Complex Left Atrial Appendage Occlusion Using the Novel Amplatzer Steerable Delivery Sheath

J INVASIVE CARDIOL 2023;35(3):E158-E159.

Key words: left atrial appendage occlusion, transseptal puncture

Left atrial appendage (LAA) occlusion has emerged as an alternative to oral anticoagulation in non-valvular atrial fibrillation. The success rate is high, but we are still facing some challenging LAA anatomies that may increase the risk of suboptimal results. Coaxiality between the delivery sheath and the LAA neck is therefore crucial. Nevertheless, even with an optimal transseptal puncture, some LAA morphologies imply some difficulties. The novel Amplatzer steerable delivery sheath (Abbott Cardiovascular) offers the possibility of deflecting the distal end in a wide spectrum of angles from 0º to 120º (Figure 1). This could be determinant to achieving a final coaxial position with the neck during the deployment and improving the rate of complete occlusion.

In this case, although we faced classical chicken-wing anatomy, it was difficult to achieve a coaxial angle, as we can appreciate in computed tomography and fluoroscopy during the first attempt with the conventional 45º x 45º sheath (Figures 2A, 2B). Using the steerable sheath, even with a posterior-inferior transseptal puncture, the angle was again not desirable (Figures 2C-2F). Therefore, with a slight deflection (red arrow), the coaxiality improved in a determinant way. These small variations must be done in the ball position to prevent complications. These corrections offer the possibility to achieve an optimal angle for the deployment (white lines in Figures 3A, 3B; Video Series), helping to complete the desired final position (Figure 3C).

In conclusion, the Amplatzer steerable sheath is useful for LAA occlusion, especially in cases with challenging anatomies. Small variations of the distal end angle can improve the success rate and reduce complications.

Affiliations and Disclosures

From the Hospital Universitario de Salamanca. Cardiology Department, Biomedical Research Institute of Salamanca (IBSAL), and CIBER-CV, Salamanca, Spain.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted August 4, 2022.

Address for correspondence: Pablo J. Antúnez-Muiños, MD, PhD, Hospital Universitario de Salamanca, Spain, Paseo de San Vicente 182, PC 37007. Email: pjantunez@gmail.com