Difficult Cases and Complications from the Catheterization Laboratory: Left Atrial Appendage Closure Step-By-Step

Abstract

A 68-year-old man with hypertension, dyslipidemia, chronic kidney disease, and history of hemorrhagic stroke was admitted to our hospital because of atrial fibrillation (AF). After transesophageal echocardiography (TEE) that excluded the presence of left atrial appendage (LAA) thrombus, he underwent electrical cardioversion with sinus rhythm restoration. Nevertheless, he presented at 1-month follow-up visit with atrial fibrillation. Due to the history of hemorrhagic stroke and the subsequent contraindication to anticoagulation therapy, he was identified as a candidate to percutaneous closure of LAA. TEE was performed before the procedure to rule out the presence of LAA thrombus and to assess the dimensions and the morphology of the LAA. The procedure was performed under general anesthesia and TEE guidance. After transseptal puncture of the fossa ovalis, a 22-mm Amplatzer Cardiac Plug (ACP) (AGA, St. Jude Medical) device was advanced in the LAA through a dedicated delivery system (12-Fr Amplatzer TorqVue 45 × 45 Delivery Sheath – AGA, St. Jude Medical). Once the correct implanting zone was localized, the device was released under fluoroscopic and echocardiographic guidance. A check for pericardial effusion at the end of the procedure was done by transthoracic echo (TTE). The patient was discharged the day after the procedure with long-term therapy with a daily 100-mg aspirin and 75-mg clopidogrel for 3 months. Endocarditis antibiotic prophylaxis was also recommended for at least 6 months (Figs. 19.1, 19.2, 19.3, 19.4, 19.5, 19.6, 19.7, 19.8, and 19.9).