Author + information
- Received March 9, 2016
- Accepted March 24, 2016
- Published online June 27, 2016.
- Fausto Castriota, MD,
- Roberto Nerla, MD∗ (, )
- Angelo Squeri, MD,
- Antonio Micari, MD, PhD,
- Mauro Del Giglio, MD and
- Alberto Cremonesi, MD
- ↵∗Reprint requests and correspondence:
Dr. Roberto Nerla, Cardiovascular Unit GVM Care & Research, Maria Cecilia Hospital, Via Corriera 1, Cotignola 48033 (RA), Italy.
A 63-year-old woman with dextrocardia (Figure 1) and situs inversus viscerum was referred to our center to undergo left atrial appendage closure (LAAC). She had a recent history of paroxysmal atrial fibrillation with poor international normalized ratio control, and in 2015 she was admitted to a local hospital with a diagnosis of non–ST-segment elevation acute coronary syndrome in the context of unobstructed coronary arteries. Her medical history included previous eye bleeding for hemorrhagic macular degeneration, so she was judged at too high a risk for long-term anticoagulation. However, because of the anatomic challenge related to her dextrocardia, she had been refused for LAAC by 2 large centers.
We decided to undertake LAAC with the plan of “reversing” fluoroscopic images at each stage in order to simplify anatomic guidance. Transesophageal echocardiography was used to size the device. After gaining right femoral venous access, transseptal puncture was performed using a Preface braided guiding sheath (Biosense Webster, Diamond Bar, California), and an 8-F transseptal sheath was introduced with fluoroscopic guidance (Figure 2). Contrast injection into the left atrium revealed the shape of the left atrial appendage (Figure 2). A 20-mm Amplatzer Amulet device (St. Jude Medical, St. Paul, Minnesota) was then positioned and, after confirming the absence of any leaks (Figure 3), finally released. Both final angiographic and transesophageal echocardiographic results were excellent, with no peridevice leaks detected (Figure 4). No clinical events were reported at discharge and at 3-month follow-up.
To the best of our knowledge, this is the first report illustrating successful LAAC in a patient with dextrocardia. Although potentially challenging, mirror-image dextrocardia should not discourage LAAC. Actually, the opportunity to acquire radiographic images in the inverted position to improve fluoroscopic guidance for septal puncture and left atrial appendage shape evaluation, as previously described (1), could help operators by simulating normal anatomy.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 9, 2016.
- Accepted March 24, 2016.
- American College of Cardiology Foundation