The percutaneous implantation of a left atrial appendage closure device offers an alternative to chronic oral anticoagulation in patients with nonvalvular atrial fibrillation and concomitant risk factors for stroke. Transesophageal echocardiography plays a key role in defining left atrial appendage anatomy and in guiding device implantation. The authors describe a case in which contrast-enhanced transesophageal echocardiography was critically important in spatially resolving the borders of the left atrial appendage, which ultimately led to successful device implantation with cessation of warfarin therapy.
Case Presentation
A 76-year-old man with permanent atrial fibrillation presented for left atrial appendage (LAA) closure device implantation as part of the WATCHMAN Continued Access PROTECT AF Registry (Atritech, Inc, Plymouth, MN). His concomitant risk factors for stroke included a history of stroke, diabetes mellitus, and age > 75 years, yielding a CHADS score of 4. Following baseline transesophageal echocardiographic (TEE) assessment of the LAA in multiple planes and exclusion of intracardiac thrombus, transseptal puncture was performed and a 24-mm WATCHMAN LAA closure device was deployed into the LAA through a 14Fr transseptal access system. TEE imaging performed immediately following device deployment (but prior to release) revealed adequate seating of the device in the LAA. However, a large cavity was noted adjacent to the device consistent with a nonexcluded accessory LAA lobe ( Video 1 and Figure 1 ). Color Doppler imaging appeared to reveal flow communication between this cavity and the left atrium, further heightening suspicion for a nonexcluded accessory lobe ( Video 2 and Figure 2 ). To more definitely define this anatomy, an ultrasound contrast agent (Definity [perflutren lipid microsphere injectable suspension]; Lantheus Medical Imaging, North Billerica, MA) was intravenously injected with concomitant TEE imaging ( Video 3 and Figure 3 ). Contrast-enhanced imaging clearly revealed lack of contrast agent within the suspicious cavity adjacent to the LAA, consistent with the transverse sinus (a potential space created because of pericardial reflections). The device was subsequently released, with an excellent postprocedural result. Follow-up TEE imaging at 45 days revealed a well-seated device with complete exclusion of the LAA and no peridevice leak ( Video 4 ).
