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Pearls From a Case of Left Atrial Appendage Closure
Pearls From a Case of Left Atrial Appendage Closure Jason H. Rogers, MD, Gagan D. Singh, MD, and Thomas W. Smith, MD
An 82-year -old man with paroxysmal atrial fibrillation (CHA2DS2-VASc score, 5) and a need for an alternative to long-term anticoagulation was referred for Watchman (Boston Scientific, Maple Grove, MN) left atrial appendage (LAA) occlusion. Initial transesophageal echocardiography (TEE) derived measurements of the LAA were as follows: 0 degrees, 21.4 mm (ostium width) × 25.0 mm (depth); 45 degrees, 16.2 × 29.4 mm; 90 degrees, 19.2 × 27.0 mm; 135 degrees, 20.1 × 16.3 mm. A, The 135-degree view revealed a predominant posterior lobe. Therefore a single curve access sheath was selected, which orients more coaxial with posteriorly directed appendages. C, A conventional inferior and posterior transseptal puncture (TSP) was performed, and initial LAA contrast injection through a 5-Fr pigtail catheter confirmed a predominantly posterior lobe. D, The single-curve access sheath was then advanced over the pigtail into the LAA, but the access sheath was pointed superiorly, and the approach angle was not coaxial with the LAA (arrow). As a result, adequate guide depth could not be achieved. B, Therefore the TSP was repeated in a more anterior and superior location, resulting in a more favorable approach angle to the LAA. E, The single-curve sheath could then be advanced
coaxial (arrow) to achieve adequate depth in the LAA for Watchman delivery. F, With this new orientation, a 27-mm Watchman device was successfully deployed in the ostium of the LAA with excellent seal and apposition. The patient was discharged home without complications, and 6-week follow-up TEE showed complete closure of the LAA.
254 CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS
KEY POINTS • The default TSP location for Watchman LAA closure is inferior and posterior in the fossa ovalis. • Although the double-curve access sheath is used in the majority of cases, the single-curve sheath can provide more coaxial alignment for posteriorly-directed left atrial appendages. • To provide better alignment for posterior oriented lobes, a more anterior and superior location (in the mid-superior/inferior and mid-anterior/posterior fossa ovalis) is advantageous.
A
B
C
D
E
F
CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS 255
An 82-year -old man with paroxysmal atrial fibrillation (CHA2DS2-VASc score, 5) and a need for an alternative to long-term anticoagulation was referred for Watchman (Boston Scientific, Maple Grove, MN) left atrial appendage (LAA) occlusion. Initial transesophageal echocardiography (TEE) derived measurements of the LAA were as follows: 0 degrees, 21.4 mm (ostium width) × 25.0 mm (depth); 45 degrees, 16.2 × 29.4 mm; 90 degrees, 19.2 × 27.0 mm; 135 degrees, 20.1 × 16.3 mm. A, The 135-degree view revealed a predominant posterior lobe. Therefore a single curve access sheath was selected, which orients more coaxial with posteriorly directed appendages. C, A conventional inferior and posterior transseptal puncture (TSP) was performed, and initial LAA contrast injection through a 5-Fr pigtail catheter confirmed a predominantly posterior lobe. D, The single-curve access sheath was then advanced over the pigtail into the LAA, but the access sheath was pointed superiorly, and the approach angle was not coaxial with the LAA (arrow). As a result, adequate guide depth could not be achieved. B, Therefore the TSP was repeated in a more anterior and superior location, resulting in a more favorable approach angle to the LAA. E, The single-curve sheath could then be advanced
coaxial (arrow) to achieve adequate depth in the LAA for Watchman delivery. F, With this new orientation, a 27-mm Watchman device was successfully deployed in the ostium of the LAA with excellent seal and apposition. The patient was discharged home without complications, and 6-week follow-up TEE showed complete closure of the LAA.
254 CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS
KEY POINTS • The default TSP location for Watchman LAA closure is inferior and posterior in the fossa ovalis. • Although the double-curve access sheath is used in the majority of cases, the single-curve sheath can provide more coaxial alignment for posteriorly-directed left atrial appendages. • To provide better alignment for posterior oriented lobes, a more anterior and superior location (in the mid-superior/inferior and mid-anterior/posterior fossa ovalis) is advantageous.
A
B
C
D
E
F
CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS 255