Left Atrial Appendage Occlusion Device Buckling: An Avoidable Deployment Complication Identified and Corrected Using Intraprocedural Transesophageal Echocardiography

Figures

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  Figure 1. Midesophageal TEE Images from case 1: (A) 2D x-plane view at 45° showing the acute angle of deployment catheter positioned into the LAA; (B) 2D x-plane view at 45° showing LAAO device buckle immediately after deployment; (C) 3D view at 25° showing collapse of device shoulder immediately after deployment; (D) 2D view with color Doppler at 44° showing the buckle at 45 days postimplantation; (E) 2D x-plane view at 115° showing device buckling and color Doppler evidence of peridevice leak at 1-year postimplantation; (F) 3D view at 45° showing device the buckle at 1-year postimplantation. AV, aortic valve; LA, left atrium; PA, pulmonary artery.

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  Figure 2. TEE MPR image from case 1. (A) Orthogonal postacquisition MPR images showing noncoaxial orientation of the catheter relative to the axis of the LAA. (B) The deployment catheter is coaxial to the LAA ostium. (C) Lack of coaxial orientation, which is noted in panel A, led to an asymmetric shape of the device face. (D) Three-dimensional view showing noncoaxial deployment catheter orientation.

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  Figure 3. Midesophageal TEE images from case 2: (A) 2D x-plane view at 60° showing acute angle of deployment catheter into LAA; (B) 2D x-plane view at 60° showing LAAO device buckling immediately after deployment; (C) 3D view at 45° showing buckling immediately after deployment; (D) 2D x-plane view at 60° showing proximal tug to relieve collapsed portion of the device face; (E) 2D x-plane view at 60° showing relieved buckle; (F) 3D view at 60° showing well-seated device. AV, aortic valve; LA, left atrium; LCx, left circumflex coronary artery; PA, pulmonary artery.

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  Figure 4. TEE MPR image from case 2. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Note that the deployment catheter appears more coaxial following a proximal tug. (C) Asymmetric device face noted due to buckle on initial deployment before proximal tug. (D) Three-dimensional image showing buckled device face before proximal tug maneuver.

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  Figure 5. Midesophageal TEE images from case 3: (A) 2D x-plane view at 40° showing acute angle of deployment catheter into LAA; (B) 2D view at 120° showing LAAO device buckle immediately after deployment; (C) 3D view at 120° showing buckling immediately after deployment; (D) 2D x-plane view at 110° showing less acute deployment catheter angle and well-seated device after initial device recapture; (E) 3D view at 140° showing well-seated device. LA, Left atrium; LCx, left circumflex coronary artery.

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  Figure 6. TEE MPR image from case 3. (A) Postacquisition MPR images showing noncoaxial orientation of the deployment catheter to the LAA ostium. (B) Noncoaxial orientation associated with buckled device. (C) Asymmetric device face before smaller device was exchanged. (D) Three-dimensional image of buckling with defect toward the mitral shoulder of the device.

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  Figure 7. Midesophageal images of transseptal puncture: (A) 2D view at 25° showing the transeptal puncture and associated color Doppler; (B) 2D view at 96° showing the transeptal puncture and associated color Doppler; (C) 2D view at 100° showing the transeptal puncture with needle shadowing present. IAS, interatrial septum.

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  Figure 8. Buckling graphic. (A) Correct demonstration of LAAO device insertion. Deployment catheter and device face are coaxial to the axis of the LAA and the LAA ostium. The device is well seated. (B) Suboptimal transeptal puncture leads to acute angle between deployment catheter and device face within the LAA. Under torque applied to improve device seating, the device can buckle, resulting in collapse shoulder and an apparent buckle in the face of the device. This could lead to a peridevice leak.