PO-01-043 CHALLENGING CASE OF LEFT ATRIAL APPENDAGE OCCLUSION AFTER TRANSCATHETER MITRAL VALVE IMPLANTATION WITH TENDYNE MITRAL VALVE SYSTEM

Abstract

Left atrial appendage occlusion (LAAO) is an alternative to reduce stroke risk in patients who are poor oral anticoagulant candidates. The Tendyne (Abbott Structural, Santa Clara, CA) transcatheter mitral valve implantation (TMVI) system consists of two self-expanding nitinol frames and a trileaflet porcine pericardial valve anchored to epicardial pad by a tether. The prominent atrial cuff of the device anchors the MV, and reduces paravalvular leak but can partially obstruct the LAA ostium making LAAO challenging We describe a case of left atrial appendage occlusion using a Watchman FLX in a patient who underwent TMVI with a Tendyne mitral valve system N/A 78-year-old woman with atrial fibrillation and TMVI with Tendyne was referred for LAAO due to recurrent bleeding. Transesophageal echocardiogram (TEE) showed a Tendyne prosthesis with the outer frame overlying the os of the left atrial appendage with a small residual elliptical opening. Computed Tomography (CT) showed partial obstruction of the LAA ostium by struts from the bioprosthetic mitral valve and a 9 x 8 mm gap permitting access to the LAA. Implantation of a single lobe device (Watchman FLX) into the left atrial appendage behind the prosthetic valve apparatus was planned to completely occlude the LAA. After transeptal puncture, a fixed single curve access sheath was introduced in the left atrium. Due to partial obstruction of the LAA ostium by the Tendyne, LAA access was challenging. With TEE guidance, a pigtail catheter was placed along the limbus side of the LAA and a glidewire was then successfully advanced into the LAA through the gap in the ostium. The angiogram showed communication of LAA with the left atrium despite partial obstruction by the Tendyne. The single curve access sheath was then advanced over the pigtail catheter past the Tendyne into the LAA and a 27 mm Watchman FLX device was deployed. In the final position the device was seated entirely behind the Tendyne valve apparatus at the level of the ostium in a stable position with no evidence of residual blood flow. Post watchman device placement, there was no damage or movement of the valve apparatus and no exacerbation of mitral regurgitation. The atrial cuff of the transcatheter mitral valve system can encroach on the LAA ostium and make LAAO challenging. Careful preoperative planning using CT can guide device selection and help mitigate challenges.