Figure Legends
Figure 1: Placement of Watchman past incompletely closed
LAA orifice. A: A 4 mm ablation catheter was used to access LAA, the
Agilis sheath was advanced over the ablation catheter, the catheter was
retracted, and contrast was injected to visualize the LAA. B: Agilis
exchanged for Watchman sheath and Pigtail catheter. C: Contrast
injection showing Watchman (outlined by black dashed line) placed distal
to orifice of the LAA. D: TEE image of the persistent connection between
LAA and LA. Dimensions of the LAA were suitable for placement of a 24mm
Watchman device. E: TEE image of 24mm Watchman placed in the LAA. F: TEE
image of Watchman device 6 weeks after implant demonstrating closure of
the LAA.
Figure 2: Placement of an Amplatzer device to close
residual LAA communication. A: An ablation catheter was advanced across
the persistent connection into the LAA. Contrast injection from the
sheath in the LA highlights that the ablation catheter was occlusive of
the persistent LAA connection. B: An Agilis sheath was advanced over the
ablation catheter into the LAA and contrast was injected into the LAA.
The sheath occluded the connection to the main body of the LA. C:
Contrast injection highlights the Amplatzer plug that was placed at the
persistent connection to the LAA. The narrow neck of the connection
(outlined) can be seen due to the contrast. D: TEE image of persistent
LAA connection, 4.4 mm in diameter in this view, with flow entering the
LAA. E: TEE image of Amplatzer plug in place, occluding the connection
seen in panel D. F: 3D TEE image of Amplatzer plug after release from
the delivery mechanism
Figure 3: Placement of an Amplatzer device to close
residual LAA communication with a preexisting WATCHMAN in place. A:
Preprocedural CT with an 8mm gap noted at the inferoposterior border of
the Watchman device. B: A 3D model was created from the pre-procedural
CT to guide device choice for closure (Scale in cm). C: Internal view of
3D model with Watchman device model printed as a separate piece to allow
it to be removed from the model LAA (Scale in cm). D: Pre-procedural TEE
demonstrating the persistent gap with flow into the LAA. E: Contrast
injection of the LAA. The LAA was entered using a 4mm ablation catheter
and the delivery sheath was then advanced over the ablation catheter
(WATCHMAN outlined by black dashed line, extent of LAA outlined in
white). F: TEE image of Amplatzer plug in place, occluding the
connection seen in panel D.