Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2024 Jun 11;8(6):ytae286.
doi: 10.1093/ehjcr/ytae286. eCollection 2024 Jun.

Case report: three ways to mitigate the risk of embolization during left atrial appendage closure in a patient with a massive and proximal left atrial appendage thrombus

Sandra Zendjebil  1 , Jérôme Horvilleur  1 , Victor Boilève  1 , Vincent Millien  2 , Philippe Garot  1
Affiliations
Case Reports

Case report: three ways to mitigate the risk of embolization during left atrial appendage closure in a patient with a massive and proximal left atrial appendage thrombus

Sandra Zendjebil et al. Eur Heart J Case Rep. .

Abstract

Background: Left atrial appendage (LAA) thrombus is a contraindication for LAA closure (LAAC). However, in selected cases, oral anticoagulants are strictly contraindicated because of a history of life-threatening bleeding, and LAAC remains the only possible therapy to avoid systemic and especially cerebral embolization.

Case summary: We report a case of LAAC despite a massive proximal thrombus in a patient who had an absolute contraindication to anticoagulant therapy, with thorough pre-planning using CT scan, device modelling and thrombus trapping techniques to reduce the risk of systemic embolic events and perform LAAC safely.

Discussion: Although LAAC remains at high risk in this setting, the use of cautious techniques and tools, from pre-procedure planning to systemic embolization prevention systems associated to a precise transoesopheageal echocardiography guiding throughout the procedure, allows it to be performed as safely as possible when no other option is available.

Keywords: Case report; Device; Left atrial appendage; Left atrial appendage closure; Stroke; Thrombus.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest: P.G. and J.H. are proctors for Abbott.

Figures

Figure 1
Figure 1
(i) Pre-procedure planning: cardiac CT-guided optimal sizing and transseptal planning to avoid supplementary manipulations and device mis-sizing. (A–C) 3Mensio™ analysis with diameters of landing zone and ostium of a cauliflower-shaped appendage: 27.4 × 32.2 mm (mean 29.8 mm) and 30.1 × 40.8 mm (mean 35.5 mm), respectively. (D) FEops HeartGuide™ simulation of a distal AMULET 34 mm device showing a good compression and ridge coverage. (ii) Procedure precautions: (E) sentinel device through right radial access. Total dose of heparin administered before transseptal punction. (F) Stiff wire and delivery sheath in the upper left pulmonary vein, no injection and no pig tail in the appendage to prevent thrombus embolization. (iii) Device deployment. (G–I) ‘No touch technique’: ball-shaped device entering the appendage without touching the thrombus, and instantaneous opening of the lobe and the disk to ensure total sealing. (J) Neither recapture, nor tug test.
See this image and copyright information in PMC

References

    1. Tarantini G, D’Amico G, Latib A, Montorfano M, Mazzone P, Fassini G, et al. . Percutaneous left atrial appendage occlusion in patients with atrial fibrillation and left appendage thrombus: feasibility, safety and clinical efficacy. EuroIntervention 2018;13:1595–1602. - PubMed
    1. Sebag AF, Garot P, Galea R, De Backer O, Lepillier A, De Meesteer A, et al. . Left atrial appendage closure for thrombus trapping: the international, multicentre TRAPEUR registry. EuroIntervention 2022;18:50-–507. - PMC - PubMed
    1. Sharma SP, Cheng J, Turagam MK, Gopinathannair R, Horton R, Lam Y-Y, et al. . Feasibility of left atrial appendage occlusion in left atrial appendage thrombus. JACC Clin Electrophysiol 2020;6:414–424. - PubMed
    1. Meincke F, Spangenberg T, Kreidel F, Frerker C, Virmani R, Ladich E, et al. . Rationale of cerebral protection devices in left atrial appendage occlusion. Catheter Cardiovasc Interv. 2017;89:154–158. - PubMed
    1. Yadav PK, Wang DD, Eng MH, O’Neill WW. Watchman in ascending aorta for systemic protection (WAASP): novel use of Watchman in ascending aorta for embolic protection-first in man. Catheter Cardiovasc Interv 2018;92:433–436. - PubMed

Publication types

LinkOut - more resources