Delayed Pericardial Effusion Following Left Atrial Appendage Closure: A 5-Year Single-Center Experience: An Interview With Steven J. Filby, MD

Dr Deepak L. Bhatt catches up with Dr Steven J. Filby about his Editor’s 2023 Top 10 article, “Delayed Pericardial Effusion Following Left Atrial Appendage Closure: A 5-Year Single-Center Experience.” Read the article here.

Transcript:

Dr Bhatt: Hello, I'm Dr. Deepak Bhatt, the Editor-in-chief of the Journal of Invasive Cardiology, and I'm really fortunate to have here a wonderful interventional cardiologist. He happens to be a former fellow of mine, but that's not why he's wonderful—he's just wonderful on his own right, because he's a great guy, and a very accomplished individual:  Dr. Steven Filby. He is currently the Head of the Cath Labs and Director of the Interventional Cardiology Fellowship at University Hospitals in Cleveland, a place that I'm quite fond of, I should say. And he has been productive in many ways, but what caught my attention was an article we published in the Journal of Invasive Cardiology, really what I thought was one of the top 10 articles of last year, where he and his group looked at delayed pericardial effusions after a left atrial appendage closure and related to us—in print—the 5-year single-center experience, and he was a senior author of this, I think, really interesting paper. So maybe you can just start off saying a little bit about why you did the study what the clinical concern was, and what you found.

Dr Filby: Sure, well, thanks for having me. The genesis of this really came from our switch to same-day discharge, you know, like a lot of hospitals after the COVID pandemic; we had a lot of interest in having same-day discharge for catheter-based procedures, including structural intervention. And as we sought to send these patients home, one of the concerns was, could they, in fact, have to return? Would there be complications that might manifest after, you know, an abbreviated time in an early discharge. We actually had 1 or 2 patients that we had recognized with the delayed pericardial effusion that further galvanized our efforts to look more closely at this and to try and understand why this process was occurring so that we could mitigate this or obviate it completely.

Dr Bhatt: Yeah, I think it's a really important relevant question. And do you think then this is a strategy, same day discharge after left atrial appendage closure that could, should be broadly employed just by medical centers around the country and around the world? Of course, during the pandemic, there was a lot of pressure to get patients out, whether it was left atrial appendage or TAVR or anything. you know, really expediting their care. And I think we learned a lot, you know, during that time period in particular, though, the period of your study, in fact, predated the pandemic starting, I think, in December of 2016. But what are your thoughts? Is this something, do your data support the concept of early discharge? Or you did mention there are still some late effusions that occurred? Is that enough of a worry to keep a whole bunch of patients there? How should we actually handle this in clinical practice?

Dr Filby: I don't think the incidence of delayed pericardial effusions is sufficient to warrant an abandonment of same-day discharge. And, you know, we've published extensively on same-day discharge. Our experience has been that this is a safe protocol to employ with left atrial appendage closure. I mean, really, we found ourselves, we moved to same day discharge, we found ourselves not really doing anything for the patient during that period of observation. And then when we looked at it, we found a cost savings associated, of course, because you're not having the patient occupy that hospital bed overnight. We know pericardial effusion in general is a feared complication of left atrial appendage. Most of those occur early in the context of the procedure, but they can occur late. We can see delayed pericardial effusions. And even with improvements in device technology, those are going to exist. But they're so infrequent, I mean, it's really a relatively uncommon thing. I really think that it's safe to continue with same-day discharge as long as you observe a few cautions during the procedure, and there's some anecdotal things that we've picked up along the way as well, but this was an observational study that still helped to inform our practice.

Dr Bhatt: That's terrific. And I think for people that are considering trying this at home, in their own institutions, it's important to let them know what sort of imaging protocol you did. I believe you, as many places that are contemplating same-day discharge of these patients, you do an ECHO beforehand, look at a baseline and then 1 afterwards, 6 hours or so, post-procedure. Is that correct?

Dr Filby: That's correct. We, you know, this, as you pointed out, this 5-year experience really straddled an evolution in our program where we changed from a TEE sizing protocol to a CT-ICE, CT-plan procedure, ICE-implanting strategy. And but for all those, all the patients we obtained a surface ECHO immediately before, limited views, and then a surface ECHO 6 hours after the implant. Again, same views, we try and get the same machine and the same ECHO tech if we can.

Dr Bhatt: Yeah, no, that's a really good system. And not that this is directly germane to the topic at hand, but you also would get then a TEE or CTA 45 days post-procedure, correct? –

Dr Filby: Yeah, our protocol practice currently, Dr. Bhatt, to get one at 4 months. We image everyone with a CT, if their renal function in this allows us to, and we do so at 4 months. And that was largely based on champion. We sort of adopted the champion protocol as we were imaging early, but because we're doing CT, we found a lot of pseudo leaks, that is, flow through the device, contrast in the appendage, that created ambiguity for us, for our imaging team and that led to unnecessary TEEs to sort of tie break the situation.

Dr Bhatt: So, in the study, you were doing 45 days post-procedure. Now you're doing 4 months.

Dr Filby: Yes, we switched over.

Dr Bhatt: Yep. Now that's really very sensible in keeping with the latest data. This I know also wasn't the exact topic of this paper, but you mentioned ICE, you know, some folks are very facile and comfortable and like ICE. Many are still using TEE guidance. Any thoughts about one vs the other?

Dr Filby: I think that there's a learning curve. Certainly, we use 2D ICE, and that requires the catheter not only in the left atrium, but manipulating in the left atrium. And you want to get 3 views, at least, so that you ensure that you have a good, that you satisfied your release criteria. And the, the movement of that catheter, the adjustment of the catheter, it does, it does, there is a learning curve associated with that. There, there's been some concern with, especially some of the data that came from SURPASS that people who are less experienced with ICE catheters may have a higher rate of pericardial effusion as, as it relates to injury from the catheter. But when we see that in more experienced hands, such as with the ICE LAA study, we don't see the same incidents of injury or pericardial effusion or complication. So, I do think that there's an operator learning curve. I don't think it's a very big curve. And I certainly, having a nice strategy for our hospital has led for a lot of efficiency and it's really been part and parcel of our same day discharge protocol.

Dr Bhatt: No, that’s terrific. Those were really some pearls of wisdom there. Any other thoughts about your study that you wanted to share with the audience?

Dr Filby: Well, I think there's a couple of things that we gleaned from it. One of the things is that the patients who experienced delayed pericardial fusions, none of them have been treated with protamine. And that's, this is, again, this is, we're really not powered to make strong statements, but it certainly did inform our practice afterwards. So, we do try and reverse with protamine in every patient that we do. One of the other things that we avoid is an aggressive tug test. I think particularly when we see an auto tug, which is when the core wire will piston within the system, we know that there's a lot of tension being placed on that device. The device itself has circumferentially mounted J-type anchors that dig into the left atrial appendage and that tissue of the left atrial appendage is exceptionally thin, on average about 0.6 millimeters. So, we're very careful not to really aggressively tug, unless we see movement. If we see device movement, we're going to be a little bit more aggressive about our tug test. Now we still do a retention or a tug test, I'm just suggesting that we don't be very aggressive about it, particularly with the Amulet device. The Amulet device has anchors that in the first generation are twice the length of the anchors with the Watchman FLX device.

Dr Bhatt: Yeah, no, those are really valuable points for folks that are doing these sorts of procedures or starting to do them. Any other parting comments to the audience?

Dr Filby: Well, I'm pleased to be to be part of this discussion and, you know, I think that going forward as this technology involves one of the things that the device companies have done is they've added more retention anchors, that helps with device stability, but there's always a trade-off. So, the more anchors you have, the more stable the device, but the more possibility for micro-fenestrations associated with the procedure. So, be cautious with your tug tests. We look forward to devices that are safer in the future as they've continued to evolve. And yeah, I think having little concern for same-day discharge, I think, I think that the incidence of this delayed pericardial effusion is really so small that hospitals can go and employ the same-day discharge and feel comfortable doing so.

Dr Bhatt: Yeah, I agree. I can't recall if his time overlapped with yours while you were at Cleveland Clinic, but one of the residents from there, Jeremiah Depta, he's in Rochester now heading up structural intervention there. They've also published some work on same-day discharge after left atrial appendage closure. And likewise, it looked to be quite safe. So, I think with enough sort of expertise and caution, it certainly can be done. And I think especially as we're trying to make procedures more patient friendly, more cost effective, those sorts of steps can really help. Well, it's been fantastic chatting with you. Congratulations to you and your team on some great work and say hello to all my friends at UH for me.

Dr Filby: Will do it. Thanks for having me again.

Dr Bhatt: Yes, wonderful speaking with you. All the best.