Acute Postcardioversion Left Atrial Appendage Stasis During Left Atrial Appendage Closure Procedures.

Background

Acute postcardioversion left atrial appendage (LAA) low-flow states are recognized but likely underdetected, as repeat appendage imaging is not routine after sinus restoration. CASE SUMMARY Three patients undergoing left atrial appendage closure (LAAC) developed new LAA spontaneous echo contrast, dense spontaneous echo contrast/sludge, or a persistent filling defect suspicious for thrombus within minutes of cardioversion. Ultrasound enhancing agent distinguished slow complete opacification from a persistent filling defect, guiding individualized deploy-vs-abort decisions.

Discussion

LAAC uniquely permits appendage imaging immediately before and after cardioversion, and serial intraprocedural transesophageal echocardiography offers a rarely available window on acute LAA stasis. Alternative contributors, including ablation, transseptal instrumentation, and anticoagulation strategy, warrant consideration, particularly in combined atrial fibrillation ablation/LAAC workflows. Prospective studies should define prevalence, risk markers, and mitigation strategies. TAKE-HOME MESSAGE Serial transesophageal echocardiography during LAAC can reveal acute postcardioversion LAA stasis; ultrasound enhancing agent can differentiate slow flow from thrombus and guide individualized deploy-vs-abort decisions.