Abstract
Objective
We illustrate transcatheter left atrial appendage closure under local anesthesia with intracardiac echocardiography guidance for a complex patient with repaired tetralogy of Fallot at high risk for general anesthesia, with preprocedural cardiac computed tomography (CT) support.
Key Steps
1) CT imaging and analysis; 2) vascular access with use of sheath-in-sheath technique; 3) transseptal puncture with VersaCross system; and 4) deployment of Watchman device in CT-planned projection.
Potential Pitfalls
1) Selection of appropriate preprocedural imaging modality; 2) use of sheath-in-sheath technique to avoid kinking of catheters; 3) use of VersaCross transseptal system to avoid repeat punctures, unnecessary exchanges, and risk of injury; and 4) avoidance of general anesthesia to reduce risk in a high-risk patient.
Take-Home Messages
Preprocedural CT analysis and intraprocedural intracardiac echocardiography imaging can guide transcatheter left atrial appendage closure procedures in complex anatomies. The use of appropriate sheaths and equipment can improve the safety profile and success rate of complex transcatheter left atrial appendage closure procedures.
Key words: atrial fibrillation, computed tomography, echocardiography, occluder, tetralogy of Fallot
Graphical Abstract
Transcatheter left atrial appendage (LAA) closure is increasingly recognized as a valid option for stroke prevention in patients with nonvalvular atrial fibrillation and a high thromboembolic risk who are not suited for long-term oral anticoagulation.1 Evidence for transcatheter LAA closure in patients with adult congenital heart disease (CHD) has been sparse. However, this group of patients not infrequently presents with atrial fibrillation, a high CHA2DS2-VASc stroke risk score, and bleeding complications on oral anticoagulation. Additionally, patients with adult CHD can pose numerous technical challenges given the heterogeneity in the underlying anatomy and often a history of multiple previous surgical and/or transcatheter interventions that may further distort the conventional anatomic landmarks.
As a National Reference Center for adult CHD interventions in Denmark, we often receive referrals for transcatheter LAA closure in this complex patient population. In this case report, we describe how the technical challenges encountered in the patient were overcome with the use of multimodality imaging including preprocedural cardiac computed tomography (CT) and intraprocedural intracardiac echocardiography (ICE) guidance, together with additional transcatheter devices and techniques.
Case Summary
The patient was a 55-year-old man with tetralogy of Fallot repaired at 3 years of age with a ventricular septal defect patch, ventriculotomy, and transannular patch. He underwent a surgical pulmonary valve replacement in 2007 with a Carpentier-Edwards PERIMOUNT Magna 23-mm bioprosthesis (Edwards Lifesciences) owing to severe pulmonary regurgitation. In 2022, he underwent transcatheter pulmonary valve-in-valve implantation with a Melody 22-mm valve (Medtronic) owing to bioprosthetic valve degeneration leading to severe stenosis. He also had an implantable cardioverter-defibrillator placed in 2018 after a few episodes of syncope related to ventricular tachycardia. Other comorbidities include arterial hypertension, dyslipidemia, diabetes mellitus, and morbid obesity with a body mass index of 41 kg/m2.
Transthoracic echocardiography imaging was limited owing to the patient’s obesity. Cardiac magnetic resonance showed a left ventricular ejection fraction of 40%. The right ventricle had an apical aneurysm with an ejection fraction of only 25%.
He developed persistent atrial fibrillation, which was managed with a rate-control strategy given his implantable cardioverter-defibrillator and limited symptoms. Given that his CHA2DS2-VASc score was 3, he was started on oral anticoagulation after discussion of risk and benefits. However, he developed recurrent lower gastrointestinal bleeding, requiring cessation of oral anticoagulation. He was referred for transcatheter LAA closure in view of recurrent bleeding events.
As a standard approach in our center, the patient underwent a cardiac CT scan for preprocedural planning. Cardiac CT analysis showed a small, highly elliptical cauliflower-shaped LAA with the pulmonary bioprostheses in close proximity (Figures 1A and 1B). Dimensions of the LAA were 12.5 × 22.7 mm at the ostium and 11.2 × 19.3 mm at the estimated landing zone (Figures 1C and 1D). Relative contraindications to transesophageal echocardiography (TEE) included morbid obesity and poor right ventricular function with ensuing risk for sedation.
Figure 1.
3-Dimensional Reconstruction of LAA
Three-dimensional reconstruction of small cauliflower-shaped left atrial appendage (LAA) shows the bioprosthetic pulmonary valve in close proximity in the minor (A) and major dimension (B). The ostium (C) and landing zone (D) are highly elliptical. CT = computed tomography; PV = pulmonary valve.
Transseptal access was planned through a central and inferior puncture at the fossa ovalis to obtain the best possible coaxial alignment of the delivery system and the LAA central axis. After adjustments to avoid overlap and foreshortening while maintaining an aligned ostium and landing zone, the optimal fluoroscopic implantation view was found to be steep at right anterior oblique 10°/cranial 40° angulation (Figure 2).
Figure 2.
Determination of the Optimal Fluoroscopic Implantation View Through Cardiac Computed Tomography Reconstruction
Traditional empirical views of right anterior oblique 30° projections with cranial and caudal tilt expose the left atrial appendage (LAA) poorly owing to overlap of structures. The optimal view is selected to avoid overlap and foreshortening, with careful alignment of the ostium and landing zone. The S curve of the LAA ostium is shown, illustrating the different projections in which the ostium can be visualized coaxially. LA = left atrium; RAO = right anterior oblique.
Procedural Steps
The procedure was performed under local anesthesia with fluoroscopy and ICE imaging guidance. Owing to repeated access and a recent abscess in the right groin, this access site was found to be inappropriate for further instrumentation (Figure 3A). Unilateral left femoral venous access was secured for ICE imaging and LAA closure device delivery sheath insertion. The increased venous tortuosity in combination with morbid obesity portended an increased risk of kinking of the sheaths. Therefore, an 11-F Super Arrow-Flex Sheath (Teleflex) was inserted to support ICE, and an 18-F DrySeal 33-cm sheath (W.L. Gore & Associates) was introduced into the inferior vena cava over an Amplatz Super Stiff Guidewire (Boston Scientific) for transseptal sheath and LAA closure device delivery sheath insertion. The patient had a history of severe radial artery spasm contraindicating radial vascular access. Hence, a 6-F 35-cm Super Arrow-Flex Sheath was placed in the left femoral artery to insert a 5-F Pigtail catheter positioned in the non-coronary cusp of the aortic valve to calibrate for CT/fluoroscopy fusion imaging and for hemodynamic monitoring throughout the procedure (Figures 3B to 3D).
Figure 3.
Access and Sheath-in-Sheath Approach
The right groin was scarred from prior repeated access and a recent abscess (A). Hence, the left groin was used as a unilateral access with a sheath-in-sheath approach for the intracardiac echocardiography catheter, left atrial appendage delivery sheath, and the pigtail catheter (B). A sheath-in-sheath approach with an FXD delivery sheath (blue arrow) within a larger 18-F DrySeal sheath (green arrow) allowed us to avoid kinking catheters in an obese patient with difficult access (C and D).
Initial transseptal puncture through the fossa ovalis was attempted with a standard 63-cm 8.5-F SL-0 sheath together with a 71-cm BRK-1 needle (Abbott Laboratories). However, this transseptal set was unable to reach the fossa ovalis owing to the patient's height, obesity, and left femoral venous approach. This issue was overcome by using an 8-F VersaCross sheath and wire (Boston Scientific) for a controlled transseptal puncture at the inferior aspect of the fossa ovalis (Figures 4A to 4C). Moreover, use of this VersaCross wire reduced the need for further wire exchanges in the left atrium. A Watchman FXD Double Curve 15-F delivery sheath (Boston Scientific) was inserted across the atrial septal septum over the VersaCross wire, and the wire was used to introduce a 5-F pigtail catheter (Figure 4D). Angiography showed an LAA in the expected location and sizing (Figure 4E). A Watchman FLX 20-mm device (Boston Scientific) was successfully deployed in a single attempt.
Figure 4.
Multimodality Intraprocedural Imaging for Transcatheter LAA Closure
Transseptal puncture was performed using the VersaCross transseptal system through an inferior puncture (A and B). The transseptal wire forms an atraumatic loop on crossing the septum, avoiding damage to surrounding structures, and eliminates the need for further wire exchanges (C). A pigtail catheter was subsequently guided into the left atrial appendage (LAA) (D), and contrast angiography showed an elliptical LAA in the position predicted by preprocedural cardiac computed tomography (E). A 20-mm Watchman FLX was advanced into the LAA (F) and subsequently deployed (G). Intracardiac echocardiography showed excellent depth, compression, and no peridevice leak (H and I).
Post-deployment ICE imaging showed good device position with adequate compression and complete seal of the LAA (Figures 4G to 4I). The patient was discharged the next day without complication. Oral anticoagulation was ceased at discharge and replaced with low-dose single antiplatelet therapy.
Potential Pitfalls
Our approach allowed for a smooth and successful complex transcatheter LAA closure without complication. Several key points that enabled this are highlighted:
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1.
Preprocedural cardiac CT imaging: A major advantage of CT imaging over TEE is consistent LAA imaging that is not operator dependent, with an improved ability to evaluate the anatomic relationships between cardiac structures.2 CT planning is associated with improved procedural success rates, device sizing, and reduced procedural time.3 In this case, preprocedural CT revealed a complex LAA morphology and cardiac anatomy, which may not have been recognized on TEE. Cardiac CT also provides valuable information about the optimal transseptal puncture site and the overall orientation of the heart in the thorax and hence can be very helpful in determining the optimal fluoroscopic implant view. This is key in achieving a smooth transcatheter LAA closure procedure and helps to avoid unnecessary radiation and injection of contrast medium. Preprocedural cardiac CT planning should be considered, if not routine, if a complex LAA closure procedure is anticipated.
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2.
Sheath-in-sheath approach: In this morbidly obese patient, the risk of sheath kinking was eliminated by working through an 18-F DrySeal sheath for the Watchman FXD access sheath and through an 11-F Super Arrow-Flex Sheath for the ICE catheter.
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3.
Use of the VersaCross Transseptal System: The VersaCross Transseptal System allows for a precise transseptal puncture through several features. Use of radiofrequency rather than mechanical puncture by means of a transseptal needle reduces the risk of needle tip slippage, allowing for a precise, targeted puncture location. As the wire forms an atraumatic loop after crossing, this reduces the risk of injury to peripheral structures or anatomy, increasing the safety profile in a patient who was expected to have a complicated transseptal access. Lastly, the VersaCross wire body is sufficiently stiff to allow advancement of delivery catheters without further wire exchanges with ensuing risk of kinking or loss of placement.4
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4.
Use of ICE imaging: By using ICE imaging to guide the procedure, we were able to perform the procedure with local anesthesia with good outcomes and safety. Avoidance of general anesthesia in this patient with adult CHD, reduced left and right ventricular function, and severe obesity was a critical consideration.
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5.
Use of the Watchman FLX device: The LAA was highly elliptical and hypercontractile on echocardiography. Hence, the choice was made to use a Watchman FLX device, given the high device conformability and reliable anchoring of this LAA closure device.5
Conclusions
In this case, we have shown that complex LAA closure procedures may be performed without general anesthesia and TEE thanks to comprehensive preprocedural CT planning and the use of intraprocedural ICE guidance. With expanding toolkits available to operators, we are increasingly able to take a safer, yet minimalist approach to complex interventions.
Take-Home Messages
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•
Use of pre-procedural CT planning and intra-procedural ICE allows for safe performance of complex LAA device closure in patients with CHD.
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•
Careful selection and use of equipment including via a sheath-in-sheath approach simplifies procedures, increasing success rate, and reducing procedural risk.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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