Author + information
- Received July 20, 2015
- Revision received August 7, 2015
- Accepted August 13, 2015
- Published online December 28, 2015.
- ∗Clinical Cardiac Electrophysiology Laboratory, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- †Department of Cardiac Surgery, Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- ↵∗Reprint requests and correspondence:
Dr. Sam G. Aznaurov, Clinical Cardiac Electrophysiology Cardiovascular Medicine, Vanderbilt University Medical Center, 1211 21st Avenue South, Nashville, Tennessee 37232-8802.
A 68-year-old man with atrial fibrillation was evaluated for ligation of the left atrial appendage (LAA) via the LARIAT Suture Delivery Device (SentreHEART, Redwood City, California). The CHA2DS2-VASc score was 4 for hypertension, cerebrovascular accident, and age. He was intolerant of anticoagulation due to recurrent gastrointestinal hemorrhage. Imaging revealed an anteriorly directed LAA of chicken wing morphology, with a secondary lobe near the ostium (Figure 1, Online Video 1).
He underwent LAA ligation using the LARIAT Suture Delivery Device via a standard transseptal and subxiphoid pericardial approach while under general endotracheal anesthesia. The delivery device was cinched over the neck of the LAA, and closure of the LAA ostium was noted (Figure 2). After tightening the LARIAT, contrast angiography demonstrated reopening of the LAA proximal lobe. A second LARIAT Plus ligature was used to resnare the neck of the LAA, but reopening of the LAA was again seen (Figure 2).
The patient was referred for surgical closure of the LAA with the Atriclip (AtriCure, West Chester Township, Ohio). Thoracoscopic access was obtained to the left chest under general endotracheal anesthesia, and the pericardium was opened posteriorly to the phrenic nerve. The 2 previously deployed LARIAT ligatures were seen, as was early necrosis of the main LAA lobe (Figure 3, Online Video 2). The secondary lobe of the LAA was unaffected by these ligatures. A 40-mm Atriclip Pro was deployed at the base of the LAA, achieving complete occlusion (Figure 3, Online Video 3). The patient had an uneventful postoperative course. Follow-up with gated cardiac computed tomography angiography showed closure of the LAA (Figure 4).
Epicardial LAA closure is an evolving option for the prevention of stroke in patients with atrial fibrillation. This case demonstrates the feasibility of completion of LAA closure after incomplete LAA ligation via a subxiphoid approach. Additionally, this case highlights the possibility of incomplete LAA closure despite a favorable appearance on angiography during deployment of the LARIAT Suture Delivery Device.
For supplemental videos, please see the online version of this article.
Dr. Ellis has received consulting fees/honoraria (<$10,000 per year) from Medtronic, Sentre Heart, AtriCure, Boston Scientific and Boehringer Ingelheim; has received significant research funding from Thoratec, HeartWare, Boston Scientific, Boehringer Ingelheim, and Medtronic; and is on the Scientific and Advisory Board of Sentre Heart and AtriCure. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 20, 2015.
- Revision received August 7, 2015.
- Accepted August 13, 2015.
- 2015 American College of Cardiology Foundation