Page 13 - Journal of Structural Heart Disease Volume 1, Issue 4

Meeting Abstracts
158
LEFT ATRIAL APPENDAGE CLOSURE USING LEFT FEMORAL VEIN APPROACH
Naseer Ahmed1,2,3, Giulio Molon3, Guido Canali3, Patrizio Mazzone4, Natasja MS de Groot2, Laura Lanzoni3, Franscesco Onorati1, Enrico Barbieri3, Giuseppe Faggian1
1 Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
2 Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
3 Cardiology Department, Sacrocuore Hospital, Negrar, Verona, Italy
4 Arrhythmology Department, S. Ra aele hospital, Milan, Italy
Introduction: Atrial Fibrillation (AF) is the most common tachyarrhyth- mia and is associated with major complications such as thromboem- bolic events. Oral Anticoagulation (OAC) therapy remains an import- ant component of AF treatment to avoid thrombo- embolism. Left Atrial Appendage (LAA) closure may be considered in patients with AF with high stroke risk and contraindications for long term OAC ther- apy. Devices for LAA closure are usually placed trans-septally using the Right Femoral Vein (RFV) approach (1; 2). Alternative approaches for accessing the left atrium have been reported, (2-6) but there are no reports on usage of the Left Femoral Vein (LFV) for LAA closure by using watchman device, that is unusual for septal puncture(7). In this report, we describe a LAA closure in an 83 year old patient using the LFV approach.
History and Physical Examination: An 83 year old male patient, with permanent AF with CHADS2 score 3, gastrointestinal bleeding (HAS- BLED = 5) was admitted at our hospital. The medical history included myocardial infarction, percutaneous coronary angio- plasty, dilated ischemic cardiomyopathy, moderate left ventricular dysfunction, NYHA class II, moderate renal failure and hypertension.
Imaging: On routine pre-procedural Echocardiogram, dilated cardio- myopathy and moderate ejection fraction dysfunction were observed. CT angiography done to observe vascular anatomy, demonstrated deployment of right common iliac vein towards left side (Fig 1 a,b). TransEsophageal Echocardiogram (TEE) used during procedure was very helpful to identify exact point (fossa ovalis) for puncture of inter- atrial septum(8) to approach LAA.
Indication For Intervention: The patient was considered a candidate for LAA closure using a Watchman device in order to avoid OAC thera- py, according to current guidelines (9).
Intervention: Classically, the puncture site is reached by pulling the trans-septal sheath down into respectively the right atrium and Fossa Ovalis (FO) while observing the two drop movement. When using the LFV approach, this maneuver is very di cult and usually unsuccessful (10), particularly due to the angulation at the junction between the left common iliac vein and inferior vena cava. This angulation turns the needle away from the interatrial septum, thus hampering good contact with the wall of FO. In our case, we were unable to see the two drop movements into the right atrium and FO even when using needles with di erent curves. Then, we combined uoroscopic and TEE images to con rm the exact position of the trans-septal sheath and subsequently steer it into the FO (Fig. 2 b, d). Using this approach we successfully performed puncture and implanted the Watchman device (Fig. 2 g).
Result: There were no complications and the patient was discharged
on the third postoperative day. After two years of follow-up the pa- tient remains asymptomatic, free of OAC therapy and without any cerebrovascular events.
Conclusion: In conclusion, trans-septal puncture guided by a combi- nation of uoroscopic and TEE images can be safely carried out using the LFV approach as an alternative option when the RFV is not acces- sible.
THORACOSCOPIC ATRICLIP CLOSURE OF LEFT ATRIAL APPENDAGE AFTER FAILED LIGATION VIA LARIAT Primary author: Christopher R. Ellis, MD, FACC, FHRS, Assistant Professor of Medicine, Director Cardiac Electrophysiology Laboratory, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center
Corresponding author: Sam G. Aznaurov, M.D., Fellow-in- training, Clinical Cardiac Electrophysiology, Cardiovascular Medicine, Vanderbilt University Medical Center
Additional authors: Stephen K. Ball, M.D., Assistant Professor Cardiac Surgery, Vanderbilt University Medical Center
Con icts of Interest And Financial Disclosures:
Christopher R Ellis, MD, FACC, FHRS:
Received consulting fees/honoraria (<$10,000 per year) from
Medtronic, Sentre Heart, AtriCure, Boston Scienti c and Boehringer Ingelheim. Received signi cant research funding from Thoratec, HeartWare, Boston Scienti c, Boehringer Ingelheim and Medtronic.
Member of Scienti c and Advisory Board: Sentre Heart, AtriCure. Sam G. Aznaurov, MD: None Stephen K Ball, MD: None
Clinical History And Imaging: A 68-year-old male with paroxysmal AF was evaluated for ligation of the LAA via LARIAT sub-xiphoid ap- proach. His CHA2DS2-VASc score was 4 for hypertension, prior cere- brovascular accident, and age >65 years. He was intolerant of antico- agulation with both dose-adjusted warfarin and rivaroxaban, due to recurrent, transfusion-dependent gastroin- testinal hemorrhage. His HAS-BLED score was 4. Pre-procedure gated CT angiography revealed an anteriorly directed LAA of chicken wing morphology, with a small secondary lobe near the ostium. He underwent LAA ligation utilizing a LARIAT ligature, via standard trans-septal and sub-xiphoid pericardial approach under general endotracheal anesthesia. The suture delivery device was cinched over the proximal neck of the LAA, and complete closure of the LAA ostium was initially noted (Figure 1a). However, after tightening the LARIAT, repeat contrast angiography of the LAA demonstrated gradual reopening of the LAA ostium and proximal lobe, as the delivery device was removed. A second LARIAT Plus liga- ture was used to re-snare the proximal neck of the LAA, but reopening of the LAA ostium was seen on repeat contrast angiography (Figure 1d). The patient was referred to the cardiothoracic surgery service for closure of the residual lobe of the LAA with an Atriclip-Pro device.
Intervention: Totally thoracoscopic access was obtained to the left chest under general endotracheal anesthesia. The pericardium was opened posteriorly to the phrenic nerve, and the LAA was visualized. The two previously deployed LARIAT ligatures were seen, and early ischemia of the LAA superior lobe was noted distal to the suture liga- tion neck (Figure 2). The basal accessory lobe of the
LAA remained una ected by these ligatures. A 40mm Atriclip-Pro was
Journal of Structural Heart Disease, December 2015
Volume 1, Issue 4: 155-159