Prolapse of left atrial appendage during transcatheter left atrial appendage closure

We present the case of an 89-year-old gentleman referred for transcatheter left atrial appendage (LAA) closure (LAAC). Intra-procedural transoesophageal echocardiogram (TOE) was used to size the LAA and a 27 mm Watchman (Boston Scientific, Marlborough, MA, USA) LAAC device was selected (Panel A). The LAAC device was placed but needed to be repositioned. As the device was recaptured for repositioning, it was noted on TOE as well as fluoroscopy that the LAA had prolapsed and was essentially inverted into the left atrium (LA) (Panels B and C, Supplementary material online, Video S1). The LAA remained prolapsed after a period of monitoring despite an elevated LA pressure. Both fluoroscopy and TOE were used to asses for perforations, with none being present. Using fluoroscopy and TOE guidance, a pigtail catheter was used, in conjunction with puffs of contrast, to help push the LAA back to its original position (Panels D and E, Supplementary material online, Video S2). Subsequently, a 27 mm Watchman device was successfully deployed for LAAC. A 45-day post-LAAC TOE demonstrated complete seal of the LAA without any significant leaks noted. Prolapse of the LAA has been documented in the surgical literature with the inverted LAA often noted on post-operative imaging. Here, we report the first documented occurrence of prolapse of the LAA during percutaneous LAAC and provide a strategy for correction. During LAAC, LAA prolapse is easily recognized on fluoroscopy and/or TOE, and in this case was easily corrected. In this case, the mechanical solution was helpful because it allowed us to complete the case. We otherwise would have had to terminate the case and follow the patient for spontaneous resolution.

Supplementary material is available at European Heart Journal online.

ACP is supported from the NIH NCATS (KL2TR002552) to Scripps Research.