Case Study

Transseptal Transcatheter Left Atrial Appendage Closure Device Implantation in the Presence of an Interatrial Cardiac Tumor

Hiren Patel, MD, Rachel Garcia, MD, Augustin DeLago, MD, Anthony Nappi, MD, Mohammad El-Hajjar, MD
Division of Cardiology, Albany Medical College
Albany, New York

 

Hiren Patel, MD, Rachel Garcia, MD, Augustin DeLago, MD, Anthony Nappi, MD, Mohammad El-Hajjar, MD
Division of Cardiology, Albany Medical College
Albany, New York

 

Introduction

Transcatheter left atrial appendage (LAA) closure devices such as the WATCHMAN Device (Boston Scientific) offer an alternative strategy to long-term anticoagulation in patients with atrial fibrillation at an elevated thromboembolic and bleeding risk.1 Atrial and interatrial septal anatomy often determine a patient’s eligibility for having this device implanted via a transseptal route.2,3 The following case describes a patient that underwent a successful transcatheter WATCHMAN device implantation in the presence of an interatrial cardiac tumor.
 

Case Description

An 82-year-old male with an elevated thromboembolic risk from atrial fibrillation was referred for transcatheter LAA closure device implantation. He had been a poor candidate for long-term anticoagulation due to significant history of epistaxis requiring multiple blood transfusions, and had an increased fall risk from progressive polymyalgia rheumatica. A pre-procedural transesophageal echocardiogram (TEE) evaluation of the LAA revealed a 1.5 cm by 1.5 cm left-sided interatrial cardiac tumor (Figure 1). Therefore, the patient was deemed a poor surgical candidate by cardiothoracic surgery, and subsequently proceeded with the transcatheter LAA closure with a WATCHMAN device.  
 
Via right femoral vein access, the atrial septum was punctured with a transseptal needle and guiding introducer under fluoroscopy and real-time three-dimensional (RT-3D) TEE guidance to avoid the cardiac tumor and provide favorable device delivery (Figure 2). A 14 French single curve WATCHMAN access system was advanced across the septum, and successful LAA occlusion with a 24 mm WATCHMAN device was achieved (Figure 2). The cardiac tumor remained undisturbed during (Figure 3) and after (Figure 4) the procedure.

Discussion

An LAA occluder such as the WATCHMAN device is an alternative strategy to long-term anticoagulation in patients with atrial fibrillation at an elevated thromboembolic and bleeding risk.1 Presence of any cardiac tumor in the interatrial location is an absolute contraindication to transseptal puncture due to the potential risk of tumor disruption and embolization. This excluded patients from the pivotal clinical studies on the safety and efficacy of the WATCHMAN device2,3; thus, no data is available on peri- and post-procedural outcomes in these select patients with interatrial cardiac tumors. In clinical practice, this often excludes ideal patients with atrial fibrillation (which frequently coexists with cardiac tumors) whom are poor surgical and long-term anticoagulation candidates with an elevated thromboembolic risk from having an LAA closure device. However, this case demonstrates that with the use of appropriate imaging techniques, transcatheter LAA closure with the WATCHMAN device can be safely and successfully performed in the presence of an interatrial cardiac tumor under direct visualization with RT-3D TEE. In conclusion, the absolute contraindication of the presence of an interatrial cardiac tumor in patients being evaluated for transcatheter LAA closure device implantation should be reconsidered if transseptal puncture can be performed with newer imaging modalities, as illustrated in this case.
 
Disclosures: The authors have no conflicts of interest to report regarding the content herein.   

References

  1. Reddy VY, Doshi SK, Sievert H, et al; PROTECT AF Investigators. Percutaneous left atrial appendage closure for stroke prophylaxis in patients with atrial fibrillation: 2.3-Year Follow-up of the PROTECT AF (Watchman Left Atrial Appendage System for Embolic Protection in Patients with Atrial Fibrillation) Trial. Circulation. 2013;127(6):720-729.
  2. Holmes DR, Reddy VY, Turi ZG, et al; PROTECT AF Investigators. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet. 2009;374(9689):534-542.
  3. Holmes DR Jr, Kar S, Price MJ, et al. Prospective randomized evaluation of the Watchman Left Atrial Appendage Closure device in patients with atrial fibrillation versus long-term warfarin therapy: the PREVAIL trial. J Am Coll Cardiol. 2014;64:1-12.