Successful percutaneous left atrial appendage closure using re-shaped curve sheath created by simultaneous virtual reality simulator

An 89-year-old male with persistent atrial fibrillation and a chronic subdural haematoma was admitted to our hospital for percutaneous left atrial appendage closure (LAAC). Baseline computed tomography (CT) and transesophageal echocardiography (TEE) revealed a relatively larger orifice and shorter depth of the left atrial appendage (LAA). Based on the LAA size determined by imaging modalities, a 35 mm WATCHMAN-FLX was chosen. Despite the transseptal puncture site being changed twice, the coaxiality and angulation of the original double-curved delivery sheath (DS) during insertion into the LAA orifice were inadequate to. Therefore, we employed a virtual reality (VR) simulator and simultaneously attempted to image the ideal DS curve to align with the patient's LAA anatomy. Our findings are interesting in that, although VR simulation are infrequent during LAAC, they may be helpful in understanding the reasons for procedural difficulty and guiding procedural success in patients with complex LAA anatomy.