Interventional Occlusion of an Incompletely Ligated Left Atrial Appendage Using a Disc-And- Ball Occluder: Feasible and Effective

A 79-year-old female patient with chronic atrial fibrillation (EHRA 3 CHA2DS2-VASc score of 4, HAS-BLED score of 2) on full anticoagulation was referred to us for further evaluation and management. In June 2021, she underwent surgical mitral and tricuspid repair, and suture ligation of the Left Atrial Appendage (LAA). A subsequent transesophageal echocardiogram (TEE) demonstrated incomplete closure of LAA with two residual communications (2x3mm, 3x5mm) (arrows) between the left atrium and LAA by color Doppler interrogation (Figs. 1A, 1B). 

Using conscious sedation and under TEE control, transseptal puncture was performed and through the LAmbre™ LAA Closure System delivery sheath, a 4F Multipurpose catheter was used to cannulate the ostial defect. Following cannulation of the larger defect, a 16/22 mm LAmbre™ occluder was easily deployed with a very good angiographic and echocardiographic result (Fig 2). Follow-up TEE after three months revealed complete closure of LAA. 

Follow-up echocardiographic studies demonstrated that a completely closed LAA following surgical ligation was present in only 45-72% of cases (1). Furthermore, 41% of unsuccessful surgical closure appendages contain thrombus, which are associated with thromboembolic events (2). Therefore, it seems logical to close those defects.

Transcatheter occlusion of post-surgical defects using numerous devices has been practiced for a couple of years. The choice depends on the anatomical features of defect and residual cavity.  LAmbre™ LAA Closure System with a “cover”-and - “umbrella” concept looks an attractive device for partially ligated LAAs with small ostium and large remnant “Neo-LAAs”, taking the advantage of simultaneously sealing the ostial defects and obliteration of Neo-LAA. Our case illustrated the feasibility of this device among those patients. To the best of our knowledge, this is the first use of LAmbre™ occluder in these patients.

Figure 1A: Transoesophageal echocardiographic image displaying two residual defects after incomplete surgical ligation of the LAA

Figure 1B: Transoesophageal echocardiographic color doppler image displaying a bidirectional flow across the residual defect after incomplete surgical ligation of the LAA 

Figure 2: Transoesophageal echocardiographic 3D image of pre and post occlusion of the LAA using LAmbre™ LAA Closure System

References

1.         Squiers JJ, Edgerton JR. Surgical Closure of the Left Atrial Appendage: The Past, The Present, The Future. J Atr Fibrillation. 2018;10(5):1642.

2.         Kanderian AS, Gillinov AM, Pettersson GB, Blackstone E, Klein AL. Success of surgical left atrial appendage closure: assessment by transesophageal echocardiography. J Am Coll Cardiol. 2008;52(11):924-9.