Percutaneous closure of a left atrial appendage with relevant suture dehiscence
Percutaneous closure of a left atrial appendage with relevant suture dehiscence
V. Veulemans 0
A. Polzin 0
M. Kelm 0
T. Zeus 0
0 Division of Cardiology, Pulmonary Diseases and Vascular Medicine, University Hospital Düsseldorf , Düsseldorf , Germany
Atrial fibrillation is a widespread disease and highly relevant as it carries an extended risk for ischaemic stroke. Surgical closure of the left atrial appendage is routinely performed during open heart surgery in patients with atrial fibrillation with the aim of thromboembolic protection. In this report we present a successful percutaneous closure of a left atrial appendage, which showed clinically relevant suture dehiscence several years after surgical closure. Atrial fibrillation is linked to an increased risk of ischaemic stroke. In patients with a CHA2DS2-VASc score of ≥2, oral anticoagulation is recommended if not contraindicated; in patients with a CHA2DS2-VASc score of ≥1, oral anticoagulation should be considered according to the current ESC guidelines . The left atrial appendage (LAA) is considered the main source of thromboembolic material. Surgical LAA closure has long been practised during open heart surgery. There is evidence, however, that up to 60% of all surgical closures are unsuccessful while suture and stapler exclusion (i. e. closing the orifice of the LAA cavity) seem to have particularly low success rates compared with surgical excision during which the LAA is actually removed . In addition to that, thrombotic material could be detected in
Left atrial appendage closure; Suture dehiscence; Percutaneous device
the LAA in up to 40% of all patients who had undergone
suture or stapler exclusion . However, there are no
controlled clinical data concerning surgical exclusion and only
two randomised controlled trials concerning percutaneous
closure [3, 4]. Thus, percutaneous device closure may be
considered if long-term oral anticoagulation is
contraindicated, in accordance with the current ESC guidelines (Class
IIb) . Surgical closure of the LAA may also be
considered during open heart surgery (Class IIb) .
There is evidence that an incomplete surgical and
percutaneous exclusion of the LAA is associated with an
increased risk for thromboembolic events; [2, 5] however,
there is no directive how to treat patients in this
We present here the case of a 76-year-old male patient,
with coronary artery disease, who underwent coronary
bypass surgery in 1996. During the following years, he was
diagnosed with severe mitral valve regurgitation and atrial
fibrillation. Surgical valve repair was performed in 2011.
Preoperatively the patient was diagnosed with liver
cirrhosis due to chronic hepatitis B infection. With an elevated
lifelong bleeding risk due to liver dysfunction, the LAA
was surgically closed during valve surgery. The
postsurgical course was uneventful and the patient was discharged
on aspirin alone. In 2015, the patient suffered an ischaemic
stroke. On the stroke unit a thorough search for the cause
of the ischaemic event was carried out. Transoesophageal
echocardiography (TEE) showed suture dehiscence of the
LAA ostium with residual blood flow and smoke within the
LAA (Figs. 1 and 2).
The patient had a high risk of a recurrent stroke
(CHA2DS2-VASc score = 6). As life-long
anticoagulation was risky (HAS BLED = 5), we decided to perform
a percutaneous LAA closure.
Fig. 1 Suture dehiscence (gap 6 × 8 mm)
Fig. 2 Residual flow in the LAA
The patient agreed after intensive discussion of the
procedural risks and alternative therapeutic options. As heparin
is applied during the procedure, we waited for six weeks
after the stroke to minimise the risk of secondary
intracerebral bleeding. The procedure was performed under
conscious sedation and with TEE guidance.
The transseptal sheath was inserted through the right
femoral vein. With TEE guidance the interatrial septum
was punctured in an optimal inferior and posterior position.
As the entry of the LAA was too small for the
advancement of a pigtail catheter into the LAA, an Amplatz Super
Stiff (Boston Scientific) guidewire was positioned in the left
upper pulmonary vein. The initial plan was to close the
Fig. 3 ASD-Occluder placed in the LAA
LAA with a 16 mm AMPLATZER Amulet LAA Occluder
(St. Jude Medical, SJM). Therefore a 13 F 45°/45° double
bend sheath (SJM) was introduced over the stiff wire into
the left atrium. Despite good echo guidance, the sheath
could not be advanced safely into the LAA. We thought
that this was mainly due to the relatively large sheath
diameter in correlation to the small, residual LAA ostium
and the double bend curve. Therefore we changed to a 9
French standard single bend sheath (45°, SJM). The 9 F
sheath could be advanced effortlessly into the LAA. As the
oval shaped residual LAA ostium measured 6 × 8 mm, an
8 mm AMPLATZER Septal Occluder (SJM) was chosen.
A smaller one was considered to achieve insufficient
anchoring. A bigger one was considered to increase the risk
of erosion due to the 18 mm distal disc diameter, which
would be placed within the LAA. The waist of the 8 mm
ASD occluder could be positioned within the LAA ostium
and the proximal disc covered the LAA ostium completely.
Neighbouring structures were not affected. The occluder
was released and TEE showed a good final result (Fig. 3).
The patient was transferred to the intermediate care unit,
where he spent 24 h free from events. We recommended six
months of dual antiplatelet therapy (aspirin and clopidogrel)
followed by life-long therapy with aspirin only. Follow-up
of 13 months until now has been uneventful (Fig. 4).
Surgical atrial appendage occlusion is often performed
during open heart surgery. Insufficient occlusion leads to an
elevated risk of thromboembolism. Our patient suffered
a stroke several years after a surgically occluded LAA.
Transoesophageal echocardiography showed a residual
entry to the LAA. Percutaneous closure could be performed
with an atrial septal defect (ASD) occluder.
Post-interventional imaging showed that the LAA ostium was perfectly
With regards to the possible impact of ischaemic strokes
it seems sensible to perform TEE controls after surgical
and percutaneous LAA closure. There is little evidence
on when to perform these tests. Concerning percutaneous
device closure, TEE is routinely performed three months
after the procedure in our clinic. As suture dehiscence
in surgically closed LAA might occur later on, it may be
Funding Master Research Agreement with Philips
Conflict of interest L. Kleinebrecht, V. Veulemans, A. Polzin,
M. Kelm and T. Zeus declare that they have no competing interests.
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