Background-Left atrial appendage (LAA) ligation with the Lariat device is being used for stroke prevention in atrial fibrillation. Residual leaks into the LAA are commonly reported after the procedure. Little is known about the anatomic LAA remodeling after Lariat ligation. Methods and Results-In an exploratory study, we evaluated LAA 3-dimensional geometry via computed tomographic scan in 31 consecutive patients before Lariat closure and after a minimum of 30 days post procedure. Thirteen

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... nts were classified as unfavorable cases based on anatomic criteria. Our population had an average age of 70±12 years, a mean CHADS2 (congestive heart failure, hypertension, age>75, diabetes mellitus, history of stroke) score of 3.2±1.2, a mean CHADS2VASC (CHADS2 in addition to female sex, ages 65-75, as well as double impact of age >75, vascular disease) of 4.2±1.5, and a mean HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding predisposition/history, labile international normalized ratio, elderly, drugs/alcohol) bleeding score of 4.0±1.1. Successful suture deployment was achieved in all cases, but 3 patients had intraprocedural residual flow into the LAA (leak). On follow-up, 10 patients (32%) had recanalized residual LAA cavities, which were morphologically similar to the original LAA, albeit significantly smaller in volume (22.5±13.3% of the original volume). Recanalization was not associated with age, sex, comorbid conditions, stroke or bleeding risk scores, follow-up interval, baseline LAA volume, or morphology. Unfavorable cases had anatomic outcomes comparable with those of the anatomically favorable population. No patients have exhibited thromboembolism after 842±338 days post ligation. Conclusions-Incomplete LAA ligation after Lariat is common. However, the remodeled LAA cavity is dramatically reduced. Diminished cavity size and tightening of the LAA orifice may play a role in the reduction of thrombus formation. Circ Arrhythm Electrophysiol December 2015 protocol. Initial data (n=8) were collected retrospectively from patient charts. The subsequent 23 patients were consecutive patients studied prospectively. This data included medical history, procedural reports, and major events, including thromboembolic and hemorrhagic incidences. CHADS2 (congestive heart failure, hypertension, age>75, diabetes mellitus, history of stroke), CHADS2VASC (CHADS2 in addition to female sex, ages 65-75, as well as double impact of age >75, vascular disease), and HASBLED (hypertension, abnormal renal/liver function, stroke, bleeding predisposition/history, labile international normalized ratio, elderly, drugs/alcohol) scores were then calculated (Table 1 ). Figure 6. Complex left atrial appendage (LAA) stump morphology after successful Lariat ligation of a complex LAA. A and B, Threedimensional reconstructions of the LAA before ligation. A large posterior-superior LAA lobe is seen. C and D, LAA angiograms before and after Lariat ligation, showing complete occlusion without leaks. E and F, Computed tomographic images post Lariat, showing protruding LAA tissue against the LAA neck (arrow, density consistent with tissue and not with thrombus), and a complex, ring-like geometry of the LAA stump.