Emergency left arial appendage clipping after percutaneous pulmonary vein isolation in a patient with a partial anomalous pulmonary venous connection Niels J. Verberkmoes, MD, Ferdi Akca, MD, PhD From the Heart Center, Catharina Hospital, Eindhoven, The Netherlands.
Introduction Currently there is increasing scientific interest in left atrial appendage (LAA) closure strategies in order to eliminate the major cause of thromboembolic events. However, in the case of an acute LAA perforation with cardiac tamponade, a fast and reliable closure technique is mandatory for the survival of the patient. This could be very challenging when the patient is in hemodynamic shock.
seemed too risky on the beating heart. Therefore we tried to solve both perforations simultaneously by placing a 40 mm epicardial clip (Atriclip, AtriCure, Dayton, OH) (Figure 1). Despite limited view owing to the severity of the bleeding, the clip could be placed under manual guidance, resulting in adequate hemostasis without the need for additional sutures. Furthermore, a successful surgical pulmonary vein isolation was performed. The patient recovered well without any complications.
Case report A 66-year-old female patient with a history of diabetes and a previous percutaneous pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation presented with a recurrence of symptomatic atrial fibrillation. Because of an intolerance to antiarrhythmic drugs, a redo PVI procedure was performed. Preoperative computed tomography revealed a partial anomalous pulmonary venous connection of the left upper lobe. The left superior pulmonary vein drained to the left innominate vein, and the left inferior pulmonary vein connected very caudal to the left atrium. During the PVI procedure, a transseptal puncture was performed with an 8.5 F puncture sheath. There were difficulties identifying the ostium of the left inferior pulmonary vein. This required multiple maneuvers using a 7 F NIH (National Institutes of Health) angiography catheter. These maneuvers were complicated by cardiac tamponade, resulting in hemodynamic shock. Percutaneous pericardial drainage was performed with a temporary hemodynamic recovery. However, owing to persisting blood loss the patient was transported to the surgical operating room for salvage surgery. Immediate sternotomy and pericardiotomy were performed, and 1000 mL of blood was evacuated from the pericardium. Two acute perforations of the LAA were identified, being at the base of the LAA and in the LAA roof. Since one of the perforations was just above the base of the LAA, safe placement of standard surgical sutures KEYWORDS Left atrial appendage; Perforation; Epicardial clip; Atrial fibrillation; Cardiac surgery (Heart Rhythm Case Reports 2017;3:400–401) Address reprint requests and correspondence: Dr Niels J. Verberkmoes, Heart Center, Catharina Hospital, Michelangelolaan 2, PO Box 1350, Eindhoven 5602 ZA, The Netherlands. E-mail address: niels.verberkmoes@ catharinaziekenhuis.nl.
Discussion In the case of acute cardiac perforations requiring surgery, it is a priority to maintain hemodynamic stability by controlling the bleeding, or by instituting cardiopulmonary bypass. For control of bleeding owing to LAA perforation, several closure techniques could be considered nowadays, including classical surgical suturing and the use of endocardial (Watchman/Amplatzer) and epicardial (Lariat/Atriclip) devices. During classical suturing there is a high risk of creating
Figure 1 Postoperative computed tomography scan displaying the position of the epicardial clip on the left atrial appendage (yellow asterisk) and the partial anomalous pulmonary venous connection (red asterisk). Innominate vein (A), descending aorta (B), left pulmonary artery (C), right pulmonary artery (D), left inferior pulmonary vein (E), left atrium (F).
2214-0271/© 2017 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.hrcr.2017.05.009
Verberkmoes and Akca
Emergency Left Atrial Appendage Clipping
KEY TEACHING POINTS Current percutaneous left atrial appendage (LAA) closure techniques could be too time-consuming with the risk of significant amounts of residual flow, which makes them unsuitable for LAA closure after acute perforation. In our patient, surgical epicardial clipping provides full hemostasis for perforations that could not be closed using traditional suture techniques. Patients with an anomalous pulmonary vein anatomy could be more at risk for LAA perforation and great caution must be taken during percutaneous pulmonary vein isolation.
new perforations owing to the use of sharp needles in the fragile LAA tissue, and additional risk of damaging nearby vital structures (in this case, the circumflex artery). The use
401
of endocardial closure techniques and the Lariat device to resolve acute LAA perforation might be too timeconsuming and perhaps too unreliable owing to residual flow.1,2 Our case demonstrates that emergency surgical LAA clipping is a feasible atraumatic fast solution, irrespective of the LAA anatomy. Despite multiple bleeding sites at the LAA, the epicardial clip provided complete hemostasis, without the need for additional sutures or initiation of cardiopulmonary bypass. This case demonstrates reliable hemostasis using an epicardial clip for acute LAA closure.
References 1. Pillarisetti J, Reddy YM, Gunda S, et al. Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm 2015;12:1501–1507. 2. Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 2012;59:923–929.
Introduction Currently there is increasing scientific interest in left atrial appendage (LAA) closure strategies in order to eliminate the major cause of thromboembolic events. However, in the case of an acute LAA perforation with cardiac tamponade, a fast and reliable closure technique is mandatory for the survival of the patient. This could be very challenging when the patient is in hemodynamic shock.
seemed too risky on the beating heart. Therefore we tried to solve both perforations simultaneously by placing a 40 mm epicardial clip (Atriclip, AtriCure, Dayton, OH) (Figure 1). Despite limited view owing to the severity of the bleeding, the clip could be placed under manual guidance, resulting in adequate hemostasis without the need for additional sutures. Furthermore, a successful surgical pulmonary vein isolation was performed. The patient recovered well without any complications.
Case report A 66-year-old female patient with a history of diabetes and a previous percutaneous pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation presented with a recurrence of symptomatic atrial fibrillation. Because of an intolerance to antiarrhythmic drugs, a redo PVI procedure was performed. Preoperative computed tomography revealed a partial anomalous pulmonary venous connection of the left upper lobe. The left superior pulmonary vein drained to the left innominate vein, and the left inferior pulmonary vein connected very caudal to the left atrium. During the PVI procedure, a transseptal puncture was performed with an 8.5 F puncture sheath. There were difficulties identifying the ostium of the left inferior pulmonary vein. This required multiple maneuvers using a 7 F NIH (National Institutes of Health) angiography catheter. These maneuvers were complicated by cardiac tamponade, resulting in hemodynamic shock. Percutaneous pericardial drainage was performed with a temporary hemodynamic recovery. However, owing to persisting blood loss the patient was transported to the surgical operating room for salvage surgery. Immediate sternotomy and pericardiotomy were performed, and 1000 mL of blood was evacuated from the pericardium. Two acute perforations of the LAA were identified, being at the base of the LAA and in the LAA roof. Since one of the perforations was just above the base of the LAA, safe placement of standard surgical sutures KEYWORDS Left atrial appendage; Perforation; Epicardial clip; Atrial fibrillation; Cardiac surgery (Heart Rhythm Case Reports 2017;3:400–401) Address reprint requests and correspondence: Dr Niels J. Verberkmoes, Heart Center, Catharina Hospital, Michelangelolaan 2, PO Box 1350, Eindhoven 5602 ZA, The Netherlands. E-mail address: niels.verberkmoes@ catharinaziekenhuis.nl.
Discussion In the case of acute cardiac perforations requiring surgery, it is a priority to maintain hemodynamic stability by controlling the bleeding, or by instituting cardiopulmonary bypass. For control of bleeding owing to LAA perforation, several closure techniques could be considered nowadays, including classical surgical suturing and the use of endocardial (Watchman/Amplatzer) and epicardial (Lariat/Atriclip) devices. During classical suturing there is a high risk of creating
Figure 1 Postoperative computed tomography scan displaying the position of the epicardial clip on the left atrial appendage (yellow asterisk) and the partial anomalous pulmonary venous connection (red asterisk). Innominate vein (A), descending aorta (B), left pulmonary artery (C), right pulmonary artery (D), left inferior pulmonary vein (E), left atrium (F).
2214-0271/© 2017 Heart Rhythm Society. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.hrcr.2017.05.009
Verberkmoes and Akca
Emergency Left Atrial Appendage Clipping
KEY TEACHING POINTS Current percutaneous left atrial appendage (LAA) closure techniques could be too time-consuming with the risk of significant amounts of residual flow, which makes them unsuitable for LAA closure after acute perforation. In our patient, surgical epicardial clipping provides full hemostasis for perforations that could not be closed using traditional suture techniques. Patients with an anomalous pulmonary vein anatomy could be more at risk for LAA perforation and great caution must be taken during percutaneous pulmonary vein isolation.
new perforations owing to the use of sharp needles in the fragile LAA tissue, and additional risk of damaging nearby vital structures (in this case, the circumflex artery). The use
401
of endocardial closure techniques and the Lariat device to resolve acute LAA perforation might be too timeconsuming and perhaps too unreliable owing to residual flow.1,2 Our case demonstrates that emergency surgical LAA clipping is a feasible atraumatic fast solution, irrespective of the LAA anatomy. Despite multiple bleeding sites at the LAA, the epicardial clip provided complete hemostasis, without the need for additional sutures or initiation of cardiopulmonary bypass. This case demonstrates reliable hemostasis using an epicardial clip for acute LAA closure.
References 1. Pillarisetti J, Reddy YM, Gunda S, et al. Endocardial (Watchman) vs epicardial (Lariat) left atrial appendage exclusion devices: understanding the differences in the location and type of leaks and their clinical implications. Heart Rhythm 2015;12:1501–1507. 2. Viles-Gonzalez JF, Kar S, Douglas P, Dukkipati S, Feldman T, Horton R, Holmes D, Reddy VY. The clinical impact of incomplete left atrial appendage closure with the Watchman Device in patients with atrial fibrillation: a PROTECT AF (Percutaneous Closure of the Left Atrial Appendage Versus Warfarin Therapy for Prevention of Stroke in Patients With Atrial Fibrillation) substudy. J Am Coll Cardiol 2012;59:923–929.
