Steerable Delivery Sheath for Left Atrial Appendage Closure in Patients With Severely Enlarged Left Atria.

Background: Enlarged left atrium (LA) is frequently identified in patients who undergo left atrial appendage closure (LAAC) and negatively affects the device's final position and intervention results. Steerable delivery sheath (SDS) could represent an option to overcome these difficulties. We aimed to assess the feasibility of SDS-assisted procedures and compare their efficacy to the standard sheath strategy. Methods: This study analyzed patients from our institution's LAAC registry who had severe LA enlargement on CT scan (index LA volume >90 mL/m2) and underwent AMULET device implantation between January 2019 and March 2023. The patients underwent postprocedural CT scan to assess the device's position, residual LAA filling, and peridevice leaks. Results: A total of 195 consecutive patients were screened and 47 (24%) met the inclusion criteria (n = 22 SDS group; n = 25 standard group). There was no difference in baseline clinical, anatomical, or procedural characteristics. The procedural technical success (96%) and complication rates (9% vs 4%; P = .59) were comparable in both groups. Post-LAAC CT scans were obtained in 19 SDS group and 22 standard group patients. We observed significantly lower incidences of residual patent LAA (26% vs 72%; P = .005), peridevice leaks (16% vs 64%; P = .004), and off-axis device position (0% vs 27%; P = .02) in SDS compared to the standard group, suggesting a better LAA sealing. Conclusions: Severe LA enlargement was frequent among LAAC candidates. In this situation, the use of SDS appears feasible and safe, leading to more efficient closures on follow-up imaging without a higher risk of periprocedural complications.

[A complicated left atrial appendage closure : percutaneous management of LAA rupture]. / Ma fermeture d'auricule s'est compliquée : traitement percutané d'une rupture d'auricule gauche.

An 81-year-old patient was referred for left atrial appendage closure. Anatomical LAA analysis by CT scan showed an inverted chicken wing morphology. The procedure was performed through i an infero-anterior transseptal puncture and led to "sandwich" closure strategy using an AMPLATZER AMULET 25 mm device. Despite successful deployment of the occluder, a hemopericardium soon developed related to an iatrogenic LAA perforation/partial rupture and leading to major hemodynamic instability. After pericardocentesis, it was decided to inject activated thrombin into the pericardial sac to achieve in situ hemostasis. This strategy enabled coagulation of the hemopericardium and cessation of active bleeding, without recourse to surgical treatment.