INTRODUCTION
Left atrial appendage (LAA) closure is a well-established stroke prevention strategy as an alternative to systemic oral anticoagulant in selected patients with high-risk nonvalvular atrial fibrillation1,2. Its rationale lies in excluding the left atrial appendage where most clots form in the left atrium. Closure of the LAA is safe with a low, acceptable risk of complications1,2. Currently, LAA occlusion is extended to patients with high HAS-BLED score or those who cannot tolerate, refuse or contraindicated for long-term oral anticoagulation therapy3. In all other patients, oral anticoagulant remains the preferred thromboprophylaxis in patients with atrial fibrillation.
Elderly patients with atrial septal defect (ASD) often present with heart failure, impaired exercise capacity and chronic atrial fibrillation. They are usually symptomatic and ASD closure is often indicated to alleviate symptoms. To our knowledge, there is no published guideline to guide management in this unique group of patients. Some centers may attempt rhythm control and ASD closure while others opt for rhythm control and ASD closure. We opted for off-label transcatheter closure of LAA and ASD, which treats both the large left to shunt while providing the patients with effective thromboprophylaxis. Both the procedures utilities similar equipment such as transesophageal echocardiogram and the approach, which places the long sheath into the left upper pulmonary vein during closure. Also, the presence of an ASD simplifies the process of the LAA closure. Both procedures may even be performed together. However, such an approach is unconventional and not well studied. The objective of this study was to describe the feasibility and safety of closing both the LAA and ASD in patients with ASD and chronic atrial fibrillation.