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. 2024 Mar 22;3(4):101290.
doi: 10.1016/j.jscai.2023.101290. eCollection 2024 Apr.

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

Nicolas Amabile  1   2 , Ayoub Belfekih  1 , Vincent Balmette  1 , Khalil Mahmoudi  1 , Nicolas Mignot  3 , Clemence Roig  1
Affiliations

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

Nicolas Amabile et al. J Soc Cardiovasc Angiogr Interv. .

Abstract

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.

Keywords: atrial fibrillation; left atrial appendage closure; left atrium remodeling.

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Figures

None
Graphical abstract
Central Illustration
Central Illustration
(A) The TorqueVue fixed-angle delivery sheath. (B) The Amplatzer steerable delivery sheath with multiple tip deflections. (C) Differences in coaxial alignment between left atrial appendage (LAA) axis and standard (C1) or steerable (C2) delivery sheaths. (D) Differences in LAA closure and device position on follow-up imaging between steerable delivery sheath and standard patients.
Figure 1
Figure 1
Representative examples of patients treated with the standard (A1-A3) or steerable (B1-B3) delivery sheath. Patient A had a cactus-shaped left atrial appendage (LAA), baseline index LA volume = 110 mL/m2, and was treated with 22 mm AMULET device implantation. The follow-up CT scan revealed an off-axis prosthesis (A1-A2) since the lobe was not perpendicular to the appendage wall on the landing zone. In addition, persistent LAA patency was observed (red arrow) in relation to a peridevice leak. Disc/lobe misalignment was also identified (A2) since the axes of the disc (dashed yellow) and the lobe (dashed purple line) intercepted with an angle >30°. Patient B had cactus-shaped LAA, baseline index LA volume = 160 mL/m2, and was treated with 31 mm AMULET device implantation. The device's final position was optimal with the correct apposition of the lobe on the appendage wall. There was no residual LAA patency, nor peridevice leak observed. The disc and lobe were correctly aligned.
Figure 2
Figure 2
Workflow of the study. CT, computed tomography; LAA, left atrial appendage; LAAC, left atrial appendage closure.
Figure 3
Figure 3
Follow-up computed tomography scan data. LAA, left atrial appendage.
See this image and copyright information in PMC

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