Double trouble during the left atrial appendage occlusion procedure

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Imaging

Background:

• Percutaneous structural interventions are increasing, leading to more frequent encounters with rare anatomical variations.
• Lipomatous hypertrophy of the interatrial septum (LHIS) is an uncommon finding on transthoracic echocardiogram (TTE).
• Transseptal puncture is a critical step in many structural heart procedures, including left atrial appendage (LAA) closure.

Observation:

• This report details a case of left atrial appendage (LAA) closure in a patient with an extreme form of lipomatous hypertrophy of the interatrial septum (LHIS).
• The extreme LHIS presented significant anatomical challenges for standard transseptal puncture techniques.
• Transthoracic echocardiogram (TTE) identified the lipomatous hypertrophy, underscoring its importance in pre-procedural planning.

Findings:

• Performing transseptal puncture was exceptionally difficult due to the thickened and hypertrophied interatrial septum.
• The anatomical abnormality required modifications or alternative approaches to successfully cross the interatrial septum.
• Successful LAA closure was ultimately achieved despite the challenging anatomy.

Implications:

• Extreme LHIS can pose significant technical hurdles during percutaneous structural interventions requiring transseptal access.
• Awareness of LHIS and its potential impact on procedural success is crucial for interventional cardiologists.
• This case emphasizes the need for careful pre-procedural imaging and potential adaptation of techniques for complex anatomical variations.