Abstract
Left atrial appendage closure is a useful technique for patients at high thromboembolic risk and contraindications for oral anticoagulation therapy. However, it can be challenging when anatomical difficulties are encountered. We present a unique case of atypical appendage uptake and how we completed the procedure.
Highlights
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Different anatomic features of the left atrial appendage require original and strategic solutions to achieve procedural success.
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Accumulative experience with challenging cases will help interventionalists overcome similar complex anatomies.
A 65 year-old man was referred for progressive neurological impairment. He had severe obesity, hypertension, type-2 diabetes and was a former smoker. Computed tomography showed a 11 × 10 mm basilar artery aneurysm. ECG revealed a persistent atrial fibrillation. Transthoracic echocardiogram showed mild left atrial enlargement and no structural heart disease was noted. An estimated CHA2DS2-VASc score of 3 indicated a 3.2%/year stroke risk and oral anticoagulation was considered. However, cerebral aneurysm rupture rate was elevated (estimated at 14.5% risk/5 years) and thus oral anticoagulation was contraindicated. The patient was referred for left atrial appendage closure. Transesophageal echocardiograma (TTE) revealed a single-lobe, windsack type, left atrial appendage (LAA). General anesthesia and TEE guidance during the procedure were used. After uneventful transeptal puncture, contrast injection showed a challenging upward uptake of the LAA. The complexity of the case lies on the acute angle of the sheath towards the roof of the LAA with little help from TEE ( Fig. 1 ). In addition, LAA followed an upward course (opposite to “conventional” downward course). Fortunately, after several rotation maneuvers a 20-mm Amplatz ocluder (St Jude Medical Inc., St. Paul, MN, USA) was advanced distally into the LAA and the distal disc was released. Further deployment was performed under gentle traction of the catheter, achieving a complete expansion of the device with complete exclusion of the LAA.
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