Complex transcatheter left atrial appendage closure using a tailored trans-jugular approach simulated by 3D printing: a case report

Abstract

Background: Transcatheter left atrial appendage (LAA) closure (LAAc) is less feasible in patients with unusual LAA anatomy.

Case summary: A 65-year-old woman with persistent atrial fibrillation was referred for LAAc. Transesophageal echocardiography (TEE) revealed spontaneous contrast in the LAA without formation of a thrombus; the LAA shape was tortuous and difficult to assess. A first LAAc procedure was unsuccessful given the unsuitable sheath position. Therefore, a soft three-dimensional (3D) model printing was performed by laser sintering and revealed excessive sheath kinking with an inferior approach, but successful deployment would be feasible using a superior approach. Successful trans-jugular implantation of a Watchman FLX 31 device in stable position without residual leakage was achieved during the subsequent procedure. At 3-month follow-up, and after cessation of oral anticoagulation, the patient's symptoms improved. Imaging demonstrated complete LAA occlusion and correct placement of the device along the LAA superior axis.

Discussion: This is the first-reported clinical case of a complex transcatheter LAAc through a trans-jugular approach. Simulating the patient's anatomy with a laser sintering 3D-printed model showed why the transfemoral approach failed, validated the trans-jugular procedure, enabled selection of the simple curve access sheath that had the most direct trajectory towards the LAA, confirmed that transseptal puncture was possible, allowed determination of the angle of puncture, enabled selection of the most appropriate LAA device and had a very low cost compared with planning software or other printing methods.

Keywords: 3D printing; Case report; Left atrial appendage; Percutaneous closure; Preprocedural planning and simulation; Trans-jugular; Transseptal puncture.

Figure 1

Pre-procedure imaging. (A) Biplane TEE view showing a large LAA(*) ostium close to the mitral prosthesis ring (M). Owing to the low position, the usual landmarks (such as the circumflex artery) are absent. (B) Pre-procedure CT scan: volume rendering of the left atrium in purple, right atrium in transparency green shell, including inferior (IVC) and superior vena cava (SVC). Note that mitral (M) and aortic (A) prosthesis are superimposed in using volume rendering filled to remark the horn-like shape of the LAA with basal insertion and directed upwards (blue arrow). (C) SLS 3D-printed model with exact representation of the left atrium, right atrium which is sectioned in order to see the orifice corresponding to the thin inter atrial septum (red arrow). Note the aortic and mitral bioprostheses.

Figure 2

Simulation using 3D-printed model. (A and B) Anterior and posterior view through a window cut in the posterior wall of the left atrium. Successful testing of the simple curve access sheath via the jugular vein and the superior vena cava (SVC). Note the perfect alignment with the LAA (blue arrow). (C) Appropriate deployment of a Watchman Flex prosthesis; good apposition without leak or bulging, in line with the LAA axis.

Figure 3

Second procedure. (A) Fluoroscopy view: the single-curve sheath is correctly placed into the ostium of the LAA(*) and fits its curvature as predicted by the testing on the 3D model. (B) TEE 3D view shows the same orientation of the sheath into the LAA. (C) TEE biplane view: Delivery of the Watchman Flex prosthesis (red arrow) in the axis of the LAA, resulting in an optimal position, without impairment of the mitral prosthesis (M).