Coil Closure of Peri-Device Leak After Left Atrial Appendage Occlusion: A "Soccer Ball" Seal.

BACKGROUND

Peri-device leak after left atrial appendage closure has emerged as a clinically relevant finding, which has been associated with residual thromboembolic risk. Strategies to achieve complete seal after left atrial appendage closure (LAAC), including coil- and plug-based approaches, are increasingly being used in selected anatomies.

CASE SUMMARY: An 82-year-old woman with paroxysmal atrial fibrillation underwent prior LAAC. Follow-up cardiac computed tomography and transesophageal echocardiography demonstrated a skirt leak caused by incomplete sealing of the inferior aspect of the device, with persistent communication between the left atrium and distal appendage lobes. Given concern for residual embolic risk, she underwent transcatheter leak closure under transesophageal echocardiography and fluoroscopic guidance using detachable coils (Ruby Coils; Penumbra). The final fluoroscopic appearance was a compact ball-like coil mass within the appendage, with complete angiographic occlusion.

DISCUSSION: Multimodality imaging defined the mechanism of residual leak and guided selection of coil embolization over focal plug-based closure. In selected anatomies, coil closure alone may provide an effective solution for persistent peri-device leak.

TAKE-HOME MESSAGE: Residual peri-device leak after LAAC should be characterized mechanistically, not only by size. In anatomically selected skirt leaks, coil embolization can achieve durable closure with excellent imaging and clinical follow-up.