Hybrid Left Atrial Appendage Exclusion Management: WATCHMAN After AtriClip

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/25.00353. Epub November 21, 2025.

AtriClip (AtriCure) is the most widely used device-based technique for epicardial left atrial appendage (LAA) exclusion. Nonetheless, incomplete occlusion or residual stumps can occur and sustain thromboembolic risk. We report the case of an 88-year-old woman with paroxysmal atrial fibrillation, sick sinus syndrome status post permanent dual chamber pacemaker, elevated thromboembolic risk (CHA₂DS₂-VASc 6 [female, age >75 years, hypertension, coronary artery disease/aortic plaque, history of acute decompensated heart failure]), severe aortic stenosis, and a history of bleeding (mechanical fall resulting in subdural hematoma) that precluded long-term anticoagulation.

The patient had undergone surgical aortic valve replacement and coronary artery bypass grafting with concomitant AtriClip LAA exclusion 8 years ago at an outside facility prior to presentation. Transesophageal echocardiography (TEE) revealed incomplete closure (Figure 1A and B). Because of residual stump and the patient’s bleeding tendency, percutaneous closure was pursued. A 20-mm WATCHMAN device (Boston Scientific) was deployed with appropriate compression and stability, meeting PASS (position, anchor, size, seal) criteria (Figure 2A-C; Video 1). Post-deployment imaging confirmed complete occlusion with no peridevice leak, and the patient recovered uneventfully on a tailored post-implant antithrombotic regimen (Video 2).

This case highlights a clinically important limitation: even with AtriClip, incomplete closure can occur and leave a thrombogenic remnant. Salvage percutaneous closure has emerging support. Ice et al described the first successful WATCHMAN implantation for an 18 × 13-mm AtriClip stump, while Golzarian et al reported a multicenter series of 3 surgically incomplete closures—including 2 AtriClip cases—all successfully treated with a WATCHMAN device.^1,2 Together with our experience, these reports reinforce that staged endocardial closure is safe and effective.

Three key lessons emerge: first, surgical LAA exclusion should not be assumed successful without follow-up imaging; second, TEE is indispensable for both detection of incomplete closure and procedural planning; third, in patients unable to tolerate anticoagulation, percutaneous closure offers a definitive solution.

Leili Pourafkari, MD^1,2; Jeong Hwan J. Kim, MD¹; Jonathan Lalezari, MD¹; Ali Sovari, MD^1,3

From the ¹Department of Cardiovascular Disease, Los Robles Regional Medical Center, Thousand Oaks, California; ²Department of Anesthesiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York; ³Department of Cardiology, St. John’s Regional Medical Center, Oxnard, California.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: The authors confirm that informed consent was obtained from the patient for the intervention described in the manuscript and to the publication of their data, including all images.

Address for correspondence: Ali Sovari, MD, Department of Cardiology, St. John’s Regional Medical Center, 1600 N. Rose Ave, Oxnard, CA 93030, USA. Email: alisovari@gmail.com