A giant left atrial appendage: a case report on the feasibility of closure with a custom-made device

Background: Transcatheter left atrial appendage occlusion (LAAO) is a valuable therapeutic option for stroke prevention in patients with atrial fibrillation (AF) at high bleeding risk. However, complex LAA anatomies sometimes preclude the adoption of commercially available LAAO devices. The design of a custom-made LAAO device is a promising strategy in these cases. However, few examples of custom-made devices in case of giant LAAs have been reported.

Case summary: An 85-year-old man with permanent AF with CHA₂DS₂-VASc 4 and recurrent active gastrointestinal major bleedings was referred for transcatheter LAAO at Parma University Hospital after multidisciplinary team evaluation. Pre-procedural coronary computed tomography angiography revealed a giant windsock LAA, with a maximum ostium diameter of 44 mm, a landing zone diameter of 34 mm, and maximal length of 49 mm. Patient's management was particularly challenging given that available LAAO devices were too small to completely exclude the LAA. In accordance with the manufacturer, a custom-made LAmbre™ Closure System (Lifetech Scientific, Shenzhen, China), which specifically fitted with patient's LAA anatomy, was designed and successfully deployed under transoesophageal echocardiography (TEE) and fluoroscopic guidance. Periprocedural TEE confirmed the appropriate position of the device and the absence of peri-device leaks. No adverse ischaemic and haemorrhagic events were reported at 3-months follow-up.

Discussion: We present a case of a successful transcatheter LAAO procedure by deploying a custom-made LAmbre device 38/46 mm to mechanically exclude a giant windsock LAA. This case illustrates the effectiveness of a custom-made device strategy, which potentially enables the closure of all complex LAA anatomies.