Page 13 - Journal of Structural Heart Disease Volume 5, Issue 1

Case Report
2
Figure 1. On contrast injection (RAO 200, CAU 180) showing bi- lobed LAA morphology with very wide ostium.
Video 1. On contrast injection (RAO 200, CAU 180) showing bi- lobed LAA morphology with very wide ostium. View supplemen- tal video at https://doi.org/10.12945/j.jshd.2019.010.18.sup.01.
merular filtration rate = 48 mL/min) with an ejection fraction of approximately 40% underwent a perma- nent AF (CHADSVASc and HASBLED scores of 4). He underwent anticoagulation using rivaroxaban 15 mg.
He was undergoing follow-up as an outpatient be- cause of chronic anemia and heart failure symptoms, and was admitted at our hospital with lower gastroin- testinal (GI) bleeding and decompensated heart fail- ure. The patient was hemodynamically stable and had bilateral crepitation at the bases of the lungs along with mild pedal edema on physical examination. His hemoglobin level was 8.4 g/dL and serum creatinine was 193 μmol/L. Colonoscopy revealed two colonic polyps. Considering difficult anticoagulation due to the persistent anemia and lower GI bleeding, he was referred for LAA device closure.
Echocardiography documented a severely dilated LA (indexed LA volume, 63 mL/m2). Pre-procedural transesophageal echocardiography revealed a LAA ostial diameter of 20 mm with a depth of 27 mm. The procedure was performed under general anes- thesia. A right femoral venous access was used after the transseptal LA puncture pressure was measured. A double curved Watchman access sheath was posi- tioned in the LAA over a pigtail catheter. On contrast injection (RAO 20, CAU 18), a bilobed LAA morphol- ogy with very wide ostium was observed (Figure 1, Video 1). After multiple measurements, implanta- tion of two devices was planned as a single device was thought to be inadequate to cover the whole ostium. By using a 14-F Watchman delivery system, a 33-mm Watchman device (Atritech Inc., Boston Scientific, Plymouth, MA) was selected and implant- ed successfully in the anterior lobe. The device was released after confirming the stability by using a tug test. Both angiography and echocardiography re- vealed a significantly sized lobe posteriorly (Figures 2 and 3, Videos 2 and 3), which was sealed using a 21-mm Watchman device (Kissing Watchman) by us- ing the same delivery system (Videos 4 and 5). Resid- ual peri-device leaks were excluded, and the stability of both devices was assessed (Figures 4 and 5). The patient was extubated and transferred to the critical care unit for recovery. He was discharged afterward with clopidogrel 75 mg daily and an adjusted dose of warfarin. He underwent follow-up transesophageal echocardiography (TEE) after 6 weeks of the proce- dure, which showed well-seated watchman devices with trivial peri-device leakage (Video 6). No other complications were observed. The patient was ad- vised to discontinue anticoagulation.
Journal of Structural Heart Disease, February 2019
Volume 5, Issue 1:1-6