Complex Transcatheter Left Atrial Appendage Closure Under Intracardiac Echocardiography in a Patient With Repaired Tetralogy of Fallot.

objectiveWe illustrate transcatheter left atrial appendage closure under local anesthesia with intracardiac echocardiography guidance for a complex patient with repaired tetralogy of Fallot at high risk for general anesthesia, with preprocedural cardiac computed tomography (CT) support. KEY STEPS: 1) CT imaging and analysis; 2) vascular access with use of sheath-in-sheath technique; 3) transseptal puncture with VersaCross system; and 4) deployment of Watchman device in CT-planned projection. POTENTIAL PITFALLS: 1) Selection of appropriate preprocedural imaging modality; 2) use of sheath-in-sheath technique to avoid kinking of catheters; 3) use of VersaCross transseptal system to avoid repeat punctures, unnecessary exchanges, and risk of injury; and 4) avoidance of general anesthesia to reduce risk in a high-risk patient. TAKE-HOME MESSAGES: Preprocedural CT analysis and intraprocedural intracardiac echocardiography imaging can guide transcatheter left atrial appendage closure procedures in complex anatomies. The use of appropriate sheaths and equipment can improve the safety profile and success rate of complex transcatheter left atrial appendage closure procedures.