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.