy. Optimal management requires (1) vigilant, multimodality imaging follow-up; (2) stringent, patient-tailored anticoagulation with real-time INR or DOAC level assessment; (3) consideration of genetic or laboratory markers of thrombophilia; and (4) advances in device bioengineering to accelerate endothelial healing. Further studies should refine risk-stratified antithrombotic strategies and validate imaging biomarkers to pre-empt DRT in high-risk LAAC recipients.
Related Concept Videos
07:41Echocardiographic Evaluation of Atrial Communications before Transcatheter Closure
07:28Donor Posterior Atrial Flap Rotation for Left Atrial Cuff Reconstruction in Lung Transplantation
09:15In Vitro Thrombosis Test for Ventricular Assist Devices
08:34Left Atrial Stenosis Induced Pulmonary Venous Arterialization and Group 2 Pulmonary Hypertension in Rat
06:25Cooling or Warming the Esophagus to Reduce Esophageal Injury During Left Atrial Ablation in the Treatment of Atrial Fibrillation
08:49Cardiac Loading using Passive Left Atrial Pressurization and Passive Afterload for Graft Assessment