Author + information
- Received February 12, 2018
- Accepted February 22, 2018
- Published online July 16, 2018.
- Mohamad Alkhouli, MD∗ (, )
- Zakeih Chaker, MD,
- Muhammad Al-Hajji, MD and
- Partho P. Sengupta, MD
- ↵∗Address for correspondence:
Dr. Mohamad Alkhouli, West Virginia University Heart and Vascular Institute, 1 Medical Drive, Morgantown, West Virginia 26505.
Residual leaks are not uncommon following percutaneous left atrial appendage occlusion (LAAO). There are currently no guidelines on the optimal management of these leaks, but life-long anticoagulation has been recommended in large persistent leaks. Percutaneous closure of peridevice leak is a viable alternative in patients with large leaks who are intolerant of long-term anticoagulation.
An 86-year-old frail female with coronary disease, prior coronary bypass grafting, severe aortic stenosis, atrial fibrillation (CHA2DS2-VASc [Congestive heart failure; Hypertension; Age ≥75 years; Diabetes mellitus; prior Stroke, transient ischemic attack, or thromboembolism; Vascular disease; Age 65 to 74 years; Sex category] score = 6, HASBLED [Hypertension, Abnormal liver or renal function, Stroke, Bleeding, Labile international normalized ratio, Elderly (age >65 years), Drugs or alcohol] score = 2), ischemic cardiomyopathy, and a history of gastrointestinal bleeding was referred for transcatheter aortic valve replacement and LAAO. Following an uneventful implantation of a 29-mm Evolute-R valve (Medtronic, Minneapolis, Minnesota), LAAO was planned with a 33-mm Watchman device (Boston Scientific, Marlborough, Massachusetts). The LAA was large and bilobar with inadequate depth to achieve central device position between the 2 lobes. Therefore, the Watchman device was implanted in the anterior lobe with adequate seal of the LAA (<5-mm gap) (Figures 1A to 1D, Online Videos 1 and 2). At 45-day follow-up transesophageal echocardiography, the leak appeared larger and the LAAO was deemed incomplete (Figures 1E to 1H, Online Video 3). Therefore, percutaneous closure of the leak was undertaken. Transseptal puncture was performed with an Agilis sheath (St. Jude, St. Paul, Minnesota), which was then steered near the leak under echocardiography guidance. Angiography of the left atrium and LAA revealed a widely open LAAO (Figure 2). The leak was accessed with a 6-F multipurpose guiding catheter and a Wholey wire (Medtronic). Two 12-mm Amplatzer Vascular II Plugs (St. Jude) were then sequentially deployed across the leak, resulting in complete occlusion of the LAA (Figures 3A and 3B, Online Videos 4 and 5). Follow-up cardiac computed tomography imaging showed obliteration of the leak (Figures 3C and 3D).
This case illustrates the challenges of LAAO in large bilobar LAA and the deficiency of the arbitrary definition of adequate seal (<5-mm gap) used in clinical practice (1). It also demonstrates the feasibility and effectiveness of percutaneous closure of peridevice leak with Amplatzer Vascular II Plugs.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
All authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Clinical Electrophysiology author instructions page.
- Received February 12, 2018.
- Accepted February 22, 2018.
- 2018 American College of Cardiology Foundation