# Percutaneous left atrial appendage closure with concomitant dual-device implantation: a single-center observational study

## TL;DR

This study examines the safety and effectiveness of using two devices to close the left atrial appendage in patients with complex heart anatomy.

## Contribution

The study presents the largest cohort to date on dual-device left atrial appendage closure in complex anatomies.

## Key findings

- Technical success was achieved in all 10 dual-device implantation cases.
- One patient experienced a non-clinically relevant pericardial effusion within the first week.
- At 1-year follow-up, three patients developed pericarditis, with no thromboembolic events or device-related issues.

## Abstract

Percutaneous left atrial appendage (LAA) closure (LAAC) is a proven stroke prevention strategy for patients with atrial fibrillation (AF). However, incomplete sealing in complex LAA anatomies may compromise efficacy.

This study evaluates the safety, feasibility, and efficacy of concomitant dual-device LAAC in multilobed anatomies, representing the largest cohort examined to date.

We reviewed all LAAC procedures performed at the University Hospital of Bern between 2009 and 2025. Baseline characteristics, procedural details, and follow-up data were analyzed for patients receiving dual-device LAAC. Endpoints included technical success, complications, thromboembolic events, and device-related issues. Continuous data were expressed as mean ± standard deviation or median values, while categorical data were reported as percentages. Group comparisons were conducted using t-test, Mann–Whitney U test, or chi-square test. Differences were expressed as 95% confidence intervals, and a p-value of less than 0.05 was considered significant.

Of 1,307 LAAC procedures, 10 included dual-device implantation. The mean age of the patients was 71 years, and all patients were men. The Congestive heart failure, Hypertension, Age ≥75 years, Diabetes mellitus, prior Stroke or TIA, Vascular disease, Age 65–74 years, Sex category (CHA2DS2-VASc) and Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile INR, Elderly, Drugs/alcohol (HAS-BLED) scores were 3.5 ± 1.8 and 2.9 ± 1.4, respectively. Most patients (70%) had paroxysmal AF. Preprocedural and intraprocedural transesophageal echocardiography (TEE) confirmed multilobed LAA anatomy in all cases. Half of the procedures were fluoroscopy-guided with one delivery sheath and transseptal puncture, while the other half were TEE-guided with a double sheath and two transseptal punctures. Only Amplatzer devices were used: Eight procedures employed two devices of the same type [five Amulet, three Amplatzer Cardiac Plug (ACP)], and two procedures combined different types (Amulet + ACP, ACP + Amplatzer Vascular Plug). Technical success was achieved in all cases. Within the first week, one (10%) patient experienced a clinically non-clinically relevant pericardial effusion. At 1-year follow-up (completed in nine patients), three (30%) patients developed pericarditis. No thromboembolic events, device-related thrombosis, or device embolization occurred.

In this small cohort of patients with complex multilobed LAA anatomy, concomitant implantation of two Amplatzer devices proved to be a feasible strategy with acceptable short-term safety, although potentially associated with an increased risk of pericarditis.