Simultaneous Endocardial and Epicardial Approach for Successful Closure of Left Atrial Appendage With Difficult Anatomy

Left atrial appendage closure (LAAC) is increasingly used for stroke prevention; however, left atrial appendage (LAA) anatomy may pose significant challenges. A 67-year-old man with paroxysmal atrial fibrillation, CHA2DS2-VASc Score of 3, and recurrent falls was referred for LAAC. Owing to challenging anatomy noted during preoperative imaging, epicardial access was obtained at procedure onset. Following multiple unsuccessful endocardial attempts, LAAC was successfully achieved by an epicardial device. Preprocedural imaging can identify challenging LAA anatomy and assist in procedural planning. In patients with challenging LAA anatomy, obtaining epicardial access up front before endocardial closure attempts offers an additional immediate option in case of failure. This case highlights the importance and use of both endocardial and epicardial LAAC strategies for a comprehensive LAAC program. We demonstrate that a methodological approach with preprocedural LAA imaging and endocardial and epicardial LAAC strategies results in successful clinical outcomes.