A Hole in the Plot of a Left Atrial Appendage Occlusion

R. A., 73–year–old female patient with medical history of paroxysmal atrial fibrillation (CHADS2–VASc2 4), hypertension, diabetes and dyslipidemia. She had been admitted to ER because of hematuria, discovering with subsequent exams a papillary carcinoma of the bladder, treated with TURB. Immediately after the procedure a STEMI occurred and pPCI was performed, implanting a DES in middle LAD. DAPT was started with aspirin and clopidogrel, LMWH was added for stroke prevention and after 2 days dabigatran 110 mg bid was added to therapy. After 2 days Hb dropped to 7.5 g/dl (starting from 9.7 g/dl) and 2 red blood cell transfusion packs were needed to restore Hb levels to 10,1 g/dl, but in a few days of NOAC+DAPT HB felt again to 7.1 g/dl. She accepted our proposal LAAO on account of increased bleeding risk. Anticoagulation therapy with dabigatran was discontinued 48 hrs before the procedure, and the patient was maintained on LMWH. Cardio CT was performed as per our protocol before procedure, demostrating a LAA without thrombi. While tenting of inter–atrial septum puncture at TEE suddenly appears a filamentous formation adherent to atrial septum, with proximal edge embedded in PFO. After many failed attempts (snare, pigtail) to remove or reduce this formation we decided to perform a trans–septal puncture near PFO in order to perform LAA occlusion and subsequent PFO closure using the same 9F catheter, avoiding multiple pass through a potential dangerous situation. This will allow trapping and immobilization of the filamentum through fossa ovalis while performing LAA occlusion, avoiding possibility of migration, programming of jailing it into PFO closure device, achieving immediately closure of both PFO and delivery catheter hole. R.A. was discharged at 5 days after LAA + PFO closure with DAPT con ASA 100 mg + clopidogrel 75 mg/die. Hb was 9.2 g/dl. TEE at discharge and at 30 days FU showed devices in situ in absence of pericardial effusion; Hb raises up to 10.2 g/dl. Once you started a procedure you may have plan A, B, C and even D if it occurs to manage all kind of complications