Lessons learned from experimental models of cerebrovascular aneurysms to improve endocardial device occlusion of the left atrial appendage

In patients with atrial fibrillation, left atrial appendage (LAA) occlusion devices represent an alternative to anticoagulation but are associated with residual peridevice leaks (PDLs) and device-related thrombi (DRT). Similarly, cerebrovascular aneurysms can be treated with coil embolization, but pericoil leaks represent a significant limitation. In experimental models of cerebrovascular aneurysms, endothelial denudation achieved independently with (1) embolization with radioactive coils, (2) mechanical removal of the endothelium, or (3) radiofrequency ablation was dramatically effective in preventing or eliminating pericoil leaks. Anatomical, physiological, and blood flow similarities exist between the LAA and saccular aneurysms. Concepts developed in treating aneurysm leaks can be used to treat similar problems in the LAA. Learning from aneurysms, we conceived of a novel technique to denude local endothelium and thus eliminate residual leaks around LAA-occlusion devices. We recently successfully tested this hypothesis in patients with a PDL in a prospective manner in a multicenter study. In this article, we expand on the rationale of the technique developed to close PDLs and potentially also prevent DRTs.