Presentation of the case
- A 76-year-old female patient was referred to our Structural Heart Interventions Program (SHIP) for evaluation of treatment options for left atrial appendage occlusion (LAAO).
- Arterial hypertension and diabetes mellitus.
- Permanent atrial fibrillation on anticoagulation therapy with edoxaban 60 mg daily since 2018
- In 2023, she was diagnosed with breast cancer, which was treated surgically, followed by adjuvant radiotherapy and hormone therapy
- More recently, she was diagnosed with an intestinal extragastrointestinal stromal tumor (ETP), for which treatment with imatinib was indicated, with absolute contraindication to oral anticoagulation.
Diagnostic workup: echocardiography
- Normal left ventricular dimensions
- EF 60%
- Severe LA dilatation area 35 cmq
- 2+ mitral regurgitation
- Normal aortic valve
- Right heart not dilated
- 1+ tricuspid regurgitation
Diagnostic workup: cardiac CT reconstruction
Morphology: Chicken wing
Angiographic projections for morphological assessment
Diagnostic workup - cardiac CT: LAA Diameter at LZ
Orifice measurement
Perimeter 72,8 mm
Min. diameter 22,2 mm
Max. diameter 23,8 mm
Mean diameter 23 mm
Perimeter derived 23,2 mm
Diagnostic workup - cardiac CT: LAA length
LAA DEPTH
Distance 26,1 mm
Planning
Given her elevated thromboembolic risk (CHA₂DS₂-VASc score of 6) and a similarly high bleeding risk (HAS-BLED score of 3), further increased by the potential interaction between non-vitamin K oral anticoagulants (NOACs) and imatinib, the continuation of systemic anticoagulation was deemed unsafe.
Following a multidisciplinary evaluation, a left atrial appendage closure (LAAC) procedure was scheduled. To minimize the risk of bleeding, a mini transesophageal echocardiography (mini 3D-TEE) probe was selected.
Fusion between CT images and angio was decided to guide the procedure.
Introduction
Coming soon: Part 2 including a series of short videos illustrating how the team managed the procedure step-by-step
08 Sep 2025
Sealing the risk: a case of left atrial appendage closure
A 76-year-old woman with permanent atrial fibrillation, a history of breast cancer, and a recent diagnosis of an intestinal stromal tumour presents with a high thromboembolic and bleeding risk, making long-term anticoagulation unsafe. Cardiac CT reveals a challenging left atrial appendage anatomy. How would you treat this patient?
Authors
Interventional cardiologist / Cardiologist
CNR PISA - Pisa, Italy
Interventional cardiologist / Cardiologist
Fondazione Toscana Gabriele Monasterio - Massa, Italy
Interventional cardiologist / Cardiologist
Fondazione Toscana Gabriele Monasterio - Massa, Italy
Interventional cardiologist / Cardiologist
Fondazione Toscana Gabriele Monasterio - Massa, Italy
Interventional cardiologist / Cardiologist
Fondazione Toscana Gabriele Monasterio - Massa, Italy
By S. Berti , G. Benedetti , L. Pastormerlo , A. Eposito , M. Casula
Presentation of the case
Diagnostic workup: echocardiography
Diagnostic workup: cardiac CT reconstruction
Morphology: Chicken wing
RAO 20°
CAU 20°
RAO 20°
CAU 20°
RAO 20°
CRA 20°
RAO 20°
CRA 20°
Angiographic projections for morphological assessment
Diagnostic workup - cardiac CT: LAA Diameter at LZ
Orifice measurement
Perimeter 72,8 mm
Min. diameter 22,2 mm
Max. diameter 23,8 mm
Mean diameter 23 mm
Perimeter derived 23,2 mm
Diagnostic workup - cardiac CT: LAA length
LAA DEPTH
Distance 26,1 mm
Planning
Given her elevated thromboembolic risk (CHA₂DS₂-VASc score of 6) and a similarly high bleeding risk (HAS-BLED score of 3), further increased by the potential interaction between non-vitamin K oral anticoagulants (NOACs) and imatinib, the continuation of systemic anticoagulation was deemed unsafe.
Following a multidisciplinary evaluation, a left atrial appendage closure (LAAC) procedure was scheduled. To minimize the risk of bleeding, a mini transesophageal echocardiography (mini 3D-TEE) probe was selected.
Fusion between CT images and angio was decided to guide the procedure.
Introduction
Coming soon: Part 2 including a series of short videos illustrating how the team managed the procedure step-by-step