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4 mm ablation catheter was used to access LAA, the Agilis sheath was advanced over the ablation catheter, the catheter was retracted, and contrast was injected to visualize the LAA.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.