Objective:

To reframe post-LAAO imaging findings as imaging-defined residual risk markers and propose an evidence-informed framework that explicitly links management considerations to supporting evidence.

Approach:

• Imaging Findings Organization: Post-LAAO findings are categorized into three domains: device surface abnormality, residual communication, and device-appendage geometry.
• Evidence Linking: Each clinical consideration is linked to its principal supporting evidence sources, including randomized trials, registry data, and expert consensus.

Key Findings:

• Device-related thrombus (DRT) occurs at a rate of approximately 6.3 per 100 patient-years, compared to 1.7 per 100 patient-years in those without DRT, highlighting its clinical relevance.
• Hypoattenuated thickening (HAT) presents a range of imaging phenotypes from expected healing to thrombus-like abnormalities.
• CCTA detects residual appendage patency and peri-device leak (PDL) more frequently than TEE, but this does not guarantee clinical actionability.

Interpretation:

Post-LAAO imaging should transition from binary surveillance to risk-weighted interpretation, with most management implications based on expert consensus and observational data rather than prospective trials.

Limitations:

• Current guidelines acknowledge uncertainty in imaging surveillance and management of DRT and PDL.
• The proposed framework is provisional and not validated as a treatment algorithm.

Conclusion:

Outcome-linked imaging thresholds and prospective validation are necessary for incorporating imaging-defined residual risk into clinical decision pathways.