Fig. 8.1
Large LAA closed with Amulet 34 mm: the RAO-Cranial angiography revealed a large LAA with an ostium of 36 mm (green line 1) and a landing zone (neck) of 31 mm (green line 2). The RAO-Caudal view showed an ostium of 30 mm and a landing zone of 32 mm
Fig. 8.2
A 34 mm Amulet was implanted. The tug test resulted in device pop-out
Fig. 8.3
The device was re-positioned deeper using the “triangular shape technique”. All five signs of stability were fulfilled
Fig. 8.4
The final angiography showed complete sealing of the LAA
8.2 Closure of a Shallow, Double Lobe LAA with Embolization
Learning objectives: interpret warning signs of device embolization.
The angiography shows a funnel-shaped LAA with two lobes visualized in the RAO caudal projection (Fig. 8.5). As the distal lobe does not anchor adequately (Figs. 8.6 and 8.7) the device embolizes after release (Fig. 8.8).
Fig. 8.5
Device embolization of a 25 mm Amulet occluder: angiography in the RAO-Cranial 20 view revealed a relatively shallow funnel shaped LAA. The LCx coronary artery is stented so it can be used as an anatomic landmark on fluoroscopy. Angiography in the RAO-Caudal 20 view reveals a double-lobe shallow LAA. The quality of angiography is suboptimal due to the lack of selective injection
Fig. 8.6
Device embolization: a 25 mm Amulet device was implanted but the device was not placed distally enough. According to the instructions for use (IFU), 2/3 of the device lobe must be placed distal to the LCx artery (this is usually an echocardiographic criterion). In this case the stented LCx artery can be seen on fluoroscopy and the lobe of the device is not deep enough. Moreover, there is no separation between the disc and the lobe and the disc has only a slight concave shape. Device lobe compression and orientation are adequate. Therefore, in this view only 2 out of the 5 signs of stability are visible
Fig. 8.7
The RAO-Caudal view reveals a shallow implant without lobe-disc separation or a concave shape of the disc. A tug test was performed (not shown) that showed good stability of the device (probably due to the anchoring by the device stabilizing wires) so the device was released
Fig. 8.8
The device embolized immediately after release. It was successfully snared percutaneously without complications
8.3 LAA with Two Proximal Lobes
Learning objectives: exact positioning of the Amulet device allows for complete sealing.
CT and angiography allow for exact understanding of the anatomy of this particular LAA (Figs. 8.9 and 8.10). Sizing of the distal and proximal landing zones lead to the decision of using a 28 mm Amulet device (Fig. 8.10). An initial release was too proximal (Figs. 8.11 and 8.12), therefore a more distal release was performed (Fig. 8.13). This finally resulted in a good device position with complete closure as judged by angiography (Fig. 8.14) and TEE (not shown). A final prolonged tug test confirmed good device position (Fig. 8.15).
Fig. 8.9
Closure of LAA with an additional small lobe close to its ostium (Amulet 28 mm): pre-procedural MSCT allows for a detailed evaluation of the LAA. Multiplanar reconstruction shows a LAA with a relatively small ostium and an early lobe close to the ostium (panel a). The landing zone for the Amulet lobe is 12 mm distal to the ostium (red line 4, panel a), which is at a “step-down” between green line 3 (20 mm) and green line 2 (25 mm). In panel b, in a different plane, the ostium is larger and the landing zone is 25 mm. In this plane the LAA looks quite shallow. Based on the MSCT data, the patient was judged suitable for an Amulet size of 28 or 31 mm (25 mm landing zone). However, due to the relatively low depth a 28 mm device seemed more appropriate
Fig. 8.10
The RAO-Cranial angiography reveals a LAA with an ostium of 23 mm and a landing zone between 19 and 27 mm due to the “step-down” created by the additional early LAA lobe. The RAO-Caudal view shows an ostium of 22 mm and a landing zone of 25 mm. A 28 mm Amulet device is chosen
Fig. 8.11
The device is advanced using the ball technique in an RAO-Cranial view. The LAA ostium is denoted by the green line
Fig. 8.12
The Amulet lobe deployment is performed. In the Cranial view the device lobe looks off-axis and as if it is protruding into the left atrium. Before deciding to recapture a caudal view was taken, which reveals good device orientation but relatively proximal position of the lobe. The LAA ostium is denoted by the green line
Fig. 8.13
Decision is made to recapture the device and reposition it deeper. The “triangular shape technique” is used in order to advance the device safely deep in the LAA. The final Amulet lobe position is 2 mm deeper than the first one. The LAA ostium is denoted by the green line
Fig. 8.14
Angiography in the RAO-Cranial view showed complete closure of the LAA, except for a small leak that allows contrast to enter the early lobe (arrow). The Amulet disc apposition was considered optimal (concave shape, separation between disc and lobe). Good device position is confirmed in the RAO-Caudal view and all 5 signs of device stability are present. In addition, no interference between the device disc and the mitral valve is seen. TEE confirms the findings of angiography. LV—left ventricle
Fig. 8.15
A prolonged (3 min) tug test is performed before final release of the device. Final TEE interrogation reveals no leak in the LAA. No peri-procedural complications occured. TEE at 1 week showed good device position, absence of thrombus, and complete LAA closure
8.4 LAA with Chicken Wing Morphology
Learning objectives: how to negotiate a chicken wing with the Amulet device.
Closure of a LAA with chicken wing morphology requires a special technique. Measurements of the distal and proximal landing zone can be done via MSCT (Fig. 8.16). The 28 mm Amulet is deployed using the ball technique which allows us to push the device distally (Figs. 8.17 and 8.18). Following recapture and a more distal deployment, the device settles in a stable position and the proximal part of the LAA is completely covered (Figs. 8.19 and 8.20).
