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A 79-year-old woman in permanent atrial fibrillation with CHA2DS2-VASc score 6 and under acenocumarol therapy was referred to our department for percutaneous left atrial appendage (LAA) closure after suffering a hemorrhagic cerebrovascular accident. Transesophageal echocardiography (TEE) revealed a thrombus in LAA (Figure 1). We planned to implant LAmbre™ (Lifetech Scientific Corp., Shenzhen, China) with simultaneous use of a cerebral protection device, Sentinel™ (Claret Medical, Santa Rosa, CA, USA) (Figure 2). The procedure was guided by TEE without any contrast injection. A partial umbrella delivery of a LAmbre 24/30 mm was done in front of LAA ostium and the whole system was advanced up to the point immediately before thrombus in LAA superior lobe. At this point, the umbrella delivery was completed and afterward the cover part was immediately unsheathed (Figure 3). TEE revealed a proper position of LAmbre, so the device was eventually released (Figure 4). Sentinel™ did not contain any debris. The patient's postoperative course was uneventful.
The presence of thrombus in LAA has been considered a contraindication to percutaneous LAA closure since the manipulation of catheter and device may lead to systemic embolisation. We used partial deployment technique of umbrella at the orifice of LAA as described in some reported cases.1) Thereafter, the system was advanced up to the landing zone where the device was completely delivered trying not to touch the thrombus.
In selected patients LAA closure in the presence of thrombus is safe and feasible and should not be considered an absolute contraindication.2)
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