Author + information
- Received March 22, 2017
- Accepted April 6, 2017
- Published online November 6, 2017.
- Steffen Gloekler, MD,
- Samera Shakir, MD and
- Bernhard Meier, MD∗ ()
- ↵∗Address for correspondence:
Dr. Bernhard Meier, Department of Cardiology, University Hospital of Bern, 3010 Bern, Switzerland.
A 54-year-old woman with persistent atrial flutter or fibrillation requested left atrial appendage (LAA) closure because of poor dabigatran tolerance at a tertiary center in the United States. She had undergone atrial septal defect device closure there 9 years earlier. The 24-mm Amplatzer Septal Occluder (ASO) (Abbott, Plymouth, Minnesota) with a 36 mm disc diameter was deemed prohibitive for transseptal passage based on transesophageal echocardiography (TEE) and computed tomography (1). She traveled to Switzerland for treatment.
Under local anesthesia with exclusively fluoroscopic guidance (TEE not repeated), an 8-F transseptal sheath–needle set (Medtronic, Minneapolis, Minnesota) was selected to perforate the lower part of the left disc of the ASO (Figure 1A). After pre-perforation with the stiff end of a 0.014-inch coronary guidewire, the needle and the dilator of the transseptal sheath could be passed. During pre-dilation with a 7-mm angioplasty balloon catheter over a 0.035-inch Backup wire (Boston Scientific, Marlborough, Massachusetts), the patient surprisingly converted into sinus rhythm (Figure 1B, Online Video 1). Through a 12-F TorqVue sheath (Abbott), LAA angiography (Figure 1C) and closure with an Amplatzer Amulet 22-mm device (Abbott) (Figure 1D) were performed. On the way out, the trans-ASO access hole was closed with an 8-mm ASO (Figure 1E). Dabigatran was immediately discontinued. Clopidogrel (75 mg) for 1 month and acetylsalicylic acid (100 mg) for 5 months were prescribed. The patient left the hospital the next morning after transthoracic echocardiography had verified correct positions of the 3 devices.
TEE follow-up at 6 months (patient had remained in sinus rhythm and well) showed complete closure of the LAA and the atrial septum with all 3 devices free of thrombus and in correct positions (Figure 1F).
Dr. Shakir has received a grant from the Swiss Heart Foundation. Dr. Meier has received speaker fees from Abbott. Dr. Gloekler has reported that he has no relationships relevant to the contents of this paper to disclose.
- Received March 22, 2017.
- Accepted April 6, 2017.
- 2017 American College of Cardiology Foundation