Threading a needle: percutaneous closure of an incompletely ligated left atrial appendage

Atrial fibrillation increases the risk of ischemic stroke by increasing left atrial appendage thrombus formation. Previously surgically ligated atrial appendages can recanalize, which increases stroke risk. Percutaneous ligation of such appendages is technically challenging due to altered morphology but feasible. We present a case of a successful percutaneous closure of a previously incompletely ligated atrial appendage using a WATCHMAN FLX device and discuss our approach to similar cases with challenging anatomy. Thorough pre-procedural imaging for case planning is indispensable and dictates feasibility and procedural success.