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Christoph Hammerstingl, Georg Nickenig, Simultaneous closure of the left atrial appendage and a severe LVOT: atrial shunt defect, European Heart Journal - Cardiovascular Imaging, Volume 14, Issue 11, November 2013, Page 1118, https://doi.org/10.1093/ehjci/jet117
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A 72-year-old male with atrial fibrillation was transferred to our clinic for the evaluation of the interventional closure of the left atrial appendage (LAA) after a major bleeding complication under the novel anti-factor Xa inhibitor rivaroxaban. He had a history of biological aortic valve (AV) replacement and pericardial patch plastic of the left ventricular outflow tract (LVOT) after abscess forming infective endocarditis of the AV and LVOT (Panel A, preoperative state, arrows indicating on AV-LVOT overlapping abscess). At the time of hospital admission, the patient presented with NYHA III functional class and peripheral oedema. Three-dimensional transoesophageal echocardiography (3D TEE) showed an atypical severe shunt defect directed from the LVOT into the left atrium [Panel B, arrows indicating on LVOT patch plastic after abscess excision with Doppler colour flow via the defect at the patch-insertion (Supplementary data online, Video S1)] and an LAA anatomy suitable for the interventional device closure. Repeated open-heart surgery was declined because of high-surgical risk (logistic EuroSCORE 37.4%; STS-Score: 12.3%). Therefore, the 3D TEE-guided interventional device closure of the LAA and the LVOT shunt defect was planned. First, an interventional closure device (AMPLATZER™ Vascular Plug III) was inserted after retrograde probing of the LVOT shunt defect [Panel C, fluoroscopic image of the combined interventional approach with transseptal puncture (arrow indicating on AMPLATZER™ TorqVue FX delivery system) and 3D TEE-guided transaortal, retrograde defect probing, Panels C and D (dotted line arrow indicating on the Amplatzer™ super stiff wire crossing the LVOT defect; *, AV prosthesis)]. Secondly, LAA device closure (AMPLATZER™ Cardiac Plug, St Jude Medical, MN, USA) was performed via an interatrial transseptal sheath with good acute fluoroscopic and echocardiographic results [Panel E, fluoroscopic result with arrows indicating on the closure devices in situ; Panel F, 3D TEE imaging after defect and LAA closure (Supplementary data online, Videos S2 and S3)]. Finally, the patient was discharged on Day 3 after the intervention improved functional NYHA class II.
