Three-Dimensional Transesophageal Echocardiography to Facilitate Transseptal Puncture and Left Atrial Appendage Occlusion via Upper Extremity Venous Access

Left atrial appendage closure devices are increasingly used in patients with atrial fibrillation at high risk of bleeding and a high thromboembolic risk. The Lariat device (Sentreheart, Redwood City, CA) is an option for those patients who cannot tolerate anticoagulation.1 There are no published data on either transseptal puncture and left atrial procedural manipulation to achieve percutaneous left atrial appendage closure using upper extremity venous access or the use of 3-dimensional transesophageal echocardiography (3D TEE) to guide upper extremity–based percutaneous procedures.A 68-year-old man with a long standing history of persistent atrial fibrillation and a CHA2DS2-VASc (congestive heart failure or left ventricular dysfunction, hypertension, ageu003e75 years old, diabetes mellitus, stroke or transient ischemic attack or thromboembolic event, vascular disease [prior myocardial infarction, peripheral artery disease, or aortic plaque], age 65-74 years old, sex category [female gender]) of 3 was unable to tolerate oral anticoagulants because of gastrointestinal bleeding and a history of a fall with consequent subdural hematoma requiring evacuation. Other significant medical history included placement of an infrarenal inferior vena cava filter because of totally occlusive bilateral common femoral deep venous thromboses.Because of his significant cardioembolic risk and hemorrhagic risk, as well as his inaccessible lower extremity venous system, we attempted percutaneous left atrial appendage closure using upper extremity venous access. Using an 8 Fr sheath, the right internal jugular vein was cannulated and then exchanged over a guidewire for a 61-cm 8.5 Fr inner diameter Agilis sheath (St. Jude Medical, St. Paul, MN). As we expected to use equipment not specifically designed for manipulation …