Implantation of left atrial appendage occlusion devices and complex appendage anatomy: The importance of transesophageal echocardiography

Percutaneous delivery of left atrial appendage (LAA) occluding devices represents a novel approach for stroke prevention in patients with atrial fibrillation. Transesophageal echocardiography (TEE) has a pivotal role throughout these procedures, facilitating device size selection and ensuring optimal deployment of the device. We report a case of an LAA occluding device implantation in which apparent proper positioning on fluoroscopy was determined by TEE to be malpositioning with a nonocclusive, perpendicular orientation to the plane of the LAA ostium. This problem appeared to be related to a complex, multilobed LAA anatomy and was readily resolved by repositioning of the device under TEE guidance.