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Left Atrial Appendage Closure With Watchman
Left Atrial Appendage Closure With Watchman Jay Thakkar, MD, and Jacqueline Saw, MD
A 79-year-old man with persistent non-valvular atrial fibrillation had spontaneous subarachnoid bleeding while on theraputic warfarin, and subsequently recovered functionally. His CHADS2 score was 4 and CHADS-Vasc score was 5, and he was referred for left atrial appendage (LAA) closure. A, and (B) Baseline imaging were performed to exclude LAA thrombus and assess LAA anatomy. Preprocedural cardiac computed tomography angiography (CCTA) showed a challenging superior-anteriorly directed (retroflex) chicken-wing LAA anatomy. C, For the Watchman device (Boston Scientific, Natick, MA), the widest LAA ostium at 0, 45, 90 and 135 degrees, and LAA depth were measured on transesophageal echocardiogram (TEE), and the maximum diameter was 27.8 mm and depth was 29 mm. The procedure was performed under general anesthesia and TEE guidance. Right femoral venous access was obtained. Transseptal puncture was performed with an SL1 sheath and BRK-XS needle in an inferoposterior position of the fossa ovalis, to enable coaxial sheath access into the retroflex LAA. Activated clotting time (ACT) was maintained >250 s and mean left atrial pressure >12 mm Hg (for accurate LAA measurments). A 14-Fr anterior-curve sheath was preplanned based on CCTA for the retroflex LAA, and was advanced to the left upper pulmonary vein through a Super-Stiff Amplatz wire. D, A 6-Fr marker pigtail was then used to advance the sheath into the LAA and cineangiogram performed. E, The access sheath was advanced into LAA distally and counter-clocked
to maintain anterior-superior direction. F, A 33-mm Watchman device was deployed in the proximal LAA, and tug test showed good anchoring. The PASS criteria were verified, with good position (P), anchor (A: stable on tug), (G) size (S: compression 8% to 20%), and (H) seal (S: peri-device leak <5 mm). (I) The device was released and final 3-dimensional TEE showed successful placement. The patient tolerated the procedure well and was discharged the following day after transthoracic echocardiogram.
250 CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS
KEY POINTS • Percutaneous LAA occlusion can be performed safely (risk of major periprocedural complication <1.5% including ischemic stroke, pericardial tamponade, and device embolization), and is a feasible alternative to long-term anticoagulation in patients with non-valvular atrial fibrillation. • CCTA is a useful complimentary imaging modality to TEE for preprocedural planning, especially for complex anatomy. • PASS criteria should be achieved for implantation.
A
B
C
D
E
F
G
H
I
CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS 251
A 79-year-old man with persistent non-valvular atrial fibrillation had spontaneous subarachnoid bleeding while on theraputic warfarin, and subsequently recovered functionally. His CHADS2 score was 4 and CHADS-Vasc score was 5, and he was referred for left atrial appendage (LAA) closure. A, and (B) Baseline imaging were performed to exclude LAA thrombus and assess LAA anatomy. Preprocedural cardiac computed tomography angiography (CCTA) showed a challenging superior-anteriorly directed (retroflex) chicken-wing LAA anatomy. C, For the Watchman device (Boston Scientific, Natick, MA), the widest LAA ostium at 0, 45, 90 and 135 degrees, and LAA depth were measured on transesophageal echocardiogram (TEE), and the maximum diameter was 27.8 mm and depth was 29 mm. The procedure was performed under general anesthesia and TEE guidance. Right femoral venous access was obtained. Transseptal puncture was performed with an SL1 sheath and BRK-XS needle in an inferoposterior position of the fossa ovalis, to enable coaxial sheath access into the retroflex LAA. Activated clotting time (ACT) was maintained >250 s and mean left atrial pressure >12 mm Hg (for accurate LAA measurments). A 14-Fr anterior-curve sheath was preplanned based on CCTA for the retroflex LAA, and was advanced to the left upper pulmonary vein through a Super-Stiff Amplatz wire. D, A 6-Fr marker pigtail was then used to advance the sheath into the LAA and cineangiogram performed. E, The access sheath was advanced into LAA distally and counter-clocked
to maintain anterior-superior direction. F, A 33-mm Watchman device was deployed in the proximal LAA, and tug test showed good anchoring. The PASS criteria were verified, with good position (P), anchor (A: stable on tug), (G) size (S: compression 8% to 20%), and (H) seal (S: peri-device leak <5 mm). (I) The device was released and final 3-dimensional TEE showed successful placement. The patient tolerated the procedure well and was discharged the following day after transthoracic echocardiogram.
250 CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS
KEY POINTS • Percutaneous LAA occlusion can be performed safely (risk of major periprocedural complication <1.5% including ischemic stroke, pericardial tamponade, and device embolization), and is a feasible alternative to long-term anticoagulation in patients with non-valvular atrial fibrillation. • CCTA is a useful complimentary imaging modality to TEE for preprocedural planning, especially for complex anatomy. • PASS criteria should be achieved for implantation.
A
B
C
D
E
F
G
H
I
CONGENITAL ABNORMALITIES, PSEUDOANEURYSMS, AND SHUNTS 251