JH

We describe an 82-year-old female with paroxysmal atrial fibrillation, prior stroke, heart failure with preserved ejection fraction, and advanced chronic kidney disease who was referred for LAAC due to gastrointestinal bleeding and gait instability with increased fall risk. Her CHA₂DS₂-VASc score was 6 and HAS-BLED score was 4. CTA was contraindicated due to a GFR of less than 30 mL/min/1.73m². The patient did not tolerate transesophageal echocardiography due to dysphagia.

Based on cine imaging, early long-T1 imaging, and late gadolinium imaging did not demonstrate LAA thrombus (Figure 1).  The measurements of the LAA ostium were as follows: area 717 mm², maximum diameter 32 mm, minimum diameter 28 mm and depth 34 mm (Figure2, panel A-C). Based on the left atrial appendage measurements acquired by CMR, a 35 mm WATCHMAN device was selected (1).

Right common femoral vein access was obtained with micropuncture technique under ultrasound guidance. The Seldinger technique was then performed to place two 8 French Sheaths. The left atrium was accessed using an AcuNav intracardiacechocardiographic (ICE) probe. A Baylis needle was utilized for transeptal puncture and a Double Curve access sheath was used for device deployment. Angiography of the left atrial appendage was performed using a 6 French angled pigtail catheter.

Right common femoral vein access was obtained with micropuncture technique under ultrasound guidance. The Seldinger technique was then performed to place two 8 French Sheaths. Heparin was administered to achieve an appropriate activating clotting time. The left atrium was accessed using an AcuNav intracardiac echocardiographic (ICE) probe. A Baylis needle was utilized for transeptal puncture and a Double Curve access sheath was used for device deployment. Angiography of the left atrial appendage was performed using a 6 French angled pigtail catheter. LAAC device sizing was confirmed via angiography and ICE imaging (Figure 5, panel A-C). After satisfying the P.A.S.S. (Position, Anchor, Size, Seal) criteria, a 35 mm WATCHMAN^™ FLX device was successfully deployed with 28% compression. The patient was uneventfully discharged home on the same day.

CTA and TEE are both accepted imaging modalities for LAAC planning^2-4. However, TEE used for structural interventions has been associated with serious complications^4-5. While CTA has advantages over TEE for LAAC planning, it is contraindicated in patients with renal dysfunction. Our case report highlights the possibility of using CMR for select patients. Here we present a case in which a patient was unable to tolerate TEE from prior stroke and CTA was contraindicated due to renal dysfunction. CMR provided detailed anatomy of the LAA, without risk of renal injury or radiation exposure, and accurately predicted the appropriately-sized device in our patient.