Transjugular Watchman Implantation for Left Atrial Appendage Occlusion in Anomalous Inferior Vena Cava

Figures

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  Visual Summary. Clinical Challenges, Key Procedural Steps, Potential Pitfalls, and Take-Home Messages From Transjugular Watchman Implantation for LAAO in a Patient With an Anomalous IVC With Azygos Continuation This summary highlights the rationale for a transjugular approach, critical technical considerations during transseptal access and device deployment, procedural outcome, and key lessons learned for managing similar complex venous anatomy. AF = atrial fibrillation; CT = computed tomography; IVC = inferior vena cava; LAA = left atrial appendage; LAAO = left atrial appendage occlusion; TEE = transesophageal echocardiography.

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  Figure 1. Multimodality Imaging of an Anomalous Inferior Vena Cava With Azygous Continuation (A) Selective venography demonstrated a prominent azygos vein draining into the superior vena cava. (B) Three-dimensional reconstructed model demonstrating the anatomical complexity of an anomalous inferior vena cava with azygous continuation, which precludes a transfemoral approach for Watchman FLX placement. (C) Contrast-enhanced abdominal CT demonstrating an anomalous inferior vena cava with a prominent azygos vein. CT = computed tomography; LAO = left anterior oblique; RAO = right anterior oblique.

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  Figure 2. Preprocedural Imaging Demonstrating the Feasibility of Right Internal Jugular Venous Access for Left Atrial Appendage Occlusion (A) CT angiogram of the patient's head and neck with 3D reconstruction. (B) CT angiogram of the head and neck with 3D reconstruction (anterior and posterior views) demonstrating the feasibility of LAAO Watchman device access via the right internal jugular vein. 3D = 3-dimensional; CT = computed tomography; LAAO = left atrial appendage occlusion.

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  Figure 3. Cardiac Computed Tomography Evaluation of the Left Atrial Appendage

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  Figure 4. Fluoroscopic Images Demonstrating a Transseptal Puncture Followed by Intrasseptal Balloon Dilatation NC = noncompliant; TEE = transesophageal echocardiography.

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  Figure 5. Intraprocedural Advancement of the Watchman TruSteer Delivery Sheath to the Left Atrial Appendage (A) Fluoroscopic image demonstrating advancement of the Watchman TruSteer delivery sheath toward the left atrial appendage. (B) Three-dimensional reconstruction illustrating advancement of the Watchman TruSteer delivery sheath toward the left atrial appendage.

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  Figure 6. Intraprocedural Imaging of Successful Left Atrial Appendage Occlusion With a 31-mm Watchman Device (A) Fluoroscopic image demonstrating the successful deployment of a 31-mm Watchman device within the left atrial appendage. (B) Three-dimensional reconstruction model illustrating the successful deployment of a 31-mm Watchman device within the left atrial appendage. LAO = left anterior oblique.

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  Figure 7. Watchman Device Deployment Real-time 3D TEE multiplanar reconstruction obtained intraprocedurally demonstrates optimal Watchman device positioning, secure anchoring, and adequate device compression. 3D = 3-dimensional; TEE = transesophageal echocardiography.

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  Figure 8. Postprocedural CT Imaging of the Left Atrial Appendage Shows Successful Deployment of a 31-mm Watchman Device With Complete Occlusion and an Adequate Seal CT = computed tomography.