Closure of Left Atrial Appendage With Persistent Distal Thrombus Using an Amplatzer Amulet Occluder

Abstract: A 73-year-old patient with permanent atrial fibrillation presented for left atrial appendage (LAA) occlusion. Transesophageal echocardiography demonstrated a thrombus in the distal LAA. This image series illustrates a “no touch” technique that was used to ensure successful implantation of an Amplatzer Amulet LAA occlusion device without the use of an embolization protection system.

J INVASIVE CARDIOL 2016;28(9):E75-E76
Key words: left atrial appendage, thrombus, LAA occlusion

Case Presentation
A 73-year-old patient with permanent atrial fibrillation was referred to our hospital for left atrial appendage (LAA) occlusion. He had a history of insufficient anticoagulation with phenprocoumon after suffering from a stroke. Novel oral anticoagulants were not an option because of severe chronic renal failure.
Transesophageal echocardiography (TEE) revealed a thrombus in the distal LAA (Figure 1A), confirmed by contrast-enhanced ultrasound (SonoVue; Bracco) (Figure 1B). Anticoagulation with phenprocoumon was reinitiated. At 4-week and 8-week follow-up exams, TEE showed a persistent distal wall adherent thrombus (Figure 1C). In view of the patient’s high risk for recurrent stroke, LAA occlusion was considered. The patient was informed about an increased risk for periprocedural stroke and that patients with LAA thrombus were excluded in all studies examining LAA occlusion.

An Amplatzer Amulet LAA occluder (St. Jude Medical) was chosen because the alternatively available Watchman LAA closure device (Boston Scientific) would have required a deep introduction of the delivery sheath into the LAA.  After successful transseptal puncture and crossing, an Amplatz Super Stiff guidewire (Boston Scientific) was positioned in the left upper pulmonary vein. The delivery sheath was positioned very proximal to the LAA ostium and contrast agent was injected in this position very slowly to avoid thrombus mobilization. The occluder was discharged partially until it formed an olive (Figure 2A). The diameter of the partially opened occluder was measured with TEE and compared to the size of the mid part of the LAA (Figure 1D). Release of the device was continued until the diameter of the opened corpus of the Amplatzer Amulet LAA occluder was larger than the measured value (Figure 1E). This technical approach avoided a deeper protrusion of the device in the LAA. Using this “no touch” technique, we achieved perfect implantation position of the Amulet device (Figures 2B and 2C).

The patient was reassessed by a neurologist and demonstrated no neurological deficit. Six weeks after implantation, a routinely performed TEE confirmed a good position of the occluder without thrombus. Accordingly, anticoagulation with phenprocoumon was stopped.

This is the first published case demonstrating that closure of LAA with a distally located thrombus can be safely performed with an Amplatzer Amulet LAA occluder without using an embolization protection system.

From the Department of Cardiology, Heart Center Osnabrück – Bad Rothenfelde, Niels-Stensen-Kliniken, Marienhospital Osnabrück, Osnabrück, Germany.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Lange reports consultant and proctor honoraria from St. Jude Medical. The remaining authors report no conflicts of interest regarding the content herein.

Manuscript submitted April 28 2016 and accepted May 2, 2016.

Address for correspondence: Mathias Lange, MD, Department of Cardiology, Heart Center Osnabrück – Bad Rothenfelde, Niels-Stensen-Kliniken, Marienhospital Osnabrück, 49074 Osnabrück, Germany. Email: mathias.lange@mho.de