J INVASIVE CARDIOL 2019;31(2):E41-E42.
Key words: cardiac imaging, transesophageal echocardiogram
A 69-year-old woman with atrial fibrillation (CHA2DS2-VASc score of 4; HASBLED score of 3) and history of gastrointestinal bleeding on oral anticoagulation underwent left atrial appendage (LAA) occlusion. Three-dimensional transesophageal echocardiogram (TEE) showed a three-lobed LAA with an oval orifice of 23 x 17 mm and depth of 13-17 mm (Figures 1A and 1B). LAA angiography showed a maximal landing zone of 14 mm (Figure 1C).
A 24 mm Watchman device (Boston Scientific) was initially chosen. However, the LAA could not be completely sealed despite multiple attempts at deploying the device from different lobes (Figure 1D; Video 1). A larger 27 mm Watchman device positioned deep into the posterior lobe with a shoulder hanging outside the LAA also failed to adequately seal the LAA (Figures 1E and 1F; Videos 2 and 3).
A specially sized LAmbre LAA occluder (Lifetech, Inc) with a 16 mm umbrella articulated to a 30 mm cover (Figure 1G) was designed to tackle this complex LAA anatomy, including the discrepancy between the orifice and landing zone in this case. The delivery sheath was positioned within the LAA without selective engagement of any lobes. The umbrella of the device was pushed and rolled out of the sheath, first allowing its eight claws to capture the trabeculae of the LAA for anchoring (Figure 1H; Video 4). The cover of the device was then unsheathed to occlude the orifice of the LAA with an inward indentation (Figure 1I; Videos 5 and 6). The multilobed LAA was completely occluded with a single attempt using the LAmbre device.
Although reported failure rates of the Watchman device are low, the ball-shaped device is not suitable for shallow and multilobed LAAs, as in this case. The LAmbre device is available in two configurations – standard (cover 4-6 mm larger in diameter than the umbrella) and special (cover 12-14 mm larger than the umbrella) – which allows the ability to close a wide range of LAA anatomies. This case illustrates that the LAmbre device can be used for complex LAA anatomies that are not suitable for the Watchman device.
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From the 1Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong SAR, China; 2Division of Cardiology, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong SAR, China; and 3Centre Medical, Hong Kong SAR, China.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lam is a clinical proctor for LifeTech, Inc. Dr Cheung is a clinical proctor for Boston Scientific. The remaining authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript accepted August 28, 2018.
Address for correspondence: Chak-yu So, MBChB, Division of Cardiology, Department of Medicine and Therapeutics, 9/F Clinical Sciences Building, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR, China. Email: firstname.lastname@example.org