Very small LAA with a challenging closure

Recurrent strokes despite anticoagulation, a failed first attempt at left atrial appendage closure (LAAC), and a challenging small chicken-wing anatomy: this case brings together several factors that complicate procedural planning and device selection.

In a 65-year-old woman with paroxysmal atrial fibrillation, pre-procedural TOE and CT imaging highlighted the anatomical challenges facing the Heart Team after an unsuccessful implantation of a 20 mm single-disc occluder.

What strategy would you choose to achieve successful LAA closure in this demanding case?

Author

Fadhel Nabil Hamidani

Interventional cardiologist / Cardiologist

Hildesheim, Germany

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Part 1 - Case presentation

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Learning objectives

To learn how to perform LAAC in challenging anatomies
To learn how to use CT-scan and 3D TOE for planning
To understand value of different devices in complex anatomies

Patient description

A 65-year-old woman with paroxysmal atrial fibrillation and prior recurrent strokes despite anticoagulation referred to us for left atrial appendage closure after a failed first attempt in another center.

In 2022, she suffered prior brainstem stroke with acute distal syndrome, dizziness, and tendency to fall to the left (on Lixiana)

In 2020, she had a history of transient ischemic attack in the vertebrobasilar circulation

She presented with: