Left atrial appendage occlusion guided by intracardiac echocardiography in a patient with a 34 mm atrial septal defect occluder: a case report.

Background: Intracardiac echocardiography (ICE)-guided left atrial appendage occlusion (LAAO) is increasingly common. Patients with previous atrial septal defect closure constitute a significant challenge for transseptal access. Case summary: A 49-year-old man with persistent atrial fibrillation, hypertension, and reduced left ventricular function was considered for LAAO after a life-threatening intrathoracic bleeding while on oral anticoagulation. Percutaneous atrial septal defect closure was performed 15 years before with a 34 mm Amplatzer Septal Occluder. Preprocedural cardiac computed tomography demonstrated the atrial septal occluder device with a small native interatrial septum at the inferior margin. The left atrial appendage landing zone measured 17 × 22 mm. The LAAO was performed under local analgesia. A steerable sheath was used to guide the transseptal puncture, and the ICE probe was traced along a guidewire across the atrial septum. A 12-F Amulet delivery sheath was advanced through the same transseptal hole. Under ICE and fluoroscopy guidance, a 25 mm Amplatzer Amulet was deployed. Follow-up imaging showed a well-positioned device with a small peridevice leak at the disc. Discussion: This case report illustrates the feasibility of LAAO performed with ICE guidance from the left atrium in a patient with a large Amplatzer Septal Occluder with a small native interatrial septum. It demonstrates that prior atrial septal defect closure should not be considered as a contraindication for LAAO but warrants careful preprocedural planning.