1. Delayed Common Post-operative complications occurred after LAAO Dr. Iat-Lon,Leong Department of Medicine, Division of Cardiology Macau Kiang Wu Hospital

2. Atrial Fibrillation Stroke prevention is an important Consideration. (1/3 Afib patients will suffer a stoke) Treatment with anticoagulant medications. The majority of embolic strokes originate from the left atrial appendage ( 90% of the clots form in the LAA) Left atrial appendage occlusion devices offer a non- pharmacologic alternative to anticoagulant medications.

3. Case Information Asian Gentleman 67 y.o PH: HBP & T2DM Holter : Paroxysmal atrial fibrillation and atrial flutter (2010) CHA 2 DS 2 -VASC Score :3

4. Case Information Anticoagulant medications Warfarin 3~3.5mg  Dabigatran 110mg BID Poor INR control Recurrent Side effect Petechiae 11/2010 Transient Ischemic Attack 2/2012 Hematuria 1/2014 Thalamus hemorrhage 4/2014 Stable after Conservative treatment

5. Case Information HAS-BLED Score: 4 HAS-BLED score: 4. The patient has a HIGH risk of bleeding (HAS-BLED score >/=3). The risk of major bleeding within 1 year in patients with atrial fibrillation enrolled in the Euro Heart Survey, expressed as bleeds per 100 patient years: 8.7%. Some caution and regular review of the patient is needed following the initiation of antithrombotic therapy, whether with oral anticoagulation or aspirin.

6. LAAO 2014/06/21 LAA Orifice diameter 21.6mm (TEE) 26mm Amplatzer Cardiac Plug was selected Smooth Procedure Angiography and TEE were performed Antithrombotic Therapy (Dual platelet inhibition) : ASA(100mg/d)+Clopidogrel(75mg/d) =4-6 weeks=> ASA(100mg/d) Good condition follow up at 7/2014

7. REFERENCELAA Orifice

8. TEE

9. IMPLATIONANGIOGRAPHY

10. Nightmare 22/7 was send to AED Complain : SOB, Abdominal pain and sweating for half hour BP:79/53mmHg, Pulse: 87bpm, SPO 2 : 95 % FAST test : Large pericardial effusion ◦ Pericardiocentesis : bloody drainage solution Continue to observation at ICU

11. Recurrent drainage of pericardial effusion 400~500 ml drainage Solution /1 st day 10~20ml drainage at follow time CT (23/7) : No Peri-device Leak, Mild pericardial effusion, No significant contrast extravasation

13. Treatment 1. Stop Antithrombotic Therapy 2. Pericardial drainage 3 Remove the drainage set 7 days later ECHO follow up : No significant pericardial effusion Patient discharged at 15/Aug Good Condition F/U at OPD

14. Question 1. Why was it happened 1 month after procedure? 2.Why did it occur so urgent in this event ? 3. Did it relate with antithrombotic therapy? 4. How is the follow up of this procedure?

15. LAA occlusion Complication ComplicationRATE Pericardial Effusion5% Stroke (Procedure-Related,No Procedure-Related)0.9% Device-associated thrombus4.2% Bleeding0.8% Vascular Complications0.8% Device Embolization0.6% V Reddy,et al Circulation,2011

16. Amplatzer Left Atrial Appendage Occlusion: Single Center 10-Year Experience 152 pts in Europe

17. ACP Post-Market EU observational Study

18. ACP Post-Market EU Observational Study

20. Antithrombotic Therapy First 6 weeks TEE ruled out thrombus and Peri-Device flow OAC, Dual Platelet Inhibition  ASA 100mg/d Antithrombotic Therapy Time Aspirin 100mg/d + Clopidogrel 75mg /d  Aspirn 100mg/d6 weeks Aspirin 100mg/d6 weeks Warfarin/NOAC (prexisting OAC)6 weeks

21. Conculsion: Cause of Pericardial Effusion is unknow Dual platelet inhibition?? No Guideline can be follow of the Antithrombotic Therapy (ASA? ASA + Clopidogrel? Warfarin?) Regular Follow up is necessary (TEE/CT/ECHO) Closely monitor at first month 6 week / 3 month / 6 month /1 yr

22. In the future More Trial to reduce the Probability of complications Recommendation of Antithrombotic Therapy Type and Duration

23. Thank you