Extract

Percutaneous left atrial appendage (LAA) closure is feasible in the majority of patients. However, certain LAA anatomies may pose substantial technical challenges. We describe two unusual ‘Whale Tail’-like LAAs and novel closure methods with the Watchman (Boston Scientific, Marlborough, MA, USA) and Amulet (Abbott, St Paul, MN, USA) Devices.

Patient 1: A 67-year-old male with atrial fibrillation (CHA2DS2-VASc = 6) was referred for LAA closure due to gastrointestinal bleeding on Warfarin. Transoesophageal echocardiography (TOE) showed a bilobar LAA (Supplementary material online, Video S1). He declined thoracoscopic surgical exclusion. Left atrial appendage angiography revealed a whale tail-like appearance (Panel  A). Placement of an oversized Watchman device (24-mm) was unsuccessful in sealing the LAA. A second transseptal puncture was performed, and two 21-mm Watchman devices were sequentially deployed in a kissing fashion (Panels  B and C, Supplementary material online, Video S2). Computed tomography imaging and TOE at 45-days showed adequate LAA sealing, and no device thrombus (Supplementary material online, Video S3, Panel  D).

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