“Kissing-Watchman technique “: A complex Left atrial appendage anatomy closure using two devices.

Background
Left atrial appendage closure (LAAC) remains an alternative to lifelong use of anticoagulation in patient with non-valvular atrial fibrillation for stroke prevention. For a complex left atrial anatomy, complete closure of the appendage may not be possible with a single device. Based on the anatomic morphology and profile, a complete closure of the left atrial appendage was made using two devices, so called the “Kissing – Watchman technique”.

Methods
80-year-old male with atrial fibrillation underwent transcatheter watchman implantation. When a 6F pigtail catheter was advanced into the LAA and multiple cine-angiograms were performed to determine orientation and size of the LAA, he was noted to have a large bilobed appendage. Given the anatomy a complete closure with one watchman device was deemed not possible. A 33 mm Watchman device was successfully implanted into the anterosuperior lobe of the LAA. Intraoperative TEE showed the posterior lobe not covered by the Watchman device. Patient was subsequently bought back for complete closure, and using standard techniques involving TEE and fluoroscopy a 27 mm Watchman device was implanted.

Results
Intra-operative TEE demonstrated successful closure of this complex atrial appendage with no residual peri-device leakage. There was no evidence of major complications including device dislocation, significant peri-device leakage, Pericardial effusion, stroke or major bleeding.

Conclusions
The staged “Kissing-Watchman” may be a reasonable option in patients with complex left atrial appendage anatomy in whom complete closure with a single device is not possible.