Uncommon cause of dyspnoea after percutaneous closure of the left atrial appendage

Extract

A 69-year-old female with persistent atrial fibrillation and history of recurrent strokes presented with progressive shortness of breath. Three years ago, percutaneous closure of the left atrial appendage (LAA) for stroke prophylaxis was performed using an Amplatzer Amulet^® device (St. Jude Medical, MN, USA).

Coronary angiography revealed a filling of the LAA and subsequently of the LA after contrast injection into the left main artery (Figure  1  A and B, see Supplementary material online, Movies S1–S3). Intravascular ultrasound identified two large fistulas with a diameter of 2 mm, originating from the proximal and distal left circumflex artery (LCx), respectively (Figure 1C, see Supplementary material online, Movie S4). Reviewing the procedure of LAA closure 3 years ago, the device was adequately sized (28 mm lobe size; 24 mm landing zone diameter) and placed. Transoesophageal echocardiography showed the closure device in typical place. Color Doppler ultrasound revealed only a small jet from the LAA into the LA. The fistulas were successfully sealed by implantation of two covered stents (Figure 1D, see Supplementary material online, Movie S5). The post-interventional course was uneventful.