An Amulet to Say “Big is Not Enough“

Abstract: We report the case of a man affected by non-valvular atrial fibrillation in whom a severely enlarged left atrial appendage with a narrow neck was successfully closed with a 34 mm Amplatzer Amulet device (St. Jude Medical). In the presence of a huge appendage with a narrow neck, as in this case, the Amulet should be considered an available option to ensure the feasibility of percutaneous closure.

J INVASIVE CARDIOL 2016;28(2):E26

Key words: atrial fibrillation, left atrial appendage closure, Amulet device

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An 88-year-old man with permanent non-valvular atrial fibrillation and contraindication to anticoagulation was referred to our institution for percutaneous left atrial appendage (LAA) closure. A severely enlarged LAA was documented by preoperative transesophageal echocardiography (TEE), which demonstrated a landing zone ranging from 26 mm at 87° up to 36 mm at 100° with a neck of 25 mm (Figure 1A). LAA angiography from multiple projections confirmed a mean landing zone diameter of 34 mm (Figure 1B). Neither the Watchman device (Boston Scientific) nor the first-generation Amplatzer Cardiac Plug (St. Jude Medical) was compatible with such remarkable measures. Although the lobe of the LAA was roomy enough for any available device, the neck was within the appropriate range for attempting the implantation of the novel Amplatzer Amulet device (St. Jude Medical). A 34 mm Amulet was selected and successfully implanted (Figures 1C and 1D). The wide lobe – which has more and stiffer stabilizing wires and a longer waist compared with the Amplatzer Cardiac Plug – acted like an anchor at the level of the neck and efficiently stabilized the system. In fact, even without evidence of compression at fluoroscopy, the excellent anchoring was demonstrated by vigorous tugging (Video 1). The large disc, which is designed to prevent embolization from periostial trabeculae, provided full coverage of the very large LAA ostium (38 mm at 48° TEE and 37 mm at angiography). Control TEE confirmed the absence of peridevice leaks or mitral valve impingement, and follow-up was uneventful.

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From the Department of Cardiac, Thoracic and Vascular Sciences, University of Padua Medical School, Padua, Italy.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors reports no disclosures regarding the content herein.

Manuscript submitted May 18, 2015, final version accepted May 28, 2015.

Address for correspondence: Giuseppe Tarantini, Ospedale di Padova, Centro Cardiologico Gallucci, Clinica Cardiologica, Via Giustiniani, 2, 35128 Padova, Italy. Email: giuseppe.tarantini.1@gmail.com