Percutaneous Left Atrial Appendage Closure: Current Evidence and Procedural Insights

Fig. 1.. Anatomy of the left atrial appendage (LAA). (A) Proximal neck. (B) Functional (trabeculated) portion. AO, anatomic ostium; LZ, landing zone; LCx, left circumflex artery.

Fig. 2.. Anatomic variant of the left atrial appendage (LAA) depicted by transesophageal echocardiography (TEE). (A) Windsock; (B) Chicken wing; (C) Cactus; (D) Cauliflower.

Fig. 3.. Evolution of the serious adverse event (SAE) rates within 7 days and implant success across the PROTECT AF, CAP, PREVAIL, CAP2, and EWOLUTION studies. CAP, the Continued Access to PROTECT AF; CAP2, the Continued Access to PREVAIL.

Fig. 4.. Left atrial appendage closure (LAAC) in a patient with complex anatomy. Transesophageal echocardiography (TEE) revealed a left atrial appendage (LAA) with a large proximal lobe, presenting a challenge for percutaneous closure. Nevertheless, an Amulet device was deployed successfully, with the lobe of the device positioned in the proximal lobe of the LAA and the disc effectively sealing the anatomical ostium.

Fig. 5.. Transesophageal echocardiography (TEE) shows the tenting effect of the transseptal needle on the fossa ovalis in an inferior (left) and posterior (right) position.

Fig. 6.. Middle and inferior transseptal puncture (TSP) approach. A transseptal puncture (TSP) in the inferior (A) and middle (B) portions of the fossa ovalis in a patient with an inverse chicken-wing morphology (C) of the left atrial appendage (LAA), clearly visualized in the angiographic image (D).

Fig. 7.. Transseptal puncture (TSP) using the VersaCross system. The Versacross wire, within its sheath, is seen in contact with the interatrial septum under fluoroscopy (left). Transesophageal echocardiography (TEE) reveals tenting at the level of fossa ovalis and the wire crossing into the left atrium (middle), where it immediately assumes a pigtail shape (right), providing a safe means of crossing the septum.

Fig. 8.. Advancement of the sheath over the VersaCross wire. The Versacross wire is positioned in the left superior pulmonary vein (LSPV), as seen in the fluoroscopy image (upper left) and confirmed by transesophageal echocardiography (TEE) (upper right). The dedicated sheath for left atrial appendage closure (LAAC) device was advanced successfully over the same wire up to the LSPV, as visualized by TEE (bottom image).

Fig. 9.. The Watchman FLX™ device has two rows of 9 J-shaped anchors, with a total of 18 anchors (reproduced with permission from Boston Scientific).

Fig. 10.. The Watchman FLX™ sheath (left) alongside its delivery system containing the preloaded device (right).

Fig. 11.. Measurement of the landing zone and depth of the left atrial appendage (LAA) for the Watchman FLX™ device. LCx, left circumflex artery.

Fig. 12.. Watchman FLX™ size selection is based on the diameter of the left atrial appendage (LAA) landing zone. The recommended compression range is 10%–30%. The required depth for device implantation may vary depending on the degree of compression (reproduced with permission from Boston Scientific).