In April 2011, an 82-year-old woman with chronic atrial fibrillation on warfarin underwent surgical mitral and tricuspid repair, ligation of the left atrial appendage (LAA), and unsuccessful MAZE procedure. A subsequent transesophageal echocardiogram (TEE) demonstrated residual communication between the left atrium (LA) and LAA (Fig A and B).
Baseline 2- (A) and 3-D (B) TEE showed the residual communication (white arrow) between LA and LAA (*).
What would be your next step in managing this patient?
The correct answer is: b. Endovascular LAA closure.
We proceeded to the residual LAA communication clsoure with transcatheter, transfemoral technique.1 Following successful transseptal puncture, the baseline LAA angiogram was performed. Given its nonthrombogenic property and the sufficient LAA ostium rim, the Gore Helex Septal Occluder (W. L. Gore and Associates, Newark, Delaware) was used (off label use), and completely sealed the LAA ostium.
Surgical LAA ligation is frequently incomplete (77%). Moreover, 41% of patients with unsuccessful surgical closure have LAA thrombus.2 Our case demonstrates that the residual communication secondary to incomplete surgical ligation can be closed percutaneously.
Baseline selective LAA angiogram showed LAA with rim (C, arrow head). The final angiogram (D) and TEE (E and F) showed a well-seated occluder device (white arrow), with no residual flow, that completely closed the LAA ostium.
Matsumoto T, Nakamura M, Yeow WL, Siegel RJ, Kar S. Transcatheter left atrial appendage closure after incomplete surgical ligation. JACC Cardiovasc Interv 2013;6:e11-2.
Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by trans- esophageal echocardiography. J Am Coll Cardiol 2008;52:924–9.