Stroke After Surgical Left Atrial Appendage Clip With Residual Neck Thrombus: Transcatheter Plug Closure

Background Incomplete left atrial appendage clip closure is a recognized complication and may increase thromboembolic risk. Case summary A 72-year-old woman with persistent atrial fibrillation presented with a left middle cerebral artery stroke while on apixaban. History included mitral valve repair with epicardial left atrial appendage clip and AV-junction ablation with a leadless pacemaker. Local transesophageal echocardiogram (TEE) reported complete ligation without thrombus; cardiac computed tomography at our institution demonstrated incomplete ligation with a narrow residual ostium and an 11 × 6 mm thrombus. With Sentinel cerebral embolic protection, intraprocedural TEE identified a 6 × 5 mm residual communication. Single transseptal access (Agilis sheath, VersaCross RF wire) permitted traversal of the neck; a 12-mm Amplatzer Vascular Plug II was implanted. TEE and angiography confirmed complete seal; recovery was uneventful. Take-home messages Computed tomography and TEE should confirm exclusion before stopping anticoagulation after clip ligation. Plug occlusion performed with cerebral embolic protection can convert incomplete surgical exclusion to complete closure.