Background: to prevent stroke in patients with atrial fibrillation (AF), oral anticoagulation (OAC) is often prescribed especially for those with high risk (CHADS2-VASC score ≥ 2), however some patients present contraindications to OAC or they have persistent thrombosis. Left atrial appendage (LAA) closure (LAAc) has emerged as a safe and effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF).
Case description: a 61-year-old woman was referred to our cardiology department for left atrial appendage (LAA) closure (LAAc). She had history of previous mitral valve surgery and replacement with mechanical prothesis (On-X 25/33 mm) and permanent atrial fibrillation (AF) with CHADS2-VASC score 4 and HAS-BLED score 2. The patient presented after a third episode of cardioembolic stroke and transesophageal echocardiography (TEE) revealed a thrombus within the LAA despite anticoagulation treatment. Due to multiple episodes of embolic stroke despite adequate oral anticoagulation, the patient was candidate for LAAc. In preparation for the procedure, TEE and computed tomography (CT) scan were performed to evaluate the anatomy, the size and the potential interference of the prosteshis ring with the LAA. Spontaneous echocontrast was present, the morphology was cauliflower with the ostium close to the mitral prosthesis ring. The anomalous anatomy of the patient increased the technical complexity of the intervention: thus, the procedure’s simulation on a 3D printed model resulted of great help in the choice of the most suitable device. The model was printed in deformable material mimicking the atrial wall mechanical behaviour. After written informed consent, the procedure was performed using a standard transvenous approach. Transseptal puncture was performed postero-inferiorly under TEE guidance and Watchman FLX 35 mm was successfully implanted without residual leak. No complications occurred during the procedure. At 1-month follow-up visit, imaging demonstrated complete LAA occlusion and correct placement of the device with an adequate compression and no residual leak.
Conclusion: this is a clinical case that describes complex LAAc in a patient with mechanical prosthetic mitral valve. Simulating the patient’s anatomy with a 3D-printed model can be useful in complex LAAc procedures to guide prosthesis selection and device sizing reducing procedure time and the risk of failure.
