Sealing a Multilobe Left Atrial Appendage With Kissing-Watchman Technique

Key words: angiography, cardiac imaging, kissing-Watchman technique, new technique, transesophageal echocardiography

A 72-year-old man was admitted because of persistent atrial fibrillation after suffering a stroke 4 months prior. CHA₂DS₂-VASc score was 4 and HAS-BLED score was 2. Considering the potentially life-threatening bleeding complications, the patient chose left atrial appendage (LAA) closure instead of long-term anticoagulation therapy.

Transesophageal echocardiography (TEE) showed a large-ostium, 26 x 31 mm LAA; angiography showed a cactus morphology with 3 early outgoing lobes (Figure 1A). A significant residual leak persisted after we chose the upper lobe as the landing zone for a 33 mm Watchman device (Boston Scientific). We then tried to repeatedly deploy the Watchman in the medium or lower lobe zones, but significant residual leakage still persisted. Therefore, we planned to close the LAA with a kissing-Watchman technique. First, a 27 mm Watchman was anchored in the upper lobe, and pull test was performed to ensure stabilization. Transesophageal echocardiography (TEE) showed a 16 mm residual leakage in the lower lobe, so a 21 mm Watchman was placed next to the first device (Figure 1B). The tug-test was performed on both devices; TEE showed no residual leaks. Postprocedure TEE 2 months later showed a 2 mm residual leak between the devices (Figure 1C), while TEE at 16-month follow-up showed no device-related thrombus and no residual leakage (Figure 1D). Warfarin was prescribed for the first 2 months, and dual-antiplatelet therapy (aspirin 100 mg/day and clopidogrel 75 mg/day) was given until 12 months; aspirin 100 mg/day was then prescribed indefinitely.

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^*Joint first authors.

From the Division of Cardiology, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, Chengdu, China.

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

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted March 26, 2019.

Address for correspondence: Cong Lu, MD, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, No. 32 West Second Section First Ring Road, Chengdu, Sichuan, China. Email: lucong100@126.com