J INVASIVE CARDIOL 2017;29(4):E51-E52.
Key words: left atrial appendage closure, thrombus, TriGuard embolic protection device
An 83-year-old man was referred for left atrial appendage (LAA) closure at our institution. History included permanent atrial fibrillation (AF) with high thrombotic risk (CHA2DS2-VASc score 6) and bleeding risk (HAS-BLED score 6), recent left main and left circumflex drug-eluting stent implantation, and prior history of brachial artery embolism. The patient needed prolonged dual-antiplatelet therapy due to recent coronary stenting and anticoagulation because of AF at high thrombotic risk. Therefore, we decided to perform percutaneous LAA closure in order to avoid the high bleeding risk related to triple antithrombotic therapy (TAPT). Transesophageal echocardiography (TEE) performed before the procedure revealed a thrombus in the LAA. As a result, he was discharged on TAPT with an increase in target international normalized ratio (range, 2.5-3). TEE performed after 4 and 8 weeks of treatment showed only a mild reduction in thrombus size. Since the patient had a prior history of embolism, an elevated bleeding risk, and documentation of persistent LAA thrombus despite anticoagulation, we decided to proceed with percutaneous LAA closure with concomitant use of a cerebral protection device. The TriGuard embolic protection device (EPD; Keystone Heart Ltd) was chosen for this purpose. It is a nitinol-frame mesh filter that is placed into the aortic arch and covers all three aortic arch arteries, maintaining blood flow to the cerebral vessels through 250 µm pores while deflecting larger emboli to the descending aorta. First, right femoral vein and left femoral artery (FA) accesses were obtained. Unfractionated heparin was given in order to obtain an activated clotting time of ~250 s. An angiogram of the aortic arch was performed (Figure 1A) and the TriGuard EPD, folded into a 7 Fr Mullins sheath, was delivered from the left FA into the ascending aorta. Placement was achieved via uncovering the device by pulling back the sheath (Figures 1B, 1C) and allowing the deflector to open up in the aortic arch (Figure 1D). A pigtail catheter was inserted to facilitate close contact of the device against the ostia of the cerebral vessels. The standard procedure of percutaneous LAA closure was followed, and a 22 mm Amplatzer Amulet was successfully deployed (Figure 2) followed by TriGuard EPD removal. The patient’s postoperative course was uneventful.
Patients with known LAA thrombus are usually excluded from percutaneous LAA closure because of the high risk of embolization during the procedure. There are few reports in the literature showing successful percutaneous closure of LAA with persistent thrombus after embolic cerebral protection device placement, but to the best of our knowledge this is the first to use the TriGuard EPD.1-5
We report on first-in-man percutaneous LAA closure with the Amplatzer Amulet device in the presence of LAA thrombus using the TriGuard EPD as a cerebral protection device.
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2. Meincke F, Kreidel F, von Wedel J, Schäfer U, Kuck KH, Bergmann MW. Percutaneous left atrial appendage closure in patients with left atrial appendage thrombus. EuroIntervention. 2015;10:1208.
3. Cammalleri V, Ussia GP, Muscoli S, De Vico P, Romeo F. Transcatheter occlusion of left atrial appendage with persistent thrombus using a trans-radial embolic protection device. J Cardiovasc Med (Hagerstown). 2015 Nov 7.
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5. Lansky AJ, Schofer J, Tchetche D, et al. A prospective randomized evaluation of the TriGuard HDH embolic DEFLECTion device during transcatheter aortic valve implantation: results from the DEFLECT III trial. Eur Heart J. 2015;36:2070.
*Joint first authors.
From 1Interventional Cardiology Unit, San Raffaele Scientific Institute, Milan, Italy; and 2Interventional Cardiology Unit, EMO-GVM Centro Cuore Columbus, Milan, Italy.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 22, 2016, provisional acceptance given September 22, 2016, final version accepted November 2, 2016.
Address for correspondence: Francesca Del Furia, MD, Interventional Cardiology Unit, San Raffaele Scientific Institute, 60 Via Olgettina, 20132 Milan, Italy. Email: email@example.com