Highlights
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This case provides a unique approach for left atrial appendage occlusion using a Watchman and Amulet device.
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Our technique for left atrial appendage occlusion shows the safety of utilizing a staged closure when necessary.
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Complex left atrial appendage is being more frequently encountered, so novel solutions are needed.
A 72-year-old male with a history of hypertension, dyslipidemia, coronary disease with elevated coronary calcium score, and paroxysmal atrial fibrillation (CHA 2 DS 2 -VASc score of 3 and HAS-BLED score of 3) was referred to the structural heart clinic for left atrial appendage occlusion (LAAO) due to bleeding complications associated with anticoagulation for stroke prevention. He was subsequently scheduled for LAAO with a Watchman device (Boston Scientific, Marlborough, MA, USA). Left atrial appendage (LAA) anatomy was obtained exclusively using intraoperative transesophageal echocardiography (TEE) since a high volume of LAAO cases at this institution limit access to scheduling preprocedure imaging. Intraoperative TEE showed that he had a bilobed LAA, and due to the dimensions of the individual lobes ( Figure 1 ), a single LAAO device was unable to cover both. Previous reports of bilobed LAAO using multiple devices have described both staged and simultaneous placement of LAA occluders in the individual lobes with success. , It was ultimately decided to cover the larger lobe with a 27-mm Watchman Flex device and to re-evaluate the smaller lobe 45 days later for staged closure. This approach was selected to allow for endothelization and stability of the implanted Watchman device prior to placing a second occluder. The patient was kept on apixaban and low-dose aspirin during this time to prevent device-related thrombus and to lower embolic stroke risk still present.
TEE at 45 days after the initial procedure showed the previously placed Watchman device had adequately closed the larger lobe, but the second, smaller lobe was still patent. Since this represented an incomplete LAA closure, it was decided to proceed with occlusion of the second lobe. A cardiac-gated computed tomography angiography with LAA protocol for planning of the second intervention showed cross-sectional dimensions of the LAA ostium measuring approximately 8.5 mm × 7.7 mm while TEE measured a diameter between 0.9 cm and 1.1 cm ( Figure 2 ). Currently there is no Watchman device indicated for this size, so a 16-mm Amplatzer Amulet device (Abbott, Abbott Park, IL, USA) was chosen. Other devices were also considered, including an Amplatzer Vascular Plug II (Abbott, Abbott Park, IL, USA), since Amplatzer Vascular Plug II devices have been used off-label for LAAO. The structural team’s intent, however, was to take advantage of a dedicated device specific for LAAO, utilizing additional anchoring provided by an Amulet device’s stabilizing wires and a larger disc that would overlap and cover the previously placed Watchman device. The Amulet device was successfully deployed with closure of the second lobe verified by intraoperative fluoroscopy and TEE with some initial degree of slight overcompression ( Figure 3 , Supplemental Videos 1 and 2 ). The patient was re-evaluated at 45 days postprocedure and found to have stable position of both devices with adequate closure of both lobes without peridevice leak or device-related thrombus ( Figure 3 ). Apixaban was discontinued, and the patient was placed on low-dose aspirin and clopidogrel as recommended by the Amulet instructions for use.
