Background: Percutaneous left atrial appendage occlusion (LAAO) is usually performed under fluoroscopy and transoesophageal (TEE) guidance. Fluoroscopy includes the use of nephrotoxic contrast dye injection into the LAA for angiographic assessment. A significant proportion of patients with indication for LAAO has advanced chronic kidney disease. Furthermore, in patients with LAA thrombus mechanical manipulation inside the LAA must be avoided to prevent mobilization of the thrombotic mass.

Objective: The aim of this study was to investigate the efficiency and safety of contrast-free LAAO with the AMPLATZER^TM Amulet^TM device.

Methods: Patients with chronic atrial fibrillation and advanced chronic kidney disease and/or persistent LAA thrombus despite effective oral anticoagulation were included. LAAO was performed under TEE- and fluoroscopy guidance without any contrast dye. Follow up (FU) visit at 3 month and 6 month included TEE or TTE and clinical examination, thereafter telephone FUs were performed. 

Results: 17 patients (mean age 72±8 years; 8 male) at an increased risk for thromboembolism (mean CHA₂DS₂-VASc score 4,6±1,7) and bleeding (mean HAS-BLED score 3,8±0,7) were included. 7 patients presented with chronic kidney disease stage 4 or 5, 7 patients with LAA thrombus and 3 patients with both. LAAO was feasible in 100% of cases. Initial TEE based device sizing was accurate in all patients, no patient required a change of device size. Mean procedure, LA and fluoroscopy times were 42±11min, 29±10min and 6,2±4,2 min, respectively. There were no periprocedural adverse events. 3/17 (18%) patients had a non-significant peri device leak of < 3 mm at 3 and 6 month FU. No device thrombus was observed. During the FU (mean duration 14 months, ICR 3-26) 1 patient died from urosepsis, no thromboembolic events or major bleedings were reported. 

Conclusion: In this single center study, percutaneous LAAO without the use of contrast dye appears feasible and safe and is associated with high procedural success and favorable long-term outcome in selected patients.