Catheterization and Cardiovascular Interventions 85:E58–E62 (2015)

Recurrent Syncope After Left Atrial Appendage Occlusion Ignacio Cruz-Gonzalez,1* MD, PhD, Jose-Angel Perez-Rivera,1 MD, PhD, and Armando Bethencourt,2 MD, PhD We present the case of a 72-year-old woman with permanent atrial fibrillation and contraindication to long-term oral anticoagulant therapy who underwent left atrial appendage (LAA) occlusion. A 24-mm Amplatzer Cardiac Plug (St Jude Medical) device was deployed. The inferior part of the external disc of the device appeared to be over the posterior leaflet of the mitral valve but no significant mitral stenosis or mitral regurgitation was detected before deployment. After the procedure the patient suffered several syncopes when she tried to stand up. A transesophageal echocardiography (TEE) was performed and no significant differences on the device position were detected, it was not possible to perform the TEE in a stand-up position due to the patient symptoms (hypotension, tachycardia, dizziness, and loss of consciousness). After discussion with the surgical team, surgical removal of the device and surgical exclusion of LAA was performed. The symptoms disappeared and the patient was discharged. In the best of our knowledge, this is the first time that recurrent syncope has been described as a complication of LAA occlusion. VC 2014 Wiley Periodicals, Inc. Key words: left atrial appendage occlusion; complications; syncope

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia. Patients with AF are at an increased risk of having a cardioembolic stroke [1]. It is postulated that the source of thromboembolism in 90% of patients with non-valvular AF arises from the left atrial appendage (LAA) [2]. Percutaneous exclusion of LAA is a new approach for the prevention of strokes in high-risk patients with AF and contraindication to long-term oral anticoagulant (OAC) therapy [3,4]. Recently, several devices such as the Watchman device (Boston Scientific, Natick, MA) and the Amplatzer Cardiac Plug (ACP; St. Jude Medical, St. Paul, MN) have shown encouraging results for selected patients [5–7]. CASE REPORT

We describe the case of a 72-year-old woman with paroxysmal AF on chronic OAC therapy who was admitted for upper gastrointestinal bleeding. Her previous medial history included hypertension, hyperlipidemia, and a previous stroke. Her CHA2DS2VASc score was 5 (adjusted annual stroke rate 6.7%) [8] and her HAS BLED was 4. Provided the complexity of the patient’s medical condition, and the risk for future bleeding complications on long-term OAC therapy, the use of a percutaneous device to occlude her LAA was explored. C 2014 Wiley Periodicals, Inc. V

A transesophageal echocardiogram (TEE) was used to exclude the presence of thrombus in the LAA (Fig. 1) and to guide the implantation. The procedure was performed percutaneously using a transseptal approach under fluoroscopic imaging and TEE monitoring. The procedure was complicated by a cardiac tamponade after transseptal puncture that was treated with pericardial drainage without further complications. Several fluoroscopic images were obtained before implantation in order to define the size of the device. The diameter of the neck of the LAA by angiographic imaging was 22 mm and 19 mm by TEE. A 24-mm Amplatzer Cardiac Plug (ACP) device was deployed in the 1

Division of Cardiology, University Hospital of Salamanca, Spain 2 Division of Cardiology, Son Dureta Hospital, Mallorca, Spain. Conflict of interest: Dr. Cruz-Gonzalez and Dr. Bethencourt are consultants of St. Jude Medical. *Correspondence to: Ignacio Cruz-Gonzalez, MD, PhD, Cardiology Division, University Hospital of Salamanca, Paseo San Vicente 58– 182, 37007, Salamanca, Spain. E-mail: [email protected] Received 3 March 2014; Revision accepted 13 July 2014 DOI: 10.1002/ccd.25608 Published online 16 July (wileyonlinelibrary.com)

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Fig. 1. TEE 2 chambers view showing the absence of thrombus in LAA.

Fig. 2. TEE 2 chambers view that confirms the absence of flow within the LAA.

LAA, the implantation was suboptimal as the device did not have the recommended tire shape but the device was stable and the LAA was totally occluded. Intraoperative TEE (Fig. 2) and angiographic contrast injections were utilized to determine proper device implantation and opti-

mal LAA exclusion. The inferior part of the external disc of the device appears to be over the posterior leaflet of the mitral valve (Fig. 3); however no significant mitral stenosis or mitral regurgitation was detected (Fig. 4). Follow-up echocardiogram before discharge confirmed

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exclusion of the LAA with no significant mitral stenosis or regurgitation. During admission the patient referred dizziness and hypotension, it was supposed to be related to hypertension therapy and it was discontinued. She was discharged 2 days after the procedure on dual antiplatelet therapy.

After discharge the patient referred several syncopes always related to stand up position. The patient was admitted again and a new TEE was performed. The LAA was excluded and there was no significant difference on the device position, however it was not possible to perform the TEE in a stand-up position due to the patient symptoms (hypotension, tachycardia, dizziness, and loss of consciousness). No significant ventricular or atrial arrhythmias were detected in Holter monitoring. After discussion with the surgical team, surgical removal of the device and surgical exclusion of the LAA were performed (Fig. 5). The symptoms disappeared and the patient was discharged without further complications. DISCUSSION

Fig. 3. Fluoroscopic image that shows the device resting on the mitral valve.

We present a case of a patient with AF no longer suitable for chronic OAC therapy referred alternatively for percutaneous exclusion of the LAA with an ACP device. This device is designed for closure or occlusion of cardiac structures not involving the septal wall such as the LAA. The device is constructed from a nitinol mesh and Dacron and consists of a lobe and a disk connected by a central waist. The sizes of the lobe ranged from 16 mm to 30 mm and the disc diameter ranged from 20 mm to 36 mm. The lobe of the device is designed to conform to the inner wall of the LAA with a depth of 10 mm or more and provide secure device placement and retention

Fig. 4. TEE 4 chambers view showing the inferior part of the device over the posterior leaflet of mitral valve and no significant mitral stenosis or mitral regurgitation was detected. Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

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Fig. 5. Intraoperative images showing the device (arrow) over the mitral valve (Panel A and B) and after explantation (Panel C).

Fig. 6. Illustration showing the hypothetical mechanism of the syncope. The external disc of the device is over the posterior leaflet. A direct stimulus of the device disc over the mitral valve can be a possible mechanism of the syncope. Or a mechanism similar to myxoma-related syncope (with obstruction of the mitral valve) can be involved in this case.

with the stabilizing wires. The size of the device should be, at least, 2 mm larger than the diameter of the LAA landing zone. Complications related to the transseptal puncture such as cardiac tamponade or air embolism have been described during percutaneous exclusion of LAA and they appear to relate more to procedural technique than to device used [9]. Acute ischemic stroke due to air or thromboemboli, sepsis, vessel perforation during vascular access, or embolization have been also reported [10]. However, in the best of our knowledge, this is the first time that recurrent syncope has been described as a complication of percutaneous exclusion of LAA.

The exact mechanisms of the syncope in this patient were not clearly established. The external disc of the device was over the posterior leaflet of the mitral valve and this seemed to be the final cause of the syncope, a deeper implantation of the device could potentially prevent this complication. It can be speculated that a mechanism similar to myxoma-related syncope can be involved in this case. In patients with atrial myxomas, dynamic obstruction of the valve may occur, resulting in exertional dyspnea, syncope, or sudden death [11,12]. Signs and symptoms depend on size, position, and mobility of the tumor, varying body posture [12]. However, in the present case no movement or migration of the device was documented either by TEE or by direct inspection during surgery. Anyway, the patient did not tolerate a TEE in a stand-up position, so recording of the position of the device in stand-up position was not available. Neurally mediated syncope can be another option. A wide variety of stimuli can trigger this reflex, the most common stimulus being orthostatic stress. A direct stimulus of the device disc over the mitral valve cannot be excluded as a possible mechanism of the syncope (Fig. 6).

CONCLUSION

Percutaneous exclusion of LAA is an attractive approach for the prevention of strokes in high-risk patients with AF and contraindication to long-term OAC therapy. Although complications during the procedure have been described, this is the first time that recurrent syncope has been reported as a complication of this technique. These complications should be taken into account when considering the risk/benefit ratio of this procedure. The position of the disc of the device

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in relation with the mitral valve should be always checked before deployment. 7.

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tion in Patients with AF (PROTECT AF) clinical trial and the Continued Access Registry. Circulation 2011;123:417–424. Park JW, Bethencourt A, Sievert H, Santoro G, Meier B, Walsh K, Lopez-Minquez JR, Meerkin D, Valdes M, Ormerod O, et al. Left atrial appendage closure with Amplatzer cardiac plug in atrial fibrillation: Initial European experience. Catheter Cardiovasc Interv 2011;77:700–706. Lip GY, Nieuwlaat R, Pisters R, Lane DA, Crijns HJ. Refining clinical risk stratification for predicting stroke and thromboembolism in atrial fibrillation using a novel risk factor-based approach: The Euro Heart Survey on Atrial Fibrillation. Chest 2010;137:263–272. Cruz-Gonzalez I, Perez-Rivera A, Lopez-Jimenez R, RodriguezCollado J, Martin-Moreiras J, Cascon M, Arribas A, Gomez JC, Maree AO, Martin-Luengo C. Significance of the learning curve in left atrial appendage occlusion with two different devices. Catheter Cardiovasc Interv 2014;83:642–646. Urena M, Rodes-Cabau J, Freixa X, Saw J, Webb JG, Freeman M, Horlick E, Osten M, Chan A, Marquis JF, et al. Percutaneous left atrial appendage closure with the AMPLATZER cardiac plug device in patients with nonvalvular atrial fibrillation and contraindications to anticoagulation therapy. J Am Coll Cardiol 2013;62:96–102. Surabhi SK, Fasseas P, Vandecker WA, Hanau CA, Wolf NM. Right atrial myxoma in a patient presenting with syncope. Tex Heart Inst J 2001;28:228–229. Reynen K. Cardiac myxomas. N Engl J Med 1995;333:1610– 1617.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd. Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

Recurrent syncope after left atrial appendage occlusion.

We present the case of a 72-year-old woman with permanent atrial fibrillation and contraindication to long-term oral anticoagulant therapy who underwe...
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