Percutaneous Closure of Residual Left Atrial Appendage Flow After Failed Surgical Ligation
Presenter
Rahul Sawhney, DO, Baylor Scott & White The Heart Hospital - Plano, Plano, TX
Rahul Sawhney, DO1, Marika Harada, MD1, David Cheng, MD1, Imran Baig, M.D.2 and Srini Potluri, M.D., FSCAI3, (1)Baylor Scott & White The Heart Hospital - Plano, Plano, TX, (2)Baylor Scott & White Health, Dallas, TX, (3)Baylor Scott & White The Heart Hospital - Plano, Frisco, TX
Keywords: Left Atrial Appendage Closure (LAAC)
Title
Percutaneous Closure of Residual Left Atrial Appendage Flow After Failed Surgical Ligation
Introduction
Left atrial appendage closure has gained popularity from both surgical and percutaneous approaches. Herein we report a case of failed surgical ligation of an appendage which we successfully sealed using an off-label septal occluder device.
Clinical Case
An 82-year-old woman with remote history of coronary artery disease status post coronary artery bypass grafting, paroxysmal atrial fibrillation anticoagulated with apixaban, prior traumatic intracranial hemorrhage (ICH), and essential hypertension developed frequent falls. Based on her prior history of ICH, she was referred for left atrial appendage occlusion (LAAO) evaluation. Her CHA₂DS₂-VASc score was 6 and her HAS-BLED score was 3. She was felt to be a good candidate for LAAO on the basis of her history, fall risk, stroke risk. A prior coronary CTA was reviewed for LAA anatomy. The LAA was cauliflower shaped with landing zone maximal/minimal diameters of 21.1 and 16 mm, circumference of 58.3 mm, and distal tip to landing zone length of 15.2 mm. There was no evidence of a prior closure device or clot. She was brought to the cath lab for plans of LAAO with a WATCHMAN FLX™ (Boston Scientific, Marlborough, MA) under general anesthesia. Following transseptal puncture, a LAA angiogram was performed and demonstrated a small appendage. Concomitant TEE showed what appeared to be a prior surgical ligation with residual flow in two small lobes; this anatomy was not amenable to a WATCHMAN™ device. The procedure was aborted in favor of returning for closure with another device such as a vascular plug or septal occluder. After 4 months she returned for repeat attempt at LAAO. Following repeat transseptal puncture, an anterior curve WATCHMAN sheath was utilized to achieve access to the LAA. Initially a 25 mm Amplatzer™ Cribriform Occluder (Abbott Cardiovascular, Plymouth, MN) was attempted but appeared too large. Instead an 18 mm device was successfully positioned and deployed after adequate tug test and complete seal/no residual flow on TEE. She was discharged home on dual antiplatelet therapy with aspirin and clopidogrel for 6 months. Follow-up TEE after 6 weeks showed normal position of the occlusion device without residual flow. There was a persistent iatrogenic atrial septal defect with left-to-right shunting without evidence of hemodynamic complication. TTE with bubble study after 1 year showed resolution of the atrial septal defect and satisfactory position of the LAAO device. She remained free of bleeding complications on baby aspirin monotherapy.
Discussion
Small data series/institutional experiences have demonstrated that peri-device leaks can be sealed with coils, vascular plugs, septal occluders, etc. These data however strictly focus on leaks after percutaneous closure devices and usually rely on the existing device to anchor the closure device. We describe a novel case that demonstrates that percutaneous occlusion of a failed surgical ligation can be safe and effective with an adequately shaped/sized device. Of note, our case also highlights the importance of accurate documentation as the patient’s original operative report from 20 years prior made no mention of prophylactic LAA ligation.