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Case Report Percutaneous Closure of a Very Large Left Atrial Appendage Using the Amplatzer Amulet Xavier Freixa, MD, a Jason Leung Kwai Chan, MD, a Apostolos Tzikas, MD, PhD, b Patrick Garceau, MD, a Arsène Basmadjian, MD, a and R eda Ibrahim, MD a a Department of Medicine, Montreal Heart Institute, Universit e de Montr eal, Montreal, Qu ebec, Canada b St Luke’s Hospital, Thessaloniki, Greece ABSTRACT Although percutaneous left atrial appendage (LAA) closure is becoming a common procedure worldwide, there are still some anatomic limitations. The size of the LAA is one of the current limi- tations as the most popular devices do not allow the closure of very large LAAs. The new Amplatzer Cardiac Plug 2, also called “Amulet,” has been redesigned not only to improve delivery and safety but also to allow the closure of larger LAAs. The present report describes the successful closure of a very large LAA using the Amulet. R ESUM E Bien que la fermeture percutan ee de l’appendice auriculaire gauche (AAG) soit devenue une intervention fr equente à l’ echelle mondiale, quelques limites anatomiques existent encore. La taille de l’AAG est l’une des limites actuelles alors que la plupart des dispositifs les plus courants ne permettent pas la fermeture de très grands AAG. La nouvelle prothèse Amplatzer Cardiac Plug 2, egalement appel ee « Amulet »,a et e repens ee non seulement pour am eliorer les r esultats et l’innocuit e, mais aussi pour permettre la fermeture de plus grands AAG. Le pr esent rapport d ecrit la r eussite d’une fermeture d’un très grand AAG en utilisant l’Amulet. Case Report The patient was a man aged 72 years who had a history of hypertension, diabetes, and chronic atrial fibrillation (AF). The patient presented with a stroke while being on warfarin as a result of a subtherapeutic international normalized ratio (INR) (1.34). Other relevant conditions included the presence of a 10-mm secundum atrial septal defect (ASD). A double procedure, percutaneous closure of the left atrial appendage (LAA) and the ASD, was indicated, given the high risk of stroke recurrence (CHADS 2 ¼ 5), the chronic INR lability, and the fact that an isolated ASD closure would preclude a future percutaneous LAA closure. Transesophageal echocardiography (TEE) at 120 revealed a very large LAA with a dimension of 31 mm at the ostium and 29 mm and 28.3 mm at a depth of 10 mm and 15 mm from the ostium, respectively (landing site range of the device lobe). After cannulation of the right femoral vein, a 5F marker pigtail catheter (Merit Medical, South Jordan, UT) was advanced through the ASD in order to perform selective angiograms of the LAA, revealing even larger diameters (34.8, 31.5, and 30.4 mm, respectively) (Fig. 1). A preloaded 34-mm Amplatzer Amulet (St Jude Medical, St Paul, MN) was chosen. The Amulet was introduced in a 14F TorqVue 45 -45 delivery sheath (St Jude Medical). The device was then deployed optimally in the LAA after minimal repositioning (Fig. 1). Subsequently, using the same delivery catheter, a 12-mm Amplatzer Septal Occluder was implanted in the ASD. Both devices were placed success- fully, with excellent results and no residual shunt. Discussion LAA closure is slowly becoming an established procedure in reference hospitals around the world. Percutaneous LAA closure is mostly performed in AF patients with a high risk of stroke (CHADS 2 score 1) and a formal contraindication or at high risk for anticoagulation. To date, the Protection in Patients With Atrial Fibrillation (PROTECT AF) trial 1 is the only available randomized trial comparing oral anticoagulation vs LAA closure in patients with AF and no contraindication for oral anticoagulation. Although LAA closure showed non- inferiority in terms of efficacy, the higher rate of adverse events in the intervention group was considered a main limitation for its usage in patients without contraindication for oral anticoagulation. Currently, the most used devices are the Amplatzer Cardiac Plug 1 2 (ACP-1) (St Jude Medical) and the Watchman (Boston Scientific, Boston, MA). 3 The rate of complications with both devices is gradually diminishing as a result of the growing experience of operators. Nonetheless, the highly variable anatomy of the LAA still represents a technical challenge in many cases. Another challenge for LAA closure is sometimes the degree of dilation of the appendage, as chronic AF is commonly associated with Received for publication November 20, 2012. Accepted December 29, 2012. Corresponding author: Dr R eda Ibrahim, Montreal Heart Institute. 5000, Belanger Street. Montreal, Qu ebec H1T 1C8, Canada. E-mail: [email protected] See page 1329.e10 for disclosure information. 0828-282X/$ - see front matter Ó 2013 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.cjca.2012.12.022 Canadian Journal of Cardiology 29 (2013) 1329.e9e1329.e11 www.onlinecjc.ca
