Residual Left Atrial Appendage After Incomplete Surgical Closure

BACKGROUND: Anticoagulation reduces the risk of stroke in patients with atrial fibrillation, but not all patients can tolerate therapy. Although surgical left atrial appendage occlusion (LAAO) offers an alternative approach, incomplete left atrial appendage (LAA) closure can present management challenges. CASE SERIES SUMMARY: We present 2 cases of residual LAA after surgical LAAO. In one case, an 81-year-old man with prior AtriClip developed anemia and subclinical bleeding, precluding long-term oral anticoagulation. Incomplete surgical LAA closure was confirmed on computed tomography, and he was successfully treated with transcatheter LAAO. In the second case, an 84-year-old woman with prior AtriClip and history of intracerebral hemorrhage presented after an acute ischemic stroke. Her high bleeding risk and residual LAA anatomy precluded both standard-dose therapeutic anticoagulation and transcatheter intervention. DISCUSSION: Incomplete surgical LAA closure presents unique management challenges. Both transcatheter and medical management have roles, depending on individual patient anatomy and comorbidities. Careful follow-up imaging is crucial for identifying residual LAA patency after surgical occlusion.